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Upper Limb Orthopaedic Emergencies (Orthopaedic Academy & The 6PM Series)
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Upper Limb Orthopaedic Emergencies (Orthopaedic Academy & The 6PM Series)
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Language: EN.
Segment:0 .
It's a good evening, guys, welcome to tonight's lecture.
My name is here, I'm one of the co-founders of the six PM series. We've also got Greg carburettor essential series that we do. You've seen some of the videos and we have some really nice, remarkable guests with us today who are more familiar in FRCS territory, which is quite a bit beyond for some of us, but they are interested in undergraduate teaching. We got in touch with them a while back.
It was a great, productive conversation that we had. So this is our first lecture together that we're collaborating and they have a fantastic course that's coming up in April as well, that we could talk a little bit about at the end. So I'll start here and I'll let them introduce themselves. So I've got Mr ulnar nerve I. Would you like to introduce yourself as we wait for everyone to enter?
Well, good evening, guys. Mr a I'm one of the founders of the orthopedic Academy. It's my pleasure today to be here with my colleague Nikki, one of the other founders of orthopedic academy, and we, you know, privilege to be with Shaair and Greg and the rest of the team of six PM. We are really impressed with this platform and with the educational value you provide and really very happy and excited to be with you guys.
So thank you for inviting us and we hope that you will have interesting and. A session tonight with us. Thank you. And then we have Miss Evans as well. She was just doing her pose there. If she's free now, miss Evans, would you like to introduce yourself there briefly? Yeah, Thanks very much.
My name is KneeKG and I'm a special doctor and trauma orthopedics. And I have an interest in education at all levels. So I was previously the undergraduate lead for the Lancaster and UConn medical schools. And we do a lot of our process teaching as well. So I'm really glad to be here as well and looking forward to it. Thank you very much. Thank you.
So we're very excited, guys. And if you're new to the 6 PM series or if you're new to any of the talks that I do, I always like to have a mentee poll to gauge where our audience is watching from. It really gives us an idea of the breadth and the depth of the kind of people that we've attracted to the talk that we have today. So the best way to do that is if you have your phone with you, you can type in w-w-what and put in a code, so the code is up there.
But if you aren't able to see it for whatever reason, the code is 81202830. We'll give about five minutes or so for this to go through and then we'll start and we'll hope that everyone that wants to be here tonight is in tonight's talk. I'm just going to make a quick post to that. Everyone on our social media streams that we're alive and we will get we will get on to it.
Then if you have any questions or anything at all, guys, please let us know in the chat and we will try and get to them as we can. The two.
OK, so guys, if you have any friends or anyone that's also thinking of coming tonight, let them know that we're about to start. And we'll go from there, so, right, so people have answered the people, so where do you watch it from? So obviously most people here are watching from England. So that's good.
You have a couple more minutes before we start. So the Scotland, so nice to hear someone's watching Scotland apart from me. Bristol, swindon, Australia, Bulgaria and Wales. Yeah, we've got quite an international crowd there. So it will be it'll be. It'll be interesting if you're from anywhere else that's away from us or very international. We'd be really cool and interesting to know.
So do pop it in. And yeah, that's it. So Mr. Arno and miss, are you ready? We can. We can get started soon. Yeah, I will. Is it OK if I start? Or Yeah. Lovely, thank you.
So there are people from Australia, Nike for you. Nike trained in Australia, so great place. Oh, it's so lovely. So can you see my screen now? yes, we can. Lovely right, so welcome, guys. So to this teaching session, the aim is to give you the information in a small bite size kind of box.
We we're not here today to bombard you with a lot of information. We're just going to give you some information that you can retain and and it will influence your daily practice and be useful for you, for your exams and for your daily jobs. So we talked today about some orthopedic emergencies, and the next one we're going to talk about is in the hand infected flexor-pronator sinusitis. It's one of the rare orthopedic emergencies.
You won't see this. This is not very common. You won't see it in every on-call. Call on every orthopedic elective attachment you do, but you need to be able to recognize it because it's a true orthopedic emergencies. You don't want to be missing this. It's potentially can be limb disabling condition. OK, so there is it's a serious condition.
So remember that whenever you see infections of the hand infected flexor-pronator sinusitis, so what is that? What is infected flex of sinusitis? It's an infection of the flexor sheath that surrounds the flexor tendons in the hand. OK, so flexor tendons in the hand? Yeah, we're going to have a question later on about what's the function of this. But as you can see in the picture, the flexor tendon is surrounded all around by this flexor sheath.
Yeah so this flexor sheath unfortunately can get infected. So how are you going to recognize this? And we have to agree first on some orthopedic principles as we are here today doing this orthopedic specific teaching. So I would like to introduce some of the main principles of orthopedic examination. So orthopedics is different from other medical and surgical specialties. When you do inspection, palpation, percussion and auscultation in orthopedics is completely different.
It's nice and simple. It's look, feel and move. So guys, whenever you see any orthopedic patient, you're presenting a condition to your seniors on a meeting, in a trauma meeting, or you're referring a patient. And from A&E, always remember these three aspects of a clinical assessment look, feel and move. That's how we present orthopedic patients. OK so infected flexor-pronator and invités this is how it presents.
Look so we start with looking on inspection. What you see? Is the finger is held in a slightly flexed posture? Yeah that's the first sign on Un inspection, on looking second son on looking. There is this fusiform swelling that involves the whole finger. Sausage shaped, Yeah. So two sides of an inspection.
Finger held and slightly flexed position and the fusiform swelling. Second, feel. Unfeeling, you do this, you palpate along the course of the flexor tendons of the finger and so sorry, Mr ohno, just. Are you onto another slide because we can't see the slide? I'm very sorry. Yes, I am.
No, no, no problem. No problem. Not following my second slide. Yeah, yeah, no, no. I think he might even be on slide 4 by now. No, actually. How about now? Is that better? Yes, it's better now.
Yes sorry, it's not in a slide mode, but sorry about that. I don't know why. Why the slides more did not follow me. So so yeah, look, feel. Move Yeah. And these are the four clinical signs. So looking inspection fingers held in slightly flexed posture. And there is fusiform swelling.
Phil, palpation along the course of the flexor tendon is painful all over. Yeah Other conditions when you get septic arthritis, for example, the swelling and the tenderness will be specific to the infected joint, but in a flexor thing of itis. The sweat, the pain and tenderness will be all along the course of that tendon. McCain and then move.
