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But yeah, so if you just move on to the next slide, thank you. Yeah. So, so t top knife, as we were talking, highly recommend, good little bedtime read, just gives you some very um nice little anecdotes um with regard to sort of damage control surgery. Um So a little bit about the types of vascular surgery. Next slide, please. So generally speaking, uh it's either blunt or penetrating or a combination of the two. I probably teaching you all to suck eggs. Um And generally speaking, if you have a vascular injury and vascular injuries, that only form about 4% of all trauma, um mainly because vascular structures are fairly deep and surrounded by other fairly important structures. And it's very rare to have an isolated um vascular injury unless it's particularly penetrating. Um And next slide, the by far the most commonest um trauma that we see is iatrogenic. Next slide, I think it's, are you moving slides? I am I am sorry. Um It should be on the pathogenesis of penetrating. What can, can everyone see what slide I'm on. Tom theology of vascular injury. It's not moved on. Yeah. Yeah. So I think there must be something thankfully not me. Perfect. Yeah, we're moving. Ok. Cool. So, so penetrating trauma, um, as I said, IIC trauma is actually the by far the commonest, if I had a pound, every time I went to Papworth, I could probably retire. Um, so in terms of penetrating trauma, we're talking all sorts of either high energy, low energy almost always will involve either more than one structure or arteries and veins. Um, a common one we see in other brooks is people trying to scale all those um, fences that you can see on the bottom, right of that um screen and doing all sorts of damage. Um It's interesting, we were just talking about nerve injuries. It's very common. If you're going to injure a blood vessel, you almost certainly going to injure a nerve in the same sitting. Um Next slide. Um So in terms of blunt, this is probably where we commonly meet in terms of orthopedics and vascular is your blunt injuries, your fractures. Um And generally speaking, um it will be the intima that is most commonly injured if it is a simple blunt trauma or an avulsion type injury. Um And as I mentioned, it will also injure other things. So, bone, bones, nerves, et cetera, um essentially, these are much more difficult to manage actually in older patients because they often have underlying disease as well. And that can add to the complexity of the management of these patients but we can we'll touch upon that um later on uh next slide, please. So when you have an injury, what is the usual outcome from our point of view? So these are the things we look for when we are asked to assess a trauma venue description. So you can bleed fairly obvious they're blood vessels and that will either be external if the skin is broken or uh if contained will present itself as some sort of pulsatile hematoma. Um if you get an intimal injury, um so within the blood vessel, you're going to have an ischemic limb. Um and sometimes you get that even without injury to the intima and say young patients who might have a bit of spasm. So the left side of this is probably the commonest that we would see in terms of major trauma. Um your chronic pseudoaneurysms, your uh avi fistulas, they are much less common, usually with slightly lower energy. Um and or with the electrogenic um injuries. Will you see those next slide, please? So, basically, in terms of assessing a limb, as far as I'm concerned, there are two types of signs. You have your hard signs, simple, straightforward, almost always need an operation and they are bleeding ischemia. It's that simple, as I said, vascular surgery is not difficult at all. So if you've got very obvious, very clear demonstrable, either through the mechanism of injury or from the patient that you're seeing that you've got someone who's bleeding, who is, who's got a profoundly ischemic limb. Those are hard signs. You, you're not gonna be messing about next low key. Now, the slightly softer signs as I like to call them are things like, oh, well, there was spurting, bleeding at the sea. Now, I tend to take those with a bit of pinch of salt because the number of tiny little superficial veins that I've tied off as a result of that. So if once you've taken your tourniquet off, there isn't any bleeding, it's almost always not going to be anything major. Um If you've got hematomas that are small but not expansile, if you can feel a pulse, but maybe it's a bit weak proximity to the vessel in terms of whatever mechanism of injury, you've got the nerve that is related to the artery and or vein is also injured, but you've got no hard signs of injury. All of these are what I call soft signs and all that means is you've got time to investigate. Essentially, that's what I'm trying to say is if you think there might be an injury, you've got time. These aren't patients, I'm necessarily gonna be rushing that minute to theater. So next slide please, I group vascular trauma into four groups just to make life simple for myself. And group one, I lovingly call the