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Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (2)
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Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (2)
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Language: EN.
Segment:0 .
My name is Nicky Evans and.
I I'm one of the faculty of this course, so the idea of this course is that we give you a little bit more teaching rather than just the intensive vyver course. So we allocate a little bit more time and the faculty have picked cases that, you know, probably warrant a little bit more discussion and we need to make sure that you get it right for your exams.
So the way the course will run is that we've allocated an hour to each section and there's six questions six candidates. We'll ask it. We'll give you a bit of time to walk through the answer and then we'll give you the information that we think should be in a model type of answer. There should be time for questions and the focus will be on the participants.
But if the observers have some questions, then we can always discuss them as well. And we've allocated a lunch break in the middle and we'll do a summary at the end of the day. So we've already named you all. So P1 to six will be the participants and we can see that usually. And we'll just go through and ask you the. We'll have a little chat at the end, I went to an update course last Saturday and I got some information on the part two exam about what we can expect in the future.
So I'll have a little chat about that at the end of the day. But as it's now 9.4, I think we should probably start soon. When first comes back, we might run through his slides at some stage, but I can't move them on. It looks like he's just going to outline the course. And so we've also got the intensive vyver course coming up next weekend. I think in combination with OK. We've also got a basic science course, which is running, I think, the week after.
So they're all available on our website, which is orthopedic Academy. Co.uk and you can book onto those if there's spaces available. So I think we can fill us back seriously with us. Can you hear me? Yes, we can. We can't, we can't see what we can do. I'm very sorry about that.
That's OK. Um, I was I don't know what happened, but. Can you hear me now, ok? Yeah, we can. So I just outlined the course and I was hearing you completely. Yeah thank you for that. So obviously, please see my screen this.
Our faculty have been handpicked for their teaching skills, particularly the field of as far case exam. And as Nick explained, it will be a case discussion course where we take you through the cases. They are high yield exam specific questions. And so you will most likely will encounter a few of these questions in your example. OK this all previously asked question exam questions.
So what I encourage you guys is. This is going to be a long day for you. Yeah, and that's exactly how the exam will go. The exam is a long day. Yeah so look at this as a marathon. It's not a sprint. And stay focused throughout the day. So when you are asked the questions, obviously you are in the spotlight.
But when your fellow candidates been asked, questions also stay focused and imagine this question been asked to. And when the answer is given. See if it goes in line with the answer you were going to give if you were the candidate. We want. We're not here to teach you Orthopedics at all. Yeah, we are here just to encourage you and mentor you to score your highest potential score in the exam.
OK, we'll ask you to please, guys, obviously, as you could see to me, they can be technical problems. Don't worry about it. If you miss out anything, we will, we will go through it again for you. But please, if you are not answering, stay muted and just to give your fellow candidates time and the space they need to answer.
OK And obviously, follow us and we are doing some more courses, case based discussions and basic sciences courses, so we will be very welcome to discuss those with you later on. If you interested. And without further ado, we will start the course now. So we'll go through the whole old stations of the exam as it is with the new format. And we will start with basic sciences, as you are all guys fresh in the morning.
So we have allocated you can't get participants from 1 to 6. And we we'll go into in that order. Yeah observers, obviously there are a number of observers here. Some of them could not get a chance of space because we are limited, obviously because of the structure of the course to how many participants we have. So and yeah, there would be a number of observers as well with us.
So without further ado, I will hand over to Mo now to start the basic sciences session. All right. OK, so just start by. So 10 minutes each. OK, right. So watch this video for me. In terms of what you see. OK say a video of a patient walking.
I can see her using a stick on the left. I can see that her hip is sagging on the right. This would be in keeping with a trend, then typekit the shoulders do not seem to be drooping that much. So I would expect, Yeah. OK, so imagine trying to find it.
What do you think of what would is holding the stick? So she's actually holding said I was looking at this. She's holding the stick on the left, which would indicate that the problem is on the right. This would indicate that she's attempting to bring the anti clockwise movement about the hip to put the abductors at a advantage on the right side. So that would be, do you think? OK, but you mentioned she's got Brandenburg Gate.
Which which doctors. Are therefore affected in this scenario, so the doctors that will be affected will be the right of doctors, as I'm sure. In order for you to increase your anticlockwise moment for handling, you must she is she holding the stick in the right side, holding on the left side? Is she doing it correctly?
No, because if it was a true trend, then about the opposite side, so the unaffected side, if the right side was affected, the left hip would be drooping. Yeah so you expect it to hold the other side, isn't it? So you'd probably advise this lady to hold it and the other side is not doing much. You're right. OK, we'll move on. So well, are the definitions in pre requisites of gate?
How would you define gate? OK, so gait is a complex. Coordinated motion, which applies on a number of. On pre-requisites, it allows a study of how the human body propels itself a movement, the pre-requisites as per the. Casper Sundays clearance I believe.
Which is. Looking at stability and stance. Economy of movement and clearance in swings. Stability for submitting stance. OK pre-positioning this on the web. Sorry, my watch. I'm pre-positioning off the foot economy of gait clearance and swing and stability stance.
OK, fine, so great. Now you mentioned that it's OK now. What about the components of gate? So the components of gait are either. So proponents of gait include gait cycle. Yeah, so the stance phase and the swing phase starts phase makes about 60% of the entire gate, where a swing phase makes about 40% of the gait cycle in terms of the.
The stance phase, the phase, it's to do with the. He will strike into three rockers, he'll strike flat foot and then toe off. And it's to do with contraction of the muscles associated with this. So in terms of the heel strike, it's eccentric contraction of to be honest a followed by the.
Midfoot or of foot would be eccentric contraction of the gastric soulless complex, followed by concentric contraction of the gastric complex. This allows the patient or human body to move in terms of swing. There is a pretty swing mid swing and terminal swing. OK OK, now what about what about the rockers of gate, what do you understand by the rockers of gate?
So the rockers of gait enable initially for us to accept weight so initially as the weight acceptance. So when you strike your hill, then goes onto the flat foot and then toe off, which allows which locks to show part joint tightens your winless mechanism, allowing for a stable foot to be. Able to propel us forward. So there's a number of mechanisms that are associated with this.
The set a the locking of the show parts joint where the lines are now. Not parallel, but there are crossed the subtitle the joint itself, evertz and locks itself as well with a screw home mechanism. So the Archimedes' screw type mechanism off the foot? OK, so we kind of go off slightly in terms of what's the ground reaction force doing in each of the rocket stages so quickly in the first stage?
So what first rocker? What is it doing? Yeah so the ground reaction force would be behind the knee to allow the allowed me to be an extension and to allow. And the second, it would be in front of the me. OK and then. And then it would return back to.
I think it would remain in front of the front of the knee. Yeah, OK, right. OK, we better just go through things. About three minutes there. OK? so how did that go? I know I've not looked at it recently, so it was a good moment. No problem.
I apologize. I think for us just told me the video was only half showing. Was that ok? Was that the code? I do apologize. Yeah, so the video video showed, OK, just the slides are just the left hand side of the slide, just a little bit. Few few letters are missing, I think.
Well, even this one, I could see this. Yeah, that's better. Yeah, thank you. OK, apologies. Yeah so so with this, you described it perfectly in terms of both gait B got thrown off the fact that she was holding the stick on the wrong side. OK, so you described her numbers perfectly, but you change your answer because she was holding the stick on the left side.
So you thought it must be the right side that's affected, but she's just not doing it correctly. So stick to your guns. If you are trying to say this lady is actually holding a stick on the wrong side and the following reasons. OK, so you are right. Don't let it sort of sway you, because that might be a trick. They want to see if you understand what's going on.
So yes, a gait is something to definitely brush up on. It can be a very common question. So you mentioned the prerequisites a crew member is paces, so repositioning of the foot, adequate slap length clearance and swing energy conservation stability stance. OK, so just remember those sort of prerequisites when I mentioned the gait cycle, just sort of break it down. OK, so BBB quite sort of clear.
Just say the gait cycle split into the stance phase and the swing phase stance comprises 60% Swing is 40% of the gait cycle. It stands for a gait cycle goes from the heel strike of one foot to the heel strike of the same foot. OK, that's one cycle. Then that way, the examination. What are you talking about? And then the other thing is split the stance split up into OK, heel strike load response, mid stance, terminal stance.
So this is pretty swing says five five bits to it, the three bits to the swing swing part. You can rattle that off. So that is the gait cycle as you've described it. Just be careful about going into the muscles because that's massive and you can talk about the muscles around the hip, around the knee and around the ankle. OK, so that's just that's too big a topic.
So I didn't quite ask that. I ask you about the gait cycle. Describe the gait cycle. So be careful to answer the question that's given to you. If they want you to elaborate on a particular part of the gait cycle and what muscle function is happening around it, then they'll ask you that we then go on to the rockers and you understood the rockers. You described them.
You mentioned rockers earlier when about the gait cycle. Be careful with rockers. Rockers are only involving the foot and ankle joint, but only describe what's going on at the foot and ankle joint and nowhere else. So, you know, people just throw rockers in while describing gait, and you might get yourself in a bit of a mess. So the rockers briefly see a heel strike.
You can even mention the class lever class to lever, so you write back the ground reaction force behind the ankle joint and the knee joint, creating a flexion moment. So flex and then it goes and tearing apart. The second rocker creates an extension moment and that's a passive motion, then is that you've locked in a sort of passive motion. And then it goes onto 3 Rock to see right about the contractions, essentially contraction to advance in first rocker eccentric contraction of gas strokes in the second hand and concentric contraction of gas rock in the third rock as well.
OK, so you're right about those. And if you do really well, that could go on and ask about how grind reaction if they works, you know, because that applies what's going on in terms of ground reaction force patients to CP and weak digastric muscles and how it counteracts flexion movement, the knee and the ankle joint in the stance phase. So because CP patients collapse, don't they?
They can't extend any structure not functioning, they're flexed and it's quite exhausting. So this ground reaction airflow helps to prevent the knee from collapsing keeps it a straight to moment in the midst stance phase. So just something so that could have gone on to there. If you do really well, kind of applying it to real situation because you can get that in the station as well as CP patient, you know, things like that.
Good so believe so this is a extension and coal plant inflection moment coupling. Yeah, Yeah. So that's it. You're helping, but by fixing the gas strike, you're helping to keep the knee extended. Otherwise it will collapse down. So you've got the you've got the ankle, you've got the solid anterior tibial strap that's giving you that the Fort anteriorly to keep the.
Because what happens is the tibia wants to progress, doesn't it, during the second rocker? And that's the tibial progression. So it will continue to progress because there's nothing counteracting it because gas rocks is weak. So you're counteracting it by having a solid part anteriorly to prevent the tibial progression going further and in these sort of patients. So anyone with gastric weakness.
Mohamed Mahmoud is the next. OK, Mohammed, so one of the things about the exam high, particularly in pediatrics, is not necessarily the most complex things which we might. We might touch on some of those soon, but it's how you're going to manage as a day one consultant and what are you going to do so? So classic thing would be an off ended forearm fracture, you know, and they might not be a trick to it.
They just want to know how you're going to handle it. And so this is one of those cases. So we're going to talk about this, Mohammed. So you've got a 14-year-old female who's been come in when you're on call first weekend on call as a consultant. I'm sorry, I don't have the lateral, but she's come in and the emergency department have called you and said, look, this girl's got to be a fracture.
We've put it in a bag slap what you want to do with her? No OK. Yeah OK, so this is an AP radiograph of this girl left leg in a cluster, and it shows the spiral fracture at the junction of middle lower third left tibia. It looks like the fibula is broken at a lower level as well.