If generally in orthopedics. Patients are in pain, so you have to be very careful when you move them. Patients will be reluctant to actively move if they have infected finger. Yeah, so you try to gently passively move them and they will be in a lot of pain. OK, so there are active movements. They're not unlikely to be able to do.
And there is passive movements, which you do. And there will be in a lot of pain. So these four signs. They are called carnival signs. OK kind of all signs start with a K. Because see the first signs of. Uh, in fact, that sine of artists. Please remember, guys, this picture, it will be very useful to you when you go to your orthopedic attachment.
So here we can see on inspection how the whole finger is red and swollen. And it's and they will have tenderness along the whole course of the flexor tendon here. You can see also an inspection how the finger is being held in a slightly flexed position. And another principle I would like to introduce to you guys is that again, in orthopedics generally.
The conditions are painful. And patients. They try to hold their limit in the comfort position, and that tends to be in slight deflection. The reason is flexion increases the space. Yeah and therefore, it will reduce the pressure within the confined space and reduces the pain. So whenever you see someone septic arthritis fracture, any orthopedic condition is causing pain.
Patients try to hold their painful part in slightly flexed position. OK so I hope now, you guys, you'll be able to recognize this condition when you see it. Yeah the reason it's serious is because it can lead to irreversible stiffness. So it's potentially disabling and can cause tendon rupture. The infection can spread.
And further up in the foreground or into deep into the bone. And if I go to the first slide here, you can see how some of the flexor tendon she is connected to the pound and up on the forearm so the infection can actually spread. Patients can potentially use lose the whole arm. So what do you do now you've recognized this condition? What do you do, you do your usual history examination documentation.
This condition again is a priority. It can't wait. If someone refers you a patient or you suspect in any a patient with infected sinusitis, you don't wait to experiment. You need everything else. And you go to see this patient. Yeah, you do routine, tough stuff. History, examination, documentation. You do the bloods, including blood culture, because you might need them culture specific antibiotics later on and you do x-rays just in case there is bone extension or there is a foreign body.
Yeah, principles of treatment generally, again, infection always elevates, you get cellulitis in the legs, in the arms, you get infection, you get septic arthritis, always rest and elevate. Yeah, elevation reducing the edema reduces the pain. Very, very important elevation is as important as antibiotics. And then you start intravenous antibiotics immediately, you don't wait for culture, you don't wait for anything. And you have to give them a big, hefty dose of antibiotics.
Not that 250 oral flu clocks. That's not going to work. It has to be big, hefty IV dose, according to your local hospital protocols. And once you manage this patient, initially, you immediately. If you are in any, you refer to the orthopedic or the hand team or if you are already an orthopedic trainee, you would then you refer to your seniors immediately.
This patient needs to be again. I can't stress this enough. This patient need to be attended to immediately. These patients need to be managed urgently. OK, if you're not getting a response from the senior, from the first person you refer to, you go up to the next level until you get to the consultants with no response. This is, as I said, it's potentially disabling condition.
And for you guys, just to be aware of the principles of the surgical treatment after you've given the antibiotics is basically an orthopedic infection. It's wash out, but the pain principle of wash out is you wash out from proximal. To disturb. Yeah you don't want to wash out from this style push infections proximally up the forearm. You sort of wash it from proximal, push all the infection away towards the tip of the finger outside the limb.
OK, so you open one opening here and the APR at the MCP level, MCP level and another opening this in the finger. And sometimes that can be transverse incision and you put this cannula. Under the flexors sheet, and you keep push until you get a clear fluid coming out from the other end. First of all, obviously when you start washing, there'll be a lot of pus. Then you keep washing, washing and sometimes that might need to be repeated next day.
So that's all I wanted to talk about in this condition. In fact, the flexor-pronator egawa test, I hope you guys be able now to recognize this as an emergency and deal with it. Do the initial management. That's our aim of today. I just have one question for you. Uh, so, guys, we talked about this flexor sheath. What do you think is the function?
Why do we have this flexor-pronator? Why does the tender run on its own? Why does it need this flexor flexor sheath to surround it? These are the options. Um, please. Oh, yeah, we'll start the poll, and this is anonymized, yeah, so please, yeah, it's all. It's all anonymized. Everyone have a go.
There's really there's no well, there's no right or wrong answers that anyone can see, but have a go, try and you understand some of the functions. And what's really interesting here is guys that out of all the lectures that we've done, we actually talked about this. So if any of you come to our previous lectures, this be quite new and this point is quite correct.
It's a serious thing to encounter during an on call, so it's definitely worth being aware of. I'd be honest, you're all my orthopedic training. I only saw this three times. Yeah, but you don't want to miss it. Yeah and especially if you work in any, and you might see it more often. And I probably if you are, you want to specialize in hand surgery.
You work in the hand unit. It might be a more frequent attendance. And OK, so we will give you guys a few more seconds to participate. We'd like to get at least 70% of people to answer. Yeah, I know my guys just have a good. Have a go at it. You won't lose anything. And we'll take your questions as well afterwards if you want to clarify.
Right, so we will end it there. Share the results. What do you think of that? Mr that's brilliant, brilliant guys. Really, really impressive and encouraging. 76 got the correct answer. 76% 76% Yeah, 76% of people, which is very good. So yeah, it does.
Match the function of the flexor tendon sheath. It helps the tendons glide smoothly because here between the tent, the tent between the tendon and the sheath there is synovial fluid. Yeah so the synovial fluid obviously will ease that movement. Yeah and just to make it more interesting, there's another function of this, which is nutrition. So the synovial sheath and the synovial fluid inside it, they are full of nutrients, so they provide one of the main suppliers of nutrients to the flexor tendons.
So that's why when this space is compromised and the scarred up, the tendon becomes necrotic and the tendons scars up as well. And obviously, once the flexor tendon scars up, it has very poor prognosis. It doesn't loosen up afterwards. You could have all sorts of manipulation in a surgical release, whatever never recovers fully. So you don't want patients to go that far.
So brilliant. Very, very impressive. So thank you, guys. So this is just one of four topics we're going to cover today. So just before I hand over to Nikki, I just want we are. For those of you who are interested in orthopedics. We are running two days orthopedic course. We are founded.
Myself and KneeKG and. And covering all aspects of basically coming in two days, it's an online course. So you all you can contact your here or go to the Academy if you're interested to book. And we are educational, but the very keen on obviously orthopedics that we specialize in, and if any of you is interested to stay Follow us. Please go and follow us on social media and on website telegram group, where about our other few educational events.
