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Still lighting, right? Well, great. Hello everyone. Welcome to the last session of the undergraduate surgical teaching series today, we're extremely fortunate to have MS Katie. He, he's here with us to deliver a session on trauma and orthopaedics. Katie is an S T four on the Southeast Scotland Training program. She went to the Saint George's Hospital Medical School and previously worked in London and on the English South Coast, she hopes to eventually sub specialize in pediatric orthopedics outside of work. She loves the cycle and border without further a do. I would like to invite Katie to deliver her presentation. Well, thanks so much for Lucas for the introduction to Beatrice as well and everyone behind the scenes at the Surgical Society for having me. It was really kind of you. Um So we can talk a little bit about a kind of day in the life of an uncle with PD pressure today. Um I wanted to cover some stuff that I thought was kind of high yield for your exams regardless of your year of study, but also hopefully some interesting stuff that has border epic ability to whatever specialty you end up doing. And then if you've got some time at the ends happy to do. But if a careers chat and take any questions as we go, um I know you can type in the chat throughout. So more than happy if people ask questions at any point and if anything is not clear, please shout. Um So the day in the life, I think it's nice to get a bit of context and to what a specialty is like. So my alarm is set for six AM most days, which doesn't seem too bad to me now, although I think when I started it did, um and I like gobble up some breakfast and hop on my bike and I'm working at the Royal at the moment. So it's a nice short commute from the meadows for me. And this is kind of how my day works. I'm not, I'm normally at work before 7 30. So I think the thing about a surgical career is that it is, it is maybe a relatively earlier start and some other specialties get in hop on a computer check on any patient's. I've got in the hospital or read up on any cases. I've got for theater that day. You're in clinic and then orthopedics are day really starts with their trauma meeting at eight o'clock. And if you've done your placement at the Royal Cocody, um you'll hopefully been to those trauma meetings where you kind of discuss everything that's happened in the last 24 hours and what the plan is for the day, then we normally go on a bit of a ward round. Always get a coffee at some point. And when you've got a day in theater, you generally have your team brief at 8 30. And if you're in clinic, your first patient general at nine o'clock and then the uncles kind of change a bit as you become more senior. So when I first started in your first few years, when you're more of an S H O U generally like a 12 hour on call with a day shift, night shift pattern and you're on site the whole time. And now I do a kind of 24 hour on call, which sounds a bit scary, but I'm nonresident overnight. So I normally get an uninterrupted um night in my own bed, which is really nice. Actually, if your work life balance I find and, but today, your uncle, um we're going to do three cases. I think it was a pretty representative of the kind of spread and butter stuff you get referred as an orthopedic rich and as I said, hopefully some high yield stuff from your exams. Um So this is a bit of a busy slide, but it kind of is representative of the things you get called about when you're on call. And so there are three main camps of people that call you. Number one of the calls from any and the calls and GPS and the calls from the ward or other specialties. It tends to be like a really interesting smattering of stuff. You see loads of broken hips and lots of wrist fractures, ankle fractures and they're definitely some more spicy, high energy trauma as well, especially if you're working in a big center like Edinburgh. And then the calls from the community tend to maybe be, um, like you see lots of kind of POSTOP calls about people that had recent orthopedic surgery and maybe having problems. And you get lots of calls about kind of hot swollen joints and question of whether it could be a septic joint or not. And we're going to talk to one of those cases later on and then a whole myriad of kind of paced up problems, um, from the wards and, and as well, communication with families and, and patient's as well. You often get called to ask to do that, which is really important. But I think your first call is going to be a pretty bread and butter, um, a and equal. You are an 83 year old woman. She was found on the floor this morning by her carers. I think she had about six hours on the floor overnight. She's got some medical conditions. She's hypertensive, got some heart heart failure when she has dementia and, and it's pretty frail has carried three times a day use a trolley indoors and doesn't doesn't really get out the house anymore and she's, she's certainly very confused in a and E with names. Yes, score of two abbreviated mental test score. But we don't really know what her baseline is and you pull back the sheets and have a look at her and this is what you see. Um I think if you could talk back to me and ask you what this shows, but this is, this is a classic kind of clinical sign of a broken hip of a neck of femur fracture. Her left leg is the broken leg and you can see that it's shortened and externally rotated and the whole thigh looks a bit swollen and abnormal as well, which you quite often see with a broken hip. So, and the very sensibly send it down for an X ray and this is what we're looking at and we're going to talk a little bit. We're gonna have a little moment here to dwell on looking lots of X rays of broken hips because I think something that comes out very often in exams is high your topic and it's a good thing to get your head around. And this is a comparison. So this is a normal hair point hand side. Um Again, I don't, um Lucas, can you see my cursor or probably, unfortunately, God, that's okay. And don't you work at all? And hopefully this kind of demonstrates the difference between them if you see the the X ray on the left hand side, the broken hip, you can see that kind of jagged edge of the fracture just where the ball of the femur meets the shaft there. We've got some more X rays as well. Totally delete it, delete this a bit more. Um So when it comes to neck of femur fractures were absolutely obsessed with talking about like where exactly the fracture is and the femoral neck And the whole reason that we're so obsessed with it is because it really informs our treatment. Um So the big thing to get your head around. And I think if you take home, one thing from today's talk is I want you to understand the difference between intracapsular and an extracapsular neck of femur fracture. And honestly, if you can just get your head around that, that's like pretty much orthopedics nailed for your finals, honestly, because it's, it's probably those high yield things we ask about. So, um in the picture, you can see all the blue stuff that's extracapsular. So the hip capsule is an anatomical structures are kind of a thick kind of pocket of tissue. And it basically attaches at the front of the hip along the intertrochanteric line. So that's the hip, that's the line between your lesser to cancer and