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the Mr Pressure Go Whose, um, the general Medical fellow will be answering the questions and also be teaching half the session is Well, so without further ado, some basic stuff that refund of already mentioned. Um, the thing is, with this section is we will be covering quite a lot of things. Um, we'll cover apple in spines, lower limb and pediatric orthopedics. Old way basically from top to toe. So there will be quite a lot of contents going through. So this actually will roughly be two hours long, not from half seven, but from now. But we will try and get to the end of it, especially if we can. Okay, so, um, so, first of all, starting off with them some bone structure. This isn't quite simple. Slides. Uh, some of you must be confused. A quarter things with bone. So ultimate it's all about bones. Um, if we look at the structure of bone here, you've got the AC. Difficile is just right at the end. These articulating segments of a bone and the next to the growth of it in Children, which is the fine six, which is six between The line here is well on diet for six, which is the shaft off boating this spring, much that self explanatory condyles are around prominence that located towards the end of a bone that normally allows articulation between one bone on another. Happy condyles happy being Ah, it becomes from elected word over. It's basically a prominence on top of a combo that is usually where the muscles and connective tissues attaches to the bone. Um, some of the other lesser tuberosity try catheters to Bickell's, all of which you were here. Multiple times intubated elevation are basically prominences in the bone, where I the muscle of patches or tendons and ligaments attach is too as well moving on. So this is quite a self explanatory slight that tells you how to deal with everything in the, uh, orthopedic. So as with any other medical speciality, you know, to take a detail history, you have to examine the patient. You were then request appropriate investigations made diagnosis following these investigation on make a treatment blow. The difference with orthopedics is that the thing that we have to do when we take a history is to find out about mechanism of injury. This is quite important to know whether it's dramatic or there is non traumatic whether the patient has any previous month medical history, any operations fax this all will be needed when you make a decision to make a treatment open injuries is quite common and orthopedics which will come up later on. And if there is only one thing you take home from an automated examination, this is to check for neurovascular stability. What does this mean? So it's near Oh, and vascular. Therefore, you have to check if the nerves are intact. Therefore, can they move there? They moved their fingers. I can do a week, so that's those on. But if you translate that to realize if on on checking your vascular stability of the arms and like vascular, if we have to feel for a pulse, then you always have to document all of this information. An investigation in orthopedics, you pretty much will always need to do an imaging of some sort. But it isn't. It is the it is knowing when to get these limiting just quite important. Um, I used the pneumonic boxes here s O. B. If you used the request of bloods always for orifice tints. Most also been expressions will be elderly and frail, and most, most of the times they will. They will come in after a four. So ah, fall is a medical diagnosis that could have lost a lot of causes. Therefore, checking for patients orifice is might be useful, but I mean by that is so you have three main orifice is one is a urinary tract. The patient has a urinary tract infection doing a urine dip and setting and forth. Um, CNS might be helpful. The second track is the Risperdal three track. Therefore, checking for a sputum culture of the patient Have a cough. Second for pneumonias by doing a chest X ray will be helpful as well. And lastly, with thinking about patients would have diarrhea. Uh, well, it's impossible, um, infections around the bowel doing Ah, um, uh, culture of that would be helpful as well. Extendable X ray ECD is the e and X for special text on special image things. The next thing we gotta do is to make a diagnosis following your emitting and your examination. And in most times where there is a district cation, the the most important principle is to perform a reduction and to stable access, which we'll talk later on. And then you would usually in for that arrested a multidisciplinary team to either conservatively treat this patient. I'm using analgesia, settling them to fracture clinics, making sure that they have the appropriate medications that they need. Or you get them the theater in which, uh, we will be going through a lot today about when you think people theater as well. So how do you stabilize? Join? This is a common picture. You will see if it's actually if you have been doing from a lot of headaches recently. So starting from here, we've got cast the two main, uh, material that they use either a fiberglass, other glass pipe or ah, a scar that is made up of gypsum for cement. On the main importance is the difference between a cast which fully covers the circumference off a limb. Uh, in regards to when you're applying, um, versus a back slab, which is where you only cover three quarters off. There's a conference of the liver, and this is simply to allow for swelling to happen in order to prevent compartment syndrome. And in order to prevent the swelling to cause more harm to the patient in itself. Collar and coffee used the mobilize and elevate the limb soft collars and aspirin collars. You used them for cervical fractures or dislocation. Air cast boot is quite self explanatory. If you got ankle fractures a sling, it's well you normally use the mobile Mobile in the shoulder is well and attractions spent. Whenever you have an open injury or a neck of femur fracture on the future of spent just quite specific to escape for tractors, we'll touch up on all of these things. Run. So, uh, to get things going, we got several scenarios. This is the first scenario is about open fracture. So you're called to any to see a 32 year old male. That's a part of a trauma call. He has been hit by. A car was walking across the road. The STD Teresa is right that would live. He's conscious on talking about God when he arrived, but when he arrived, his leg looks like this. So the first thing that you're going to think about is how would you manage his liver injury? What we're going to do So, um, the next slide will compose a lot of pictures, so produce a few visual Leninist dismounted. Stick more rather than listing out what what to do. So the first step to to manage any kind of scenarios. Trauma scenarios, despite quoting some general principle. So you would always take things like I would manage distractions in appropriate resuscitation area by using the 80 at best guidance that's advanced from a life support by using an eighth through the approach is stable, patient and insured it a hemodynamically stable. Then there were more rural orthopedically. Relevant thing comes in when you're checking for bleeding. So the first step here is the check for any occult or for catastrophic hammers just ongoing from the liver itself. Obviously, it does have a rich the only way to stop it. It's to apply pressure, but sometimes you can put a tourniquet above the limbus. Well, I guess what this picture is This is a picture of somebody holding, um, someone's risk to check for a pulse. Therefore, this is a sex for neurovascular stability. That's why I said earlier, and this differ from obviously one lived to another on how you would elicit that as well. Um, this next picture is the stabilize or to split any other open injury. See if there's an obvious fracture. Like what you can see here, Um, putting in a splint on making sure that you put the protective cover on top of it to prevent any further. The contamination is important. Medical photography then gets involved. You want to make sure that you take a picture as an orthopedics. You always come into this big meeting in the morning present. Your case is and say this is what I've seen. This is the initial picture. And when you apply the splint or you perform a reduction, this is the picture of the X ray. After I've done my reduction as well. On this picture correlates the IV antibiotics Whenever there's an open fracture, there is a track that opens from the skin to, uh to the actual well, the insides of off a bone and joint. So there there will be a great potential for infection. So prompt IV antibiotics and the techs in his job will be important for this as well. Then you get the next Ray you always do an AP in a lateral x ray off that joint on the joint above and below. On all of this, you can access by having a look at the British orthopedic associative or the British surgeries in a plastic record structure on death, attic surgeons guidelines and managing open fractures. There is a classification Portis, but for medical students purposes, you don't need to know this so far. So just a recap. This is what you need to do when you're reading unopen fracture. If we're happy and there's no question in the chance which there's no questions, we're going to move on to scenario number two. So I will leave. You got to read the scenario the OSTEO bi team will release a poll on. Then we will stop the time when we roughly know that most people have an answer. Okay, One person demonstrated. Okay, We got a mixed responses now, but one common answer or addressed 15 more seconds. Got just under 50 review answering. So, just under a quarter of you do not worry. This is know on examination, not getting much. We don't know who you are. You know who have you with big? Which answer? So they're destroying on, sir and see if we can get if you can get the correct. That's it. Okay, so and this is the result that you put in. Most people said, be so, uh, which is the correct answer? This is a classical example of compartment syndrome. How do we know that this is the compartment syndrome? It's a young gentleman who had a fracture on his lower limb is have increasing amount. He's been asking for increasing amount of pain relief because of pain. Is complaining of severe pain in his He can't straight leg raise a well. The leg is swollen and wrist pain and passive movements. This is the classical description off someone who's having Compartment syndrome, and this is actually that indicate and indicates that that if we don't do anything, today is the Rubies ischemia and soon it will be reversed somewhat, much as well reduced sensation to touch. This is, as a result, off nerve compression as a result of the build up, but you can still have a pulse. We just apparent in the States, so treatment Talk about syndrome. Urgent Fasciotomy Option C is actually the answer. If the question would have asked you what would be your more the most immediate management Be so then you would give analgesia, and you would use in the split. Sometimes compartment syndrome could be called by, ah, split. That's that's fine. So what it is, um, it's an increasing pressure within a confined compartment space to definitely be a factor. Swelling will build up on before example in the lower limit of four compartments, and these compartments are basically, um, hold on together by fascia. Therefore, the swelling the swelling won't be able to go anywhere or move out, and therefore, as a result of this increased pressure will be the reversible damages. The muscles and your vascular structures causes trauma. Crushed burns Tradjenta. If you put in your cast in slips through tightly back on, course this swelling to not be able to go anywhere else. Um, IV fluid. Um, problems. If you don't candidate people properly, the nurses run IV fluid. I mean this quite rare, but you know it's there. Um, so the history of the pain that it's other proportion to the clinical situation you would normally have a patient who's screaming in pain, who's had lots of lots of your, um, more Tramadol, but it's not cutting it. It's all so you have to think about apartment syndrome. In that case, on examination, you have pain with passive stretching of the muscles. What does that mean? That means if I'm passively stretching the muscles like this, um, paid the pressure to be screaming in pain. On you have the classical five piece that you see in export pain parasthesia paralysis pallor on bail NoSalt the lymph itself. It is a clinical diagnosis on some textbooks mentioned intercom pound, mental pressure monitor. But this is only normally use in a patient who's had a higher body trauma. Who is low D. C. S is not kind of awake to say that I've got pain in my leg, but you are suspecting compartment syndrome, the legs actually quite swollen. Therefore, rather than doing a fasting after, maybe just just this will cut it open. You want to check first if this is actually compartment syndrome or not, um, do a blood ck creating kindnesses Well, to make sure that you're not missing a rough time, I'll assist and treated by keeping the limited neutral level. Give him fluids, removing your dressing on performed urgent faster after, based on then monitoring the kidney function. Okay, any questions at all? Um, would, you know, want to take the splint after 12 fasciotomy? I believe I've asked. I've answered that question is your, um that's basically that will be the first step to do. But in someone who's had one who has had a confirmed compartment syndrome, you want to perform that faster? Me without delay. Well, an incision should be made. Um ah is not the answer that a medical student be expected to know, But basically, you would open up all the four compartments in the lower limbs pressure. And I have an idea, I don't know, but it's basically you will be opening all the four compartments and releasing the fashion to allow this to go through moving on the second business osteomyelitis. So we're talking about ultimately emergency here. Osteomyelitis is basically a bone infection. It can be acute. It can be chronic. It affects the lower limb. So now we think we're thinking okay now ought to be the emergencies mostly happen to be in the lower limb. Um, and it happens also invertebrate in adults and also in in pediatric long bones as well. When you're dealing with Children, what what would be the history? So patients present with bone pain and they would have features of systemic infections that would be things like fever, tachycardia, hypertension on do. Sometimes you give him fluids, and then oh, you have been responding to it. How does it normally spread? 