So I'll hand over to KneeKG now, I'll stop sharing. Problem so just before we do that, Mr rhino, there's a question that someone's asked. It may be very trust specific or hospital specific, but what they've asked is what kind of an empirical antibiotic would you use? And they asked the Ku Klux Klan or someone asked vancomycin. Yeah, Yeah. That's a very sensible question.
Yes, there it is. Hospital according to hospital protocols where I work before majority, it was augmenting camozzi slap or 4 o'clock since Allen. But that depends on the local hospital policy and the microbiology policy. So I would start with the broad spectrum. You won't go wrong with camozzi. Yeah and then you can consult a microbiologist if you like.
You can give them a call. You can check your hospital policy. But if you are in that column, the cloud covers. But it's very important that you check what's the most likely causing organism in this patient? Yeah if this patient is known to have other sources of infection in their body, they have whatever infection they have. An open wound where that will open wouldn't happen, obviously, if it happened in the sea or in the farm, what they are exposed to.
This is all criteria the Place Part of the selection of antibiotics, you going? But I think if you can go give it a class for the patients not allergic, that will be a good choice to start with. And then you can consult the microbiologist. You need to consult them anyway. Yeah so yeah, I think that's very good. And am I wrong?
Am I right in saying that Staph aureus is probably one of the most predominant bugs that affect? Yeah, absolutely. OK, so so let's move on to Miss Evans here. We if you can share your screen if you're ready. Thank you. Thanks very much. I will just go on Slido. Yeah all right, so I've got two things to talk about, so I'll just rattle them off because I think we're behind on time.
OK, so the first one, we've got an 18-year-old male playing rugby. He's had a tackle and he's got pain and he can't move his right shoulder. OK, so what are the important things that we need to look at? In the history and the examination, ok? And this guy's got a dislocated shoulder. This is something that you are going to see. Doesn't matter where you work, whether you're in A&E, whether you're a gp, whether you're doing some sports medicine, you're going to see a dislocated shoulder.
OK, so from when you look at the patient, what you'll notice is that the tip of the equilibrium is a lot, a lot more visible on the affected side because you've lost that normal contour that you see when the human is in place like it is on the opposite side. So what you can say is that there is some asymmetry of shoulders, and that's what you can see. And if we turn to the X-ray.
Here is the glenoid. OK and here is the humeral head and the humeral head, the articular surface should be up here with the glenoid. OK, so what do I need to know about the history? Well, I need to know the patient's age and how it happened. The most obvious things I need to know if he's got any altered sensation, particularly in the distribution of the auxiliary nerve, which is in the regimental bunch area of the shoulder.
Whether he's got any other symptoms that could reflect a wider brachial plexus injury and then other things I need to know is what his medical. Any of the medical problems know if I need to give them an anesthetic. And have you ever dislocated it before? Does he have a history of dislocation of other joints like his kneecaps or his other shoulder? He dislocated this one 20 times.
Does he dislocate it when he's in his sleep if he put his hand over his head? So there are things we need to know. Because it will affect our management if we take this as an isolated first event, traumatic dislocation of the shoulder, then. What we're going to do is hopefully reduce it. But one of the things that we kind of wanted to show you is like, why does it dislocate?
Well, unlike the hip, which is also a bone joint. The upper limb. Kind of sacrifice the stability for your range of movement, so your upper limb, you can do all these movements that you need to do with your upper limbs, your hands and everything you need to do that you don't do with your hips, hopefully. And so in order to get that range of movement, we have to sacrifice some of the constraints.
So if we look at the bony anatomy, we've got a humeral head with a bony glenoid and the bony glenoid is quite flat checked, a little bit like a pear, and it's quite flat and the humeral head sits on it. And that articulation itself, there's not a lot of limitation there. You've got these other bony constraints around, but again can move around that.
And if we look at the glenoid itself, we have to glenoid labrum and the glenoid ray labrum is a thick cartilage that goes from the rim of the glenoid. Into the joint capsule. And it causes a negative pressure effect within the joints that kind of sucks the humeral head in. So when we look at the static and dynamic restraints of the shoulder joints, then static restraints would be things like the labrum, the joint capsule, the capsule, the ligaments which I won't go into.
And the negative articular pressure. And then we've got dynamic restraints which go around the shoulder, as you can see here, which are the rotator cuff tendons, which are subscapularis bas status impersonators, those minor the long end of the biceps, which crosses. And through the superior part of the capsule to insert the superior margin of the glenoid and then the scapula muscles like the torso.
So reduction maneuvers now if you go into the internet and you look up how to reduce the dislocated shoulder, you'll see lots and lots of different ways and lots of people doing YouTube videos and things like that. These are the three most common ones, I think. OK and the Hippocratic message is the one that was all it used to be in all the textbooks where you put your foot in the axilo. The traction attraction is probably the most common one that you see in the emergency department, so you need two people.
You need a sheet, not a blanket, not a blanket because it stretches. You want the sheet because it's a lot firmer. Give you the traction and you usually pull your arm into about 30 degrees of abduction. Bend the elbow. The other person pulls and you try and push it in. Now, in the emergency department, you probably do this.
Ideally under some propofol if you've got someone there that can do it, because if you have an 18-year-old muscular guy who's waited for hours to see you, this is going to be a struggle. If we just give them midazolam and morphine, then you might not get enough relaxation to give them propofol. There's a good chance you'll be able to get it in. And then the other method is the one that I kind of use myself, which is Cocker's external rotation method and the idea is you don't have to put as much traction on the arm.
It's more of a leverage type thing and you basically. You basically externally rotate to you, unhinge and and lever it back in, and I tend to do this. More, because I get the ones that they can't reduce in emergency, so I take them to theater, they're under a jar and I could do this pretty easily. If you try and do this with any kind of force, then you risk fracturing the humerus.
So what do we do with them when we've put it back in place? Well, it all depends on whether they've got any complications and, you know, whether it's their first microfracture or not on the age of the patient, so. If it's an isolated injury, there's no fractures and no nerve injuries, and they're over the age of 20. Then you can probably just give them a sling and discharge if they've got anything else.
So if the recurrent dislocations, if they've got a fracture, either of the humeral neck of the glenoid, if you can see it or if they've got a greater lesser tuberosity fracture, we need to follow them up. If they've got a pattern of the current instability, if is any nerve injuries and rotator cuff tears tend to happen in the more elderly patients, so the young patients?