You said that you don't have a lateral view, so sorry. So I would like to I would like to take a history from this patient about the mechanism of injury. Was that a high injury injury or is it a low energy injury or any other associated other pain elsewhere in the body? I'll approach her, according to the Atlas protocol, making sure that there is no other injuries. And then I would assess her neuromuscular status and soft tissue envelope, excluding any open, any open injury and excluding any signs of compartment syndrome.
OK as well. All right. So she's a basketball player. She's a very tall, 14-year-old. She was playing basketball and she landed and twisted on her ankle. This is an isolated injury. It's closed. And she's otherwise fit and, well, neurovascular intact, no medications, no allergies.
How would you like to treat her? OK, so she's 14 years old, so she is nearly an adult now. I cannot comment. I mean, given that one one, one view only, but for this, I would be more inclined for internal fixation for this fracture. So my options are.
And if the multiple parties is closed, so I may go for an intermittent interlocking nail or if not, if not, I may consider and I may consider flexible, flexible nails for fixation. OK, so you've mentioned the growth plates and she's 14 and she's very tall. What's the problem with using flexible nails in this scenario?
So this fracture is rotational and length unstable. So and also she's 14, so she is her hair weight, as is not appropriate for using the flexible nail or whatever. Yeah, I agree. OK, so we're going to do we're going to do a tibial nail standard tibial nail. So I may consider super popular, super popular nail or a standard table nail.
Yeah OK. So is there anything in particular that you would be thinking about doing a tibial nail in this girl? Uh, yeah, I mentioned about the growth plate. What size Natalie are going to use? Yeah, it would be a bit challenging.
It would be smaller than the usual. OK, so I may consider using like a smaller, smaller diameter nail for that. Ok? are you aware of what sizes we can use? I think it's maybe size nine. OK all right, let's stop there, then, because we're coming to the thing, OK, so how do you think you did?
Uh, I think it's tricky just getting one view and a plus there as well. So I don't know if it's a recent or old injury in the first place. And then, yeah, it's difficult to treat with the 14 years old. Yeah, you can consider non operative treatment if the alignment is fine. I was about to say that as well. But I cannot judge that with just one view.
I think you can say that in the exam, but as I said at the beginning, this is another one for my fracture clinic. I had, you know, good fracture clinic, you know, and she's 14. She's very tall and she wants to get back to sport, obviously. And I agree with you, and so this is what we did. We did a tibial nail deal now. OK the point about the question about the implants is because if you take this patient to theatre, so the smallest one that we have on the shelf is a 9 millimeter diameter.
So if you want to use a tibial nail, what are you going to do if she's patient, if the patient is anesthetized on the table and you can't get a millimeter down? They do do an eight millimeter, but you need to order it in. Ok? and the point about the 8 and 9 millimeter tibial nails is that you're locking screws or smaller. All right.
So, so in the traditional nails, they're 5 locking screws. But in the eight or nine millimeters, they are 4 millimeters. So you need to remember that I make Scribner's aware of it. OK so these are just little technical points that can come up as you being a day one consultant on call, you're on call with the most junior registrar. Your anesthetist is drinking coffee and the staff are all obstetric staff in the theater and you've got a 14-year-old professional basketball player.
All right. So the point of the exam is to make sure that you are safe as a day one consultant, and these are all the little things that they could throw at you because it's real life. Yeah, Yeah. But you know, I think you did well, you could manage it. Intra operatively. I agree that flexible nails are probably not appropriate.
This girl was 82 kilograms because she was over 6 foot tall. And you're right, trying to control the rotation would be difficult. And she's 14. Her growth plates are almost completely fused and the tibial nail is a good option for her. And as you can see, we got a good reduction. Yeah Yeah. And so she's happy with it.
So we're just, you know, consider prophylactic treatment and get her moving as soon as we can when the wounds have settled down. But yeah, I think that was a good answer. So just be aware of the way that they can take you. You know, and yeah, that's it. So the first of those two first cases were all about what you're going to do day one consultant. All right.
So be prepared for something that might be easy, but you need to know when you're in charge of how you're going to handle it. That's the main thing. Exam all right. So KneeKG is ripple. Hi I think you're just wondering if you find that the medullary canal is not wide enough to accommodate 8 or nine?
What options we have for operating in with the lens length unstable fracture. So you'd need to consider something like a plate if you're going to go down that route? Yeah, I and can this patient be initial? X-rays could suppose a little. If there is no grass or angulation expected in the later could have been pretty non operatively because I understand the rotational threshold is quite acceptable.
Yeah, provided you keep close, follow up. Yeah, you mobilize it. You might need to wedge the cast. You might need to manipulate it a little bit. Yeah non operative is always an option. What I found is particularly with kind of athletics in children and adults, there seems to be this push from the coaches to nail them all so they can get back to sport, any sooner.
But you shouldn't be put under pressure by that. You could certainly manage this on operatively, but I would say keep close, follow up regular X-rays until you've got callus. OK all right, let's move on to you, George. You are sitting in clinic and rheumatologist sends you this 6 to seven-year-old lady, ok? Presented with a right knee pain.
This is her activity. These are two AP radio girls, both knees. I can see that there is a Vegas alignment of both knees with lateral joint space narrowing and signs of degenerative changes here. I'd also like to get lateral views of both films. Did you say she was rheumatoid? No she was sent to you by rheumatologist. Oh, I see.
So the diagnosis here is bogus pattern osteoarthritis, which is bilateral but symptomatic in the right knee. Am prepared to start by in my assessment, doing a full history, asking about when the pain comes on, whether it pains related to activities, whether it stops it from doing her daily activities, if there's any other joints involved and particular attention by looking at her past medical history and medications as well.
I'd like to know if this is a systemic problem. Also without changing my management down the line. And then. And then, yeah, I'd like to get sort of further weight bearing. I'm guessing these a weight bearing films in history, what we'll do next. Then I'll take two to examination. I'd like to check the affected limb check limb length check for any fixed flexion deformities, check the range of movement of that knee.
You're not going to make a walk. Start off with gates or yes, start. Get it. Get it to walk and assess their gait, and then again, down to the couch and do sort of focus examination of the knee. I'd like to see if this is correctable or not. And I'd like to see if there's any fixed flexion deformity. Good OK. Your check that there's a deformity of around 20 degrees, while Volker's of around 20 degrees, which cannot be passively corrected.
OK and range of motion is 2,200 degrees. OK, what else you're going to check? Clinically, you want to check that it's not coming from, you know, there's any spinal or pelvic condition, so I would ideally next, I'd like to get long legged views and then, OK, that's fine. So what are the causes of this are? It is electrical compartment arthritis.
So you can get idiopathic sort of osteoarthritis and get inflammatory arthritis, post traumatic arthritis or secondary to previous infection? All right. OK, so you are saying that while arthritis can be idiopathic rheumatoid, post-traumatic or most infections. Yeah, any other cause? And OK, that's fine.
So this arthritis is arthritis affecting lateral component in the knee compartment. So from the mechanics point of view, how what happens actually on weight bearing? Some weight bearing your central axis is realized. What is central axis? It's from your center of your hip going through the center of the knee to the center of the ankle.
OK, and what happens. So it's laterals yet? Sorry what happens to it? And so you're it it laterals you, so the pressure goes through for you. And so this is a arteritis. How would you do your preoperative assessment? Your take on these three examination will diagnose if you were thinking.
Now about knee replacement because she's functionally she's probably failed candidate. There are two treatments targeted by rheumatologists before. So what is your preoperative assessment? I'm already thinking that this is a going into the complex primary category, and I'm thinking this she may need constraint devices and also to check the integrity of screen replacement.
So you start from the sort of least constraint which is your cruciate retaining. Then it moves up to your posterior stabilized, total stabilized and then further hinged prosthesis. So without more linearity. So the ability to change components either in the tibial or femoral components to change alignment joint line.
All right. OK, that's fine. So you want to do knee replacement. What are principles in general of any replacement principles to achieve a pain free functional joint? So surgical principles are to achieve a balanced knee, both soft tissue and bone with bony cuts and restore the correct alignment?
OK, so you're in of total knee replacement is to get in less mobile joint, isn't it? Yeah so what are the principles of your operation? So you want to give the government's balanced. You're going to preserve the second thing you said it resolved. Is it so am I getting cut off with my wife? Why was it clear? No, no.
It's like, OK, fine. All right. Yeah fine. It's fine. Don't worry. Just take some scenario. So, yeah, OK. Fine so as the causes of this, arthritis can be rheumatoid commonly rheumatoid arthritis, it can be trauma when you have fragile epicondyle and modern nights, or it can metabolic like rickets, which is called general welcome and then developed arthritis.
Or it can be post infections in Asian countries. You get tuberculosis and then it kills and loses arthritis. OK, so this. So what happens to mechanical axis? OK, mechanical is false lateral to the center of need. This is a full food. Or, in other words, knee goes in medial to the mechanical axis, isn't it? Mm-hmm So how does normally mechanical axis?
What angle does it make with the anatomical? More Alexis normally have about seven degrees of Vargas, OK, 5 to 7 degrees of the sun. Yeah, if the person is tall, is it likely to be seven or five? So, so more. As in seven know, if the person is tall, OK, be more likely to be seven less or 7 and more or 5 and less.
So be less than, OK, that's fine. So you're going to do preoperative assessment, basically, you're going to take history examination. All right. In history, you're going to ask him, how did it start and how is it bothering him or bothering her? OK and what has been done for that? All right. And in examination, and we're going to ask risk factors and an examination.
You're going to make a walk and see for Bulger's test. And you're going to make us sit and kick and sit for politicking because common in this case for telemarketing, isn't it? And you want to make a lie down? See this. Where is the pain? All right. And assisted range of motion.
No one see if the conformity can be corrected. Jagged ligaments. And assess common perennial. Why, why should this common personnel. So you can come and stretch or with the various deformity? Well, not really. OK, so then most people would do a limb length arrangement, all right, and get a good idea to give weight bearing AP and lateral.
If it's rheumatoid arthritis, then you'll tell rheumatologist that you're planning a knee replacement and you need some optimization. All right. And then you'll test her for other things, pre-op assessment, everything. And one of the important things is about common terminal again, because if you're going to correct it during the knee replacement, then you might cause it to be paralyzed because of stretching hematoma or a retraction or laceration.
Well, this is a very important point. So when you're actually doing knee replacement, what are the stats, what are special precautions you're going to take? And so careful sort of lateral release. You didn't need electoral age, isn't it? Sorry you need electoral rules. Yeah, actually.
Yeah careful sort of electoral release, meticulous in the states. So start with the message and you're going to put tourniquets into it. You take medial epicondyle or delay approach, isn't it? Yeah medial approach supine with the knee flexed. Avert the patellar, then you'll do limited media release. I'm not going to do too much like modestly, and you might have to do a lot of lateral release, which starts from taking off to fight down Kessler release it and release.
OK release of popliteal standon, etc., isn't it? Then when you are, you can take this for moral code, but when you are trialling, then what? What do you require trialling? Because there might be hyperplasia of lateral gondolier to follow the White side line for getting the rotations represented. Then possibly ought to use it if the deflection deformity or possibly use a cruciate substituting thing.
And last but not least, you might have to resurface the patella because there's more chance of politicking and pain. These are things that the patient develops foot drop. Then it can be the hematoma or laceration. Which is I don't know how to really but depends on your surgical acumen and your thing or can be stretching. So fast food, things are treated operatively, the second stretching is treated with sensitivity, so in barging in the summary, sorry for that.
And somebody you have the axilo of both needs shows while arthritis of both knees. OK, I will start with the history asking how this problem started. What is how is bothering you, Sarah and what has been done? I'll ask for the risk factors. I'll make patient walk. See for the virus there severity, localized pain, see range of motion, collectability ligament and common position.
No and then hip and spine, I'll do like length, weight bearing views, probably the long legs. Use OK and if it's a remarkable rheumatoid arthritis, then I will have it reviewed by rheumatologists because she needs optimization of rheumatoid arthritis. I'll start with conservative treatment. If it's not working, then operate your operation it requires other than what you're done in history.