you're greater trochanter, which is the red line here is supposed to demonstrate that and then everything in the grain and the white is intracapsular. So it's inside the capsule and then there's lots of kind of little areas of the femoral neck where you can break be it subcapital. So that's just below the ball bit transcervical as the name suggests is right through the neck and then basicervical, it's right at the bottom of the neck just as it is, it's kind of nearing the intertrochanteric line. And I mean, the reason we're so obsessed about is it always kind of comes back to Natalie with us. It was all to do with the blood supply to the femoral head. Um If you remember, you have your femoral artery comes down and that divides into a deep branch and then yet these medial and lateral circumflex arteries, they form this little like network of retrograde blood supply up the femoral neck towards the femoral head. And if you have a break that's inside the capsule to an intracapsular fracture, there's a risk that those retrograde blood vessels can tear. If those vessels tear, your femoral head can lose its blood supply and the femoral head can die. And that's something called avascular necrosis. Um that's bad because it means that fractures won't heal and the femoral head collapses and becomes very painful and the hip joint sort of stops working. So all of our surgical treatment is influenced by the anatomical location of the of the fracture. And essentially, you're trying to avoid avascular necrosis of the femoral head. So, if you can just get that concept straight in your head. You'll be flying here, going to listen to nothing else I say. So let's kind of applies to some X rays now. So you can kind of put your anatomical knowledge to test so to speak. So this is our lady in A and E um So I would ask you if you're all together but have a think to yourself if you think this is an inter capsule, extracapsular or sub shock and subcontractors when it's right down the kind of formal shaft and whether you think it's displaced or undisplaced. So hopefully, you can appreciate this is an irregular fracture. I really appreciate if you haven't looked at many broken hips, it might be difficult to fully appreciate that. But I'm hoping that you can kind of visualize where the intertrochanteric line is and appreciate that the fracture line is medial to that. Um And so this is, it's a, it's a different patient and this time they've broken there right tip, have a little moment to look at that and think you decide if you think that's into it or extracapsular and if it's displaced or not. Um Let me here, you've got a nice normal hip on the left hand side to compare to hopefully, this one's a bit clearer that this is this intracapsular. So this is definitely kind of medial of that of that intertrochanteric line. And you can see that it's displaced as well. The, the ball has kind of fallen away from the normal anatomical position of the neck. And then lastly another break, this one is a bit kind of lower down the femoral shaft pretty distal to both the lesser trochanter and the intertrochanteric line. So this is a pretty classic subtrochanteric fracture and we say subtrochanteric, we mean it's basically below the level of the letter to cancer which is fractures and this is obviously pretty displaced. This is another one, maybe a bit more subtle. Um But hopefully, you can visualize that little black wispy line that's going right across the femoral neck there. And this is an intracapsular fracture again. But unlike the previous one, we looked at, this is pretty undisplaced. You can see that there's a break there, but the brain's haven't moved around at all. So looking after a neck, a fema fracture is, is a really important and really difficult thing to do. And I think broken hips in general are really high yield topic for your exams because there's so many different areas that you have to consider when you're looking after them. You really have to think about why they fell over the sorts of talk about kind of mechanical falls. But, you know, I I think that that term is a bit antiquated and you really got to take the time from your history and collateral history and examination to try and figure out why they've had a fall and make sure you don't miss something major like a heart attack or a stroke or a chest infection. Um It's not them with their feet. Most hostels have local protocols or performers are managing these patient's, which is great. Um The fluid resuscitation, if they need it, you know, if you've been on the floor for six hours with no, no food, no fluid, you're gonna be pretty rapidly dehydrated and you're already a very kind of frail person. Pain relief is obviously really important and and pain is such a driver of delirium. So, anything that you can do to mitigate that is really important. And then the next step to really should be, how can we get this patient fit for an operation as quickly as we possibly can. And and that often is with the joint help with the Ortho Geriatrics team. And this is there's been a real national drive in recent years to have better team working with the Ortho Geriatrics team. And those amazing clinicians are so good at optimizing these incredibly free operations for what is pretty major surgery. Um If you ever have a place in and you'll see some of these fascia Ayaka blocks happening. So this is a really nice way to give regional anesthetic. So um you can do it with a kind of landmark techniques and strain on the left or with no sound machine. You basically identify the plane of fascia around the iliac is muscle and infiltrate it with a big volume of local anesthetic, probably like 40 mills of quite dilute like anesthetic that something like chirocaine. Um and this basically numbs the whole kind of hip region. And it's a really good adjunct to analgesia. It means that you don't have to load up these frail old people and loads of opiates as well, which is really good. Okay. If you can take a photo of anything, I would take a photo of this flow chart because it informs our surgical decision making. So hopefully we've got it relatively straight in our head. Born intracapsular and what extracapsular fractures? And if you think it's back again, you know, inter capsule factors, we really worry about the blood supply to the femoral head. So the kind of remedy to that is to not to try and fix the fracture, so to speak is to replace the entire femoral head. We can look at some more X rays at that in a moment. Whereas fractures that are extracapsular or intracapsular but undisplaced, you can generally get away with trying to fix those fractures. They should have a good blood supply and should heal up. So let's look at those x rays again. And hopefully this will clarify this whole concept a bit more. So our patient are later, we decided she's got an extracapsular displaced fracture. So it's extracapsular. So we don't have to worry about the blood supply to the thermal head. So we can get away with trying to fix this fracture. And what we generally do that with is something called a dynamic hip screw, which is a big screw that goes into the femoral head and it has a barrel um in a plate alongside it where the hip can actually slide up and down on it. So hopefully, as the fracture starts to compress up and he'll the little screw kind of telescopes at the end of the plate. And that