Generally will have a labral tear or a fracture. And where's the elderly because the rotator cuff are already starting to regenerate? They might take the rotator cuff with a dislocation. And I'm just going to quickly say, don't miss the post, Julie dislocation, so you'll hear it described as a light bulb sign. This is what it looks like. But if you have somebody in a sling with their arm in internal rotation, it might look like this.
So your clue is the lateral. So you can't try and get an auxiliary lateral if they've got a cursory dislocation. They're unlikely to be able to abduct their arm enough to get an axillary lateral. So they do a scapula lateral, which is this one. And if you look at this one, you can see the y of the scapula and the humeral head is pointing out the back. That's the key.
And these are often missed, and the problem is they're missed. And then we see them later on, and by that stage, they're locked in this position. So we have to do an open reduction. So here's my question. Which is following can happen with a shoulder dislocation. We know it fracture fracture, proximal humerus, auxiliary artery, rotator cuff tear or all of the above.
So guys told us they're up, we'll give you about a minute and a half. But we'd like a lot more people to engage at this time. Oh OK, so guys, we're going to finish up the poll just now.
Or that share these results. OK, that's pretty good. So the answer is E, all of the above. Don't fracture of the glenoid, yes, you can. That is called a Bankart lesion when it's just the labrum. And or they could actually fracture a small piece of bone off as well, so you can get a fracture right to the proximal humerus. Yes, you can get a greater tuberosity fracture.
You could get a lesser tuberosity fracture. You can have a surgical neck of the humerus microfracture or you can have. You may have heard of Sachs defect, which is just that the anterior superior part of the humeral head where you get a cortical compression, and that's whole of the topic by itself. So the answer to that is to. Axillary artery injury.
Yep, it definitely can axillary artery burns quite close. To wear the shoulder is and depending on the degree of trauma and displacement, you could absolutely get an injury rotator cuff tear, we've discovered that in the elderly, so the answer is eat all of the above. So well done. Everybody answered.
Apart from the two C and d, I mean, theoretically, they're both correct. All the answers are correct, but yeah, well done. You want me to carry on? Yeah, please. Yeah OK. With many questions, I can't see the chat in this. So there was a question, but I think Mr. arnault's answered it, and it was that would you inform ortho if you're going to initiate shoulder reduction?
And if anyone didn't read the question, the answers of the chart, but it just talks about if there's any neurological deficit. And if you have experience in giving sedation, I'm guessing this question in context of being an Eddie. Yeah And I guess the other thing is, if there's a fracture. So if it's a greater tuberosity fracture, then there's probably very little risk if you're doing much damage by putting it back in.
But if you have a surgical neck fracture that's displaced and you try to push it back in, you could displace that fracture and make the problem worse. That would be the other reason I would call ortho. Yeah, OK, good. I'll quickly cover these ones then. So they first talked about an orthopedic emergency. For me, this is a bigger orthopedic emergency, so typical story would be a child at the age of six falls off some monkey bars or something like that, and they've got a painful, deformed elbow.
And here we have a epicondyle of fracture. OK when I was a medical student and junior occupied, I could not get my head around this little practice at all. So I've tried to make it quite easy. But essentially, it's a break at the distal part of hubris. And it's either displaced, a bit displaced, really displaced or absolute mess. All right, so that's what we're going to look at.
So your history? Typically, it's a kid that's fallen off something. They've got a painful, swollen elbow that they don't want to move. You've got always going to think of non-accidental injury when it comes to children's fractures. So if you've got a delayed response or a history that doesn't fit, you've got to think about it. But generally, these are not due to niye, they're due to kids falling off.
In your examination, your main point. What you need to tell the orthopedic surgeon on the phone is whether the fracture is open or closed. And because some of them are open, if there's any skin puckering, so if you can imagine this proximal fragment can actually tent and tear through the anterior part of the biceps and kind of buttonhole through it. And then when it goes, when it moves, it pulls a piece of skin back at it.
That type of fracture, you're not going to be able to reduce it without opening it because you can't get the fracture piece back in. All right. Next thing, does the child have a radial pulse really important? You need to feel a pulse, ok? If there is a post, great, if there is no pulse, the next thing is the hand warm and pink or is it white and cold?
OK but that's what we're going to go with that one. And the nerves are the most commonly injured nerve is the anterior Rochester branch of the median nerve. OK, without going into all the different nerve examinations, children. The OK, so the way that you can test the major nerves in the hand is I get them to make an OK sign, which is your median nerve.
And until you get them to make an L side, which is going to be your radio and you post your interest. Yes and then I get them to do star, which is your ulnar nerve abduction. Some people do cross over their fingers through scissors, whichever you want to do. So you can get some kind of idea of the assessment. And the other thing is if you think there's a nerve injury.
You can look for the sympathetic part by putting a wet swab on their fingers and see if their fingers wrinkle. That's another test that you could do in a bind. So let's have a look at some things, so Gotland classification one, two three, then somebody added the four. OK, so one is on display, you're probably not even going to be able to see it.
The only thing you might see is a poster area of fat cat sign, which is what this X-ray shows here. OK this little bit at the back. So an A fat cat size can be normal a posterior fat pad sign. There is an injury in about 80% of the cases, so child painful elbow all posterior slap outside, it's got a super alert until proven otherwise. OK, so that's type 1.
Type 4 is where, like the one we've just seen where there's no connection anterior or posteriorly and it moves all over the place and it's going to have to go to theater. All right. We have the ones in between. So number two and number three? Number two is quite displaced. Number 3 is more displaced.
Number two helpfully is divided into and b, which depends on whether the piece is rotated or not. I do not think you need to know that at this level, all you need to know is whether some things are one. Or whether it's something else, to be honest, so were to when you get the slight tilt, we talk about the anterior humeral line, which goes down the anterior aspect of the humerus and should cross through the Allen.
So there it is in this picture. And here it is in this picture through the middle of the Allen. But if we look at this one, this one and this one, you can see that it goes the line. The anti-human line goes in front of the Capitol Allen. So we've got. Usually a 2 type injury. Now some of these are acceptable, if they're tilted back any further than what we could do is a close reduction, which is where we just push it back into place and put them in a plaster.
Sometimes if they're a bit rotated, we put wires in if there are three like this one. And then we're going to take it to now. I will go through the whole business of what we have to do from your point of view, seeing this patient in emergency, the thing that we want to know is the Australian examination. Give the kids some pain relief, give them a back slap because you can imagine these bones moving around is going to be painful.