1 95% spreads by him. It's by blood. If they've got sepsis anywhere else that can that can spread to the bone on. The rest would normally spread it from a local infections. This is a boil or abscesses, that it's just being left there. Or it could always be a Tradjenta whenever you have an open wound or surgery as well on for the sake of exams. Staph aureus to be a most common suspect and see this is skin Promensil on. But if it's spread through, then you can easily cause off to my Lexus. All of these other ones are extras. Pseudomonas would be your, um ah, bug of choice of the patient has this and I video and also salmonella. If the patient has sickle cell, well, investigations wise acid, as with anyone else was going infection. Their blood Smith show that they've got a race. What's our count rate? CRP ray CSR of positive blood cultures on. You can prove this in the bone biopsy in culture, which is quite a late investigation. You don't want to be waiting, but if you want to treat the patient straight away, uh, by giving IV antibiotics, you what you would want to do an X ray, which which will steal haziness around the bone as well on do you can also see loss of density on some for me is basically infection will break bone and your body will try to make new bone as well. So as a result, you may have this food. Things called sequestrum involve a cream, which is basically one of them is a is a broken bone product, and the other one is a newly reformed bone that could harbor infection as well. A day under the day. Always refer to orthopedics. Anyone who suspected osteomyelitis today with the determine who gets the surgical department, Um when, uh, when indicated as well risk factors for osteomyelitis, one that is basically things that would predispose you to having an infection in first place. It's like diabetes. If you're a fast your path. If the infection it's even know suppressed on the steroids, they have got sickle cell disease. If they have a tendency to take intravenous drugs or drink lots of alcohol's on. But if they have open fractures as well, Okay, that's all. Orthopedic. Emergency kind of the way. That's one thing out of the way. We're moving on to upper lip. No, it should be much more easy to think about. Um, so we're going to start if it's shoulder trauma. So they're made four main problems with the shoulder that you can think of. If you if you think of a skeleton, we can have problems with the with the shoulder joint and the clavicle you could have problems with, um, the soft tissues and muscles. Uh, that is the rotator cuff. You can have a problem with the humerus on. Do you can dislocate this Children as well. So, uh, this is another scenario, which is a basketball injury. I'm a basketball player, so I love basketball injury. So have a good by SPF. Okay, keep going. I've only got 25 30 people answering. Yeah, That's it. Deep going. Five more seconds for three to one. Okay, we're close to full now. All right. Okay. So most of you again answered it correctly on Syria Shoulder sedation. So this is a 34 year old chap was had was basically been blocked. So this is this guy. This the rest of the Westbrook? It's been, uh, been blocked by another of his bigger mates. Actually can see this normally happens either. If you have injury when your when your shoulders and a deduction, it's an extension on. But it's basically, uh, if you have, if you have a trauma from from the end of the hand or if you've been tackled, uh, say, for example, when you're playing rugby from behind. So what normally happens is that your arm will be stuck in a deduction on external rotation, and it would be pain all over because the joint it's not it's not in the right place, basically so a little bit on shoulder dislocation. There are only two place where you can dislocate your shoulder. One is in the glenohumeral joint, which is basically the shoulder joint or the acromioclavicular joint, which is the chromium on, but ah, acromion off the scapular and the clavicle. So that is only fraction, and it is only difficult in 12. So the cases that don't worry about that amongst us glenohumeral joint dislocation, the most common type is a bacteria district, a dislocation to 95%. Before we talked about what happened. And the problem with this is that once you have an anterior showed investigation, this tends to be recurrent. Why? Because the muscles and the tendons and the ligaments around the area becomes what weekend and what What happens next is that if you have recurrent shoulder dislocation, you're more prone to have beast to lesions called Bank are legions and he'll sex defense. So, um, basically, what what these two leaders are, um, bankcard lesion is the fracture. So I I think the best you break the bank, so back out lesion is a fracture off the glenoid Lapril complex. So basically, the stock, it, uh so specifically the an interior inferior part of the earlier retinoid label complex as a result, off repetitive dislodgement of this humeral head. So when was hail Sex defect is, um, a posterior superior fracture on the humeral head as a result of the same thing. Basically, the way I remember it is your X ray would look like this. That shows that your humeral head would be an Syria and inferior leads displaced with regards to everything else. Therefore, back at leisure anterior inferior fracture off the glenoid labrum. So it's the fracture is on is actually on the rib rather than the ball on Hill Sachs defect is under completely opposite side posterior superior aspect of that. Okay, um, moving on posterior superior and inferior joined. This location is quite a rare, but these are some signs that you can see lightbulb sign on, do a picture of inferior shoulders like Jessica's it easy one. You always have to do the same thing. Do an X ray of the AP and last review and check the neurovascular stability before and after you do a reduction. All of these shoulders needs to be reduced back in place. They can't be sent home unless they've all been reduced satisfactorily. Give them analgesia, put the ministering and send them to a fracture clinic or virtual practically nil as it's covered. It a student you're happy with. That is in the right place, moving on to Clavicular and shoulder fracture clavicle fracture. Particular fractures one of the easiest to manage. It normally happens right in the middle of the clavicle. There is a classification system called almonds. All one type one is normally where it happens. Just like this picture, you would normally diagnose it by having a field, um, around the classical, for anything or any obvious signs. There's one sign that you need to pick up is when the skin is looking like it's bunching up. So we call that skin painting, and normally what happens is that there will be some more direct damage as a result of this pokey bones that's just protruding through some part of the skin. Or if you haven't got any, uh, near a vascular status, then then you would, uh, that would be an indication to bring them to the attorney as well. Moving onto shoulder fracture. This normally happens in the proximal humerus, following what we call a foot, so that before, on to an outstretched hand way, we'll go through all of that later on. But mostly you get a neck X ray. You prove that there's a fracture which is just no dislocation it all. And you give them analgesia, conservative treatment, putting the ministering, and you send them back into virtual fracture clinic. So a bit of a knack to be off the humeral fracture. The two things that you need to know is the anatomical neck, which is quite close to the ball itself and the surgical neck, which was quite lower down. Anatomical neck fractures quite rare. How do you fracture? How did you fracture part of your bone here? It's quite difficult right to death for in Israel. But if that if it did happen and it is displaced by more than one centimeter, you risk avascular necrosis to the humeral head. So basically, any joints that has a head, a ball ahead and socket joint such a humorous that if they hit a view fractured near the neck off the head off the humerus or the fever itself, you are putting a patient at risk off a vascular necrosis because it had been off how the blood supply is, uh, it's applied there. So surgical neck fractures are usually associated with axillary nerve injury. So, um, exhilarating injury. You can also pick up from the previous lights that we have mentioned so in. And Syria when a funeral joint desiccation could cause an excellent injury. So the exhibited nerve supplies the deltoid. Therefore, you're you will have some difficulties in a be adopting your shoulder and you have loss of sensation over the regimental badge areas. So that's basically where people in the army is used to wear the regimental patch, which is just basically by that on. If you have an impacted surgical next, you treat them with a collar and cuff for three weeks again conservative on, do you send them for physical therapy? So generally, approximately humeral fracture is treated conservatively. Unless you've got significant displacement on X ray at which you'll always speak to orthopedics. Anyway, on this may require on open reduction, internal fixation already use of I am device. All right. So moving on to shoulders now you're non traumatic. Uh, shoulder injuries. We've got the next scenario. Can we after the SBA Up the pole up, please. Okay. 15 seconds left. Okay, five seconds for that. Okay. Right. So, for the first time, both of you got the answer raw. Most of you went for rotator. cuff tear, which is quite common, but the actual accelerated several chromium in binge mint. So well, let let's let's go through this question. So we've got a swimmer who has presented with left sided shoulder pain, which has worsened over the last three months, So it's been going on for a while. She describes experiencing pain, particularly when swimming front or back. Cross basically what it's doing in the picture doing that, but not during breast stroke, that's all. She cannot lie on the affected side and, you know, part patient, you know, pain on shoulder, a deduction from 90 degrees to 120 degrees of activity movement. But there's no pain in population, so the answer is some acromial impingement on. But we'll go through the before different types off, um, of the injuries to the shoulder when, as we go through. So rotator capital, a gene, therefore main spectrums off the disease that basically started off with initially seven from me and impingement. So some acromial impingement is an early early sign or pathology that could eventually lead to either Casodex and the nicest or a tactic of tear rotator cuff tear is your worst nightmare. So it's basically when the tendon of your rotator cuffs get torn. Therefore, you've got no muscle movement, that's all. You can't really a pdf the around it all. So that's your rotator cuff week. The rotator cuff tears if you go muscle weakness and wasting, as there is initially no movement of that muscle talk present from 0 to 15 degrees. And why is that? Because you're a tasting of muscles, which is the six muscle supraspinatus infraspinatus terrorist minor in substance. Larry's The Supraspinatus is the is the main rototeq muscle, which a beat up the arm. So basically lift the arm up for the 1st 15 degrees. So if you've got a rotator cuff tear, your supraspinatus does that work? Therefore, you can't Maybe Dr you're on a subacromion impingement. However, on sometimes in the literature is no explained really well, some across me an impingement off what? So it is the subcranial impingement off the supraspinatus tender. So what will happen is, um, as the name says, the Supraspinatus tendons is basically getting squished. True is getting compressed. A subacromial space I did by osteoarthritis is, or by narrowing of the gap that has happened a series of, um ah calcific deposit, or just simply a knack to be on his own. So what happens is that the tendon moves ask you a beat up your arm as the muscle lengthens and Children's, the tendon basically bulls from down to up. And what happens is as it goes through that compression space, which is normally through a painful arc of a deduction between 60 degrees to 120 degrees, you can feel it on your on your shoulder. Actually, you patient would normally complain of pain as a result of impingement is well cast perfect tendonitis. On