And same incision, but limited medial is more lateral. It's actually structures you might have to do postural or use a cruciate substituting knee replacement during styling to prevent external rotation and probably resolve this patella. All right. So these are the thing which it is in direction should go. All right, gentlemen. Yeah, thank you.
This is the case now. So 27-year-old fell from a mountain bike, sustaining this injury. Isolated, closed. So tell me what you see on X-rays and define. First of all, tell me what exactly the diagnosis is and then tell me, how are you going to manage? OK, so I can see your AP lateral, and it's like, I'm just moving.
Yeah so beer and beer and lateral views of the wrist, right wrist of this a mature individual. The most striking feature is a fracture dislocation of the wrist with the completely disrupted Gilda's line, and there is an abnormal a position of in the AP view, I can see the scaffold is in flexed position. I cannot. There is an abnormal overlap of the unit over the capital and in the lateral view, I can see the laminate is not placed in the fossa.
So this is a unit dislocation with the maple type for. OK and describe the images that you see below. The post-production ones. The post in the label post-production wants. OK OK. So I mean, I was describing this only sorry about that. All right. OK no worries. So I so I mean, though they are production X-rays radiographs so I can still see on the AP radiograph, the abnormality is there and there is complete disruption of the proximal row of the carpal relationship and flexed attitude of the signature sign of the scaffold.
The abnormal overlap of the capitated with the laminate and unit is absent in the laminate fossa and then the lateral view. I can see there's a specialty teacup sign unit is not well oriented in the unit fossa, and there is a complete dorsal dislocation of the distal rest of the carpal bones from the unit. So this is a laminated dislocation. OK how are you going to manage?
OK, so my initial assessment in the Ed would be to take a focus history as to the mechanism exact mechanism of injury, the time since injury, the fasting status of the patient, any medical comorbidities. Then I will assess the patient, ensuring that this is a closed injury and ruling out any compartment syndrome. I'll assess the neurovascular status, especially the median nerve, because I'm expecting the compression, possibly compression of the median nerve because the nation, because of the nature of the injury, I will assess and document that I will also look for any associated injuries in the hand as well as in the elbow.
And apart from that, all that I would like to proceed from dental. So considering this, there hasn't been no reduction attempt. I will do one single redaction attempt in the eddy under conscious sedation. What do you see the pictures there? OK, so this is what they have attempted. And as you can see, it is labeled as production.
So I would not give any further attempt of reduction. This on the basis of the clinical assessment if there are no median of symptoms. This would need an emergency reduction in the theater. And if there are, we didn't have some symptoms. I would do an extended carpal tunnel release as well at the same time. So I will inform the theaters for a possible emergency procedure.
I will get in touch with the anesthetist. At the same time, I will talk to my colleague about my plan and if they are happy for me to go ahead with a closed stroke, open reduction and extended carpal tunnel decompression. I will go ahead with that. If I'm hearing you are a lower limb surgeon, what would be and on call consultant? So what would you do?
So basically, go ahead and fix everything. No, no. So this injury has four components. One is the decompression of the medial note. Second is that reduction reduction of the dislocation. Third is the fixation of the couple bones, and the fourth is the ligament reconstruction. I would be OK to do the initial reduction and extended carpal tunnel decompression.
And with the after informing my colleague I will leave the fixation and the ligament reconstruction for them to take over. Once the patient is stable. Do you want to get any further imaging? Uh, considering the nature of the injury, it seems to be quite a high energy trauma, though it's an isolated injury.
I would like to get us CT scan because there are abnormal overlapping of the couple bones, so there could be a possible scaffold or other couple bone fracture, which I would try to delineate delineate with the CT scan. Yes OK, so you have done this CT scan and as you correctly identified or showed some concern, there is a separate fracture, there is a spectrum fracture.
There is also a small ernor styli fracture. So now you have decided to go to theater. Tell me, is a you're aware of any specific maneuvers that you're going to. Trying to reduce this dislocation. So I will consent the patient for a closed stroke, open reduction and not decompression and appropriately marked and consented patient, patient, supine with the arm on the board.
I will do. I will put the I will give an adequate longitudinal traction and sustained traction for around 10 to 15 minutes. How by Chinese finger trap method. And following this, I will do the extreme extension, hyperextension of the wrist and then intraoperatively directed pressure on the unit, push it into its position and then flexing of flexing Palmer flexing the wrist.
So if I'm able to achieve the reduction, I will. I will put the limb in the back slap and do the X-rays again. If not, I will go for an open reduction through the volar approach. OK all right, so tell me about mentioned about the destruction of the last lines. What are the likely structures that are damaged apart from the dislocation and fractures?
so I'm asking about the ligaments system should. OK, so the ligaments that are disrupted are the scaffold, sorry, radio slap radio slap ligament. Then the capital ligament, unito fractured ligament and the. OK, OK, I'm going to stop you. Can you tell me the sequence that normally results in this kind of dislocations?
So the effects are not to me how this injury occurs, but what is the sequence of failure of the ligament structures? Yeah so in the according to the Mayfield's classification in type one, it is a scalpel in it or a radio scalpel, capitated ligament injury in the type 2. There is a capital luneta ligament injury. Additional capital eliminated ligament injury in type III. That is, there is no typekit ligament disruption.
And in type four, it's a I'm just getting confused. think it's the gharial. You're saying it right? Yes the last one is, I think, radio learned disruption, ligament disruption. The first one is when the unit is unit dislocation. Yeah, I think I'm not sure about that at most. Probably it's a radial unit. Ligament disruption?
OK all right. OK, so you've attempted to close the production. You were successful in that and you have done median nerve decompression. Uh, now what? OK, so I will inform about this to my colleagues and do I'm aware of the principles that it needs a ligament reconstruction, the dorsal scaffold, the scapula ligament reconstruction is approached from the dorsal aspect and to the dorsal approach and typekit ligament disruption is repaired is approached from the volar incision.
OK, so suppose you are the hand surgeon which approach to take and why? So I'm going to avoid fracture there, which is displaced. Yeah so because I will because the ligament reconstruction as well as the steroid fracture fixation needs to be done, I will just I will first note the level of the scaphoid fracture if it is a proximal pole or a waist fracture, if it is a fracture, sorry, it is a waste of this statewide fracture.
OK, so if it is a waste of this compound fracture, I will do a percutaneous fixation of the skip right from the Waller approach. And for the ligament reconstruction, I will take the dorsal Burgers flap for the ligament reconstruction. OK all right. We're going to stop here. Let me just.
All right, so this has been done. And you see that. Yeah, I can see that, Yeah. Now one thing is very important that these injuries are again life changing injuries, depending on the patient's profession and the overall activity that will need to inform the patient that this is a very nasty injury and it will never be going to be exactly normal as the other side.
And most likely, this patient is heading. What next step will be future? Because I can see the physician of the skin for it, though it is out to lend, but there is a significant appreciable gap between it, between the fracture fragments. So possibly it could result in a separate nonunion and subsequently support nonunion advance collapse. OK, so that's one thing.
Yes, I agree with that. Anything else? Uh, taking a holistic approach. What do you think this patient is heading towards? So later on, it's heading towards the different spectrum of the slap skipper, non-union at once collapsed and with the associated ligament injuries in the rest of the couple bones that he would be heading towards a pan pan.
Arthritis, pain, carpal arthritis very soon. OK, so what would be the options then? So the options, if the degenerative process is rapidly progressing. And it ends up into a pan breast arthritis, the options realistically are to go for wrist fusion or. And Camille's arrest replacements, though they don't have very good results, but that could be an option.
OK other options are also proximity to me. OK, and restitution is the ultimate one, which is where this patient is heading to works so well done. OK, so you followed that sequence, and the important aspect is that you realize that this is an emergency that needs to be taken to care regardless of the time, and it needs to be reduced. And that helps in terms of minimizing the compartment syndrome and also the median their symptoms.
Uh, wise, there are different ways, if you have mentioned, however, different surgeons have their different preference. But the ultimate point is that regardless of what is done, this type of injury is not very promising in terms of the outcome, and ultimately this region will be defined. You follow the correct Mayfield classification sequence describing the tenotomy. So well done.
OK I just want you to know. I mean, when you were asking the approach, so would you tell me more about it? How can we approach? The only purpose that I ask you the approach because you will be asked in the exam is not to. There is no right or wrong. OK Yeah. As long as you can see that I do this approach and one of the reasons you can simply say that I'm familiar with this approach and hence I would, and that is a justifiable answer.
But you have other options. Other answers to say that I do want to approach because of you may be the slippery fracture is the background is such that I can fix it there, and from there I can continue extending my incision and then I can do the medial nerve decompression. So there are pros and cons. There are different ways and hence surgeons. They haven't got any a unified view on this.
How to fix them. The reason I ask you is to check that if you get confused or you say as long as you say some approach and you defend that with a reasonable answer, that is what is looked at. OK can I ask two questions, please? Yes so looking at the red dot X-ray before the cluster is it a purple?
The location with where's a little dislocation as well? That's exactly why I put this X-ray on initially. From that AP view, it does look like that the wrist joint is dislocated and radiocarbon dislocation is there. However, as they're trying to pull and improve the position, the bottom picture shows that it is the DNA dislocation. All right, thank you. So the second question is assuming that you are not the not the hand surgeon and you are in the middle of the NIPE and you've tried the closed reduction and it's failed.
So you would it be enough to just decompress the median nerve through the extended carpal tunnel approach and just take the heat of the situation and leave it dislocated for the hand surgeon to do his approach? Or should you go for the posterior approach or the approach used? So again, the answer lies in multiple factors. Number one tie means, for example, it's 6 o'clock in the morning, then you can simply do the decompression and leave it for the hand surgeon to come and take over.
O'clock second factor is, is this injury closed or open? Because that would lead your. If it isn't open, you need to do the open approach or extend from the open wound and try to reduce it. The third thing that needs to be taken into account is that if you simply do the median nerve decompression and leave it dislocated, this is not ideal. You should be able to attend an open reduction.
And this is the discussion that you will have before going to theater with the hand surgeon that what approach he prefers. So some surgeons prefer Waller approach, so they will tell you, yes, if you stuck and you need to do the open reduction, can you do it more slowly? Because I have plans on that. So you can do so. But there is no definitive answer to your question that I can say, yes, you can leave it dislocated or no, you cannot, because that depends on multiple factors.
We're in just one final question. Just just kind of leading on from that, I've done next fixes for quite bad carpal fracture dislocation. Is that an option here? You could say we'll just span this out. Yes spending that is always an option. You can spend it, which is absolutely fine, and you would help the soft tissue to recover or at least prevent it from getting worse in terms of the compartment, syndrome or swelling.
Thank you. Brilliant, guys. Any more questions? Fine, good, we can move on now. As the next candidate number five, I'm going to rapidly through this, OK, right, let's start the stopwatch.
OK, so you've got a 27-year-old female who's complaining of her ankle giving way. Me only a few questions or what focus history do you need? So I would like to ask this lady, what is there any associated pain? So now only when she gives way, so only when she gives way, she gets pain, ok? And is there any evidence?
And how long has it been? Yeah OK, so so it's been going on for a few years now. She keeps on. She keeps on giving away. She didn't. She gets no pain, otherwise gets pain afterwards. But it's an unstable yet OK. And any history of logging episodes or no logging episodes.
And I would like to also like to know, was there any history of trauma following which this has started? Well, yeah, she's twisted ankle a few times, so that's considered trauma. Yeah, OK. And I would also like to know, is there any problem on the other side or is it unilateral? Then there's just this side that does this thing.