examinator. So they are patients like this that rock up major trauma, hard signs, shocked. They need to go to fit. There is almost always no reason to put these patients through the scanner. They often are put through the scanner, but that's because they've been put through before anyone's called us. But if this pitched up right now to R EDI, I would not bother taking this chap to the scanner. He needs to go to the theater. Next slide, please. So the group two, your other patients that also need to go to theater are your ischemic. So there's a very obvious hard signs of the limb ischemia. Yes, you can put them through the scanner if you wish. But ultimately, you know where the injury, you know what the problem is. Um and you just need to take them to theater and deal with it. So next slide, this is again, if someone's got a fractured femur as is on this um X ray, you know where the issue is. And yes, and if you really haven't had a CT and you really desperately want to know what's going on, we can do an angio. It's why we have a hybrid theater. That's the beauty of it. Um But you ultimately know if a patient's got hard signs, you know what the mechanism of injury is, then you know what the issue is. It's really not that hard. Next slide, please. The other sort of ischemic in which there is a slight challenge are hard signs, but they've responded to treatment. You've got a bit of time and also the site of injury may not necessarily be clear. What I mean by that is, you know, multiple projectiles or a mangled limb or there's potentially more than one level of injury. Um And as I mentioned earlier, the older patient who may have some underlying arterial disease, it is helpful to have that imaging in order to be able to plan your management, which we'll be talking about. So that's why I've kind of done you a little wee Yes, they need to go to the theater. However, imaging would be helpful because it gives you preparation in terms of managing your ischem. A now there there's always a moment where you kind of stop and go hang on. Is this actually a mangled limb? Ie is this limb even salvageable? And these are, these are multidisciplinary multiteam, usually almost always multi consultant discussions, but having the information upfront, at least, you know, if the limb is obviously not in the bin, then there is a sort of pause here that allows you to be able to assess whether you think you can reconstruct it because it may be reconstruct from a vascular point of view. But if for example, from an orthopedic point of view, you're not gonna be able to reconstruct a usable limb, then those are the discussions that are to be had. Next slide, please. So group three are the ones I mentioned before the So sign. So you've got maybe have an injury, maybe don't have an injury, not really sure. I've put a BPI on there, but I actually almost never use it. Um, partly because it can be misleading, partly because it can be very difficult to perform in the acute setting. But it is a, if you've got a minute, it's worth doing if you really are not so sure. And with those, they're going in the scanner, if we're really not sure, you just put them in the scanner and it means that you can prevent an unnecessary surgery. Uh and also to confirm or if you that there is indeed a injury or not. And then uh next slide please. Then these are the patients in which you have no injury or either because their neurovascular exam is normal or because their CT is essentially normal. But if the mechanism of injury has a high index of suspicion that they may go on to have a problem, then follow up is essential. So we often have these ads where patients have either dislocated knees or elbows, et cetera. And while they may be neurovascularly intact or at least vascularly intact, if the mechanism of injury is such that you are concerned, then follow up is almost always essential. Next slide, please. So, imaging CT is almost always what we will be looking at. In certainly in acute setting, we have an excellent vascular lab at Cambridge. Um in fact, one of only three in the whole country that have a high level of accreditation because of the quality of their imaging and they are always very, very helpful and unfortunately, don't work out of hours. But certainly in hours in that group three that I mentioned where you're not sure that is where, where they shot and they, that is the reason why it may be other vascular centers. ABP R may be a gold standard for us because we have such an excellent vascular lab. We actually use toe pressure much more commonly than we do. ABP. It's far more accurate. It's less reliant on calcification of arteries and gives you a much better picture in terms of distal perfusion. Um So these are just a couple of CT S from some traumas that we've had where you very obvious vascular injuries. And like I said, it's not hard, the contrast goes, it stops, it comes back again. Next slide, please. So the essential philosophy about managing these is whether or not you require damage control. That really is the decision is, is this someone in whom I need to do damage control or is this someone who is gonna have something