the other hand, what what distinguishes it between the tear and a subacromion impingement is that there is extreme pain on part patient because you have you have calcification all the way through there for when you're part waiting. The joint area you were inflict pain to the patient and lastly, there asked in Brooklyn because I've dropped. It is well so you can have gout. You can have student got to do your shoulder, but that's normally diagnosis by a joint aspiration and microscopy as well, so acid with any kind of automatically injuries you would want to exclude a fracture by doing a doing an X ray, and then asked were talking about soft tissue injuries. We would want to do an MRI scan or an ultrasound scan in the hand of a competent, uh, right. The Aquaphor and most of these are treated conservatively, however, surgical treatments, which is them at risk? Optically, it's available if it's not responding to pain relief and conservative, my friend. So, um, for shoulder pathologies, If you guys don't take anything home, it's all this slide is most important thing. If you want to know which shoulder pathology is have happened, all you have to do is examine the shoulder joint on. Ask the patient to a beat up the shoulder. If you've got weakness on the patient kind of live. There are from 0 to 15. That basically tells me that the super Spanish isn't working. Therefore, the pictures got a rotator cuff tear. If they've got a partial tear, they may have some, uh, uh, power there. But when you do pass it movements and let it go, they may or may not be able to hold it there as well. If you go a painful are between 60 and 1 20 degrees. Like we said, when when the swimmer does, it's, um um front and back cross that is subacromial basement, which is here, Uh, but if you've got no specific pain, it's all but the patient has just extremely tender all the way around. Then you can think about Costa Big tendonitis or arthropathy. Um, are we? Are we happy with with everything If you got to have any questions, problem in itself. Moving on there is an African groups. There's another condition called invasive Capsule. Like this, this is more well known as frozen shoulder. Uh, what it is is basically the shoulder joint. That's that's, you know, um so keep pressing the the most that's basically frozen. It's the glenohumeral joint that is that the here into the humeral head, which could be bilateral in both cases. And this is normally affects middle aged female who is diabetic. So if you think about your Goldstone's, it affect people of feeding male who are fast in their forties with diabetes who could be pregnant. This is one of those diseases that effects them is well and normally what happens is basis will present with big shoulder pain. They will have stiffness on restriction of movements, especially when did they doing external rotation to that patient would normally complain of. I can't sign my hair. I can't move my arms out. And that would have been the classical symptoms from the capsule like this. It is a clinical diagnosis, but the symptoms. If the symptoms are a difficult you would want to request an MRI. It is it's self limited condition. You typically treat the picture by using conservative for medical management by using the therapy and said, or all steroids intraarticular steroids on only only very rarely, patients would need surgery or if they want to do it privately. So that's the shoulder done. We're moving on into, um uh, the arm and the upper arm and the elbow fractures, including the what happens in peace fractures as well. So there's another SBA here now. This time is an elbow pain. So can we have the SBA pull up, please? Okay. 10 more seconds. It is a bit of a long winded experience. Five seconds. Okay. How close it all. Now, um, we just, uh 32% and so see the answer is see so well, don't produce of you who to see which will see basically what it is, is someone's been painting a lot and they're tender across a lateral, bony prominence of the elbow and has pain when you assess to see 6 57. Never, Um, he then complaints of pain on the GI people form. Ah, particular movement. So initially, what's the diagnosis? Diagnosis in here would be lateral epicondyle, lightest, as as it is 10 minutes across the lateral bony prominence. Um, and this is basically asking you what kinds of, ah muscle movements that the common extensive tendon provides because the lateral epicondyle axis on its own. It's basically, um, Mike Rowe tests in Common Extent attendant following a repetitive injury to this normally happened in anyone who requested we do who do this kind of movements basically idea if you are Ah, um, tennis player. If you're a painter, if you do lots of weight lifting, it can affect this really anyone. So the last relapse condyle of the elbow is where these common, except attendants attach is to. Therefore, if you have happy Condylox, it's over there. You will have problems with all the muscle functions that affect your extension. So disagrees wrist extension, and whenever there's extension, Super Nation would follow a swell. So what happens is when you're testing the patient for this condition, you would normally ask them to extend their risk against resistance and see if they can do that. So and if they again can't supinated, then that would imply there's inflammation or microgestin common extensive tendon, is it? It's more common than the medial epicondyle active, which is basically the other side golfers elbow. It is a clinical diagnosis, you know, only having a normal X ray, and you don't need an MRI for this because all you will see it's just inflammation around the joint area. The pain is actually quite a long lasting. It is typically a chronic pain that lasts for weeks and weeks. It can go up to two years, but that's with anything else. You're always treat things conservatively. First, algesia physical therapy started injection, which in most of the cases would send your patient home happy, but in some very small proportions. Sometimes they would need a debridement of that tendinosis and release of any damage structure. It's all so moving on it too. It's, um ah, sibling. We've got medial epicondyle Actis, which is the golfers elbow. So it's basically, um, the same thing is micro test in a common flexor tendon that this time following repetitive injury. So if I ask you which movements would it affect then? If you've got medial epicondyle lightest, it's basically the complete opposite of your lateral epicondyle active. So that would be a reflection on pronation because the other one is extension on Super Nation. Sometimes you can have nerve damage as the old in the past is true near the medial epicondyle on What will happen is have you ever told enough damage your clothes on Onda treatment is exactly the same thing for the purposes of osteo and exams. If you want to remember which one is which medial epicondyle a goal for last relapse Condo uh, 10. It's so the way I remember it is by looking at the picture looking a this picture. If you play tennis, you do a backhand. Whenever you're doing a backhand, the first thing you see is a lateral epicondyle. Uh, whereas if you're playing gold, you're doing that the first thing you see is a medial epicondyle. I know, I know. It's a bit, um, you know, different with all the time, but it works for me. Okay? Maybe it may work for you. Okay, we're moving on to PT. Actually. Elbow injuries on what makes pediatric injuries different from adults. Well, two things, really. Children's got growth plates. Therefore, it introduced a new complete system off fracture classifications called saw after Harris to their five different types of fracture. That correlates to where I defy seas or the growth plates is so you got type one which is straight across there to a for above about three l or lower or below and type forest through or type Fife issue when you have a crush. Injury onto that growth face was just the worst possibility ever. And what else is different? Children's got strong periosteum. Therefore, when they break the bone, the bone doesn't actually break completely. You don't see the bones is completely shattered and awfully desiccated. I mean, you may do, but no, no, in most cases, well, you might see instead are these things that we call greenstick and buckle fracture with what we call plastic d formacion as well, so whenever the bone breaks, when it whenever this excessive, um, force and strengthen the bone. But because the Children's has got strong periosteum, destruction of bone basically causes a deformity. I eat the bone dispense rather than getting completely snapped off on broken. A greenstick fracture refers to a bent bone with incomplete fracture like and so what? I'm trying to say that we only have the one sided cortical breach, so breathe in here, but it doesn't go fully across to the other side. So you've got an incomplete tractor life. It is much more unstable, with a higher risk of re fracture. Therefore, you would want to immobilize any questions who's had this type of fracture and always refers to, you know, basically treat them as if they've had a proper full on tractor as they can easily Refresher Buckle fracture, on the other hand, is more of a compression injury where there is periosteal hemotomas. So therefore, what happens is the uh, the two ends of the bone would just buckle up together on because ing ah, lot of tenderness along the area as well. So instead of putting them into a full on cast immobilization. You would just split this injury and give the patient analgesia. Okay, Uh, moving on the two pediatric elbow pain, we have got another another SPH. We do. I will speed up in the in the interest of time. So if you guys go on idea of what's happening probably answers in whilst you guys are doing the SP, there's a question of keep pressing attack. Should steroid injections be keeping freely or is there a maximum number per year that one should be done? Usually you don't give statin injections like every every other week or stuff, just the just the result Pain. A steroid injections do come with its own disadvantages as well. So therefore, you would give their a dejection assess for pain wait for a couple of weeks of six weeks to a couple of months on. But if the pain is the president, you need to reconsider what a patient would need to do anything else. Oh, you did point. Uh huh. Okay, so, um, most of you answered for B, which is Radiohead Subluxation, Actually, the answer is super condo or fracture. They are quite similar on Do we? Is why we will talk through this in a moment. So this is a kid who has basically stopped using his right hand after having a fall into an outstretched hand. His right elbow is stuck infection, and he can't bend this thumb and index finger. So what happened here is that the the branch of the median nerve and Syria interosseous nervous been affected. So this these are the two common pediatric elbow injuries that correlates a trauma because I don't have a super condo, a fracture, which is which is, which is much more common in the news that if you've got, um, example reparations interviews, people are much more familiar with Super Condo. The fracture. Why is because the most common elbow fracture and Children it's it is an extra articular fracture. So what I normally have what normally happens is that you would have a fracture along the joint line. But in this case, you have a fracture dysplasia. We above the lateral and the media likely conduct a switch. This red line is showing you normally have elbow pain with limited range of movements. The elbow would be stuck in flexion. Asked where that's when you, uh when you do the structure. Some of the, uh attachment of muscles and tendons would know. Allow three elbow to be complete to be to move to be moved in to extension, so your risk there is a risk of damaging the answer instructions service, I said earlier on Break Your Last three, which is why this is much more important than a radial head subluxation a Radiohead supposition. On the other hand, it's basically when the radial head just sub locks, it just gets out of places because basically dislocated, Um, the symptoms of new patient will tell is usually they're they're able to do all kinds of movements except soup in a shin. And guess why? If you have some blocks, the radial head, most of the tendons off the common extensor muscles that we talked about earlier that would allow the picture too super neat will not be able to work properly as they've got no place for the muscle bellies to wrecks them to hook onto. Therefore, you would need to reduce this by performing a hyper pronation, whilst the elbows and breakfast flexion have not done this before, pressures and lots of this before. So if you're interested in the details from go drop attacks. Okay, Moving on to on the pond in Ms Fractious, the visa Still Elavil fractures, we said a common exam types fracture that you will come across. So we got Mantega versus galaxy, um, galaxy effects all the Children and then tell your affects younger Children. So what happens is Mantega. It's ah, fracture off the proximal. Um, whereas to get where this galaxy is some fracture of the distal part of the arm. Um, the way I remember it this by thinking off Manchester United. So my test the united, um you wanted year older that therefore the fracture is in the older boat on, but there is a dislocation of the radial head, so the radial head would just basically be dislocated on. Do you have a break on the on the older bone as