And I see it. OK, so there I would like to examine this lady and yeah, so take me through your typekit through your examination very specifically. OK, so specifically, I will be looking for any evidence of ligament laxity. I will see if they're able to do that. I will do the baton score good, OK, so you do debate and score. She's not she's not hyper like she's normal.
So you've done that. You've cleared that. That's very good. You do a general examination. And yet what I'm looking to do, I'm looking for any of us gave us gave us deformity of the foot axilo you no different. Why do you want to look for that briefly? OK, so the cables for deformity, they have very common association with the lateral ligament complex insufficiency.
OK, fine. So she doesn't have that, so that's fine. She ruled that out. She doesn't have a cavefish foot. OK and then I will, Uh, specifically, I will be looking for any, any tenderness around the area. So she's got she's got some mild tenderness anyway, in particular. Or the intellectual aspect of the midfoot or the.
OK, so she's got a bit of tenderness there. Any specific tests you know about the ulnar nerve? I will be doing during the entire drawer test for the ankle, stabilizing the tibia and doing the first. The test in the plant flexed foot in front of flexed position and testing for the entire tibial fibular anterior impurity before the ligament. So just so just watch this video can you see it?
Yes, I can see that accent, right? Describe what tests are they doing here? But this is the entire drawer test and put the foot in front of flexion. This is for the anterior a fibular ligament. Does the implant of flexion? Uh, this it is done in deflection to isolate the anterior cruciate ligament. So that the kalkilya fibular ligament is not contributing to the stage.
And what else do you need apart from plantar flexing while the position? Do you need to have a neutral position? I will be testing again the same and draw and that I will be checking for the fibular ligament probably a little bit internal rotation. OK, so you will do a thorough rotation and plant a flexion to ACDF L. So that's what you got there. What's the next thing you want to assess?
OK, I will also see if the. What's this test called? Yeah so this is, Uh, we are checking for the laxity a lateral opening of the ankle implant in front of flex and internal rotated position and comparing it with the other side. If there is a difference of more than five degrees, then it is significant. Or if the unilaterally it is more than 10 degrees that is what test is that I'm to be honest, I pulled.
It's called the pill test. Oh, Yes. Well, what are we testing with that? What are you looking at? We are again testing for the lateral opening of the laxity of the what, what's gone, what's gone here in this patient. And it is gone. Are you sure?
Because it's in the plant of flexed position. It's not the look where he's pointing. OK so it will be the calkin. Yes, this is for CFO, OK, this is the CFO. This is dose of position. It's more planned to flexor-pronator ATF. OK, so it's opening up and where his finger is indicating is normally feel CFL there. It's gone, it's not there.
And you can see that the fibular is very prominent. So that has gone OK and it goes to flexed position because that's where it normally resists, doesn't it? And you're right, about more than 15 degrees opening up. It will. It's of positive. Very good. So those two are specific tests that you want to do, isn't it? So you've done that.
What's your what's your plan? OK, so I will also like to rule out if there is any evidence of any during the examination, any evidence of sinusitis or arthritis, or any tenderness anywhere else in that along the joint line pointing towards all the joint line tenderness, what things might you need to rule out? I would like to rule out any evidence of sinusitis, arthritis, loose bodies or any osteoarthritis.
I mean, the are you going to do that? How are you going to rule out? I will actually be OK. So I will. During the clinical examination and followed by the relevant investigation I would request for an x-ray, we're building x-rays, followed by an MRI. So X-ray is normal. But yeah, MRI good MRI won't rule out other concurrent pathology, isn't it?
So OCD can be another pathology that's going on, particularly there will be painful, ongoing pain, so she doesn't have that good. So you've organized MRI. So what's the sort of what would you do next? So she's got this fairly conservative management. She's tried braces, et cetera. She's come to you. What's your principles of managing this?
OK, one thing in the history I'd missed, I would like to know the functional demands of the patient, and it's effecting it's affecting her day to day activities, day to day activities. OK and so my plan, my the management plan, having tried and failed all the conservative treatment, especially in the form of physiotherapy, if they have done that and they're continuing to suffer, that's failed.
Ok? OK. So I will offer the reconstruction of the ligament of the latter with a little bit about that. What do you know about what repairs are present? What would you do? OK, so I'm aware of the anatomical and the non-endemic anatomical repair. And if there are, Uh, Uh, Uh, high demand patients or if there is a ligament laxity or if there is give us deformity of the foot, then the non anatomical repair is preferable or also in cases where the lateral ligament complex activation is there, the non anatomical reconstruction is, Uh, is the repair you're aware of.
What is it called? So anatomical repair is the sorry you're asking about that? Yeah, that's of repair. The you mentioned anatomical repair is the Brostrom repair with the modification towards the goal. So the Bostrom repair is the repair using the native, Uh, PFL and the gauze modification is a reinforcement with the inferior extensive epimysium. Yes that's that, isn't it?
And if when would that not be suitable? So as I said, in cases of high demand patients or in cases of ligament laxity or if they're associated keeper's foot deformity or the native ligament is very attenuated and weak, which is not allow for the repair, then we'll consider the anatomical repair, but the anatomical repair, but the height. But the downside for this is it's not a very mechanically stable repair, and it causes stiffness of the ankle.
So you're aware of them what they called what they call with augmented repair called what they use. So they call called the events repair. Where the pattern is used, a whole other brain is reduced or there is a Chrisman Snook procedure where the a part of the brain is prévus is used to reconstruct the ATF as well as the CFL. What's the problem with these?
So you have to sacrifice are compromising on the strength of the peronist bravest. And that's the problem with that. A weakness in an. And also a very important natural restraint to the ankles. You're taking that away. Good excellent. So the Evans and the Watson Jones you spoke about, they're good, but they're not anatomical, are they?
They're not reconstructing the AFL or the CFL. The Christmas nook is a bit better. What's the what's the recommended or what's the most up to date one? Then it's even better than most up to date. One is the anatomical repair using hamstring tendon graft. So that avoids the sacrificing of the bravest. But at the same time, it uses the it gives its gives results closer to the anatomical repair.
Good OK. Right excellent. So that's your time up there. So he did. He did. He did very well. OK, so so how do you think that went? Yeah, I yeah, I am.
In the end, I managed to get all the things I was forgetting a few things in the beginning. No, it's good. It's good. So, you know, I think it's important to go through things quickly and cover it. We took longer than usual because there was a bit of teaching in there. So if you cut that out, it would be even shorter.
So you need to get to this stage by 3 minutes in the exam. OK, three minutes, you need to be talking about management, so it's very good. We covered a lot there. OK, so I thought you did. I thought you did really well. You knew these tests. Just be a bit clear. You knew about the associated pathology, the areas of tenodesis you the score you mentioned, which is very good.
Yes, that's very good because they're prone to the weight bearing laterally, aren't they areas of tenodesis you covered that you knew that this test is just be aware of exactly describing it because in exam, they might play you a video like this and say, take me through this examination. What are they demonstrating? OK, so this is that and that's the other one that you need to be aware of, which you manage and great you spoke about as ulnar claw repair.
And if that doesn't work in certain situations, you need to augment the repair. Also, consider arthroscopy to assess the joint surface while you're in there. That's the other thing to throw in there as well. Just shows that you're thinking about other pathologies until repair. We spoke about an augmentation using. I'm not aware of the call related procedure.
Can you just briefly? Yeah, it's very similar to the procedure, OK, but it's a bit more anatomical, a bit more anatomical of where, like CFL is so biomechanically, it's a bit more anatomical compared to the Snook. But this is not bad, you know, it's kind of a halfway house. These these are old school now. They're no longer done. They're great, they provide stability.
But because they're so stiff, they can, they fail quickly. So which tendon are we using in colleville procedure? So you can use you can use a tendon. That case you can use plantar, you can. You can also half of half a PB can also be used. OK, you've using half of pb, potentially here or any other grafts. That's fine.
Let's we've got. Yeah, it's me, my next year at Mammoth ego. So you've got a 30-year-old lady. She fell on a dry ski slope about two weeks ago. And she thought she'd sprained her thumb. But it's not getting any better, and she's finding it difficult to grip things. So she's come to see you in the clinic. So tell me what you think.
OK, so this is a clinical photograph demonstrating the stress test some ulnar collateral ligament. So I would like to ask the patient about the hand dominance, the occupation and the level of activity, any associated injuries rather than this injury, any treatment received so far.
And I would like to examine the patient traject for any associated injuries and neuromuscular compromise and the range of movement of the thumb as well. And then after that I would. A request, an X-ray of the thumb to rule out any bony abortion of the ulnar collateral ligament. And on the exam, I mean, on the examination, again, I would do the examination and extension and then 30 degrees of flexion to demonstrate or to differentiate between the lateral, the ulnar collateral ligament proper or the accessory ulnar collateral ligament.
So which one is which one is in full extension and which one is at 30 degrees? So in 30 degrees, is the ulnar collateral ligament proper and in full extension is the accessory ulnar collateral ligament. OK all right. So you find that there's opening on both positions. How are you going to manage it? So I thought I'd explain to the patient that this would need a surgical intervention to reconstruct the ligament or to repair the ligament, because usually this may, may be consistent with the standard lesion, which which means that the adductor neurosis is interposed between the insertion site of the ulnar collateral ligament, and it prevents it from healing properly so it will need surgical intervention to repair the ligament there.
OK, so you tell me about your surgical approach. So an appropriately consented, unmarked patient with a tourniquet on and the IV antibiotics, I do a lazy incision over the door, some of the carpometacarpal joints of the thumb, and I would explore the ulnar collateral ligament to make sure that it's free from the adductor aponeurosis. And the my repair will depend whether it is a pure ligament injury or if it's a bony abortion as well.
But either of these will be to reattach the ligament to the proximal attachment using suture anchors. Many anchor sutures. OK, with your surgical approach, is there anything you need to be aware of that you may want to protect? So, yes, I would be worried about the. Here it will be the branches from the superficial radial ulnar nerve.
Yeah, and which way are you going to find those? So they are on the exit at the end of the anatomical snuff box. Yeah so, OK, I try to avoid amenable to protect this as well and the extensor tendon as well, the EPL tendon, yeah, OK. All right. So that's just more or less five minutes. So let's have a little go through the slides.
So you did well, OK, there's a couple of points that I'm going to come to in a second. So inflection your collateral ligament proper is tense. So that's what you're testing. And then an extension, your accessory is tight and the other one's loose. That's what you're testing. Yeah, Yeah. Which I think you got.
And then you describe the standard lesion to me, which is where the aponeurosis tendon is interposed. And these are just the ligaments and the police. All right, so you can have a read through that. So that's why they don't heal the stent lesions because the doctor policies tendon is in between.
So I think whenever you say, describe your surgical approach, OK, you started off well with the appropriately consented marked patient tourniquet antibiotics. But I always find it useful when you ask about a surgical approach is to start with landmarks. All right. So for me, you said dorsal of the MCP joint. So the way that I would describe it would be a laser lazy.
Yes, I agree with you over the MCP joint, maybe more towards on the side. And then when you go through the skin and the subcutaneous tissue, what you're going to look for is the branches of the superficial radial nerve and make sure that you've retracted them out of the way before you consider on with your dissection. Does that make sense?
Yeah and that means that you've done it 100 times. We know that how to do it. Then you can go on to get to the orthopedic part of the operation. I mean, you know, we're all about the bones, but you need to just I always think if you start off with your landmark skin, what's in the next layer? It's like with the pediatric case, with the lateral femoral cutaneous nerve, you know, think, how do I do it?
What steps do I do in my head so that you don't miss something like retract the nerve, protect the structure, and then the examiner can just relax, and that will be a box on the thing. Protect neurovascular structures that will be a tick. That's more. Yeah all right. And it's something that you will automatically do, but you might forget under the stress of the exam.
So that's why we practice it so that it becomes automatic. Yeah OK. Does that make sense? Yeah, Yeah. Thank you. OK
Segment:0 .