definitive at the time? And this is an art rather than a science I would say. Um and what essentially you're doing is balancing the resuscitation with maintaining eventual function. So we use this philosophy very much for, for example, our ruptured aneurysms. Um and so a ruptured aneurysm will almost always have a CT. In fact, I can't think of one that I have done without one, even though they are often clapped out, they're often, you know, or BP that's exceptionally low. But we allow that kind of almost permissive hypotension because it gives us the time to do act, the, the, the days of CT S taking, you know, half an hour or longer gone, you can probably push someone through, act in about three minutes. Um And as long as they're mentating and they've got a radial pulse and they're talking to you, you have time to get the information if it's appropriate. Um Next slide, please. So how do we manage a vascular injury? And I have to say, managing a vascular injury and trauma was one of the things that probably frightened me the most when I was here in consultant, I realized actually it's exactly the same as just regular vascular surgery. If anything, it's slightly easier. But the, the principles are you need proximal control. So you need to, whatever your healthy inflow is, you need to control that you need to control distally and then you need to expose the injury and then you need to do something in the vessel. And that really is it. And that's all we do. And that's the same principle we would apply to, you know, your standard atherosclerotic ischemic limb or your aneurysm or whatever, it's always the same. And the reason I say for slightly easier is because the hard thing about all of this is getting to the artery and actually with these injuries, often the hematoma does the exposure for you. Now, what I did put at the bottom, um which I often forget but try and do when I remember is early fasciotomy in the ischemic. Because if you get a fasciotomy in early, it does a couple of things. It, when your reperfusion happens, you've already relieve the pressure. And it also allows you to assess the muscle, especially in patients that might come to us from far and wide, who may have had say a tourniquet on for a prolonged period. And you want to know whether or not you have a salvageable limb on your hands. It gives you that um slight advantage and it's just, it has its disadvantage in that when you give him heparin, it bleeds all over the place, but it is a helpful adjunct to manage your reperfusion injury basically. So next slide, so exposure, you've gotta get to the vessels. The arteries are usually in deep dark places. Um the hematoma while it does distort the tissue also actually assists in getting into the artery much quicker. Um in young patients, which thankfully, we don't have too much, we don't deal with too often. Often, their arteries are very small and almost always and spasm. Um and it can be quite difficult to find the injury. Um especially if it's say in property or fossa or in the proximal subclan or generally in areas where we don't go too often because access can be difficult. But what you need to do is just get to where it is. Um I tend to control vessels with slings, they're slightly less traumatic than clamps but are, are also not atraumatic. You do, you do have to be careful with slings. Um And my boss has always used to say to me when I was struggling with the operation is if you're struggling, make the hole bigger. Um And next slide, that effectively means so the red, the red dotted line is you can access basically any artery. Um If you follow these lines along the trajectory of the artery and yes, you have knees and ligaments and things in the way. But actually, if you really need to get to, you can get to these vessels. So next slide. So what can you do once you get to a damaged vessel? Well, to be honest, it's no different than what we would do in, you know, under normal circumstances when we're trying to reconstruct arteries that are damaged as a result of other reasons, so we can repair them. So if you've got a nice clean, penetrating, you know, knife injury, almost always, this is um we can just repair them into end or do a lateral repair. So just kind of, if you've got lots of redundancy, I tend to be quite redundant you can often snip two ends and just put them together. Um You cannot graft them if you haven't got the length or you're potentially going to be under tension. Um And your choice of graft very much depends on your injury. Um or you can patch them. That's probably more if you have got an intimal injury, ie your artery is intact on the outside, but the intima has been damaged. So we'll open the artery, we'll pull out the damaged intima. And if we are happy that the vessel on the inside is ok. That arteriotomy where we've opened needs to be patched because if you primarily close an artery, it will um narrow down. Now in the two, the two, I've marked in red at the bottom, which is shunt and ligate. Those are your damage control. So, if I've got a damaged blood vessel and I've got a very sick patient, I have one of two options. Um I can