compression allows the fracture to heal. In contrast, though there are some extracapsular fractures that we fix for the different means. And this is with some like an instrument salary device which you can see here you can see here, this is a short nail. It only goes about the level of the mid femur. This is a really commonly used implant to fix extracapsular fractures that are a bit too unstable for a dynamic Kipps group. I wouldn't get too worried about trying to understand at this at this level unless you're really interested about what fractures require a nail versus a dynamic hip screw. But of course, I'm happy to talk about that, more people interested. But what I really want you to get a training head is that an extracapsular fracture you can fix either with a dynamic hip screw or an intimate gallery device depending on the fracture pattern. That's I think that's all you need to know if your, your finals and beyond. Um So other than type of heads actually inter capital a fraction. Hopefully you've noticed that, um, and it's displaced. So these are the fractures where we worry about the blood supply to the thermal head and to remedy that, what we basically do is just go and chop out the remnant femoral head and give them a basically whole new hip. You can do that with either a hemiarthroplasty or a total hip replacement. I think it's important just to dwell on a for a moment about the differences between these. So, um as the name suggests, a hemiarthroplasty, which is on the right here, that's kind of a half hip replacement. You basically only put in a new femoral component. Um That's in contrast to a total hip arthroplasty where you also put something new in the acetabulum. So new bit in the femur and new bit in the acetabulum. And then how do you decide what patients' get hemi or which, which patient's gonna total hip? Um It's quite kind of controversial area in the literature and the neck of femur fracture population. But you know, a total hip replacement surgery is a bit longer is a bit more risk of blood loss because you're having to remit into the acetabulum. But arguably the functional outcomes are a bit better because you've now got a new articulating surface in the acetabulum and, and new articulating surface in the femur. So kind of traditionally, if you had a patient who broke their hip, he was a bit younger and very active, you know, still walking, still driving without any mobility aids. Um You'd probably t them up for a total hip replacement because they're a bit, you know, you talk about being a bit of like a better physiological patient. That that's a fair thing to say. Um whereas the kind of older frailer patient's lower demand, all the evidence seems to suggest that they just get just as good an outcome with a hemiarthroplasty. And it's a shorter, quicker, easier operation with less blood loss as well. So our subtrochanteric fracture, so again, we're far extracapsular here away away from the capsule. So these are the kind of fractures you can get away with fixing. And because these breaks happen a bit further down the femur bone, they need a bit more stability. So you generally use another introductory device, but one that's much longer that goes right down to the knee that you can see here. So there we've got another inter capsule fracture, but this one, this time is undisplaced. So this is where it can get like a little bit confusing and this is something I really wanted to get clear in your mind. So all this time, I've been saying that, you know, intracapsular fractures, we worry about the blood supply. So we just chop up the femoral head and give them a replacement. But in a break like this where there's really not been much displacement of the fracture fragments, you can try and fix it. And the reason you would do that is that you then preserve the patient's native anatomy. You keep their own femoral head, which generally is always better than a fake metal one that you've hammered in. And there's lots of ways you can, you can fix intracapsular factors. But traditionally, we use these things would cannulated hips cruise and we put three of them in, in a kind of upside down triangle configuration just like that. And again, this is kind of a controversial area in the hip fracture literature. Um But the majority of these have done well, they should heal up fine, of course. So you're always going to have that risk of avascular necrosis that I spoke about before. So you generally kind of follow these patient's up for a bit longer. And if they do run into problems, if the break doesn't heal or the femoral head starts to die, you basically can just go back in and give them a hip replacement or a hemiarthroplasty as a kind of delayed salvage procedure. So what actually happened in the, in the operating theater? I wasn't quite sure how much like blood and gore people wanted to see. But if, if you want to scan this QR code, it's a really good uh youtube video about a chap doing a dynamic hip screw. Um And hopefully during some of your clinical placements, you'll get some time to come to a orthopedic trauma theatre and kind of see this in reality. So you set up the patient this kind of extreme way on this, on this traction table where the broken leg, which is the straight one gets pulled out by this long metal bar and then you push the other leg out the way. And then the big kind of white plastic thing you can see coming in that's like a mobile X ray machine. We call the C arm because the whole operation you do um under kind of X ray guidance. So you can see where you're putting your screws on your plate into the right place. Um Make a big kind of cut down that person's thyroid as exposed, get down to the bone and put your plate and screws on. But yeah, that, that youtube you is really good if you want to see it kind of step by step surgery. The other thing about neck of femur fractures, it's really important I think to, to talk to the family about the difficult side of if this injury, it's like a really, really high mortality injury, it's like 10% at 30 days is the kind of national Hip Fracture audit data. Um So I think it's really important that the families understand early doors just how serious it is. And it's really important to establish if the patient has any kind of living will or advanced directive or a power of attorney. Um And I think pretty much every neck of femur fracture that comes into the royal and probably gets a do not resuscitate form signed unless they're like, you know, a very young fit person, just the nature of this, this patient populations, they're incredibly frail. Um And it's really important to have those resuscitation conversations early on. Okay. So we'll move on to case to making reasonable time, which is good. So now we're going to maybe like the spicier end the high energy trauma. Um So again, an equi and so I've got a young woman, she's coming for a motorbike about 15 miles an hour. So not massively fast speed and he's got a very swollen deformed lower leg. And at the moment, this is, this is all they can tell you. I think when you get a call like this, there's loads of like loads more information you need to know here and I've put it in the slide here. So lots of questions you to come to your mind. I mean, this is a young person that's had a high energy injury and you kind of have to, you know, revert to those A B, you know, a A B C D E