My name is Nicky Evans and.
I I'm one of the faculty of this course, so the idea of this course is that we give you a little bit more teaching rather than just the intensive vyver course. So we allocate a little bit more time and the faculty have picked cases that, you know, probably warrant a little bit more discussion and we need to make sure that you get it right for your exams.
So the way the course will run is that we've allocated an hour to each section and there's six questions six candidates. We'll ask it. We'll give you a bit of time to walk through the answer and then we'll give you the information that we think should be in a model type of answer. There should be time for questions and the focus will be on the participants.
But if the observers have some questions, then we can always discuss them as well. And we've allocated a lunch break in the middle and we'll do a summary at the end of the day. So we've already named you all. So P1 to six will be the participants and we can see that usually. And we'll just go through and ask you the. We'll have a little chat at the end, I went to an update course last Saturday and I got some information on the part two exam about what we can expect in the future.
So I'll have a little chat about that at the end of the day. But as it's now 9.4, I think we should probably start soon. When first comes back, we might run through his slides at some stage, but I can't move them on. It looks like he's just going to outline the course. And so we've also got the intensive vyver course coming up next weekend. I think in combination with OK. We've also got a basic science course, which is running, I think, the week after.
So they're all available on our website, which is orthopedic Academy. Co.uk and you can book onto those if there's spaces available. So I think we can fill us back seriously with us. Can you hear me? Yes, we can. We can't, we can't see what we can do. I'm very sorry about that.
That's OK. Um, I was I don't know what happened, but. Can you hear me now, ok? Yeah, we can. So I just outlined the course and I was hearing you completely. Yeah thank you for that. So obviously, please see my screen this.
Our faculty have been handpicked for their teaching skills, particularly the field of as far case exam. And as Nick explained, it will be a case discussion course where we take you through the cases. They are high yield exam specific questions. And so you will most likely will encounter a few of these questions in your example. OK this all previously asked question exam questions.
So what I encourage you guys is. This is going to be a long day for you. Yeah, and that's exactly how the exam will go. The exam is a long day. Yeah so look at this as a marathon. It's not a sprint. And stay focused throughout the day. So when you are asked the questions, obviously you are in the spotlight.
But when your fellow candidates been asked, questions also stay focused and imagine this question been asked to. And when the answer is given. See if it goes in line with the answer you were going to give if you were the candidate. We want. We're not here to teach you Orthopedics at all. Yeah, we are here just to encourage you and mentor you to score your highest potential score in the exam.
OK, we'll ask you to please, guys, obviously, as you could see to me, they can be technical problems. Don't worry about it. If you miss out anything, we will, we will go through it again for you. But please, if you are not answering, stay muted and just to give your fellow candidates time and the space they need to answer.
OK And obviously, follow us and we are doing some more courses, case based discussions and basic sciences courses, so we will be very welcome to discuss those with you later on. If you interested. And without further ado, we will start the course now. So we'll go through the whole old stations of the exam as it is with the new format. And we will start with basic sciences, as you are all guys fresh in the morning.
So we have allocated you can't get participants from 1 to 6. And we we'll go into in that order. Yeah observers, obviously there are a number of observers here. Some of them could not get a chance of space because we are limited, obviously because of the structure of the course to how many participants we have. So and yeah, there would be a number of observers as well with us.
So without further ado, I will hand over to Mo now to start the basic sciences session. All right. OK, so just start by. So 10 minutes each. OK, right. So watch this video for me. In terms of what you see. OK say a video of a patient walking.
I can see her using a stick on the left. I can see that her hip is sagging on the right. This would be in keeping with a trend, then typekit the shoulders do not seem to be drooping that much. So I would expect, Yeah. OK, so imagine trying to find it.
What do you think of what would is holding the stick? So she's actually holding said I was looking at this. She's holding the stick on the left, which would indicate that the problem is on the right. This would indicate that she's attempting to bring the anti clockwise movement about the hip to put the abductors at a advantage on the right side. So that would be, do you think? OK, but you mentioned she's got Brandenburg Gate.
Which which doctors. Are therefore affected in this scenario, so the doctors that will be affected will be the right of doctors, as I'm sure. In order for you to increase your anticlockwise moment for handling, you must she is she holding the stick in the right side, holding on the left side? Is she doing it correctly?
No, because if it was a true trend, then about the opposite side, so the unaffected side, if the right side was affected, the left hip would be drooping. Yeah so you expect it to hold the other side, isn't it? So you'd probably advise this lady to hold it and the other side is not doing much. You're right. OK, we'll move on. So well, are the definitions in pre requisites of gate?
How would you define gate? OK, so gait is a complex. Coordinated motion, which applies on a number of. On pre-requisites, it allows a study of how the human body propels itself a movement, the pre-requisites as per the. Casper Sundays clearance I believe.
Which is. Looking at stability and stance. Economy of movement and clearance in swings. Stability for submitting stance. OK pre-positioning this on the web. Sorry, my watch. I'm pre-positioning off the foot economy of gait clearance and swing and stability stance.
OK, fine, so great. Now you mentioned that it's OK now. What about the components of gate? So the components of gait are either. So proponents of gait include gait cycle. Yeah, so the stance phase and the swing phase starts phase makes about 60% of the entire gate, where a swing phase makes about 40% of the gait cycle in terms of the.
The stance phase, the phase, it's to do with the. He will strike into three rockers, he'll strike flat foot and then toe off. And it's to do with contraction of the muscles associated with this. So in terms of the heel strike, it's eccentric contraction of to be honest a followed by the.
Midfoot or of foot would be eccentric contraction of the gastric soulless complex, followed by concentric contraction of the gastric complex. This allows the patient or human body to move in terms of swing. There is a pretty swing mid swing and terminal swing. OK OK, now what about what about the rockers of gate, what do you understand by the rockers of gate?
So the rockers of gait enable initially for us to accept weight so initially as the weight acceptance. So when you strike your hill, then goes onto the flat foot and then toe off, which allows which locks to show part joint tightens your winless mechanism, allowing for a stable foot to be. Able to propel us forward. So there's a number of mechanisms that are associated with this.
The set a the locking of the show parts joint where the lines are now. Not parallel, but there are crossed the subtitle the joint itself, evertz and locks itself as well with a screw home mechanism. So the Archimedes' screw type mechanism off the foot? OK, so we kind of go off slightly in terms of what's the ground reaction force doing in each of the rocket stages so quickly in the first stage?
So what first rocker? What is it doing? Yeah so the ground reaction force would be behind the knee to allow the allowed me to be an extension and to allow. And the second, it would be in front of the me. OK and then. And then it would return back to.
I think it would remain in front of the front of the knee. Yeah, OK, right. OK, we better just go through things. About three minutes there. OK? so how did that go? I know I've not looked at it recently, so it was a good moment. No problem.
I apologize. I think for us just told me the video was only half showing. Was that ok? Was that the code? I do apologize. Yeah, so the video video showed, OK, just the slides are just the left hand side of the slide, just a little bit. Few few letters are missing, I think.
Well, even this one, I could see this. Yeah, that's better. Yeah, thank you. OK, apologies. Yeah so so with this, you described it perfectly in terms of both gait B got thrown off the fact that she was holding the stick on the wrong side. OK, so you described her numbers perfectly, but you change your answer because she was holding the stick on the left side.
So you thought it must be the right side that's affected, but she's just not doing it correctly. So stick to your guns. If you are trying to say this lady is actually holding a stick on the wrong side and the following reasons. OK, so you are right. Don't let it sort of sway you, because that might be a trick. They want to see if you understand what's going on.
So yes, a gait is something to definitely brush up on. It can be a very common question. So you mentioned the prerequisites a crew member is paces, so repositioning of the foot, adequate slap length clearance and swing energy conservation stability stance. OK, so just remember those sort of prerequisites when I mentioned the gait cycle, just sort of break it down. OK, so BBB quite sort of clear.
Just say the gait cycle split into the stance phase and the swing phase stance comprises 60% Swing is 40% of the gait cycle. It stands for a gait cycle goes from the heel strike of one foot to the heel strike of the same foot. OK, that's one cycle. Then that way, the examination. What are you talking about? And then the other thing is split the stance split up into OK, heel strike load response, mid stance, terminal stance.
So this is pretty swing says five five bits to it, the three bits to the swing swing part. You can rattle that off. So that is the gait cycle as you've described it. Just be careful about going into the muscles because that's massive and you can talk about the muscles around the hip, around the knee and around the ankle. OK, so that's just that's too big a topic.
So I didn't quite ask that. I ask you about the gait cycle. Describe the gait cycle. So be careful to answer the question that's given to you. If they want you to elaborate on a particular part of the gait cycle and what muscle function is happening around it, then they'll ask you that we then go on to the rockers and you understood the rockers. You described them.
You mentioned rockers earlier when about the gait cycle. Be careful with rockers. Rockers are only involving the foot and ankle joint, but only describe what's going on at the foot and ankle joint and nowhere else. So, you know, people just throw rockers in while describing gait, and you might get yourself in a bit of a mess. So the rockers briefly see a heel strike.
You can even mention the class lever class to lever, so you write back the ground reaction force behind the ankle joint and the knee joint, creating a flexion moment. So flex and then it goes and tearing apart. The second rocker creates an extension moment and that's a passive motion, then is that you've locked in a sort of passive motion. And then it goes onto 3 Rock to see right about the contractions, essentially contraction to advance in first rocker eccentric contraction of gas strokes in the second hand and concentric contraction of gas rock in the third rock as well.
OK, so you're right about those. And if you do really well, that could go on and ask about how grind reaction if they works, you know, because that applies what's going on in terms of ground reaction force patients to CP and weak digastric muscles and how it counteracts flexion movement, the knee and the ankle joint in the stance phase. So because CP patients collapse, don't they?
They can't extend any structure not functioning, they're flexed and it's quite exhausting. So this ground reaction airflow helps to prevent the knee from collapsing keeps it a straight to moment in the midst stance phase. So just something so that could have gone on to there. If you do really well, kind of applying it to real situation because you can get that in the station as well as CP patient, you know, things like that.
Good so believe so this is a extension and coal plant inflection moment coupling. Yeah, Yeah. So that's it. You're helping, but by fixing the gas strike, you're helping to keep the knee extended. Otherwise it will collapse down. So you've got the you've got the ankle, you've got the solid anterior tibial strap that's giving you that the Fort anteriorly to keep the.
Because what happens is the tibia wants to progress, doesn't it, during the second rocker? And that's the tibial progression. So it will continue to progress because there's nothing counteracting it because gas rocks is weak. So you're counteracting it by having a solid part anteriorly to prevent the tibial progression going further and in these sort of patients. So anyone with gastric weakness.
Mohamed Mahmoud is the next. OK, Mohammed, so one of the things about the exam high, particularly in pediatrics, is not necessarily the most complex things which we might. We might touch on some of those soon, but it's how you're going to manage as a day one consultant and what are you going to do so? So classic thing would be an off ended forearm fracture, you know, and they might not be a trick to it.
They just want to know how you're going to handle it. And so this is one of those cases. So we're going to talk about this, Mohammed. So you've got a 14-year-old female who's been come in when you're on call first weekend on call as a consultant. I'm sorry, I don't have the lateral, but she's come in and the emergency department have called you and said, look, this girl's got to be a fracture.
We've put it in a bag slap what you want to do with her? No OK. Yeah OK, so this is an AP radiograph of this girl left leg in a cluster, and it shows the spiral fracture at the junction of middle lower third left tibia. It looks like the fibula is broken at a lower level as well.
You said that you don't have a lateral view, so sorry. So I would like to I would like to take a history from this patient about the mechanism of injury. Was that a high injury injury or is it a low energy injury or any other associated other pain elsewhere in the body? I'll approach her, according to the Atlas protocol, making sure that there is no other injuries. And then I would assess her neuromuscular status and soft tissue envelope, excluding any open, any open injury and excluding any signs of compartment syndrome.