well? So what happens is normally they would Children would fall on an outstretched hand while they're in hyper pronation. And so basically, for like that on an extended elbow, and they would have a much age of fracture. On the other hand, l e active fracture would be ah, fracture off the radius, which is quite distal. So it's a fracture. A radial chef with associated dislocation off the distal radio owner joint. So you're, um, it's basically one opposite of the other one board. It's fracture one, but it's dislocated and vice versa. All of this should be treated with, um, ah ah from reduction under, uh, onder general anesthesia. Usually because these Children, no matter what you do the try and reduce this in any you will, you will not succeed, which is why the treatment will be manipulation under anesthesia, followed by unopened reduction, internal fixation and words of warning. Whenever you're dealing with any pediatric fractures, especially the got multiple fractures and they're if they're less than two years old, you should suspect a non accidental injury. So do a skeletal survey part paid. All the bony prominences have a check to the parents have a chance of it to the kids. If you have any suspicion, that's all. You can involve the safeguarding officer or contact your CVS before you move on forward. This is a less stuff stuffed. It would raise your suspicions off a nonaccidental Really? Okay, last bit of Upper Live, which is trauma to the rest of the hand. This is all of your food issue. Fall into an outstretched hand. We have a scenario if somebody falls onto a pronated arm. Endorse, deflection. So what happens is you? This person will come to you in any way that hand would look like that. Can I convince you that it looks like a dinner for, um if you say Yeah. Okay, mister, uh, what was the next step doing? X ray. Then we're going to do an X ray. We've got a next ray off the, um, the wrist here and any one spot the fracture? Yeah, it's quite easy. The fracture is in the distal radius. It's a displaced. Well, we're gonna find out by using it by getting the lateral aspect off. Ah, off the x ray as well. So how I would describe this is it's an extra articular fracture as it doesn't involve the joint off the distal radius. With the displacement, you can see it's it's looking this place already, but you need a lateral view. Then we get a lateral view. Then you can see that this proximal part it's been broken and it's bent over towards the polymer side. Or as ought to be, the PX. I just like to call it the the Volar side, but when you're describing displacement, you always refer to the distal edge of the bone. So this is the proximal edge. This is the discipline. So if the proximal and it's pointing towards the polymer side or the volar side, you describe this as a dorsal, explains mint. So the lateral view confirms dorsal displacement of the distal radius, and therefore, this is what we call her colleagues fracture. But this is one out of four of the common distal radio fractures moving on. This is your next station. They fall into a flex wrist or possibly had a blow to the back of the wrist where they're playing rugby. Oh, I had a fight on dumb. Their arms looks like this at the moment. So can I. Couldn't convince you that this looks like a garden spade, and then if I manage to do that, you don't ask me what what we're going to do next. We're going to get some images, and we're going to see and describe this image. Is it extra articular or in traffic that it's extra articular because outside the joint what which bonus affected is a distant radius? It's a displaced. Yeah, Looking about this place where you don't know Let's do a lateral view as well. So you can see here that the distal radius is this place on. But this is basically a reverse collie structure where the proximal segment has gone dorsally. Therefore, you describe it as a volar displacement because you're always referring to the distal end. And this is what they call the Smiths fracture. This is a practice over two out of four. The next bit exactly the same thing. But somebody has a foolish you do a scan. This is intraarticular this time. Because if I can convince you on this, Rector has gone all the way there across on it involves the joints. There is a break into the joint. Um, we don't know if there's a displacement. Therefore, you need a lateral view. This is the last review. And can I can I convince you that all of this is, um, is old displaced and it involves the carpal bones as well. So this has been this is, um, displayed dorsally on bear four. You've got a dorsal Barton's fracture. The bottom structure is basically an interactive a fracture. Where is your colleagues in Smith's are extra article of fracture, one point dorsally and one points to have all aside. And there is a door still Barton for all of older Barton's that's just basically referring to where the displacement is. So this is your distal radius fracture. Colleagues and Smiths. You got to know the Barton fracture. You haven't associated subluxation off the radio couple joint. Three things that you gotta watch out. It's the nerves always sick from your vascular stability. Take your median nerve so you're old enough and check your radio liver's Well, um, always do an X ray. Like we said, uh, treat the patient. You would resuscitate them. You would perform a manipulation or a close reduction. Put them in the below elbow back slab. Why the patient had a fracture will be lots and lots and lots of swelling. You don't want to put them in a cast, otherwise, your risk sending them with a compartment syndrome. You send them off to physiotherapy with a virtual practically nick on. But most of the expections would need surgery either by eating by doing an orange or using a cane, a wire fixation. And it This is just another week before. Okay, Almost done. Um, two more scenarios, and it will be moving onto spine. Can we get the pulse, please? Thank you. Okay. Three people seems to be jumping in six weeks off. Work stuff. Lovely. Sinister. 66 weeks off work. People have just changed their onset from C or just more people on three different. I understand. Okay, we go. 10 more seconds. Okay. I would stop that Pull. Um, congratulations. Most of you, 50% off the people who wants of the questions on study correctly, it is. See, mobilization would put your splint and repeat X rays. And based on what it is, is this is a suspected skateboard fracture. You can tell it from the story. Um, 30 year old man has a history of acromegaly that's actually a red herring, because that's a ah ah, a risk factor for something else but this space and presented with pain in the base of his thumb. So, basically around there, if you look on the other side, it's around the anatomical snap off the area. It is worse and longer to dinner compression, which just wait three months. If you pull the pump up and down as if you're, um you're trying to put in a telescope Hey, works. That's the type of stuff. We use it a lot, and he has recently returned from a drinking qualities. And what happened to drinking? Fancy people fall over, people punch each other People fallen joint outstretched hand, for example. So we are clearing a trauma. You've done an X ray. You've seen this. You're not sure if it's a fracture or not. And so what happened between the question is that, um, this is the X ray on that day. And this is the X ray from, uh, two weeks later or 10 days later. In fact, so what happens is some skateboard fractures don't show itself until a lot of swimming and things have done. And which is why the most important thing is whenever you suspect the fracture, especially a skateboard fracture, you always immobile, like to treat it as if as if it's a fracture and get a repeat X ray for them to skateboard fracture. Like I said earlier, sending this in the anatomical snuffbox. Which is there pain and escape for a Jew pickle? Uh, when you're about hating it or when you're telescoping the thumb, why is it problematic? Because the blood supply, which is a dose of granted the radio after a supplies the skateboard in a retrograde fashion that therefore is entering the district whole first and then going to the proximal pole. So it's basically goes instead of your normal arteries. It goes that way. This one cursed down like that on goes back up. So what happens is, the more proximal of the fracture is the higher the risk off a vascular necrosis off this, um, it's a color. Have bone. So what do you want to do to prevent that? Always do an X ray skateboard Siris this time was three views AP lateral and obliques, and you want to immobilize most of your patients who come in with a suspected skateboard fracture. This is not very bad. You put them in the future of split. That's one of the nicer looking, uh um, splint that you see in the in the initial pictures on you would always want to repeat X ray to make sure that you're not missing. Um Ah. Test. You're not missing a fact for his lab. Always do an emery. Uh, if you're suspecting a fracture, but it's not, but it's not clinically resolved. Depictions got pain. X ray is clear 10 days later. It's still clear that, you know probably do. Um all right, so when would you operate in this case? Basically, whenever you have a displaced fracture or if you have a proximal paul fracture, which happens in 20% of the case, you normally treat surgically would open reduction internal fixation by using a couple of screws. Then comes couple tunnel syndrome. What it is is quite a commonly known in medical school. It's a compression of median there for a couple. The causes of this is a pneumonic loperamide. I happen to be, uh, looking along. The cause is and came up with this, uh, a couple of the esco local extrinsic pressure. Such a ganglion. The pole lipomas hemotomas, of course, that offer obesity people pregnancy be for endocrine symptoms, have people with hypothyroidism. Ikram, actually, from the previous question are a for rheumatoid arthritis have in for your mechanical fracture. Your foot. Um, I for idiopathic. Anything could happen just randomly out of the blue and the diabetes. Um, the classical thing would be pain along the distribution of the median nerve, which is just basically across the ah lateral part of the hand, affecting your big time in the 1st 1.5 fingers. This is normally worse at night and you've got weakness off. Um, a reduction. And you have wasting of the femur evidence as well. The person you need to know is 15 steps, which is you're tapping along. The distribution of the median nerve would cause pain on the Fallon's best, which is wouldn't also called a reverse spray of science, which we call, which will stretch the median nerve and course pain as well. There are a couple of different diagnosis here that you can have like a give free time. But the treatment for this is mostly conservative. By splitting the rest of night are giving them joint injections, visit therapies, or sometimes if it doesn't work, you can do a surgical decompression of this Ah, factual compartment as well. Okay, but this is the last slide of the upper limit their policies. This this all the different fractures that you can see and think off on gets subsequent neurovascular injury that you can have. So if you have a surgical next act of the humerus, you can tell the the regimental badge area could be affected. Or, if you have exhilarating nerve damage is a result of this. You can have waiting on the deltoid process. Humorous. We've mentioned about wrist drop median nerve. If you have a super condo, the fracture you can have wasting of the answer your forearm and you can have handled valediction where it's old enough problems, fractures you can have a low hand is well, but have a look at this on your free time and try and try and make sense of it based on being that Okay, we don't further ado. I would probably get bored of me. Now I'll pass it on to pressure and we'll be doing some spine. Good evening, everyone. I hope you guys have enjoyed decision so far on depression. Go by one of the critical clinical fellows that more so hospital looking in that you know on I don't want to much waste much time in the same direction and things so far. So I go to the spines. No. So coming to the spinal are to me. So we need to know more about the Lyrica lumbar region because these are the most common. But this which accounts the emergency department so far that we need to know the basic anatomy of the Focalin by region. We just buy this slight, which shows the sagittal section cross section off the Ross. It's fine where in the anterior and posterior of you can be seen from under there because she really could see that is a ligament disconnection called on did a longer ligament chance on the anterior off anterior part of the natural body on. Well, the longer the ligament, which runs on the posterior part of the vertebral body. And there is something called us Interminable disc, which state places and connect between the two and everybody's just for acting like a cushion, uh, which composed off. Unless fibrosis, which is in the periphery coming behind the policy London ligament that is a vegetable cannot. It's the space for a spinal card just posterior due. This is, uh, it kind of structure just called us ligament on flavor. You need to remember this because this is the sexual which needs to be punctured while doing ah lumbar puncture A lumbar puncture on becoming partially You have, ah spinous process. We're just gonna get the I'm going below by super spinous