principles of management. I don't know if you've, and if you've had a A T L s, but it's the kind of advanced trauma, life support system. Um And again, it teaches you that same A B C D E systematic approach to managing a multiple e injured trauma patient. And you just got to address the things that are going to kill the patient. The quickest first and a swollen deformed leg is probably not going to kill you very quick compared to like a devastating c spine injury or, you know, losing your airway. So it's really important not to get fixated on the obvious orthopedic injury. But think about everything else. It's good to get a bit more in the history. Like, were they wearing any personal protective equipment, whether they have leathers on or a helmet? And what happened to them, pre hospital, did they have any splints put onto their legs? Was that c spine and mobilized? Maybe they had a pelvic binder put on and increasingly that pre hospital services are getting more and more kind of intervention als they can give antibiotics, they can give blood prehospital, give tranexamic acid sometimes as well. Um And then I think once you've done your initial resuscitation, ascertain the patient's stable, the next question really is if they need to have a trauma CT, which is basically a pan scan, a kind of top to toe, um, CT to look for any kind of major visceral injuries or injuries of the heart and lungs. And, and then again, this is a patient has got a nasty break of their distal tibia. This is going to need some kind of operation. So you can start thinking okay. How are we going to get this patient to the operating theater in a timely fashion. Have they got any medical conditions? We need to think of any allergies. So they starved for theater. So a little bit about describing a fracture. I think this is a really kind of important kind of fundamental thing to learn to communicate. Um I love the star acronym. I think it's really good. So if you describe a break, you can say if it shortened, translated angulated or rotated, um that to me would be really like impressive if someone was describing a long brain fracture to me and they went through those four things. So if we go maybe back a slide and look at this young young woman's break, so you can see that she's broken a distal tibia bone, that's the thick bone in your shin there between your knee and your ankle. Um It's probably a little bit short just because if they're gonna nature of the break, you can see it's a little bit displaced and you can see it's translated a little bit towards the fibula. So it's translated out laterally. It's not particularly angulated. If you look at the lateral, like the back of the, of the tibia or lines up quite nicely, but there probably is some rotational element there, isn't it? You can see it's this kind of spiral pattern of fracture which you very kind of commonly see in the distal tibia when a like a rotational or a torsion, all force has gone through the foot and this nicely leads into all these different fracture patterns that we see. So transverse is really common. That's just like a kind of simple fracture straight across the bone. Then you can have a bleak fractures which go more of a slanty angle or a spiral fracture like this young woman has where there's been this rotational force through the long bone. A greenstick fracture is something we see mostly in Children where only one side if the bone breaks, but another side of the cortex stays intact. And a communicated fracture is just a way to say it's in lots of different pieces or multi fragmentary is the other words you might hear people used. So going back again, I think the perfect presentation of this fracture here would be, this patient has a displaced spiral fracture of the distal tibia. We classically break the bones into thirds. So you say distal third of the tibia, um there's a degree of shortening valgus translation and rotation to the injury, but it's not massively angulated. I think that would be that would be a good um description. And if you're really beady eyed as well, you're on the lateral, you can see that there's a little chunk of the posterior malleolus of the distal tibia as well. So you can even say this is an intra articular fracture. It goes files right down into the patient's ankle joint, which is kind of important for planning your surgery. So you go down to A and E you see them, you take off their motorcycling leathers and you see this little red wound staring at you and it's kind of dripping dark red blood and they've got a very kind of swollen deformed looking calf. This is the classic kind of picture of what a open fracture looks like. It's only a small wound, but that is some bone trying to poke through the skin, trying to get out into the open world. And when we talk about an open fracture, that's what we talk about. It's basically a broken bone where the soft tissue end of the rope has been breached and cortical bone is now in contact with the with the outside world. Generally, there's a very kind of famous classification system for open fractures called the Bustillo Anderson classification. Again, this may be is kind of fair game for your exam. So probably worth worth learning. But essentially, there's type 123 A B and C. Um Type one is a little puncture wounds a bit like what this what this patient's got. This little tiny thing would be a grade one open fracture, so less than one centimeter across and and then a type two would be a 1 to 10 centimeter um wound. And then the type threes are the really nasty one. So that, so the type three is always more than 10 centimeters and then uh three A, you'll have minimal stripping of the periosteum. So that's that soft tissue around the bone. Um A type three B, you have lots more periosteal stripping. So the bone has really been like chewed up through the injury. And the type three C, you have a vascular injury as well. So you might have a major are three or vessel that's been lacerated to injury. And the really important thing about this, um this classification system is that your only really supposed to apply this after a fracture has been debrided in theater. So you can initially have something that's quite innocuous in A and E but by the time you've done your full debridement, you can quite easily be looking at a type three open fracture. So it's really important that the kind of immediate management of open fractures. And this is the have these great things called boast guidelines. That's the British Orthopaedic Association standards for trauma. And they've got loads of great guidelines from everything from kind of Children, supracondylar fractures to open fractures, to pelvic fractures, you name it, they have a guideline. And then I said generally just one, a four sheet and an open fracture management. I think it's absolutely fair game for exams. And it's really important thing to know. Basically, the most important thing is to get the patient antibiotics as soon as you possibly can choose it a bit like sepsis, I suppose, like the more time you wait, the higher their infection rate is going to be. So the quicker you can give it the better you generally give them something broad cover like a co amoxiclav if they're not penicillin allergic, um, it's good to kind of remove any gross contamination. So, like they've got like bits of tarmac in there or grass, pick that out, but