OK as well. All right. So she's a basketball player. She's a very tall, 14-year-old. She was playing basketball and she landed and twisted on her ankle. This is an isolated injury. It's closed. And she's otherwise fit and, well, neurovascular intact, no medications, no allergies.
How would you like to treat her? OK, so she's 14 years old, so she is nearly an adult now. I cannot comment. I mean, given that one one, one view only, but for this, I would be more inclined for internal fixation for this fracture. So my options are.
And if the multiple parties is closed, so I may go for an intermittent interlocking nail or if not, if not, I may consider and I may consider flexible, flexible nails for fixation. OK, so you've mentioned the growth plates and she's 14 and she's very tall. What's the problem with using flexible nails in this scenario?
So this fracture is rotational and length unstable. So and also she's 14, so she is her hair weight, as is not appropriate for using the flexible nail or whatever. Yeah, I agree. OK, so we're going to do we're going to do a tibial nail standard tibial nail. So I may consider super popular, super popular nail or a standard table nail.
Yeah OK. So is there anything in particular that you would be thinking about doing a tibial nail in this girl? Uh, yeah, I mentioned about the growth plate. What size Natalie are going to use? Yeah, it would be a bit challenging.
It would be smaller than the usual. OK, so I may consider using like a smaller, smaller diameter nail for that. Ok? are you aware of what sizes we can use? I think it's maybe size nine. OK all right, let's stop there, then, because we're coming to the thing, OK, so how do you think you did?
Uh, I think it's tricky just getting one view and a plus there as well. So I don't know if it's a recent or old injury in the first place. And then, yeah, it's difficult to treat with the 14 years old. Yeah, you can consider non operative treatment if the alignment is fine. I was about to say that as well. But I cannot judge that with just one view.
I think you can say that in the exam, but as I said at the beginning, this is another one for my fracture clinic. I had, you know, good fracture clinic, you know, and she's 14. She's very tall and she wants to get back to sport, obviously. And I agree with you, and so this is what we did. We did a tibial nail deal now. OK the point about the question about the implants is because if you take this patient to theatre, so the smallest one that we have on the shelf is a 9 millimeter diameter.
So if you want to use a tibial nail, what are you going to do if she's patient, if the patient is anesthetized on the table and you can't get a millimeter down? They do do an eight millimeter, but you need to order it in. Ok? and the point about the 8 and 9 millimeter tibial nails is that you're locking screws or smaller. All right.
So, so in the traditional nails, they're 5 locking screws. But in the eight or nine millimeters, they are 4 millimeters. So you need to remember that I make Scribner's aware of it. OK so these are just little technical points that can come up as you being a day one consultant on call, you're on call with the most junior registrar. Your anesthetist is drinking coffee and the staff are all obstetric staff in the theater and you've got a 14-year-old professional basketball player.
All right. So the point of the exam is to make sure that you are safe as a day one consultant, and these are all the little things that they could throw at you because it's real life. Yeah, Yeah. But you know, I think you did well, you could manage it. Intra operatively. I agree that flexible nails are probably not appropriate.
This girl was 82 kilograms because she was over 6 foot tall. And you're right, trying to control the rotation would be difficult. And she's 14. Her growth plates are almost completely fused and the tibial nail is a good option for her. And as you can see, we got a good reduction. Yeah Yeah. And so she's happy with it.
So we're just, you know, consider prophylactic treatment and get her moving as soon as we can when the wounds have settled down. But yeah, I think that was a good answer. So just be aware of the way that they can take you. You know, and yeah, that's it. So the first of those two first cases were all about what you're going to do day one consultant. All right.
So be prepared for something that might be easy, but you need to know when you're in charge of how you're going to handle it. That's the main thing. Exam all right. So KneeKG is ripple. Hi I think you're just wondering if you find that the medullary canal is not wide enough to accommodate 8 or nine?
What options we have for operating in with the lens length unstable fracture. So you'd need to consider something like a plate if you're going to go down that route? Yeah, I and can this patient be initial? X-rays could suppose a little. If there is no grass or angulation expected in the later could have been pretty non operatively because I understand the rotational threshold is quite acceptable.
Yeah, provided you keep close, follow up. Yeah, you mobilize it. You might need to wedge the cast. You might need to manipulate it a little bit. Yeah non operative is always an option. What I found is particularly with kind of athletics in children and adults, there seems to be this push from the coaches to nail them all so they can get back to sport, any sooner.
But you shouldn't be put under pressure by that. You could certainly manage this on operatively, but I would say keep close, follow up regular X-rays until you've got callus. OK all right, let's move on to you, George. You are sitting in clinic and rheumatologist sends you this 6 to seven-year-old lady, ok? Presented with a right knee pain.
This is her activity. These are two AP radio girls, both knees. I can see that there is a Vegas alignment of both knees with lateral joint space narrowing and signs of degenerative changes here. I'd also like to get lateral views of both films. Did you say she was rheumatoid? No she was sent to you by rheumatologist. Oh, I see.
So the diagnosis here is bogus pattern osteoarthritis, which is bilateral but symptomatic in the right knee. Am prepared to start by in my assessment, doing a full history, asking about when the pain comes on, whether it pains related to activities, whether it stops it from doing her daily activities, if there's any other joints involved and particular attention by looking at her past medical history and medications as well.
I'd like to know if this is a systemic problem. Also without changing my management down the line. And then. And then, yeah, I'd like to get sort of further weight bearing. I'm guessing these a weight bearing films in history, what we'll do next. Then I'll take two to examination. I'd like to check the affected limb check limb length check for any fixed flexion deformities, check the range of movement of that knee.
You're not going to make a walk. Start off with gates or yes, start. Get it. Get it to walk and assess their gait, and then again, down to the couch and do sort of focus examination of the knee. I'd like to see if this is correctable or not. And I'd like to see if there's any fixed flexion deformity. Good OK. Your check that there's a deformity of around 20 degrees, while Volker's of around 20 degrees, which cannot be passively corrected.
OK and range of motion is 2,200 degrees. OK, what else you're going to check? Clinically, you want to check that it's not coming from, you know, there's any spinal or pelvic condition, so I would ideally next, I'd like to get long legged views and then, OK, that's fine. So what are the causes of this are? It is electrical compartment arthritis.
So you can get idiopathic sort of osteoarthritis and get inflammatory arthritis, post traumatic arthritis or secondary to previous infection? All right. OK, so you are saying that while arthritis can be idiopathic rheumatoid, post-traumatic or most infections. Yeah, any other cause? And OK, that's fine.
So this arthritis is arthritis affecting lateral component in the knee compartment. So from the mechanics point of view, how what happens actually on weight bearing? Some weight bearing your central axis is realized. What is central axis? It's from your center of your hip going through the center of the knee to the center of the ankle.
OK, and what happens. So it's laterals yet? Sorry what happens to it? And so you're it it laterals you, so the pressure goes through for you. And so this is a arteritis. How would you do your preoperative assessment? Your take on these three examination will diagnose if you were thinking.
Now about knee replacement because she's functionally she's probably failed candidate. There are two treatments targeted by rheumatologists before. So what is your preoperative assessment? I'm already thinking that this is a going into the complex primary category, and I'm thinking this she may need constraint devices and also to check the integrity of screen replacement.
So you start from the sort of least constraint which is your cruciate retaining. Then it moves up to your posterior stabilized, total stabilized and then further hinged prosthesis. So without more linearity. So the ability to change components either in the tibial or femoral components to change alignment joint line.
All right. OK, that's fine. So you want to do knee replacement. What are principles in general of any replacement principles to achieve a pain free functional joint? So surgical principles are to achieve a balanced knee, both soft tissue and bone with bony cuts and restore the correct alignment?
OK, so you're in of total knee replacement is to get in less mobile joint, isn't it? Yeah so what are the principles of your operation? So you want to give the government's balanced. You're going to preserve the second thing you said it resolved. Is it so am I getting cut off with my wife? Why was it clear? No, no.
It's like, OK, fine. All right. Yeah fine. It's fine. Don't worry. Just take some scenario. So, yeah, OK. Fine so as the causes of this, arthritis can be rheumatoid commonly rheumatoid arthritis, it can be trauma when you have fragile epicondyle and modern nights, or it can metabolic like rickets, which is called general welcome and then developed arthritis.
Or it can be post infections in Asian countries. You get tuberculosis and then it kills and loses arthritis. OK, so this. So what happens to mechanical axis? OK, mechanical is false lateral to the center of need. This is a full food. Or, in other words, knee goes in medial to the mechanical axis, isn't it? Mm-hmm So how does normally mechanical axis?
What angle does it make with the anatomical? More Alexis normally have about seven degrees of Vargas, OK, 5 to 7 degrees of the sun. Yeah, if the person is tall, is it likely to be seven or five? So, so more. As in seven know, if the person is tall, OK, be more likely to be seven less or 7 and more or 5 and less.
So be less than, OK, that's fine. So you're going to do preoperative assessment, basically, you're going to take history examination. All right. In history, you're going to ask him, how did it start and how is it bothering him or bothering her? OK and what has been done for that? All right. And in examination, and we're going to ask risk factors and an examination.
You're going to make a walk and see for Bulger's test. And you're going to make us sit and kick and sit for politicking because common in this case for telemarketing, isn't it? And you want to make a lie down? See this. Where is the pain? All right. And assisted range of motion.
No one see if the conformity can be corrected. Jagged ligaments. And assess common perennial. Why, why should this common personnel. So you can come and stretch or with the various deformity? Well, not really. OK, so then most people would do a limb length arrangement, all right, and get a good idea to give weight bearing AP and lateral.
If it's rheumatoid arthritis, then you'll tell rheumatologist that you're planning a knee replacement and you need some optimization. All right. And then you'll test her for other things, pre-op assessment, everything. And one of the important things is about common terminal again, because if you're going to correct it during the knee replacement, then you might cause it to be paralyzed because of stretching hematoma or a retraction or laceration.
Well, this is a very important point. So when you're actually doing knee replacement, what are the stats, what are special precautions you're going to take? And so careful sort of lateral release. You didn't need electoral age, isn't it? Sorry you need electoral rules. Yeah, actually.
Yeah careful sort of electoral release, meticulous in the states. So start with the message and you're going to put tourniquets into it. You take medial epicondyle or delay approach, isn't it? Yeah medial approach supine with the knee flexed. Avert the patellar, then you'll do limited media release. I'm not going to do too much like modestly, and you might have to do a lot of lateral release, which starts from taking off to fight down Kessler release it and release.
OK release of popliteal standon, etc., isn't it? Then when you are, you can take this for moral code, but when you are trialling, then what? What do you require trialling? Because there might be hyperplasia of lateral gondolier to follow the White side line for getting the rotations represented. Then possibly ought to use it if the deflection deformity or possibly use a cruciate substituting thing.
And last but not least, you might have to resurface the patella because there's more chance of politicking and pain. These are things that the patient develops foot drop. Then it can be the hematoma or laceration. Which is I don't know how to really but depends on your surgical acumen and your thing or can be stretching. So fast food, things are treated operatively, the second stretching is treated with sensitivity, so in barging in the summary, sorry for that.
And somebody you have the axilo of both needs shows while arthritis of both knees. OK, I will start with the history asking how this problem started. What is how is bothering you, Sarah and what has been done? I'll ask for the risk factors. I'll make patient walk. See for the virus there severity, localized pain, see range of motion, collectability ligament and common position.
No and then hip and spine, I'll do like length, weight bearing views, probably the long legs. Use OK and if it's a remarkable rheumatoid arthritis, then I will have it reviewed by rheumatologists because she needs optimization of rheumatoid arthritis. I'll start with conservative treatment. If it's not working, then operate your operation it requires other than what you're done in history.