ligate the artery and you can ligate any artery, the the, then we'll talk about this a bit a bit later, but you can just ligate it or you can shunt them. Um And there are various things you can use to shunt with. So uh next slide, what, what should you do now? These are definitely, definitely um where experience and other teams and the injury burden and your patients state and potential reserve all come into it. So, yes, if you've got a well patient who has had a single limb injury, say, for example, who's well, you're gonna definitively repair. But if you've got someone who's either got other injuries that need to be dealt with or are more serious or needs has physiologically not done particularly well or has reserve. An anesthetist are not very happy because a they've lost, say a lot of blood and require a period of um resuscitation, then you might be thinking damage control. Now, in terms of next slide, in terms of damage control, I did say to you, you could ligate arteries. That is very true. You could ligate any artery. The question is what the consequence will be. That is what is gonna vary. And so this slide, I think is one I would just keep in, in your mind when you're thinking about these injuries. So your low risk arteries. So if you, if you in um my plastic extension colleagues may not be as happy with that. They often do try and reconstruct it but you can and, and, and you can tie off tibial as well. So if you injure tibial in the ankle, for example, that is almost always not going to be of any consequence. Um And the profunda artery can also be tied off as long as your SFA is, is intact. And then obviously, you've got these other arteries next slide that are going to result in an ischemic limb. And those are the ones you really want to reconstruct. Now, if you do have a sick patient and they are not going to cos a, you know, a reconstruction or bypass. I mean, I can do them more reasonably quickly, but it's still gonna take me two or three hours. It's not gonna be quick. Um, next slide. So if you are gonna be wanting to essentially ligate a, not get yourself out of this situation quickly. So, what, what do we do is we shunt? Um And we want the shortest shunt, the shortest fattest shunt possible, basically. Um And, and the principles of shunting are simply just to ensure you've got inflow, ensure you've got outflow. So you might want to just do a quick um, trawl of the artery with a fogarty catheter and then stick a bit of tubing. And I've used Pruitt shunts. They're the ones we use when we do carotid endarterectomies. So they are ready made shunts. The problem with them is they're very long and they're very thin. So they're the exact opposite of what you actually want in a damage control situation. So bits of chest tube, I've used, I have used an NG tube, it's whatever you've got available to you and you just cut it, secure it and you can leave it if it is a short fat one like this one in an iliac, um then you don't really need heparin. Um But if they are smaller or you're below the artery below the elbow, then they're not gonna last as long. And you really, even if you put one in have maybe, maybe at most 12 hours and that's really pushing it, um, at 12 hours. Um, and I put venous shunts in because actually, to be honest, um I would tie off most veins to be completely honest with you. Um, you can tie off any vein including the IVC. Um, next slide. Um So when you've got a sick patient, this is usually what we would do in a patient who we need to get in and get out. So we would do our embolectomies, get our inflow and outflow, secure a shunt um fascial if appropriate, then let you guys do your bit and then do the vascular reconstruction and that isn't necessarily all in one sitting that could be you do your orthopedic bit and they come back, uh they go to itu and come back or even you do the above and the orthopedic bit doesn't get done because they are if they are that sick. Uh next slide. So the definitive repair be it at the time or on return. Generally speaking, we want to use autologous material ie the patient's own vein almost always from the uninjured limb. If that's at all possible, we can use synthetic and we have Dacron and PTF E grafts. But generally speaking, we're only gonna use that on big arteries that are not gonna be exposed potentially to infection. And and a, and a graft anywhere is potentially post to infection. But I personally would not use PT in a limb. I might use it for an iliac and I might use it for a subclavian. But that really is it. Um ideally you want to take a vein from an uninjured limb or an uninjured site and use that as your interposition graft. Um, an interposition by that, I just mean within the same position as the artery was. Um I'm not talking about extraanatomical grafts whereby we can't get to the injured bit, for example, the back of the knee where we might have to do a medial approach. So we're not actually anatomical. Um and the principles are simple and as before you dir back, you get healthy tissue and you just do an end to end anastomosis. Uh Next option. Thank you. Um And bypass, as I said, is often easier um than an