The position of your backside doesn't really matter. You might have to have it by extension, doesn't matter. It's just to hold the fracture still and give some kind of pain relief. Keep the kid fasted. Find out when they've lost eaten. Call us if you've got a white hand, we're going to need vascular as well. I make sure you document everything OK.
It's really important that you document everything that goes on with these children. So here's a quick flowchart, you don't need to know all this, it's the interest anyway, because I think it's really interesting. So you've got the worst case scenario that you want to in the morning, you've got a displaced type III or type IV epicondyle a fracture with no pulse.
Now, have you got a pink hand? In which case you call orthopedics and say, I can't feel a pulse, but his hand feels warm and it's pink. And we'll probably come in and see it, and then we'll probably look at it every hour or even every half an hour because we'll be quite worried about this. We might even try and get to see it at 200 in the morning to look after it because the problem is it might be pink and warm when you ring us.
But by the time the kids, you know, been to X-ray then transferred to the wards, it could have gone white and nobody's checking on it. So what those ones will do will usually reduce them and pin it and then see whether we get a pulse back. As well, sometimes because of the point of the fracture, you get spasm of the artery, so that's why you lose the pulse. So hopefully when you reduce it, give them a bit of time, the pulse will come back, ok?
Worst case, no pulse and white hand. All right. Call us, call vascular. We're going to take that kid straight to theater and we're going to reduce it and see if it comes back, if it doesn't. We're going to open it up and the vascular surgeons are going to explore and repair the artery. OK so here's my question which nervous, most commonly injured in pediatric supercontinent fractures?
Is it a the post their interest? Yes B the a c, the radio d, the median or E the ulnar nerve. Oh so we did just answer that, guys, this is just a quick test of who was listening. But everyone should answer this. It'll allow you to jog, you've just gone through, but this is something that you'll get asked again and again and again, I can tell you at like core training interviews and three interviews, maybe afterwards, probably afterwards that.
Yeah, and then and then the day you'll encounter it. Even up to your consultant interview, probably, yeah, Yeah. OK, so got a couple more people, guys. Go on. Give it a shot.
OK all right. Five more seconds, and I'm going to pull. All right. Can everyone see the results? We can. And I have to say I'm disappointed it was mentioned. So the answer is the a interruptions.
OK and it's just the way the fact that where it comes off the median nerve, as it goes around the elbow, it's just more prone to injury from a fractured displacement than the other branches in your head. You might be thinking, oh, its posterior nerve, because that is that's near the elbow, but it comes off a little bit. You remember round as around the radial head, first to come off.
So it's not the posterior atrocious and it's not the radial. The ulnar nerve is coming down the other side. I agree it does run behind the medial epicondyle, but the way that the fracture usually displaces. It is usually a little bit superior to that, and it doesn't tend to catch the fracture tends to go away from the fracture away from the nerve of anything.
So it's not the ulnar nerve. So your choice is the median nerve or the anterior trough where the median nerve goes, it takes it out of the way. But where the anterior interosseous branch comes off, it goes right by where his fracture normally displaces, so the anterior entrusted to serve the OK side. So usually they can't flex their index finger. Yeah, yeah, they do that.
Instead, they can't flex their. That's what you want to look for. OK, thank you, everyone. That's brilliant, brilliant. Thank you. But then potentially all these nerves can be injured, but the question was the most common injured nerve. Yeah, Yeah. But obviously, potentially all the nerves, KneeKG.
All of them. Yeah, Yeah. So you check all of them. But the most common question? Yeah so we have is that one more topic that we've got left, Mr. arnault? Yeah OK, so that'll be with you. So guys, one more topic and I've I'll add the feedback at the end of that.
And please do keep your questions coming. This is the first lecture that we've done with Mr. Thomas. So they've tried to gauge a little bit what they would feel for medical students would be at an appropriate level. Of course, they can go as advanced as you like, but if there's any questions that you have or anything you'd like to add, put it in the chat and we'll try and we'll try and address it.
Thank you for explaining that here. Thank you, Nikki, for touching on the topic of this distal humerus fractures. That's another orthopedic emergencies that you leave everything and go immediately to assess. Um, can you see my screen destroyed? So now we're going to step back a little bit from all those orthopedic emergencies. All the rush of adrenaline, of all of those into another orthopedic emergency.
That's probably not as urgent as the previous ones were discussed, but it is very common these outrageous fractures, so this actually can become about fifth of your orthopedic trauma attendance and tendencies at your fracture clinic or emergency department. So it's very common. So what I want to get to obviously this debate is fracture is a huge topic.
We could spend conferences on this, but we try to cover some principles and a few minutes. So from my point of view, what I want to guys to pass on to you is that you need to be able to describe these fractures and classify them as simply as you can and to help you with that, just focus on two issues. On on your fractured description, number one is the direction of displacement and no to articular involvement, just focus whenever you see the stress fracture, no matter how awful it can be, how confusing it can be.
Just focus on those two aspects direction of displacement and articular involvement. Yeah so when we talk about forearm, wrist and hand. We don't use the terms, such as posterior, anterior medial, lateral thiswe terms we do not use because there can be very confusing. There are depending on the position of the arm and what's posterior could mean different things to different people.
So we used terms such as dorsal. OK for the extensor part. And volar for the flexor-pronator. And we used the other terms is radius. If we're talking about the lateral aspect, the thumb thumb side or ulnar nerve. OK, so Dawson, volar radioulnar and articular involvement, OK, so there are four main types that we focus on kohli's fracture, Smith fracture and Barton fractures.
OK, so Collins and Smith are extra articular fractures. Barton is intra articular fracture. I think if you know this stuff, when you go for your orthopedic or trauma elective, you'll be on the top of the class. So we start with the Cordis fracture cause fracture again. Displacement? yeah, so displacement. You describing the distal part of the fracture? Yeah always refer.
Don't get confused. Sometimes could be confusing. You see fractures, fragmented and pieces everywhere. Just focus on the distal part of the fracture. Where is that going? And here it's going. Dorsally is displacing dorsally and it's extra articular. OK, so here we have a fracture that is displaced dorsally and is extra articular, and this deformity creates this so-called dinner for deformity.
Obviously, this is quite extensive displacement. You don't always see it, but that's how they present. OK, so now one question I want to ask you guys about is how which you could think about and if someone knows the answer, please write it in the chat box is how do you know? You know, sometimes could be confusing if this is a vowel or displacement or dorsal displacement.