And same incision, but limited medial is more lateral. It's actually structures you might have to do postural or use a cruciate substituting knee replacement during styling to prevent external rotation and probably resolve this patella. All right. So these are the thing which it is in direction should go. All right, gentlemen. Yeah, thank you.
This is the case now. So 27-year-old fell from a mountain bike, sustaining this injury. Isolated, closed. So tell me what you see on X-rays and define. First of all, tell me what exactly the diagnosis is and then tell me, how are you going to manage? OK, so I can see your AP lateral, and it's like, I'm just moving.
Yeah so beer and beer and lateral views of the wrist, right wrist of this a mature individual. The most striking feature is a fracture dislocation of the wrist with the completely disrupted Gilda's line, and there is an abnormal a position of in the AP view, I can see the scaffold is in flexed position. I cannot. There is an abnormal overlap of the unit over the capital and in the lateral view, I can see the laminate is not placed in the fossa.
So this is a unit dislocation with the maple type for. OK and describe the images that you see below. The post-production ones. The post in the label post-production wants. OK OK. So I mean, I was describing this only sorry about that. All right. OK no worries. So I so I mean, though they are production X-rays radiographs so I can still see on the AP radiograph, the abnormality is there and there is complete disruption of the proximal row of the carpal relationship and flexed attitude of the signature sign of the scaffold.
The abnormal overlap of the capitated with the laminate and unit is absent in the laminate fossa and then the lateral view. I can see there's a specialty teacup sign unit is not well oriented in the unit fossa, and there is a complete dorsal dislocation of the distal rest of the carpal bones from the unit. So this is a laminated dislocation. OK how are you going to manage?
OK, so my initial assessment in the Ed would be to take a focus history as to the mechanism exact mechanism of injury, the time since injury, the fasting status of the patient, any medical comorbidities. Then I will assess the patient, ensuring that this is a closed injury and ruling out any compartment syndrome. I'll assess the neurovascular status, especially the median nerve, because I'm expecting the compression, possibly compression of the median nerve because the nation, because of the nature of the injury, I will assess and document that I will also look for any associated injuries in the hand as well as in the elbow.
And apart from that, all that I would like to proceed from dental. So considering this, there hasn't been no reduction attempt. I will do one single redaction attempt in the eddy under conscious sedation. What do you see the pictures there? OK, so this is what they have attempted. And as you can see, it is labeled as production.
So I would not give any further attempt of reduction. This on the basis of the clinical assessment if there are no median of symptoms. This would need an emergency reduction in the theater. And if there are, we didn't have some symptoms. I would do an extended carpal tunnel release as well at the same time. So I will inform the theaters for a possible emergency procedure.
I will get in touch with the anesthetist. At the same time, I will talk to my colleague about my plan and if they are happy for me to go ahead with a closed stroke, open reduction and extended carpal tunnel decompression. I will go ahead with that. If I'm hearing you are a lower limb surgeon, what would be and on call consultant? So what would you do?
So basically, go ahead and fix everything. No, no. So this injury has four components. One is the decompression of the medial note. Second is that reduction reduction of the dislocation. Third is the fixation of the couple bones, and the fourth is the ligament reconstruction. I would be OK to do the initial reduction and extended carpal tunnel decompression.
And with the after informing my colleague I will leave the fixation and the ligament reconstruction for them to take over. Once the patient is stable. Do you want to get any further imaging? Uh, considering the nature of the injury, it seems to be quite a high energy trauma, though it's an isolated injury.
I would like to get us CT scan because there are abnormal overlapping of the couple bones, so there could be a possible scaffold or other couple bone fracture, which I would try to delineate delineate with the CT scan. Yes OK, so you have done this CT scan and as you correctly identified or showed some concern, there is a separate fracture, there is a spectrum fracture.
There is also a small ernor styli fracture. So now you have decided to go to theater. Tell me, is a you're aware of any specific maneuvers that you're going to. Trying to reduce this dislocation. So I will consent the patient for a closed stroke, open reduction and not decompression and appropriately marked and consented patient, patient, supine with the arm on the board.
I will do. I will put the I will give an adequate longitudinal traction and sustained traction for around 10 to 15 minutes. How by Chinese finger trap method. And following this, I will do the extreme extension, hyperextension of the wrist and then intraoperatively directed pressure on the unit, push it into its position and then flexing of flexing Palmer flexing the wrist.
So if I'm able to achieve the reduction, I will. I will put the limb in the back slap and do the X-rays again. If not, I will go for an open reduction through the volar approach. OK all right, so tell me about mentioned about the destruction of the last lines. What are the likely structures that are damaged apart from the dislocation and fractures?
so I'm asking about the ligaments system should. OK, so the ligaments that are disrupted are the scaffold, sorry, radio slap radio slap ligament. Then the capital ligament, unito fractured ligament and the. OK, OK, I'm going to stop you. Can you tell me the sequence that normally results in this kind of dislocations?
So the effects are not to me how this injury occurs, but what is the sequence of failure of the ligament structures? Yeah so in the according to the Mayfield's classification in type one, it is a scalpel in it or a radio scalpel, capitated ligament injury in the type 2. There is a capital luneta ligament injury. Additional capital eliminated ligament injury in type III. That is, there is no typekit ligament disruption.
And in type four, it's a I'm just getting confused. think it's the gharial. You're saying it right? Yes the last one is, I think, radio learned disruption, ligament disruption. The first one is when the unit is unit dislocation. Yeah, I think I'm not sure about that at most. Probably it's a radial unit. Ligament disruption?
OK all right. OK, so you've attempted to close the production. You were successful in that and you have done median nerve decompression. Uh, now what? OK, so I will inform about this to my colleagues and do I'm aware of the principles that it needs a ligament reconstruction, the dorsal scaffold, the scapula ligament reconstruction is approached from the dorsal aspect and to the dorsal approach and typekit ligament disruption is repaired is approached from the volar incision.
OK, so suppose you are the hand surgeon which approach to take and why? So I'm going to avoid fracture there, which is displaced. Yeah so because I will because the ligament reconstruction as well as the steroid fracture fixation needs to be done, I will just I will first note the level of the scaphoid fracture if it is a proximal pole or a waist fracture, if it is a fracture, sorry, it is a waste of this statewide fracture.
OK, so if it is a waste of this compound fracture, I will do a percutaneous fixation of the skip right from the Waller approach. And for the ligament reconstruction, I will take the dorsal Burgers flap for the ligament reconstruction. OK all right. We're going to stop here. Let me just.
All right, so this has been done. And you see that. Yeah, I can see that, Yeah. Now one thing is very important that these injuries are again life changing injuries, depending on the patient's profession and the overall activity that will need to inform the patient that this is a very nasty injury and it will never be going to be exactly normal as the other side.
And most likely, this patient is heading. What next step will be future? Because I can see the physician of the skin for it, though it is out to lend, but there is a significant appreciable gap between it, between the fracture fragments. So possibly it could result in a separate nonunion and subsequently support nonunion advance collapse. OK, so that's one thing.
Yes, I agree with that. Anything else? Uh, taking a holistic approach. What do you think this patient is heading towards? So later on, it's heading towards the different spectrum of the slap skipper, non-union at once collapsed and with the associated ligament injuries in the rest of the couple bones that he would be heading towards a pan pan.
Arthritis, pain, carpal arthritis very soon. OK, so what would be the options then? So the options, if the degenerative process is rapidly progressing. And it ends up into a pan breast arthritis, the options realistically are to go for wrist fusion or. And Camille's arrest replacements, though they don't have very good results, but that could be an option.
OK other options are also proximity to me. OK, and restitution is the ultimate one, which is where this patient is heading to works so well done. OK, so you followed that sequence, and the important aspect is that you realize that this is an emergency that needs to be taken to care regardless of the time, and it needs to be reduced. And that helps in terms of minimizing the compartment syndrome and also the median their symptoms.
Uh, wise, there are different ways, if you have mentioned, however, different surgeons have their different preference. But the ultimate point is that regardless of what is done, this type of injury is not very promising in terms of the outcome, and ultimately this region will be defined. You follow the correct Mayfield classification sequence describing the tenotomy. So well done.
OK I just want you to know. I mean, when you were asking the approach, so would you tell me more about it? How can we approach? The only purpose that I ask you the approach because you will be asked in the exam is not to. There is no right or wrong. OK Yeah. As long as you can see that I do this approach and one of the reasons you can simply say that I'm familiar with this approach and hence I would, and that is a justifiable answer.
But you have other options. Other answers to say that I do want to approach because of you may be the slippery fracture is the background is such that I can fix it there, and from there I can continue extending my incision and then I can do the medial nerve decompression. So there are pros and cons. There are different ways and hence surgeons. They haven't got any a unified view on this.
How to fix them. The reason I ask you is to check that if you get confused or you say as long as you say some approach and you defend that with a reasonable answer, that is what is looked at. OK can I ask two questions, please? Yes so looking at the red dot X-ray before the cluster is it a purple?
The location with where's a little dislocation as well? That's exactly why I put this X-ray on initially. From that AP view, it does look like that the wrist joint is dislocated and radiocarbon dislocation is there. However, as they're trying to pull and improve the position, the bottom picture shows that it is the DNA dislocation. All right, thank you. So the second question is assuming that you are not the not the hand surgeon and you are in the middle of the NIPE and you've tried the closed reduction and it's failed.
So you would it be enough to just decompress the median nerve through the extended carpal tunnel approach and just take the heat of the situation and leave it dislocated for the hand surgeon to do his approach? Or should you go for the posterior approach or the approach used? So again, the answer lies in multiple factors. Number one tie means, for example, it's 6 o'clock in the morning, then you can simply do the decompression and leave it for the hand surgeon to come and take over.
O'clock second factor is, is this injury closed or open? Because that would lead your. If it isn't open, you need to do the open approach or extend from the open wound and try to reduce it. The third thing that needs to be taken into account is that if you simply do the median nerve decompression and leave it dislocated, this is not ideal. You should be able to attend an open reduction.
And this is the discussion that you will have before going to theater with the hand surgeon that what approach he prefers. So some surgeons prefer Waller approach, so they will tell you, yes, if you stuck and you need to do the open reduction, can you do it more slowly? Because I have plans on that. So you can do so. But there is no definitive answer to your question that I can say, yes, you can leave it dislocated or no, you cannot, because that depends on multiple factors.
We're in just one final question. Just just kind of leading on from that, I've done next fixes for quite bad carpal fracture dislocation. Is that an option here? You could say we'll just span this out. Yes spending that is always an option. You can spend it, which is absolutely fine, and you would help the soft tissue to recover or at least prevent it from getting worse in terms of the compartment, syndrome or swelling.
Thank you. Brilliant, guys. Any more questions? Fine, good, we can move on now. As the next candidate number five, I'm going to rapidly through this, OK, right, let's start the stopwatch.
OK, so you've got a 27-year-old female who's complaining of her ankle giving way. Me only a few questions or what focus history do you need? So I would like to ask this lady, what is there any associated pain? So now only when she gives way, so only when she gives way, she gets pain, ok? And is there any evidence?
And how long has it been? Yeah OK, so so it's been going on for a few years now. She keeps on. She keeps on giving away. She didn't. She gets no pain, otherwise gets pain afterwards. But it's an unstable yet OK. And any history of logging episodes or no logging episodes.
And I would like to also like to know, was there any history of trauma following which this has started? Well, yeah, she's twisted ankle a few times, so that's considered trauma. Yeah, OK. And I would also like to know, is there any problem on the other side or is it unilateral? Then there's just this side that does this thing.