don't try and do anymore. They used to be this like many years ago. There's this big trend for kind of washing these wounds out in any, whether they're saline, just, just don't bother, you know, they're going to get a better debridement in theater and you're not going to add anything by spring. Some saline in a, any, um, take a photograph of the wound if you can and then cover it up with a addressing which is generally a kind of saline soaked piece of gauze. And the reason you do that is to take a photo and then cover it up and don't keep like peeling off the dressing and looking at it because every time you do that, you're introducing more bugs into the wound. So, splint limb, either with a plaster cast or a fabric sprint splint or whatever you've got in the department and, and then make sure you've done a nice examination of the neurovascular status of the limb document that and then make a plan to take that patient to theater. So this is what a tiny grade one open fracture of the tibia can end up looking like after you've debrided it, after you cut back all that like devascularize, devascularize skin. Um all that periosteal stripping, you can certainly end up with a really, really big hole and you can tell a whole like that you're not gonna be able to so the edges back together and close primarily. So this is where these things get really interesting. And we also have to work closely together with the plastic surgeons who come and help us fill in that hole generally with some kind of free flap from elsewhere in the body. Um So they might take a bit of uh tissue and muscle from the top of the thigh or even the tummy or the back of the shoulder blade and basically transport that bit of soft tissue with um an artery still attached to it. It's very cool, then plug it back in to the whole you've got in the tibia. So the tiny, tiny artery back together and then you end up with a whole nice vascularized chunk of skin and fat and it's great at covering those deficits, um a tibial fracture. Um We generally fix with, with an intramedullary device a bit like what we saw in the neck of femur patient's and with something like a tibial nail which you can see on the top there. Um and even made these really kind of new snazzy ones. Now, the blue one where that that nail is actually covered in antibiotics. Um So especially in like an open fracture scenario where the infection risk is really high that can help minimize your risk of infection. And in a perfect world, you try and do this all at the same time. So take the patient to theater once. Do you have a Bride Mint put your tibial nail in? So you kind of fixed the fracture and then deal with any soft tissue deficit you have with, with whatever flap you're going to use. Sometimes though we can't use internal fixation. So we have to revert to something like this like an external fixator. And they have lots of different uses beyond the trauma context, but generally in a really, really nasty smashed up to be out with a nasty soft tissue envelope, they can be a great thing. There's a kind of temporizing measure where you're waiting for the soft tissues to settle down or where you're waiting for more definitive surgical plan. Um They can also be using them all kind of elective setting like if you're trying to lengthen a limb or do a deformity correction and sometimes you can even use them a circular frame. So when that gets all the way kind of around the leg and the foot to provide a more kind of detailed deformity correction, but generally in a trauma situation, you're putting on a pretty rudimentary like this, it's just like a few um carbon rods and a few metal pins into the tibia. This is quick, you know, allows you easy access to the rest of the leg. So the vascular surgeons have to come in and do some kind of grafting of an after they've still got plenty access. And in the meantime, the bones are being held reasonably stable and supported. They're not great though. Um, you know, they're cumbersome to have on patient's often don't like them and they have quite a high infection risk as well. Um, that's good back there. If you can imagine where those metal pins are going into the ankle. If they hang around there too long, it's quite common to see a superficial skin infection developed there. And then couple that was someone that had a nasty open fracture. They really can become a hot bit for bugs. They don't provide you absolute stability in the same way that an introductory nailed us, which sometimes is fine like in things can still heal up with that, but they're not always a brilliant kind of definitive fixation technique. Okay. Last case. Um, so now again, you only call you and they'd like you to come see a middle aged chap. So he's in the sixties, he's had this painful, hot, swollen knee for about 24 hours. And I was saying this is a really, really common thing you get called about is an orthopedic reg and I hope he has lots of kind of teaching points. For your exams as well because there's loads and loads of reasons why you can have a hot swollen knee. They're not all, uh, septic arthritis or they seem to worry about that a lot. So, they work up for a hot swollen joint, I think is pretty comprehensive. And you've got to make sure you've asked lots of questions and done lots of, kind of investigations to try and explore every possible differential. So it's really good to get a clear history from the patient. Like, was there any trauma, did anything happened to your knee um to kick this all off or was it just out of the blue? Have you ever had anything like this before? Ever had any previous issues with your joints or any previous cellulitis, any skin infections before? Um and then do a really good kind of focus orthopedic and rheumatological history. So ask about things like gout and ask about rheumatoid arthritis or osteoarthritis because those are going to be your kind of top differentials in your mind. It's really important to establish if the patient's immunocompromised. So, you know, see diabetics all the time or people on long term steroids and let alone people on kind of chemotherapy. And uh there are agents like that. It's really important to establish early on if this is a native joint. So like a joint you were born with or if this is a prosthetic joint. Is this a, is this a joint if had operated on or replaced by an orthopedic surgeon because that kind of fundamentally change is your, your thinking pattern as well because the hot swollen, um, you know, total knee replacement that, you know, and he has had surgery. Um, it's a kind of much more different beast than a native knee that's hans for them because it's kind of much more likely to be a, you know, an orthopedic related issue if you're having issues with a prosthetic joint, um, kids do a social history, find out what they do for work. Do they do lots of kneeling over or are they on their feet? A lot good to ask about sexual history, especially in those kind of young people. Um You can present with like writers triad, which is like a into particular gonorrhea. You do see it from time to time and if you don't ask, you might never know. Um And then the examination is really important you want to see, you know, is the patient, well, like they, they sick, they toxic. Are they septic or they kind of walking around quite happily, um, have a good look at their knee for any scars, which might