What are your landmarks to define this as dorsal displacement? Why is it not vowel or how do based on the X ray? If anyone knows the answer, please write it in the chat box. OK, so that's how I look. And while you guys, I think we'll move on to the next fracture, Smith fractures a Smith fracture.
The fracture displaces violently on the other direction to call his fracture, but it's still extra articular. see, the articular surface here is not violated. It's still intact, OK, but the fracture has moved violently, and the same question applies how do you know this is volar and not dorsal? So please, guys as well, try to write the chat box if the answer, we will come to that.
So someone wrote down thumb, which yeah, Yeah. Perfect so you know, it might look simple to many people. might. It might be clear to many people what's but believe me, there will be those times when you are stressed in a trauma meeting and the fracture is not very clear. Multi trauma patient. And when you get confused, what the direction of displacement.
So using landmarks is the thumb. The thumb is always on the volar aspect. If you look at the hand, always the thumb is in the volar aspect. So that's one landmark. There is the r mode. If anyone knows, please write them down. Did so, Smith fracture is the second fracture. Now we'll move to the articular fractures, and these are more simple.
One name Barton fracture, so there's dorsal Barton and volar Barton. Again, the same displacement is the displacement dorsal or is the displacement volar. And as you can see here, there is a fracture line and then it sustains here into the joint line. So, for example, you could see on this x-ray, this X-ray is a cone x-ray, and it's quite common in cases when you suspect Inkscape forehead fracture and stuff.
When they do not X-ray the hand. So how do you know what's volar and what is dorsal on this x-ray? Again, please, guys, if anyone knows the answer, please write in the chat box. Very, very important, because you need to know, is this door selling this place, you need to be able to describe it either to your seniors, the trauma meeting or when you're offering this patient.
If you are in any or, you know, if whatever you speciality, even if you are a physiotherapist, you're talking to it, to the surgeons, you need to be able to describe it accurately and you don't want to be describing it as a wall of displacement here. For example, I won't look good. So dorsal part we spoke about, and this is boilerplate Barton Barton with the fracture has line is in particular you see here it's quite impressive displacement and the fragment has displaced forwardly.
So do we have any answers about them, any more hints on the X-rays at all? No, not. Not yet. So we could maybe comment on that a little bit. Yeah so the correct answer about the thumb, obviously, and we can see here, for example, the thumb is always volar and the fracture has moved towards the thumb. So it's volar.
Yeah, so that's when I speak. Other thing is, for example, if you cannot see the thumb is missing out of the x-ray, which can happen. Is you look at the metacarpals, Yeah. So here, if you look the metacarpal bones, the dorsal aspect of the metacarpal bones is straight. Yeah, as you can see here, but the volar aspect is curved concave. Yeah so the volar aspect of the metacarpals concave, the dorsal aspect is traitorous, another sign.
Can everyone see that? I hope. Yeah, I hope it's clear. Yeah if want me to repeat it, I can, if not clear. Now how about this, ray? Now, how do we know here? We cannot see the thumb, we cannot see the metacarpals. Anyone?
0 here in the chart, because I can't see no, no good. So, yeah, so the hint is. Is this going? The basic form born, Yeah. The policy form bone is assessable with bone that's in the wrist. Yeah and it's formed an insertion or not, an insertion, it's within the tendon of the flexor carried by a lattice, but that's bone is always on the volar aspect because it's in the course of the flexor carpi ulnaris.
So it's in the flexor side, it's in the volar side. Yeah, unless it's dislocated, which I don't sure I've seen ever seen it. So it's so the basic form bone is your landmark. If you cannot see the thumb or metacarpals, the piece of foam bone is always on the volar aspect. OK, so that's how I know this is a dorsal displacement. Great I hope that was clear and helpful to you, I think.
I'm just going to go quickly through the principles of management of the structures, so generally if the fracture is displaced, it will require reduction, most commonly if the fractures are extra articular. So Collins and smith, for example, or more commonly colleagues, you could do a closed reduction and you need to stabilize them. Yeah, you can either stabilize them in a cast or if the cost is inadequate, you could put keywords in.
Yeah, we won't go into details. Exactly that's different. Lecture take longer time to explain the various reasoning in the draft trial, and so many other trials have come up. It's a matter of debate. What's the best way to fix these fractures? But that's the general principles. If there's articular fracture, it will require surgical fixation because the principles of articular fractures, they require anatomical reduction.
Yeah so intra articular fractures, they require anatomical reductions. They need an operation and they need something like this play to fix. OK, so that's the other guys I wanted to say about this radius fracture strike to keep it as simple as they can without going into too much details. Obviously, if there are any questions, we can always address in the future, lecture cover other parts and maybe more of the algorithms of treatment of bas status fractures.
So now this is my cue. Please try out, guys, I think we touched on the de La fracture, but I think it would be just good to re-emphasize the same points. I think you guys are must be masters now in neurological assessment. just the opposite. I was just going to say, just speaking from experience, there is always at least one of these questions, if not more in every single one of our papers that we seem to have.
So it's definitely worth just practicing them over and over again. Yeah yeah, know they recur at every level. These assessment questions will recur at every level and they know they'll catch you up. OK it's quite interesting the answers, but guys, this is at the end, everyone should answer this.
It doesn't matter whether you get it right or wrong, because we'll see it as a whole group, but you should give it a shot because it's your last chance to have a question a shot before we finish up. Yeah, and I encourage you all guys, because when you answer, even if you get it wrong, you tend to remember the correct answer better than when you attempted just attempted anonymized you want. You know, it's not a real test.
No one is marking you. OK, so I'm going to close the poll in five seconds, guys. 5, 4, 3, 2, 1 OK. Three excellent. Thank you. So 72% of participants attempted and now got 39% answered correctly, which is making a fist.
And what's obviously we discussed earlier with KneeKG is making the OK sign. It's the same principle. You're assessing the flexors of the hand. That's the median nerve. Yeah OK, so making a fist or OK sign? That's the median nerve. Now the second common answer some people picked here is thumb extension and extension.
Generally in the hand is the radial nerve or the extension of the thumb. You know, thumbs up or else sign, as KneeKG showed earlier. Thumbs up sign. These are extensions. And these are radial nerve or posterior interests. Snare if you want to be more specific, so so these are radial nerve, unfortunately. OK, now finger movements sideways.