interposition in position. I would only do in an artery that's very readily accessible. Um And can be anatomic or extraanatomic. Um Given the degree of trauma, we may need to get our plastic surgery colleagues involved in order to get tissue cover, you can use PTF E if you're really, really desperate as a bridge, but generally speaking, we kind of wanna be one and done. Um And if you are gonna damage control, I personally would damage control with a shunt rather than a graft unless I think we're not gonna be back in that within that six hour window. Um Next slide. Thank you. Um And then II mentioned patches, patches are basically either um we use bovine but you can also use vein. You can also use Dacron patches. I've never used a Dacron patch in my career and they are just used to close an, an artery that we've opened to explore. Um, er, I've written there, it can be difficult if significant retraction. So you're not gonna use it. If your artery is so badly damaged that it's gonna, you, you're gonna control that and, and do it into position. Um I've written Subclan and AXIL just because it's a very, it's a, the sub artery is a really hostile artery, it falls apart if you just look at it. Um And like I said, patching generally, generally speaking, we don't do all that often unless you've got a very isolated intimal um injury and an easily accessible artery. Ok. Uh Next slide. Thank you. Uh venous repair. Now, one of my colleagues is like a world renowned venous expert and he gets very upset with me because I'm just like you can just tie off anyway and you can't, um, they bleed, they're annoying, you just tie them off, you can even tie off the IVC, technically speaking. Um In fact, tying off the IVC used to be treatment for DVT to prevent PE and they discovered if you tie off the IVC, it does not actually prevent pe you can still get pee even if you've tied it off, so you can just tie them off. And we have yes, the sequelae will be a swollen limb, but the beauty of veins is you often have an excellent um venous network and you can compensate uh beautifully. And generally speaking, my, I will deal with the vein by tying it off. Um Next slide, please. Um I'm gonna touch upon this only very briefly simply because a it is not my area of expertise and we have some excellent interventional radiologists at Cambridge who are far better at talking about this than I am. But essentially speaking in most trauma, the endovascular aspect of it is often not, it's very much an evolving practice. It's unusual for us to use an endovascular approach for a very simple reason in that it's an evolving practice. Um It, you will probably almost always use exca and injury and that's surgically excess. We, they are very good at coming and helping us by say, putting a balloon for our proximal sort it out. Um It can be a bridge to definitive surgery. So if you've got someone who just need to get in and get out that, that is also an option for us. Um Next slides, um There are just a couple of pictures here of a sort of proximal axillary um puncture site bleed that has been stented. Now, the reason we're not jumping up and down about this and saying this is the best thing since Cyrus spread is because stents are nowhere near as long lasting as a bypass or a, an open surgical repair. So I would be very reluctant to be putting stents in young patients who have injuries where we can do a surgical repair on because obviously they need to last much, much longer. Um But in an inaccessible site in, you know, in extremists, yes, that, that it's better than nothing put it that way. And there are certainly certain aspects of trauma, for example, thoracic injuries where if you get a um transection, uh endovascular repair is by far better. Um So I think it is, you know, watch this space is what I would um er emphasize next slide. So in summary, well and control of vascular injuries now, effectively they can only present with vein or ischemia really. That's about it. Um Yes, imaging, if you really don't know what your site of injury is or you, there are complicating factors about that may help you in terms of management. Yes, go ahead and get imaging, but a lot of the time it's not necessary. Um The fundamentals of surgery do not change in terms of management. It is still proximal control, distal control expose and then do something the best. And that really is it um good exposure and straightforward repair and that doesn't necessarily mean all in the same sitting. It's sometimes in fact inappropriate to do in the same sitting. But the difficulty with surgery is all these decisions along the way. Um, what you can do and what you should do may not necessarily be the same things. But I, if you can get your exposure, if you can repair it as quickly as cleanly as possible, um, that maximizes your chances of success. Thank you very much. I, uh, yes. No, I think we've got a question here. So if you've already thank you for your talk. Um Just a quick question more for kind of our clinical point of view if we're ever in theater. And we're one of those surgeons that does accidentally damage a vessel during an operation. What's