indicate previous surgery. And really the biggest thing. And again, this is one, you know, one thing you're going to take home from today, if you're examining a joint that you suspect has got septic arthritis, pretty much, you know, without a doubt, the thing that the patient will loses their range of motion. Um, so that is the most important thing to ascertain, you know, when you see someone who's got a truly septic knee or a septic hip there in an absolute agony and they're generally pretty unwell that so if you try and move that knee or hip at all, they'll just absolutely scream. They won't let you touch them. Whereas people that have gout or pseudo gout and more of an inflammatory arthropathy, it might have a big swollen knee, but they will still be some movement in it. They're probably still be up to walk on the knee. And that's a really important clinical differentiator. I think between things like gout and am septic arthritis to give them a really good work up, make sure they've had a set of bloods done, um, including checking the uric acid, which will help you figure out if it's gout or not, check your inflammatory markers like the CRP. I mean, yes, excuse me, I guess it's me and Jamie's always helpful to get an X ray of the joint. Um So there is a prosthetic joint. So if this, if this is someone who's had orthopedic surgery on a joint before, um I would say just involve orthopedics much, much earlier on, we always want to know about these patient's, I guess we feel a bit of a sense of ownership about them. Um And it, this can be really kind of tricky situations to manage in regards to antibiotic treatment. And I essentially would just say, do not give them anything unless the patient is dying of sepsis in front of, you don't give them any antibiotics until you've spoken to orthopedics. And that's generally because we need to decide if we're going to try and take a sample from this joint before we start treatment. And the problem is if you start antibiotics, you can kind of muddy the water and it can become even even harder to get an organism from that joint. And if you can't get an organism from a joint, it makes tailoring your long term antibiotic treatment really quick, really tricky. Um Because if, if you get an infected knee replacement or infected hip replacement, your general and antibiotics for a long, long time, like weeks and months and if you can get the organism, that's great because you know exactly what you're trying to fight then and again, yeah, getting an X ray is always useful, getting blood cultures is always useful, but don't try and stick a needle and aspirate a prosthetic joint without talking to us. Um That's really our responsibility to do as orthopedic surgeons. So hopefully during a placement at some point, you'll get a chance to do or practice joint aspiration. It's a really kind of important skill. I think it's, you know, it's ready to be straightforward to do, especially knees if you've, if you've done a few. Um And you can see here this image on the left, they've got a kind of big swollen and they're pulling out this kind of yellowy colored fluid, hard to know that looking at that, but that looks kind of classic, like the kind of fluid you see in gout where it looks a bit kind of more yellow than usual, bit more angry. And then this person is doing a wrist aspirate here as well, which is a useful thing to know how to do as well. And that E M E M wrap youtube channel is really good as well. They've got some great aspiration technique, videos, actually loads of great videos about this on youtube can explain it and show it much better than I can. But this is the way to get your definitive diagnosis. Doing a joint aspirate is the only way you're going to find out if a joint is infected or if it's got something else going on like gout pseudogout because any concerns to the lab and look at it under the microscope. So hot, swollen knees top differentials. So if it's not septic arthritis, there's lots of other things that could be a big thing is gout and pseudogout. And this is where an X ray can be really useful. So the X ray on the top right there, the two little arrows are kind of pointing to that little like Wispy ghost like um little semi circle halo around the periphery of the knee. Um and that is chondrocalcinosis iss which is um like, you know, the X ray sign of deposited calcium pyrophosphate crystals, which is pathognomonic of pseudogout, I'd say. And pseudo gout can, it can present just like out with a big painful hot swollen knee. Now, generally have inflammatory markers. See the roof as well have a high CRP an ESR if you've got nasty arthritis that can present as a kind of flare up of pain and you can have a big hot swollen knee. And generally, then your bloods would be normal and you have a pretty good range of motion in the knee still. And, and then pre patellar bursitis is really common. I mean, I think traditionally called a housemaids knee. I don't think you shouldn't call it that anymore. But I suppose if it helps you remember that, you know, this, it's predisposed people that do a lot of kneeling at work. So quite often see in manual laborers, electricians, plumbers and, and that's very much a swelling that's localized to the pre patellar region, the knee itself will always move really nicely. They'll should have normal blood to normal X ray. Don't try and aspirate these. It's just, there's nothing really to aspirate and you won't get anything. And then the X ray in the bottom right hand corner, this is showing a lipo hemarthrosis iss so that white arrow is pointing at this fluid level within the knee and that's a layer of fat kind of floating on top of a layer of blood. Um You can see that change in the density of the tissue and you generally have a lipo hemarthrosis if you've had a fracture or a ligament injury inside the knee. So you're quite often you'll see this after an ACL rupture, which is why your knee swells up so much if you ruptured ACL or if you have something like a tibial plateau fracture or another fracture inside the knee, hot swollen elbows. Again, he's commonly and you know, 99% of the time is this thing called olecranon bursitis, which is just inflammation of the bursa around your elbow joint. There, it can quite often look quite nasty and it's really kind of like nubbin of hot red horribleness around the elbow. But despite that, the actual elbow itself will, will move nicely and have a full range generation. Um, sometimes you can have a little kind of discharging wound as well. Um But you know, again, like a bit like a people tell bursitis don't try and aspirate these, you're more likely to introduce infection than, than make anything better. These generally settle down with them, some oral antibiotics for a couple of weeks. Horse well and wrists again are really common, especially kind of older women. I I find and quite often it's, it's just a flare of, of osteoarthritis or maybe a bit of pseudogout or a different inflammatory arthropathy. V you very rarely see a true septic arthritis in a wrist, although it does happen, but I've only ever seen it and, you know, really kind of unwell immunocompromised patient's that had, you know, a bacteremia going on for another source. And it just happened to see into their wrist joint. But again, the only way to find out is by trying to aspirate the joint. Um, it's quite easy