ligament on boost. It really we have in the spine. It's ligaments. So the sexual which needs to be remembered. It's a ligament off label because this is where you need a lumbar puncture. And the thing has been, you do a spinal anesthesia, for example, epidural anesthesia. We will give anesthetic medications exactly on the urine matter, which is just in friend off ligamentum flavum. So you'll have a spinal got here, which is governed by doing on the prospect. And it just in front of that is just after the ligamentum flavum will give the spinal anesthetic medication or the so try to remember this too well, more in the next life. Yeah, so this is ah, being you can take off of the Internet. It's against to read and okay, so sorry to disturb. But while you guys are reading the question, we just have a quick, um, sort of evaluated thing that we're doing a spot off this seriously itself. We want to see whether this sort of collaboration is actually working. Um, we'd really, really love to hear your feedback on the session. And the seriousness have been always going, and whether you've enjoyed it or no, uh, Andrew's just put it in a swell. Another link that I've said is if you guys haven't opinion on the sort of discrimination that be medical students, junior doctor Scola surgeons feel in the in the workplace. It's a study that national surgical teaching society are doing, and I was asked to promote it here a swell. So if you guys can just a few minutes, we'd be incredibly grateful for that. Um, and the yeah, the feedback from will just be sent by Andrew in in a minute. Thanks for showing you can carry. I think we can close the ball now. I could see that there is a bit of confusion between a option and B because I had the, uh before when I before, like after finishing my medical school. So the thing is it you can go to the next life company, so yeah, so the interest be just alarming A. Which is the only connection between the transverse process on the spinous process On the medical is the ligament. Sorry, the bone in connection, which connects the transit process on the vertebral body. This usually gets confused. This is where people to ask you for stabilization in the medical on the laminas that we need to access. By cutting through the lamina, we'll access the best the fraternities, which comes through on pressing on the spinal cord. Well, access that this prolapse by cutting on the lamina, and we'll access the fracture by step rating by putting a screw on the critical. This is what you need to know. Next light, please. So how you known that anteromedial go through the neurological examination, so I would just like because I'm not going to deal much of the cervical pathology because that's very uncommon. So what do you usually see in the emergency department? It's a lot off emergency seen the topical, um, torticollis in spine. So for that initially, will started the past Acela, which is you try to go in from the patient that we are lifting the leg but also is, which means fancy, and we'll ask the patient reported. That is any pain in the posterior thigh, not on the back. The patient reports back pain that is false. Positive. So when that's pain or the posterior thigh, it indicates there is some despite allergy involved on. But the other thing, which you need to concentrate our minister level, at which the patient reports pain. If they put paying that less than 70 degrees, it is positive for this prolapsed. If it is more than 90 degrees more than some degrees, it's commonly due to the hip pathologies on. After doing the Sella, we need to focus on the proper for well, where there's a rating called Marci grating from 1 to 5, with one classes flickering of contraction on five being that part of it. Maximal assistance so far that we need to examine according to the levels. So L2 L3, L4, L5 and s one for that. We try to remember taking a football well, trying to get their football. We'll always try to lift your thigh first, which is a reflection eldo. And after that, he was trying to extend your knee that is empty on extended ankle that is ankle does. Infection is for great extension, which is a fight. And then you'll land the food on the floor, which is s one. So it's easy to remember trying to remember I thinking of getting a football, So l do Hip flexion Elder is me Extension forest ankle dorsiflexion L5 was great toe extension on s honest plant A friction. So after examining the power, we need to look at the sensations, which is that is a particulate area for each and every day there is in the boat is this is a picture of the friend and the fact in the friend for l to be commonly examined or the anterior aspect of time for energy at the knee and a little off me on L4. Well, examine at the level of medial malleolus for l. If I will examine that does more food on four s one we'll examine the outer border are outer aspect of the food. So I've been having a bit. The elder was on the left foot after I l trees or the knee as forests or especially over medial malleolus and favors, or the dust mite food, a soreness or the outer part off the food. So after examining the sensations, we need to focus on the reflexes by using a tendon hammer. We need to focus both on the superficial reflex, which is a plant reflex. We need to go in from the patient that we are going to scratch that out of order off the for Demery is towards the ballot. The doors. We need to, uh, look at them. It is a frax are out of the extent. And the other thing is, we need to look at the knee and the ankle reflex on. You know how to do it on. After that, we'll focus on the rectal examination, which is we need to look at the Arnold own need to know whether it has last, but that the patient is able to squeeze another thing. You need to annoys the perianal sensations, which is just around the buttock whole. We need to look at the very end of sensation on it to be. It's need to be a come back to the left on the right side, and the last thing will be the post void residual urine. We'll ask the patient oh wide, and then we need to my share using an ultrasound. If it it's more than 100 miles, then it embrace that. That is something happening in the spine, which causes the post void residual urine except the CIA. This is one of the most important lights in the spine, Uh, which is called a scar. What is God? I've been on the card. I've been asked just a bunch of nose, which starts from the lower end of the spinal cord. It's like a harsh you harshly radical of fibers. What is the importance is whenever that the car recognize him like whenever it is involved, that's more chance. The That'll be a new neurological involvement, and there's more chance the patient will not recover on, uh, biologic or from the company neurology. For that, we need to know by any money name that's fine. They ask for a saddle anesthesia, which we have examined, like compounding the very on sensation on both sides. This comes up paint. We last the patients. The pain bad is the pain. Whether it's in the back, are rather it is relating to any right on the left side on the next highest incontinence, which means both bladder and bowel incontinence on. After that, we'll examine the sensation we have examined before it becomes numbness, which always any sensation. Any problems should be compared to the other side on D E means emergency, which is the most important thing. So whenever a patient with the symptoms several anesthesia pain, incontinence, especially bladder bowel incontinence, acute onset on the patient's complaining of numbness, you need to go effort to the automatic department and and also the spines. If they are available under, it's an emergency. We need to do an Argentine compression between 20 for us. Otherwise, the patient won't recover the complete neurology. So this you need to keep in mind. Yeah, the next next light. So the next comes, uh, condition, called a spinal canal stenosis as the name in the gates, the spinal cannot and the spinal goddess mean it runs in the spinal canal. And whenever there is any of this prolapse are any do more are any surgery which causes a scar which causes a narrowing of the spinal card. On pushing on the spinal guard on gas is a compromise of that cannot. They cannot gets narrow any presses on that spinal card and also on the nose. So which accounts for the symptoms? Usually they presented low back pain and sciatica, which means the radiating pain on the pain is usually relieved on bending forward. That's the classical symptoms for spinal canal stenosis. As you can see in these pictures, the first picture on the top on the right topic bicycle test, which is when the patient bends forward on rights. A bicycle they cannot under post your diameter of the canal, usually white us so the patient will be a symptom free. Similar. Leaving the patient is, uh, doing the shopping like a running a shopping cart. Usually they're been forwards and push it because that under close your memory increased has been bending forward. That relieves the symptoms. That's a classical symptoms for this. On the any, spinal bottles even need to do an MRE to know what's the reason to evaluate whether it's a tumor or whether it's, uh, disparate up. Sorry, any of their PSA previous surgeries, So the treatment is usually will be conservative, initially on if they are civilised, dramatic. We need to go do a decompression if conservative treatment phase next time, please so far, this spinal canal stenosis. We need to know what this last lab bladder cation. What is a neurogenic claudication? So for this, this is, ah, good comparison table, which compares vascular in Urogenic. So the vascular the walking distance will usually be fixing. The patient will work for certain distance and facial and feel the pain on. If they stop, they will get it off the pain. But but neurogenic, there's usually is money for words are if they said for some time there, the pain will be really that it is on Saturday we have discussed walking uphill are the bending forward are bicycle test, which will usually be relieving for neurogenic claudication, but it will aggravate the vascular claudications on The other. Thing is, that's the name in to get it indicates, but it will be absent in vascular Find. Ended will be presented neurogenic on the last thing, which is Communist, the pain character. Usually it'll be cramping pain, especially for what's the left eye popping, and it'll start from distant approximately. But in Urogenic, it will be usually from proximal distal, and it'll be like aching pain with the numbness as well. So this you need to keep in mind with your patient reports off medication. You need to ask about that walking distance, and you need to ask them what, uh, propagates. And what makes the back pain relief on the bicycle test? Another. It's bending forwards on. The last thing is, look for the pulse and also for the car. Ask for the character of pain. Uh, next lately's So this is a scenario low back pain. I'll give 15 seconds to for you guys to read on the scenario on Answer this question. Yeah, I think from the inside would I could see that everyone have answered it, right? So the answer is, uh, IV disc herniation. So which is indicated by the alliance the patient is having a back pain. It just wasn't done. Coughing that is increasing. The abdominal pressure on the pain is relating to the post. Tia Day asked. We have examined before we have a decision before more to the next leg, please. So, having known this, we need to know what's the stage of a heavy Asian and what other symptoms. So if you could see on the right picture the first day is this big generation. And then there is something called prolapse, and then comes extrusion. But in the middle of the nucleus, Pulposus gets extraordinary. And when it's extraordinary, it gets sequestered in the Addison that is a that upper are the lower disc space, which is called a cecal station states, we just said CVS indication for surgery. So the patient will usually present with history of low back pain, a sciatica weakness on a numbness on the types are usually a central. Are Paris Enbrel depending on bad? Exactly The collapses, whether it is the central area, even though it is in there. Addition to the center of the Spiders center on the examination wise, we need to look at the Exelon and there are a few more days. Collins Last six test baron. We'll try to go when you lift your, uh, tight when you lift your leg. And if the patient reports pain on, just you need to lower it a bit. You need to lower it by 10 degrees, and then you need to Gossip likes it under stress that now, if the patient is having I read this, uh, prolapse, then it indicates patient Vincent Pain conventional report pain that indicates positive test. Another thing is, what we can do is there is something called us. The last picture shows posting sign. But if you bend the knee and the patient will the scientists that you'll be relieved on the patient will have less symptoms. So it is a positive test, which is called us both. Think this for me, this polyps. So, uh, so you will know it will be necessary. But I'm a realist. Fine lumbosacra spine. The initial treatment will be for considered by giving an incision down to 203 100 bucks if the pain is stevia. And if there's a symptomatic neurology, then we'll do our agent. A decompression biologic to be in diskectomy on the general rule, always is the no don't usually have a tennis one below the vertebral level. For example, if LDL three discussing world, the patient will have