Yeah sideways like this, whether it's opening, spreading or sizzling. This is ulnar nerve. Yeah, because the assessing the intrinsic muscles within the hand. Uh, intrinsic muscles within the hand, Yeah. So, yeah, so again. Extension generally is radial nerve with a thumb extension or fingers extension inside.
OK, sign or a fist is median nerve and finger sideways is ulnar nerve, yeah, so well done. 39% to got the correct answer. And generally, guys, obviously when you are assessing a patient. So broken, they're fractured or destroyed, just fracture coming with acute pain. Sometimes it's difficult to assess the motor function. You ask them can you do this, this, and they can't because they are in pain.
And in orthopedics, you want to gain the trust of the patient. You don't want to cause unnecessary pain. Yeah so if they are unable to move, don't force them. Don't make them move. Yeah, they cannot move. They're in pain. Don't make them. So instead, you can assess the sensory components of the nerves.
Yeah and for the sensory components, there are specific areas. So for the medial nerve is the visual aspect of the index finger. For the ulnar nerve is the volar aspects of the little finger. And for the radial nerve is that dorsal aspect of the first web space, so you could just light touch. Yeah light touch, that's what you do.
Just light touch, that's how we touch the sensation. And that could be another way of assessing the motor. Sorry, assessing the nerve for any nerve dysfunction if they are patient in too much pain and they cannot move. And that's all I wanted to talk about today again, guys. Reminder, of course, with the academy, please. And please, we would welcome you guys to stay and follow us on social media, on Telegram as well.
And we have a YouTube channel as well with educational videos for you guys. So please stay in touch with us. Always and myself and other faculty of the Academy will be very keen to hear from you and communicate with you for what you need to learn about in the future. What you want us to talk about, what complex concepts you find that you want simplifying and Shaair as well.
Will will help us stay in touch with you, hopefully. Yes so thank you so much, Mr Arno, and I think that was really good going over some concepts. And I think it always really helps to have a senior clinicians here to do some of the teaching because you can drive home some concepts that we may not be able to cover in detail. So thank you for that. And guys, just mentioning about the course, there's plenty of time to the course, but start registering.
We may run out of spaces and you know, we're really trying to gauge what people are interested in. But the good thing about the course is that it's based on the BOA undergraduate syllabus. So what we're covering is pretty much at least a very good standard of what needs to be taught. And then anything above and beyond that, let me know or orthopedic if you're interested in that. And we can certainly discuss that because what we've looked at from a lot of our polling is that undergraduate teaching in orthopedics, especially for people that are interested in it, is probably not as much as people that want to do orthopedics would like.
So if that is something that you're interested in or it concerns you, or maybe you want to do plastics or Ed, and there's elements of orthopedics that match into what you want to do, then let us know. And I'm always free to be contacted on any of the social media handles that you may know from. And that's it. We hope to have more lectures. The feedback is posted in the chat.
And thank you so much and I hope everyone has a lovely evening. Thank you. Here, I thank you for having us and all the best to the 6 PM series. Thank you, guys. Thank you. Thank you. Thank you. Bye bye.
Segment:0 .
It's a good evening, guys, welcome to tonight's lecture.
My name is here, I'm one of the co-founders of the six PM series. We've also got Greg carburettor essential series that we do. You've seen some of the videos and we have some really nice, remarkable guests with us today who are more familiar in FRCS territory, which is quite a bit beyond for some of us, but they are interested in undergraduate teaching. We got in touch with them a while back.
It was a great, productive conversation that we had. So this is our first lecture together that we're collaborating and they have a fantastic course that's coming up in April as well, that we could talk a little bit about at the end. So I'll start here and I'll let them introduce themselves. So I've got Mr ulnar nerve I. Would you like to introduce yourself as we wait for everyone to enter?
Well, good evening, guys. Mr a I'm one of the founders of the orthopedic Academy. It's my pleasure today to be here with my colleague Nikki, one of the other founders of orthopedic academy, and we, you know, privilege to be with Shaair and Greg and the rest of the team of six PM. We are really impressed with this platform and with the educational value you provide and really very happy and excited to be with you guys.
So thank you for inviting us and we hope that you will have interesting and. A session tonight with us. Thank you. And then we have Miss Evans as well. She was just doing her pose there. If she's free now, miss Evans, would you like to introduce yourself there briefly? Yeah, Thanks very much.
My name is KneeKG and I'm a special doctor and trauma orthopedics. And I have an interest in education at all levels. So I was previously the undergraduate lead for the Lancaster and UConn medical schools. And we do a lot of our process teaching as well. So I'm really glad to be here as well and looking forward to it. Thank you very much. Thank you.
So we're very excited, guys. And if you're new to the 6 PM series or if you're new to any of the talks that I do, I always like to have a mentee poll to gauge where our audience is watching from. It really gives us an idea of the breadth and the depth of the kind of people that we've attracted to the talk that we have today. So the best way to do that is if you have your phone with you, you can type in w-w-what and put in a code, so the code is up there.
But if you aren't able to see it for whatever reason, the code is 81202830. We'll give about five minutes or so for this to go through and then we'll start and we'll hope that everyone that wants to be here tonight is in tonight's talk. I'm just going to make a quick post to that. Everyone on our social media streams that we're alive and we will get we will get on to it.
Then if you have any questions or anything at all, guys, please let us know in the chat and we will try and get to them as we can. The two.
OK, so guys, if you have any friends or anyone that's also thinking of coming tonight, let them know that we're about to start. And we'll go from there, so, right, so people have answered the people, so where do you watch it from? So obviously most people here are watching from England. So that's good.
You have a couple more minutes before we start. So the Scotland, so nice to hear someone's watching Scotland apart from me. Bristol, swindon, Australia, Bulgaria and Wales. Yeah, we've got quite an international crowd there. So it will be it'll be. It'll be interesting if you're from anywhere else that's away from us or very international. We'd be really cool and interesting to know.
So do pop it in. And yeah, that's it. So Mr. Arno and miss, are you ready? We can. We can get started soon. Yeah, I will. Is it OK if I start? Or Yeah. Lovely, thank you.
So there are people from Australia, Nike for you. Nike trained in Australia, so great place. Oh, it's so lovely. So can you see my screen now? yes, we can. Lovely right, so welcome, guys. So to this teaching session, the aim is to give you the information in a small bite size kind of box.