to aspirate your wrist if you, those youtube use are great. But if you feel on the back of your wrist, if you kind of by your thumb, so on the radial side, if you rest and you'll feel a radial styloid, which is the end of your radius bone. If you come towards the middle a little bit and down, you'll feel another little nubbly bit. And that's something called Listers cubicle, which is like a little nubbin on the end of your radius bone, you can feel that little nubbly bit and then just go tiny bit more distal. You're pretty much always fall into the wrist joint. Um, find it there. It takes a bit of practice and it's pretty sore for the patient's. Um, but that's the way to where to get it from. It is much safer than trying to aspirate very early because you'll invariably go through the median nerve or the radial artery or something on the way in which would, wouldn't be great. Um, quite often when you try and aspirate a wrist you, you get a dry tap so you'll put a needle in you and you know, put a big needle in like a big white needle and a 20 mil syringe. So you like a nice lots of suction power if you know what I mean? And you still get nothing out. And what you can do then is take like a small volume of sterile saline, actually inject that into the joint and then aspirated back and hope that that's caught with it. Any bacteria or they're like crystals that are in there that you can see in the lab. It's a good tip but hot swollen fingers. That is something to be, be aware of and be really cautious about this because I feel like I was never taught this in medical school. And then, you know, you end up seeing it quite a lot when you do orthopedics. But um you can get these really nasty infections inside your flex a sheath in your finger. Quite a flex 30 no sign of itis. Um Your flexes are the muscles that kind of flex, the small joints of your hand like this. And if you remember you have two of them for each finger. But yeah, flexor digitorum superficialis haters and your flexor digitorum profundus, they kind of travel through this little tunnel a bit like a train going through a tunnel. And if infection gets into that tunnel, it can be really nasty and it can spread all the way up into your palm and into your carpal tunnel into your forearm. We can just keep going and can very rapidly make you very unwell actually. And, and it gives you a horrible kind of fibrosis in your finger. So you get really terrible long term function. Um It's really good to know this for exams. Therefore, can eval signs of flecks of sheath infection. And this picture illustrates it really nicely. So you just have this hot um like sausage finger. So you had a fusiform swelling of the finger. So it's all the way around. Um You'll be painful along the flex of sheath when you press it and then the finger kind of starts to hold itself in flexion like that because I guess maybe it reduces, reduces the pressure within the flex of sheath and it's less painful. But if you then try and straighten out the finger, the patient will really hate it and they don't like it all. And if you, you'll see some of these nanny and they're awful. It's like this big, horrible red hot swollen finger and the patient won't let you touch it. And it's like, yeah, I don't, you know, flex a sheath infection, absolute easy diagnosis, so to speak. And this is an urgent washed out in theater. It's quite a nice operation. You make a little cup over the kind of the a one pulley in the hand here. So I should have put some photos here and you basically put a little canula up into the flex of sheath, like into the tunnel and put lots of wash through. Generally does really well after that. But you need to get in there and drain the pus out of it and you will often genuinely get some pass out of the finger. So I think that's, that's good. That's what I want to do. Pretty much 50 minutes. Exactly. Doing, um, the clinical stuff. So, I haven't got anything more for that. So, I don't, if you had questions they wanted to put in the chat more than happy to take anything. Um, and I was just going to do a little brief five minutes on a career in TNO now, but more than happy to, um, go through anything again. Um, we can have a breather for five minutes. Um, and I'll be, I'll be quiet and let people type away if they want to and I will, I'll have some diet cake and if no one's asked a question, I'll just crack on. Yeah, I hope that was clear. I think if there are three things to get straight for your exams that neck a fema, um, intra versus extracapsular thing that's really just important to get your head around. That, um, so I think other things that would be really good for exams. I think it's really important probably to know about being, I haven't talked about much today but about about gout and pseudo gout from the different types of crystals. Um and how they look under the microscope that's probably like a really high yield stuff. And I guess a third one is getting on a kind of infection. Um topic would be common like positive organisms for um for infections. So, understanding about, you know what staphylococcus aureus is, you know, really common organism you see for brain enjoy infections. And then furthermore how the antibiotics work that target that. So how penicillins work and how careful supporters work, things like that and all very highly testable things. Cool. So no questions have come through. So we'll, I'll do a quick little five minutes peel and what a career in Tina is like, I'm obviously biased, but I think it's really, really fun. I think it's a really, really interesting job. It's a super interesting varied field and whatever you like doing whatever your personality is like there will be, I think a niche for you within the specialty, whether you like hitting things with really big hammer, like in the top right hand corner or if you like doing tiny things under the microscope and like the photo belay. If you like working with kids, you like with the adults, you like working with everyone. If you like doing sports stuff. If you like doing trauma stuff, if you don't like doing trauma stuff, um honestly, there's, there's, there's enough non trauma work out there. Um If you enjoy the operating, um, enjoy the anatomy and enjoy doing practical things with your hands. Um, I did my training down in London where it's just kind of where I grew up and then I worked on the south coast of England for a bit and Brighton, which is great. Um, uh, but my family live up in Scotland so I came up here, um, about three and a bit years ago now and it's been great. We definitely really, really enjoy it up here. The training programs brilliant and it's a beautiful city to live in. Well, lots of fun outdoor activities on your doorstep. Um So I'm on the kind of Edinburgh registrar's training program, which is, which is nice to get you in A S T one and take you all the way up to ST eight to the point where you're kind of ready to finish your training and, and then that whole eight year period you remain within South East Scotland. So you're only ever working at the Royal um or the borders in Melrose um in five think Khadi. Um And sometimes you got to the Forth Valley Hospital. So everything is like, you know, within an hour of Edinburgh. So you're never doing massive long commutes, which is great. I want to get some of my friends still working down south, like working in