anything over damage that's the most common died. Remember this. So the next light, the that is under collision dollars. A little abscess, as the name and against the patient usually presents with a fever back pain and also weakness on the most common reasons are I be drug. Use US diabetes mellitus and give a closest on the patient's present it focal neurological symptoms. And if you could see after digging the memory, if you could see in the picture there, issues average shows that it's a collection and just need the spinal God, which is an abscess, which compresses on the spinal part and fastest in urology. So what we need to do is we need to or decompress that is the drainage and you antibiotics according to the culture and sensitivity. Yeah, next light, please. So that is almost condition called a spondylolisthesis is, which means a sleep aid off one middlebrow with the other restaurants. You do that bony connection or less passenger active bladder, which is just near the lamina. If that is division dollars for this fracture, these removed and strips or the other on the patient usually presents with low back pain, which is worse or standing on the sciatica. And the most common reasons that drama on occasionally or the foot affects on examination that would be muscle spasm bigness, occasionally numbness as well on the investigations, which you usually take X ray, and the take an X ray standing. Push in a lot of you just to see whether it is sleep or the other. It about on memory, especially to rule out if the patient reports any weakness. Usually the treatment will be non surgical by giving on a seizure under give braces if that a severe slip are. If there is a CVS, the patient that I probably need to stabilize and fuse it by screws infuse the one below it. So this is another scenario. I'll give 15 seconds for us to really answer. Yeah, I think we can stop that for now. I think that is a definition between and the can understand that most of them are brand, said he. So the answer is striped little section of spinal card just got this brown ticket syndrome, um, one of the next night speeds, so we'll discuss about the basic syndrome, parts and drugs. The first concentrate most docile, constant room, as the name indicates tarsal. It's for Syria. The find, its proper section and vibration sensation of, uh, perceive, if that is involvement of the posterior aspect. These symptoms this sensation got affected on next lately's. So in the anterior part syndrome as the name indicates the under a spinal arteries involved, which covers the entire. It took her off the spinal cord so the patient usually presents with corticospinal tract infection, which it waas that is, loss off motor, let's palaces and also with the on ball. So there is a loss of pain and temperature, which is on the contralateral side, because usually that's fine. Autonomic back crosses over and, uh, some place on the on the site. And that will be preservation of the prostate. It doesn't one of the next day, please. So the scenario is that scenario, which be argument The brown tea got syndrome. So if the guards him is like that, usually they'll the post card will be affected. This financial, um, intractable, be affected on ball so the corticospinal directly be affected. But the pain and temperature will be usually African on the other side because it process over. That's the important thing you need to Ah, concentrator. Yeah, one of the next right. Please, on central got syndrome. Just one thing you need to remember. Usually it occurs in the cervical levels on the patient will present with the infection of the pain and temperature that is on da pain in temperature. And if it is a large lesion, they are all the other car because, been, in fact, on there doesn't so usually in presents. And, uh, pollen and I fix the pain in temperature. Needed him about the central drugs into. Yeah. Next thing I think they're called the spine, it's the next topic will be make a femur fractures. I think it will. Because of my my colleague. Right. Okay, uh, back into north. I'm back again. Just, you know, basically back into another scenario. Number of 11. I can We have to pull some guys. Hello? You know, to close back up. Thank you. Okay. Okay. 10 more seconds. Okay. I was stopped before. They're fine. So most of you went for Dynamic screw. It should have said dynamic. It's true. Basically, this scenario, it's quite obvious for the x ray that displacing that sustained a femoral fracture. So this XPA or discs that prevents be a least a year of medical student. This is probably gonna show up in at least one of your exam. If you sit and asking, you probably have a neck up in my scenario, if you are a farm, basically a doctor, uh, potentially working in any in medicine, in orthopedics, you're probably going to come across enough, so this is quite important. So what it is? Uh, the answer for this is I am now, um, graduations with those two are people who answered that. So, as you can see, Mrs Jones, a six year old woman, she enjoyed sticking her grandson on long walks in the countryside and regularly test the garden. I say all this or the examiner's say all this because it's actually quite important to find out how mobile and active they are. This will come later on when we talk about the Cheech it and how to determine which one of these were gonna prescribe or get send the patient to basically knowing their mobility is an important thing to know from the history. So last night, she unfortunately tripped over a cat poor Mrs Jones, and fell into her left hip, which is broken, uh, this bone. So in order to answer this question, we're gonna we're gonna think about where the the break is and what happened. And how do we get into? I have there but let's talk about dot First of all, so the neck a femur fractures It is very common in this country s We've got an aging population. It normally happens around 100,000 gates this know annually in Morrison Hospital, sometimes on one a. Anything. If I can see five Nexium of fractures on, you can express shot even more. When you have ah, necrophilia referrals, you can have 10 in a day, Basically. Sometimes it is a condition that's inserted with high morbidity and mortality 10% in one month, so them so that people die after a month and 30% in one year. If you compare this with congestive heart failure, it's it's slightly less that that's 50% in five years. But still the problem with neck of the femur fractures is because you've got a retrograde arterial supply to the head. Exactly the same with your ah humeral head on your skateboard fracture when you have a retrograde arterial supply that goes backwards. If you're several the neck, therefore all of these blood vessels are gonna be disrupted, and you have they've asked you the necrosis of the femoral head, which we did which will then this fall, off on them, become the coast. So neck a female. Have multiple blood. Surprise If if it's an exam question, this is what you need to stay. Media families, Complex artery. These two are just some other small branches that can help. But when you have a displaced neck of the the fracture, you would you would disrupt it. Blood supply. And then you called Zetia. So the important point is, regardless of who you are, medical students foundation doctors register not a pedic or consultant in orthopedics. You will need to know the management on the end of prevention side of things as well. So whenever we look at X rays there a couple of lines that we could have look at for the sake of osteo of exams Shepherd and Slim's is what everybody knows. The basically central lines that if you draw a line across the inside off the public brim on across the side to, uh, uh, femur, you conceited and shit dislike. It should go down nicely as occur, but the crypt half a half a sphere, whereas if you have a dislocated or fractured mecca femur or a femoral fracture you were basically loose. This this'll line this side is supposed to be here so that that's the one clear indications you can describe that this is an X ray hip off. So and so there's the most obvious finding is that there's a break in the check this side right side, then constricting a dislocated, um uh, femoral head with, um, a distance segment fracture on the head as well. And the editor is just her groin. It's light and Perkins signs, which tells you whether they are in the right place. The one correlates with the horizontal axis here where the femoral head need to touch the after tabula um, and the other side just correlates to where, um, the the central line of where the neck of the machine should live basically. So this is the way against important the anatomical classifications. How can you How can you tell if meckel femur fracture is dangerous? What should you do about it? So I've split it into all of these colorful lines. But the most important line to find out is whether the fracture is extracapsular or intracapsular. We know that if it's extra capsule so outside the capsules of the capsule. Is all of this all the way to the point of number three just before the line of number four? Then that's what that's called intracapsular fracture. Whereas if it's if it's beyond that, then you call that extra capsule factor, which is, um, less lethal left. We can say so. Number four is called the Inter Trucking Terek Line as it lives between the greater trochanter and lower trick. Answer, therefore, that splits your fracture into all of these different classifications. So either you can have an intracapsular fracture, which could be some capital turns. The Vicryl basically cycle and all of the other classifications. But what we need to know is that if it's extracapsular I eat below the intertrochanteric line, you will have a rare occurrence of a V E N. And the treatment is by using an intramedullary nail Oradea test that I'm a hip screwed. Whereas if you haven't intracapsular fracture, which goes from the edge of the femoral head above the Strattera line, this is the one that will. Potentially destructive blood supply course is high risk of a the end because it's non union. Therefore, if you're lucky and it's nondisplaced. You can put some kind of it's it's screws on. But other wasted most cases. You have to replace this hips, either partially by doing a hemiarthroplasty or doing a total hip replacement. Um, this is the classifications, but severity. If you're a medical student, forget about the power specification. Focus in the garden classification. They're four types of God in classification. I split them into, um, how displays they are. The garden one and two is your mild fracture, you know God, and one in complete, non displaced, you know, small crack. Yeah, we probably can do conserved three minutes. You here, she would be fine. Got into. It's a complete non displaced for a nondisplaced fracture, which, uh, which is when you may consider your panel it. It screws. Garden three is where it's past, the displacing the garden. For groups that it's completely falling off. You need to take the patient with it. So this is a cheat sheet that I was talking about. If you don't take anything else from this, uh, Mecca femur fracture, this is for you. It's a loan for exactly, for the sake of knowing what what happens. Let's go from? They're serious ones first from Intracapsular. If you have an undisplaced intracapsular fracture groups I ah, that one got into, um Well, why is it going that way? Uh, yeah, So you can treat them conservatively or you excited using Catalyst. It's cruise, the worse it is displaced, you can think of. You have to think about whether the place in this elderly and mobile for elderly and the mobile So if they, if they can walk around in independent, can walk unaided, go up and down the stairs. Therefore, you can give a total hip replacement where, as if they're evil, about chances are replacing the whole hip. Yes, Um ah, it's less likely to be beneficial. Therefore, performer heavy actually lasted. That's what they are. More technical reasons behind that. But for the sake of medical school exams, that that's the explanation, Um, unipolar hemiarthroplasty is getting out of fashion now for the reasons that pressure on it already answered in the in the chat section. But bipolar hemiarthroplasty is normally what's the standard Now, whenever you have an extra capsule that not regardless off it stability, you could split it, whether it's still on the intercom Pretoria, the line in which you would treat them with a dynamic hips group. As it says, a dynamic hip score is that two screws followed by another screwed. It goes down half of the femur, and this is quite dynamic. So when your patient takes a step down the stairs, that will be about the screws. Would would allow such movements to accommodate the patient's movement as well. Well, it's if it's subtrochanteric. I eat be loaded into track it very life you give you. You do when I am nail. Which is why the answer to the previous question was an iron mail. Um Okay, so I'm gonna pass it back to push on to limping. Child asked. This is, uh, this area off specialty. I go back again. Yeah. This this scenario, I think we can wait for 15 against the answer straightaway. People answering Think they're confident enough, And then he can. He remained, uh, like, Been to stop. Yeah. Course me Cool. Pull this stuff. Okay, So from the history, I think everyone I think everyone have answered. So this the answers But this disease. So from the x ray, we could see that from the history stuff in the history that this