the kind of advice you would give us to try and ensure that obviously we'd contact you guys, but while we're waiting for you to turn up the theater, yep, one of the things you would suggest for us to do in the meantime to try and optimize outcomes in the future, basically. So, so it depends where it is. But generally speaking, my advice to you is press on it and call me like that. That is you. So there was a incident, I think it was either last week or the week before in one of the theaters where a uh a surgeon was doing a revision hip, I think, and encountered some bleeding um and tied off whatever he had encountered and it turned out to be the SFA. Um So, and, and I get that, that was probably, you know, it was probably quite brisk bleeding, but it was quickly noted after the operation had finished that the patient had a white foot and no pulse. So all I would say is if you're confident that this is something you can control, fine, press on it and try and control it. But ultimately speaking, if you might be near a major vessel and like that really is just as opposed to trying to put a, the finger is mightier than the clamp. Literally just put a finger on it. Hold on, you guys get there. Absolutely. The worst thing you can do is dig around and try and clamp it because if you press on it, you still have flow beyond where you're pressing. This is that I'm actually not a massive fan of tourniquets for that very reason because if you've got a vessel injury, all you wanna do is just cover that vessel cos that is w when we do any sort of management, it is just covering the wall of the vessel. So when you press you're just covering wall of the vessel, the blood will still flow beyond it. And therefore you won't have an ischemic limb. And that really for me that bleeding, it doesn't fuss me at all. I could not care less about bleeding. What I am afraid of is an ischemic because in the scheme and it was much more difficult to manage. So, in this situation where the SFA A had been tied off, we had to do a whole interposition graft because actually, it was such a big haymaker stitch that it had taken out about three centimeters of SFA. So that's not, we can't do anything to reconstruct that. Whereas had he just pressed, we'd probably just come and put a couple of stitches in and gotten out. So it's a much easier thing to deal with than having to reconstruct. Basically reconstructing, takes time. Um, similar to that in a trauma setting, often we go to a trauma call and although it's less, less commonly used now, but you'll still occasionally find a tourniquet that's been applied, you know, kind of by the ambulance crew or somebody on site and the patient comes in because they're worried about active bleed in those cases. Is it best to obviously contact you guys or should we release the tourniquet? Look for any obvious bleeding and then try and stem it with a finger to, you know what I mean, in terms of what the advice you would give them. But again, it depends. So we had, we were called by, I think it was Luton Lieutenant Rung because there was a 13 year old boy that was stabbed by his friend. Um And so, so it was a single stab injury and they put a tourniquet on because he was bleeding quite a lot and we actually asked them to take the tourniquet off and have somebody press while he traveled all the way up here. Um, because if they had kept the tourniquet on the entire time, he'd have had an ischemic leg by the time he got to us. Um, and he'd have lost his leg. So again, it depends, it depends on what your mechanism of injury is. If this is controllable with pressure, then that is always preferable. But if this is a, you know, if it's one of those mangled limbs, then no, that it, you're not going to be able to take the to off. I think it, it depends on what you think the injury is. If, if it's a superficial, you know, if it's the GSV, that's been got because the G SV can bleed quite a lot, I have to say, um, then fine pressing will be ok. But if you have someone who you think has got maybe the artery and the vein have been injured, then you're going to need a tourniquet for that because you're not going to be able to control that with just finger pressure. So if you're not particularly suspicious, sure, take the tourniquet off, have a look. Um But if you think there is a, you know, there is a major, major arterial or, and, or venous injury, leave it on, give us a ring no point putting them through the CT scanner is all I will say no point because we're not gonna see anything. Um Unless the tourniquet is not on tight enough, which is, which sometimes happens, you can see these, I have a couple of CT S for teaching of tourniquets that are on and very clear flow beyond them. Um So yeah, so again, I'm not giving you very kind of, you must do this, you must depend on your CT, but it's just useful to have those kind of nits. And because like I said, you read some place and they're like, oh just clamp the vessel, but obviously, like you said, not what to do, right? So it's good to have those ideas because they're the kind of things if you come across, it's nice to have a little thing of what