London or on cancer and Sussex, you know, it's not uncommon to have like a two hour commute. Each way, if you're not able to move um to be closer to a placement and if you've got like a family, you're young kids or other commitments that becomes really difficult. Um So you get this great kind of stability of being in a training program and it's really nice, you feel like, you know, you're a bit of an apprentice, people are invested in you. They want you to do well, they want to see you improve. Um Have a lovely bunch of colleagues in Edinburgh, really nice, different mix of, of personalities, but I think you'll get along really well. Um I certainly feel very well supported by my seniors. I think there's been this real kind of push in recent years to, to improve the kind of equality and diversity on the training program and our intake, I think is getting there slowly becoming a bit more reflective of a um a different kind of person beyond just like white men, which is great. And I think our intake um last year was about 30% female and on a whole, you know, when you look at the program for the whole, there's about 30 of us and about a third of us are women, which is great. We're definitely lacking in diversity in other areas, but it's getting there and people are talking about it, which I think is a really good first step and I have a brilliant work life balance. I've still managed to cycle about 100 ish miles a week throughout most of the year and declining a few times a week. Um, and have a lovely time at the weekend with my friends and family. Um, which is great. I definitely don't feel massively overworked on the whole, I think. Um, and I'm also looking to come out of program for a bit next year as well when there's lots of opportunities to do that, to do some teaching and some research. So, um there's definitely opportunity there sort of take your foot off the pedal for a year or two if you want to. And I thought this is, this is like you got to talk about the stuff, you got to be honest. So this is, this is just the, the Scottish calories for full time training at the moment, this all might change by the time you guys graduate. Um depending on how the strikes go, I suppose, but you're paid well. So to a banding is probably pretty representative of most on call, um, rotors in most like acute surgical and medical specialties. Um You can see here that you get really like healthy salary if you're doing a lot of phone call out of hours time, which you generally do in our line of work. Um So the bad thing is that, you know, it's competitive to get in. And when I think back to when I was in S H O and trying to build up my portfolio. That, that is a stressful time because you're trying to, you know, really put a tick in every box and doing loads of extra work at your weekends and your evenings. And I know you are speaking to Lucas at the start of this and it's hard because the goalposts keep changing and I know they've changed the way they're doing, um F one allocations. Now they've changed the way they're recruiting score surgical training. So that can be really disheartening when you worked really hard to build your portfolio in one area and then it becomes irrelevant. So that, that's difficult. Although, you know, hopefully that, you know, even if you do a project and, you know, maybe it doesn't necessarily contribute towards your recruitment that still developing you in other ways, you've got to bring these things positively. Um The workload can be bad and I think it certainly depends on the type of job you're doing. Um you know, it's not uncommon if you're doing a busy trauma job for it to be the norm to be, you know, at work 10, 11 hours a day, plus every day, um that can get really difficult and grating, but it's generally not always like that, it kind of comes and peaks and troughs and the ankles. Do you get a bit tiring? I think it will be like old and fed up with it now. Um But again, you know, you adapt, you get used to, it actually become more confident and your knowledge grows on calls become kind of a, maybe a less stressful experience the whole because, you know, you can deal with most things. Um There's a lot to keep up with. Um, in your training, you've got a, you've got a portfolio that you've got to maintain every year and you got to do these things with WB A, that a workplace based assessments, you gonna do about 40 of those a year. Um when you're in training, which is all pretty cumbersome and you got to try and log at least 300 cases in your log book, thvso surgical cases. And that's become really difficult in COVID times for sure. There's been massive disruption to elective operating, especially. Um, but everyone's kind of in the same boat without like everyone is struggling to meet their numbers, which is a real shame. I think everyone probably have to extend their training in this climate, but it is what it is and you can only make the best of it. It's also seriously expensive to be a surgical trainee. Um uh the exams that you do like your, your mrcs um, to do part A of that. I think it's about 600 lbs and then part B is like over a grand, I think, and they have something like a 30% pass rate and you don't get refunded if you, uh if you fail. So you're always going to be kind of be a bit savvy with your financial planning if you're thinking, especially, I think you sit in your exams early and then you've got loads of yearly subscriptions to keep up with that U G M C. You know, they charge you 420 quid a year to keep your DMC registration at ST four. Um, but like you've got to have it to your job and, and all these acronyms are basically just other professional bodies and memberships, some of which are kind of mandatory, some aren't really mandatory, but you know, it's part of your kind of professional development. So it all does add up and you can claim tax rebate on these, but you will not get it for that. You were funded. So, um, you're paid well on the flip side. So I think that was all I had to say. Um, really more than happy to take any questions in the chat box. Now, if people want to email me, I'll put my email up in the chat box. Um, I really hope that was useful and interesting smattering if some, um, some original for some of you guys, I'm sure some new stuff for other guys and getting you ahead of the curve if you're not on your orthopedic placements yet. And if anyone's interested and want to spend some time in the department and what's to come to theater, come to clinic and drop me an email more than happy to put you in touch with people and find some interesting things for you to do. But all in all, it's a great job. I think it's brilliant. Get to do fun operations and like hang out with my pals all day. So I would very much recommend it and I'm going to stop presenting now and hope Lucas is going to swing in. Yes, I am. Thank you Katie for the wonderful presentation and it's very comforting to see that you're able to maintain a good work life balance, contrary to stereotypes. Um Just before all, if you leave, we'd really appreciate if you can fill in the feedback form. Uh This will be super helpful. Um You will receive a certificate of attendance after you fill in feedback form. Um Otherwise, thank you for attending and I hope you guys have a great week ahead. Thanks again for you guys for organizing and well done with a great series. Appreciate it.