is a seven year old boy who presents a progress of coupon knee pain, which is a classical history. Usually they will complain of knee pain so this, uh, pathology gets missed on examination. They will be limping on the X ray shingles that it's been used to compare the right and the left side that is fragmentation and decreasing the height of the prices. That is a proximal part of the femoral head, which is a remission size, just a classical Think CNN Birthdays Disease. Next time, please. So coming to the basic common pediatric keep pathologies will cover three topics. The first thing is DDS, which means develop. Until the space off the previous time was congenital dislocation, it waas removed because it's a series of developmental problems. We check us as this progresses, so it usually is seen in starts less than four years afford on when it is between 5 to 10 years. It is college parties on if the Chinese percent after 10 years, usually there that will be slipped capital femoral exercises, which is called a CRP. The first thing is a DDS development in the space left hip Usually that be at the this pathology will be picked on new one examination. If you have ah, examination, that will be in a symmetry of the I force, which you can see on the right picture. I talk to you the middle of the day falls, which is one of the indication for evaluating for that on the next two tests that I do this for this propagated us. First is bottle of this test, which means we need to addict flex his hip and knee should be flex to 90 degrees. We need to addict on Bush the hip forward That is sorry backwards. So if the that is BD it's that is if there is any dellape until problems in the hip, it doesn't go back. So it is a positive sign. So what? Let's just really positive when did yet on order. And it just is a relocation test where in when you hold tight? I mean, if you objected Objector next, um noted it will come back in fall back in. So that is our plan. It is. So these are the do tests which we usually do, and the baby is less than six months on Daft er that we'll need to ever late for that by taking an ultrasound. I'm not taking it off the sun because see that the baby is having ah, GD it's on. Did the management the first? According to the age, if they percent less than six weeks, we need to observe seriously every month on def they present between six weeks to six months, you could see in the picture below. There's a baby wearing a harness, which is called us, probably calmness, but in their two shoulder straps. On there's a pill extra person, which usually was the hip in objection infection so that that he present inside the double up. So if they present after six months, we need to consider whether Toprol the keep inside the acetabulum, either a close reduction are open direction. So there are various stages. If you could see in the picture on the left lower border, the second subluxation bad, and that is the minimal. The joint is minimally subtext. Lower dislocation varies right in, the head dislocates, and it stays just near. That's a double up on high dislocation bad, and there's a false joint just about the establish, which is called us for Also stable, which is a severe indication for surgery. And it's like, please. So, having learned about idiots, we'll move onto the next pathology name, that's what this disease. This is the scenario which we have discussed. So what is the definition of parties? But this is idiopathic a wrestler necrosis off Emerel. Yep. If ices for this, you need to know about the blood supply off the rocks. Mother FEMA, usually by middle and apples, a complex, similar artery. So on the branches acid in ocular artery and every Faisal arteries. So we know that it's any pathology like I know that it's Ah, this is like anybody condition, but there is no fractures. The patient presented. Keep on a knee pain asked in the scenario on they will present at the limbus well on examining that will be reduced stranger objection on internal rotation when you examined them, that will be a reduced objection and internal rotation you need to suspect off, but this disease, especially when the president between the ages, are fighting that. So we need to take an extra of the pelvis to look for any fragmentation of the hit our A reduction in the size of the head on the depend. Usually you'll be self limiting in almost two thirds of the cases on began. That is a picture on the right lower bottom, which shows cost with the bar. This is mainly don't keep the hip inside the acidophilus. This is called aspect risk, asked one of the cast. But you used to, uh, keep the hip inside acetabulum so we can try these moralities initially if the present, uh, initially and if that is no dislocation are really severe fragmentation. So when they are less than six years, we can observe, see really every month or every three months once and if the present after six years, we need to consider surgical management next week, please. So the last bit of the pathology will be slipped capital femoral. Every Fyssas as the name indicates, they that is a slip in the proximal femur, and it slips in very early. If you can see in the X ray, it slips invariably under a matter of slips, so be really so. The usual presentation will be on the picture. You can see the obese usually in his voice. More than 10 yes, on the study will be They will be unable to go. We're unable to wait here and also they have Ah, because you need pain as well and it is common in 20% it is presented. It's bilateral presentation on examination that because thing will be interrelation will be restricted as in thirties. But the other scenario which is typical for state capital femoral it progresses. That'll be increased external rotation due to this displacement. So that is one of the key points which you are, you know, on. We need to take an X ray. As usual on there is something called a frog like Latin You just just like as they're like a frog leg. You can object and take an X ray off from the dog, which was whether the head this, whether there is any sleep or not on the treatment, will usually be a candidate. It's most making an incision and putting it on the candidates loose or proximal femur just to stay, place the slip. Yeah, next time, please. Um, there are few more conditions on the first doctor. Conditions are transient. Sign of it is usually the affects the Children between 2 to 10 years, you can see they present to the emergency department. Worried about some septic joint. Are separate pathology happening? But most often 80% of the cases will be like transient sinusitis, which also means irritable hip. But that is no in pain due to the right of conviction. I don't need drama on examination. That will be six of movements that the fever a time still the inflammatory markers would be raised. But the angel management will be just observational. We can admit the child we can observe overnight. We can see and see the movements the following day. How they're responding on the other warning thing is the septic. Other days, which is an emergency. As you all know, the baby are China and presented swellin septic joint that is a cylinder and joint with the pain, and they'll be fewer onder. Most of them have a raced CRP. Under, they will be unable to have a beer. The investigation. It'll be first, take an X ray and also ultrasound guided aspiration to know what's the exact like that that there is any infection happening and send them for a culture and sensitivity as well. The treatment will be. I see all know it's It's an emergency. We need to get rid of the infection by giving a joint wash it under pregnant on giving a long term antibiotic according to the sensitivity on Dennis on a condition called us junel a day. But the catheter this which is very common. I have not seen any patients so far. So just for theoretical purpose, this is recommend arthritis. In less than 16 years old, we have the percent of pain or the hip or knee more than six weeks, which last more than six weeks. You just keep it in mind. Yeah. So next time you want Oh, some of the a dramatic causes undergoing any fuel, several other issues underneath. Can you make a lot of the time for this? FB eighties. Your stuff? Yeah. Okay. Can be easy. The bulls can stop the one sitting. I think most of them are answered. It, uh, correctly So this is a typical scenario for common, but in in no, that is coming to blend now. Policy. But in the main, I think that things are there's a fracture of the fibula injury to the fibula. And there's numbness or the does My food on the left foot is dragging on the floor, which is still that's the foot drop doing this thing fist. And that is also weakness in the direction of the food, due to the affection off superficial burning now as well anymore to the next lately's. So this is out of this scenario can give 15 seconds for you guys to answer this policy coast and results in. Okay, Can I see that this was like a like a mosquito. It is shared for everyone, but most of the candidates answered a okay on followed by a bee. Okay. Yeah. Uh, the typical got here is usually the patients at the entry push a ligament. That also percent with the typical symptoms. The only catching point here is unable to fully extent, which is a classical. Symptoms are less locking patient presented the locking. That is a typical scenario for meniscal that so for this ligamentous pathology is getting more extra piece. We need to know what are the basic ligament of structures? Which tablets s the knee? There are four ligaments. You need to remember I'm not going to discuss the name for the ligaments. The to intraarticular ligaments called us, and it and posterior a cruciate ligaments. I need it. Think as if you are putting a hand injury. Oh, until your pocket. So it usually comes from the lateral femoral Monday and inserts on the friend on the tibia on most area who she ligament usually arrest. It's on the video Female condom on inserts on the posterior aspect. After two PM on there's two extra that is extraarticular ligaments. Well, that's medial and lateral collateral ligaments as the name really gets me realist on the medial side lateralis on the lateral side, which inserts on the singular So the government ligamentous mentality is easier that is underappreciated. The patient present. That's typical history of twisting injury that is like a football injury are. We are any injury that the patient lands on just the knee on that, so they will present with instability in case of chronic on the infusion on examination that will be, if you can see in the picture that it's like my desperate it's more specific, and you try to, uh, fix that they end do an anterior woman. That would be a translation, which is positive for our ligamentous is healed up. So any ligaments pathology, we need to go. I just get a memory because MRI is the scan, which relates the soft tissue pathologies on X ray and CT for morning felonies. So treatment twice conservative. What is the minimal laxity on the terrorist initial great one on the surgical arthroscopic reconstruction by putting a new ligament, either by taking their own ligament, are taking a graft from some other like from the allograft. So having known about a cell damage is very government will go about the PCL dot supposed to eat with the ligament that that they usually presented dashboard injury. When you write a car and if that is, uh, accident with the dashboard injury, there's a direct flow. I'm in there fall on the floor. It causes a whole series of movement of the tibia, which induced the most crucial ligament. So as the name indicates, that is the best. All that supposed to drive test we could see in the picture mean 90 degree affection. If you just press it back, it will easily go back. Do you know the ligament laxity. So, as always, memory on treatment this conservative for our grade. One time on, if you receive a beer and severely instability, Mister Bill Instrumental joined a style, so we need to order out a scope in the construction next slightly. So from the scenario which we are given so many risk older us. We all know that there are two meniscus when it's medium meniscus. That that is the actual Mr Mr is more fixing on the level. Minister says it's more that's medium. Still, there are more common on. The history will be like the same. Yes, yell injury. There will be some interesting injury and the typical history. It's not knee locking on the patient is unable. Don't fully extend. There's something called us McMorris Just I'm not going to feel much about this. If you're flexing extended on, give a valgus and barest just that will be pain. You do the grinding woman off the medicine so on, uh, as always, MRI for to investigate on treatment is conservative. If it is a milder on, uh, doing arthroscopy by putting two portals under about it, if that is a city of that, yeah, next light, please. So we're on to the next scenario. We'll give 15 seconds. Very this answer. Yeah, I think you can stop your so most of them are answered it rightly so. The answer is tibial tuberosity. So this is a classical history or 14 year old? Are Listen, I done that, uh, usually presents and 100 mg pain just was building practices of a typical catchy points because you know what that is? Injury are other. Listen, present it and any pain you should think off something called us asking Slaughter syndrome, which is a ligament, this aversion off label Do pass it e But you could see in this picture of air in the blood and then it gets that