And I see it. OK, so there I would like to examine this lady and yeah, so take me through your typekit through your examination very specifically. OK, so specifically, I will be looking for any evidence of ligament laxity. I will see if they're able to do that. I will do the baton score good, OK, so you do debate and score. She's not she's not hyper like she's normal.
So you've done that. You've cleared that. That's very good. You do a general examination. And yet what I'm looking to do, I'm looking for any of us gave us gave us deformity of the foot axilo you no different. Why do you want to look for that briefly? OK, so the cables for deformity, they have very common association with the lateral ligament complex insufficiency.
OK, fine. So she doesn't have that, so that's fine. She ruled that out. She doesn't have a cavefish foot. OK and then I will, Uh, specifically, I will be looking for any, any tenderness around the area. So she's got she's got some mild tenderness anyway, in particular. Or the intellectual aspect of the midfoot or the.
OK, so she's got a bit of tenderness there. Any specific tests you know about the ulnar nerve? I will be doing during the entire drawer test for the ankle, stabilizing the tibia and doing the first. The test in the plant flexed foot in front of flexed position and testing for the entire tibial fibular anterior impurity before the ligament. So just so just watch this video can you see it?
Yes, I can see that accent, right? Describe what tests are they doing here? But this is the entire drawer test and put the foot in front of flexion. This is for the anterior a fibular ligament. Does the implant of flexion? Uh, this it is done in deflection to isolate the anterior cruciate ligament. So that the kalkilya fibular ligament is not contributing to the stage.
And what else do you need apart from plantar flexing while the position? Do you need to have a neutral position? I will be testing again the same and draw and that I will be checking for the fibular ligament probably a little bit internal rotation. OK, so you will do a thorough rotation and plant a flexion to ACDF L. So that's what you got there. What's the next thing you want to assess?
OK, I will also see if the. What's this test called? Yeah so this is, Uh, we are checking for the laxity a lateral opening of the ankle implant in front of flex and internal rotated position and comparing it with the other side. If there is a difference of more than five degrees, then it is significant. Or if the unilaterally it is more than 10 degrees that is what test is that I'm to be honest, I pulled.
It's called the pill test. Oh, Yes. Well, what are we testing with that? What are you looking at? We are again testing for the lateral opening of the laxity of the what, what's gone, what's gone here in this patient. And it is gone. Are you sure?
Because it's in the plant of flexed position. It's not the look where he's pointing. OK so it will be the calkin. Yes, this is for CFO, OK, this is the CFO. This is dose of position. It's more planned to flexor-pronator ATF. OK, so it's opening up and where his finger is indicating is normally feel CFL there. It's gone, it's not there.
And you can see that the fibular is very prominent. So that has gone OK and it goes to flexed position because that's where it normally resists, doesn't it? And you're right, about more than 15 degrees opening up. It will. It's of positive. Very good. So those two are specific tests that you want to do, isn't it? So you've done that.
What's your what's your plan? OK, so I will also like to rule out if there is any evidence of any during the examination, any evidence of sinusitis or arthritis, or any tenderness anywhere else in that along the joint line pointing towards all the joint line tenderness, what things might you need to rule out? I would like to rule out any evidence of sinusitis, arthritis, loose bodies or any osteoarthritis.
I mean, the are you going to do that? How are you going to rule out? I will actually be OK. So I will. During the clinical examination and followed by the relevant investigation I would request for an x-ray, we're building x-rays, followed by an MRI. So X-ray is normal. But yeah, MRI good MRI won't rule out other concurrent pathology, isn't it?
So OCD can be another pathology that's going on, particularly there will be painful, ongoing pain, so she doesn't have that good. So you've organized MRI. So what's the sort of what would you do next? So she's got this fairly conservative management. She's tried braces, et cetera. She's come to you. What's your principles of managing this?
OK, one thing in the history I'd missed, I would like to know the functional demands of the patient, and it's effecting it's affecting her day to day activities, day to day activities. OK and so my plan, my the management plan, having tried and failed all the conservative treatment, especially in the form of physiotherapy, if they have done that and they're continuing to suffer, that's failed.
Ok? OK. So I will offer the reconstruction of the ligament of the latter with a little bit about that. What do you know about what repairs are present? What would you do? OK, so I'm aware of the anatomical and the non-endemic anatomical repair. And if there are, Uh, Uh, Uh, high demand patients or if there is a ligament laxity or if there is give us deformity of the foot, then the non anatomical repair is preferable or also in cases where the lateral ligament complex activation is there, the non anatomical reconstruction is, Uh, is the repair you're aware of.
What is it called? So anatomical repair is the sorry you're asking about that? Yeah, that's of repair. The you mentioned anatomical repair is the Brostrom repair with the modification towards the goal. So the Bostrom repair is the repair using the native, Uh, PFL and the gauze modification is a reinforcement with the inferior extensive epimysium. Yes that's that, isn't it?
And if when would that not be suitable? So as I said, in cases of high demand patients or in cases of ligament laxity or if they're associated keeper's foot deformity or the native ligament is very attenuated and weak, which is not allow for the repair, then we'll consider the anatomical repair, but the anatomical repair, but the height. But the downside for this is it's not a very mechanically stable repair, and it causes stiffness of the ankle.
So you're aware of them what they called what they call with augmented repair called what they use. So they call called the events repair. Where the pattern is used, a whole other brain is reduced or there is a Chrisman Snook procedure where the a part of the brain is prévus is used to reconstruct the ATF as well as the CFL. What's the problem with these?
So you have to sacrifice are compromising on the strength of the peronist bravest. And that's the problem with that. A weakness in an. And also a very important natural restraint to the ankles. You're taking that away. Good excellent. So the Evans and the Watson Jones you spoke about, they're good, but they're not anatomical, are they?
They're not reconstructing the AFL or the CFL. The Christmas nook is a bit better. What's the what's the recommended or what's the most up to date one? Then it's even better than most up to date. One is the anatomical repair using hamstring tendon graft. So that avoids the sacrificing of the bravest. But at the same time, it uses the it gives its gives results closer to the anatomical repair.
Good OK. Right excellent. So that's your time up there. So he did. He did. He did very well. OK, so so how do you think that went? Yeah, I yeah, I am.
In the end, I managed to get all the things I was forgetting a few things in the beginning. No, it's good. It's good. So, you know, I think it's important to go through things quickly and cover it. We took longer than usual because there was a bit of teaching in there. So if you cut that out, it would be even shorter.
So you need to get to this stage by 3 minutes in the exam. OK, three minutes, you need to be talking about management, so it's very good. We covered a lot there. OK, so I thought you did. I thought you did really well. You knew these tests. Just be a bit clear. You knew about the associated pathology, the areas of tenodesis you the score you mentioned, which is very good.
Yes, that's very good because they're prone to the weight bearing laterally, aren't they areas of tenodesis you covered that you knew that this test is just be aware of exactly describing it because in exam, they might play you a video like this and say, take me through this examination. What are they demonstrating? OK, so this is that and that's the other one that you need to be aware of, which you manage and great you spoke about as ulnar claw repair.
And if that doesn't work in certain situations, you need to augment the repair. Also, consider arthroscopy to assess the joint surface while you're in there. That's the other thing to throw in there as well. Just shows that you're thinking about other pathologies until repair. We spoke about an augmentation using. I'm not aware of the call related procedure.
Can you just briefly? Yeah, it's very similar to the procedure, OK, but it's a bit more anatomical, a bit more anatomical of where, like CFL is so biomechanically, it's a bit more anatomical compared to the Snook. But this is not bad, you know, it's kind of a halfway house. These these are old school now. They're no longer done. They're great, they provide stability.
But because they're so stiff, they can, they fail quickly. So which tendon are we using in colleville procedure? So you can use you can use a tendon. That case you can use plantar, you can. You can also half of half a PB can also be used. OK, you've using half of pb, potentially here or any other grafts. That's fine.
Let's we've got. Yeah, it's me, my next year at Mammoth ego. So you've got a 30-year-old lady. She fell on a dry ski slope about two weeks ago. And she thought she'd sprained her thumb. But it's not getting any better, and she's finding it difficult to grip things. So she's come to see you in the clinic. So tell me what you think.
OK, so this is a clinical photograph demonstrating the stress test some ulnar collateral ligament. So I would like to ask the patient about the hand dominance, the occupation and the level of activity, any associated injuries rather than this injury, any treatment received so far.
And I would like to examine the patient traject for any associated injuries and neuromuscular compromise and the range of movement of the thumb as well. And then after that I would. A request, an X-ray of the thumb to rule out any bony abortion of the ulnar collateral ligament. And on the exam, I mean, on the examination, again, I would do the examination and extension and then 30 degrees of flexion to demonstrate or to differentiate between the lateral, the ulnar collateral ligament proper or the accessory ulnar collateral ligament.
So which one is which one is in full extension and which one is at 30 degrees? So in 30 degrees, is the ulnar collateral ligament proper and in full extension is the accessory ulnar collateral ligament. OK all right. So you find that there's opening on both positions. How are you going to manage it? So I thought I'd explain to the patient that this would need a surgical intervention to reconstruct the ligament or to repair the ligament, because usually this may, may be consistent with the standard lesion, which which means that the adductor neurosis is interposed between the insertion site of the ulnar collateral ligament, and it prevents it from healing properly so it will need surgical intervention to repair the ligament there.
OK, so you tell me about your surgical approach. So an appropriately consented, unmarked patient with a tourniquet on and the IV antibiotics, I do a lazy incision over the door, some of the carpometacarpal joints of the thumb, and I would explore the ulnar collateral ligament to make sure that it's free from the adductor aponeurosis. And the my repair will depend whether it is a pure ligament injury or if it's a bony abortion as well.
But either of these will be to reattach the ligament to the proximal attachment using suture anchors. Many anchor sutures. OK, with your surgical approach, is there anything you need to be aware of that you may want to protect? So, yes, I would be worried about the. Here it will be the branches from the superficial radial ulnar nerve.
Yeah, and which way are you going to find those? So they are on the exit at the end of the anatomical snuff box. Yeah so, OK, I try to avoid amenable to protect this as well and the extensor tendon as well, the EPL tendon, yeah, OK. All right. So that's just more or less five minutes. So let's have a little go through the slides.
So you did well, OK, there's a couple of points that I'm going to come to in a second. So inflection your collateral ligament proper is tense. So that's what you're testing. And then an extension, your accessory is tight and the other one's loose. That's what you're testing. Yeah, Yeah. Which I think you got.
And then you describe the standard lesion to me, which is where the aponeurosis tendon is interposed. And these are just the ligaments and the police. All right, so you can have a read through that. So that's why they don't heal the stent lesions because the doctor policies tendon is in between.
So I think whenever you say, describe your surgical approach, OK, you started off well with the appropriately consented marked patient tourniquet antibiotics. But I always find it useful when you ask about a surgical approach is to start with landmarks. All right. So for me, you said dorsal of the MCP joint. So the way that I would describe it would be a laser lazy.
Yes, I agree with you over the MCP joint, maybe more towards on the side. And then when you go through the skin and the subcutaneous tissue, what you're going to look for is the branches of the superficial radial nerve and make sure that you've retracted them out of the way before you consider on with your dissection. Does that make sense?
Yeah and that means that you've done it 100 times. We know that how to do it. Then you can go on to get to the orthopedic part of the operation. I mean, you know, we're all about the bones, but you need to just I always think if you start off with your landmark skin, what's in the next layer? It's like with the pediatric case, with the lateral femoral cutaneous nerve, you know, think, how do I do it?
What steps do I do in my head so that you don't miss something like retract the nerve, protect the structure, and then the examiner can just relax, and that will be a box on the thing. Protect neurovascular structures that will be a tick. That's more. Yeah all right. And it's something that you will automatically do, but you might forget under the stress of the exam.
So that's why we practice it so that it becomes automatic. Yeah OK. Does that make sense? Yeah, Yeah. Thank you. OK
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