you're going to do in that situation in order to particular, you have had to have done full dissection. You've got like putting in a clamp actually is incredibly dangerous if you don't know what you're doing. Yeah, I see way more injuries from people attempting to put clamps in if you cannot see the vessel, if you haven't dissected it all out. And you know, there's nothing behind it. That is the circumstance in which you put a clamp in other than that finger will do just fine. Yeah. No, that's great. Thank you very much. No problem. May soon. I'm Hussein. I'm one of the new Pelvic consultant staff next year. So I look forward to working with you. Um, thank you for that. It was excellent. Thank you. Um, from the orthopedic side pack it and don't do the peekaboo where, tell your anesthetist and they activate the massive hemorrhage protocol. Yeah. And call your vascular colleague. And generally if it's a vessel you can name, you definitely need vascular. I mean, I've been called to orthopedic theaters because there's been some sort of trench or breed and they've pressed and by the time I've got there, especially in the new movement hub because it takes so long to get there 99 times out of 100 the bleeding stopped by the time you got there. Therefore, it was nothing major anyway. Yeah. No, that's useful. Thank you so much. Just press. No clamps. Um Yeah, I just had a question about um with supracondylar fractures. So both says that you don't have to explore. Um you know, if the hand is perfused, even if there's no radial pulse. Now, I had a case like this very recently and she's been followed up and the pulse has come back. Is it, is it that you don't, don't explore because they invariably come back or so. So if there's, there's a, I've deliberately not put super condylar fractures in my talk today for this very reason because it is a slightly controversial area, the evidence would suggest and the evidence I put that between quotation marks because there isn't really, really good evidence would suggest that because Children remodel their arteries so. Well, it's the same with ischemic limbs in Children. We don't intervene. Um, they remodel so. Well, that if you've got good perfusion to the hand I eat, it's pink, it's warm. They will remodel and you don't need to intervene. You need to follow them up obviously. But that is the thinking behind them because children's blood vessels are very different from adult blood vessels. Um, and they tend to have very good remodeling ability. So even if you've got an intimal injury, which is almost always the because it's a stretch, isn't it? That is the mechanism of injury in these patients, they will remodel if you don't intervene in them. And actually, intervention has been shown to potentially have worse consequences than if you just leave them alone. So if they've had a super condyle, their hand is warm and pink, observe um and sit tight and is there a duration you'd say for that? You know, we do for nerves, we have a duration if we do investigations similarly for kind of vessel query, intimal damages with these, would you say after a period of time, we should get some imaging. Is there like exactly. So once you've reduced the fracture, the problem with kids are because you guys are going to have them in a cast, aren't you? Ideally you want some imaging? But you're not really going to get the imaging until they're out of the cast. So the time frame, I would say if in the 1st 48 hours is the most critical. If you've gotten out of that 48 hours and the hand is still ok, then you're probably almost certainly going to be ok. But they just need really, really close follow up. Um, if the hand is still pink and you've got the perfusion, but you still don't have the pulse, then you probably have to, 48 hours are fairly safe to say, ok, we'll leave this be and then once we've maybe followed them up in a week or two, take the cast off, feel the pulse again. And if at that point, we're still not feeling it, then maybe consider some imaging. Exactly. Exactly. So, at a week when your cast is off and you're seeing them, if you haven't got a pulse at that point, then they definitely need some imaging. Yeah, because you want to know what it is you're dealing with because you're not that I'm guessing would be the preference, would it in that case? Certainly in a ultrasound is our gold standard and we, we are very lucky. We have an excellent, like I said, an excellent vascular lab. Um, you know, if you've got a goodish lab, that is the ideal if you've got a good lab. Um, but if you've got a less good lab or people who are less experienced with these sort of very small, tiny little vessels, I mean, our guys will scan, you know, neonates happily. Um Not all centers will. Um So if you can't get an ultrasound scan, MRI is probably your next best bet. Um If they are old enough to sit still for it, um But discuss it with your local vascular surgeon basically because they'll know what the best form of imaging is available to you. That's great. Thank you. Any other questions from the audience? Uh I think that's it. Thank you very much, Miss, that's really helpful.