that would be a vision that is the full off the ligament, along with the board in the hallway anymore. Except he's so this is. But as we already discussed this opera, Vice City's of the approximately typical typical continuing the picture there on DA. The presentation will be by the Internet's, and they will not be able to wait here. Examination. That'll be resistant Knee extension on when you take an X ray off both knees just to come back. Whether it's normal, you need to take an extra police and come back if there is any fragmentation or if there is any. Yeah, between the ability of rusty on the tendon, that is something happening in the knee. Just got less Oscar status on for that. The name seems to be a big part, but the treatment is very simple. Usually will be by giving you nausea. I'm a surgical management is very, very that especially only in severe, fragmented cases, the next thing we'll we're going to discuss is osteo hundreds decisions. Just trying to him about this is just a softening off the bowl basically means that just a softening of the bull, which happens usually in the medial femoral condyle patient, usually present that pain and increasing and activity on the locking us. If in meniscus on the definition, we need to take an MRI just to see whether there is any meniscal pathology, our city think I'll stay on it just because it's happening. So the treatment is usually considered a were in some way to 80% of the patients so that he has been the that softening gets fragment that and if it becomes a loose body, we need to remove it by other stuff. On the other common presentation, usually the nurses there is something called us irritable bad. Let me write me. It is formed by gluteus Maximus on been sufficient letter, which is everything from the iliac crest it forms a band called us Iliotibial Tract was the name it gets. Really? Oh means electricity. DBS instead just inserts on the tibia. So the typical presentation will be in runners. That would be lovely. Need pain. You need to abcd and see whether that is any pain on the investigation would be by memory on conservative in most of the patients on the surgery only for this other list are in severe, severely symptomatic more the next day. Please on. Uh, next thing you need to know about is that bursa both eyes just a fluid collection in the cavity, which is mainly for a right. The friction between the joint surface is under our various, both saying the joints. I'm not going to discuss much about everything. Just try to remember to do this One is a pre patellar, which means that in front of patella and super an interpreter. Just a bone be below. So the pre patellar bursitis is called us folks mates need because he could see in the picture. It's a low kneeling if they need for a long time, and they're they're not the floor. They, uh it will, uh, help the bursa and the friend of the patella. Call this reporter, uh, bursitis housemates knee. The other thing is infrapatellar bursitis. It is called us clergyman's need because they didn't do are doing a great feeling for a long time. It usually affects their intraoperative. That buzzer does do things. You need to remember that the last thing is just for chronic information. It's the information bake assists, but usually if you could see in the picture this is ah, posterior aspect off the need. What knees? You could see that on the left me that it's ah fullness on the left knee, just mainly due to the fluid collection that gets a gastrocnemius, which is one of the a muscle in the posterior aspect of the cough that is a bus on him just gastrocnemius buzzer that usually communicates and come back mostly leave, and we could see that swelling usually appears on extension and disappears on flexion. Undid empties into the joint. So they didn't will be, uh the investigation would be by Ameri on the treatment will be the the conservative or a surgical based on how the percent next light, please. On the last meeting. The last scenario. Are you more scenario? Yeah. Can give 14 seconds. We almost that. Okay, I think that is a bit of condition between a C so x ray. Yeah, we can do the X ray, But whenever there's a typical history of sports injury when the patient is presenting with the plantar flexion injury like this and when you're not able to go plantarflex, it's obviously there is something called us Achillestendon just on the posterior aspect anymore. Next, right, please. So, yeah, from the history we can we could for we need to know about much about the anatomy so I can listen then it's just ah combination off gastrocnemius soldiers and plant, that is it's usually inserts on the calculated porosity in the posterior aspect. We know that is seven plantarflexion like in landing in any, uh, learning in the accidental in the toilet are doing playing sports, especially Dennis our football. We know there's seven plantarflexion this list and then gets fractured. That usually presents as acute presentation, and that will be an article park. And that will be a gap in pressing on the posterior aspect under this test called a Simmons test. When we asked that even see in the picture. When you ask the patient, like bone on the present a cough. If the tenderness in duct they can easily block up next. So if they're gonna start inducted receptor, then they can't plantar flex. It will be in the noodle push in our it will go up. So I'm usually in disseminated first line by doing an ultrasound on Demery is the most specific test for this toe. Know what about exactly the terrorists you ever further for surgery? So treatment is usually in the small and the presentation is secure. Well, immobilized that plaster back slow and not the back slap put a slap on friend after me. It is called us dot and slap our friends lab and we'll follow them on in fracture clinic and two weeks just to see how, uh, with the pain and the whole they are responding on. But that is sorry. That is one more condition called It's Tendonitis. Then they usually present us a chronic presentation. They presented mostly the heel pain wasn't after a long activity, usually at the end of today on, uh, andare. Few more conscious for this. Like for Cigna ciprofloxacin, you need to make sure that that's, uh, more chance off for oculist. And rate is for using ciprofloxacin on when the patient is police and having hypercholesterolemia as well. The treatment is usually by getting on the seven. That's just tendonitis, only things that we need to intervene and do surgery. So coming into the last scenario off the day 15 seconds straight diarrhea, people answering, Yeah, I think the bullet stop. Most of them are answered that right? C just open reduction in dose fixation. So I know that this is a very good question for this. We need to just start from the basics. So this is a twisting injury that I'd be player. The patient is unable to have a beer that is pain and swelling on da. If you could see getting one of the next night and discuss about this before discussing further up with the ankle fractures, but we need to know what are the basic mechanism. Our other patient will get injured that are released mechanism of the most common are in motion erosion. Objection on election injuries These are the most common attempts to be a combination off. What direction? Objection in Washington. A question. So having know the mechanism we need to go in, the patient presents the 80 we need to examine them. Look for the swelling for about exactly. They are tender, especially or whether it is in the medial managers to sit on the lateral malleolus. Or, if there are any open fracture, there is any bruise or the anterior on that last of the skin on. Also, we need to any fracture. Any injury may need to look out for euros. Plastic on. After examining the patient, we need to know what they really take an X ray. A mark for them, that is, ah, rule called us whatever angle rule, which states that if there is any tenderness or medial, a lot of malice now the patient is not able to bear weight. That's the only indication we need to taken X ray off the ankle. So after taking an extent that you need to know how to read the X ray, which is by the right right doctor, which was the ankle joint, be a distant after be a under Dallas left. One. Develop a fund along with the Dallas, Just usually, if you can see there's a smooth, uh, the gap is almost uniformly a lower of the Dallas. Well, a lot of us on that. It's a structure of it is called us syndesmosis, which is highlighted, and red, which is just a ligamentous connection between tibia and fibula. The distal aspect. There are three parts on the really middle under the posterior aspect, which is one of the stable. But on based on this there is a classification called us paper classifications. And this is one of the most important classification going to this. Well, we're going to treat about the ankle fractures, so there are three types. One is a B and C is the in the structure just below this in this Moses. And these are the levels in this Moses C is about a little less in this. So down from the down below at the level about so we know that is number. A fracture that is below the thing that's most is the fracture is stable because that is syndesmosis usually intact. It won't move. And if there is any fracture in, uh, let's never be on. Uh, like, the typical scenario be to be, uh, given we know that is a fracture at the level of syndesmosis with minimal of shift. Then that's an indication for surgery under the last thing I remember seeing fracture in the university fracture. That is a more chance for arson this morning injury. So, you know, that's never be the callus. Are they receiving about this in the small cyst? You need to are do an operation operative fixation by doing or on also, as you well know, open practice in the open fracture. We need to intervene into, uh, operative management on def. There's a rubber. A fracture are stable. With the traction, we can immobilize it back. Slap on review and, uh, tractor do any good to restart. Yeah, I think we are done. I hope you guys have enjoyed the presentation. Any doubts? You are welcome to ask in the chat. I'm going staying over. Is there any other question like they want to know? Is three stuff in there? Okay. Noted to this nurse, No question. No questions. And revamp was asking what kind of material it's used in a truss copy, replacement or reconstruction. Okay, so things one is another scope. Another thing is arthroscopic reconstruction from the name and against repair means just repairing whatever it start. Reconstruction means putting in a new ligament. Either The patient's own ignorant, which is called us autograph. Are you eating in? A little graph which is taking from the other patient, are from the get up there is called a look. Usually, what we are commonly doing is reconstruction. I know that is underappreciated. Opposed to appreciate ligament injury, Many intto reconsider so that it is better. It gives a better stability. We can't repair it because it usually causes more damage. That's more chance of failure. Yeah, missy, I don't know. I think one of the concerns that consultants was telling me that they sometimes use the fascial after Oh, you are nice thing about the water. The grass use. Yeah. Autologous. Okay. Okay. Okay. So but, uh, I do it autographed. Usually won't be commonly use here is not really here. Commonly, all over the world is hamstrings. That is, on December tendinosis virtually inserts on the medial aspect of proximity. Yeah, that's the most common thing between years. Another thing that you can use this quadriceps tendon. Well, the third thing with the you commonly use this stuff. But like and then let's see. Okay, so these are the bones, which we commonly use special. It does not for stimulating the underappreciated about it is just for reinforcing the lap band strictures. Not for it. Okay, yes. And if it's very severe, would you just consider putting any replacement, or would you still try to maintain the hosts primary structures? Okay, that's a very good question. So if that if the if it's a severe injury, that is a great, really completely we need to look at the patient's age on symptoms. The patient is reported like, for example, if the patient is presenting, like 60 70 years. But the ACL PCL are any ligament that, um, three 70 years, you need to take any extra emphasis. So if the excisions that is the degeneration of the joint, if there is operated. There's no point in stabilizing the ligament. You need to go say the right toe replacement. If the patient presents in the middle. It it's better to, uh, do, uh, give it a go by doing a reconstruction on following it up later on. If they progress to operate this latest, they just began. Consider. Well, that makes him thanks. Good. There's a question here from keep breath the years internal brace and power tape. Okay, That's okay. I can answer the question. Yeah. So, internal braces, Uh, I think it's the next level thing to discuss. I can discuss it that so internal basis, Something like a repair rather than doing reconstruction. That is, if there is a c l midsubstance step, which means that it's ah, God in like in the joint. Not I either. Attachments in the joint, we can do an internal bracing, which is reinforcing by putting a tail on, uh, attaching with screws on both sides, which is called indolent crazy. We can do that, but that's that can be done. One in the mid substance that that is in the joint. Not on the a few minutes a day on the nebulizer. Yeah,