We we're not here today to bombard you with a lot of information. We're just going to give you some information that you can retain and and it will influence your daily practice and be useful for you, for your exams and for your daily jobs. So we talked today about some orthopedic emergencies, and the next one we're going to talk about is in the hand infected flexor-pronator sinusitis. It's one of the rare orthopedic emergencies.
You won't see this. This is not very common. You won't see it in every on-call. Call on every orthopedic elective attachment you do, but you need to be able to recognize it because it's a true orthopedic emergencies. You don't want to be missing this. It's potentially can be limb disabling condition. OK, so there is it's a serious condition.
So remember that whenever you see infections of the hand infected flexor-pronator sinusitis, so what is that? What is infected flex of sinusitis? It's an infection of the flexor sheath that surrounds the flexor tendons in the hand. OK, so flexor tendons in the hand? Yeah, we're going to have a question later on about what's the function of this. But as you can see in the picture, the flexor tendon is surrounded all around by this flexor sheath.
Yeah so this flexor sheath unfortunately can get infected. So how are you going to recognize this? And we have to agree first on some orthopedic principles as we are here today doing this orthopedic specific teaching. So I would like to introduce some of the main principles of orthopedic examination. So orthopedics is different from other medical and surgical specialties. When you do inspection, palpation, percussion and auscultation in orthopedics is completely different.
It's nice and simple. It's look, feel and move. So guys, whenever you see any orthopedic patient, you're presenting a condition to your seniors on a meeting, in a trauma meeting, or you're referring a patient. And from A&E, always remember these three aspects of a clinical assessment look, feel and move. That's how we present orthopedic patients. OK so infected flexor-pronator and invités this is how it presents.
Look so we start with looking on inspection. What you see? Is the finger is held in a slightly flexed posture? Yeah that's the first sign on Un inspection, on looking second son on looking. There is this fusiform swelling that involves the whole finger. Sausage shaped, Yeah. So two sides of an inspection.
Finger held and slightly flexed position and the fusiform swelling. Second, feel. Unfeeling, you do this, you palpate along the course of the flexor tendons of the finger and so sorry, Mr ohno, just. Are you onto another slide because we can't see the slide? I'm very sorry. Yes, I am.
No, no, no problem. No problem. Not following my second slide. Yeah, yeah, no, no. I think he might even be on slide 4 by now. No, actually. How about now? Is that better? Yes, it's better now.
Yes sorry, it's not in a slide mode, but sorry about that. I don't know why. Why the slides more did not follow me. So so yeah, look, feel. Move Yeah. And these are the four clinical signs. So looking inspection fingers held in slightly flexed posture. And there is fusiform swelling.
Phil, palpation along the course of the flexor tendon is painful all over. Yeah Other conditions when you get septic arthritis, for example, the swelling and the tenderness will be specific to the infected joint, but in a flexor thing of itis. The sweat, the pain and tenderness will be all along the course of that tendon. McCain and then move.
If generally in orthopedics. Patients are in pain, so you have to be very careful when you move them. Patients will be reluctant to actively move if they have infected finger. Yeah, so you try to gently passively move them and they will be in a lot of pain. OK, so there are active movements. They're not unlikely to be able to do.
And there is passive movements, which you do. And there will be in a lot of pain. So these four signs. They are called carnival signs. OK kind of all signs start with a K. Because see the first signs of. Uh, in fact, that sine of artists. Please remember, guys, this picture, it will be very useful to you when you go to your orthopedic attachment.
So here we can see on inspection how the whole finger is red and swollen. And it's and they will have tenderness along the whole course of the flexor tendon here. You can see also an inspection how the finger is being held in a slightly flexed position. And another principle I would like to introduce to you guys is that again, in orthopedics generally.
The conditions are painful. And patients. They try to hold their limit in the comfort position, and that tends to be in slight deflection. The reason is flexion increases the space. Yeah and therefore, it will reduce the pressure within the confined space and reduces the pain. So whenever you see someone septic arthritis fracture, any orthopedic condition is causing pain.
Patients try to hold their painful part in slightly flexed position. OK so I hope now, you guys, you'll be able to recognize this condition when you see it. Yeah the reason it's serious is because it can lead to irreversible stiffness. So it's potentially disabling and can cause tendon rupture. The infection can spread.
And further up in the foreground or into deep into the bone. And if I go to the first slide here, you can see how some of the flexor tendon she is connected to the pound and up on the forearm so the infection can actually spread. Patients can potentially use lose the whole arm. So what do you do now you've recognized this condition? What do you do, you do your usual history examination documentation.
This condition again is a priority. It can't wait. If someone refers you a patient or you suspect in any a patient with infected sinusitis, you don't wait to experiment. You need everything else. And you go to see this patient. Yeah, you do routine, tough stuff. History, examination, documentation. You do the bloods, including blood culture, because you might need them culture specific antibiotics later on and you do x-rays just in case there is bone extension or there is a foreign body.
Yeah, principles of treatment generally, again, infection always elevates, you get cellulitis in the legs, in the arms, you get infection, you get septic arthritis, always rest and elevate. Yeah, elevation reducing the edema reduces the pain. Very, very important elevation is as important as antibiotics. And then you start intravenous antibiotics immediately, you don't wait for culture, you don't wait for anything. And you have to give them a big, hefty dose of antibiotics.
Not that 250 oral flu clocks. That's not going to work. It has to be big, hefty IV dose, according to your local hospital protocols. And once you manage this patient, initially, you immediately. If you are in any, you refer to the orthopedic or the hand team or if you are already an orthopedic trainee, you would then you refer to your seniors immediately.
This patient needs to be again. I can't stress this enough. This patient need to be attended to immediately. These patients need to be managed urgently. OK, if you're not getting a response from the senior, from the first person you refer to, you go up to the next level until you get to the consultants with no response. This is, as I said, it's potentially disabling condition.
And for you guys, just to be aware of the principles of the surgical treatment after you've given the antibiotics is basically an orthopedic infection. It's wash out, but the pain principle of wash out is you wash out from proximal. To disturb. Yeah you don't want to wash out from this style push infections proximally up the forearm. You sort of wash it from proximal, push all the infection away towards the tip of the finger outside the limb.
OK, so you open one opening here and the APR at the MCP level, MCP level and another opening this in the finger. And sometimes that can be transverse incision and you put this cannula. Under the flexors sheet, and you keep push until you get a clear fluid coming out from the other end. First of all, obviously when you start washing, there'll be a lot of pus. Then you keep washing, washing and sometimes that might need to be repeated next day.
So that's all I wanted to talk about in this condition. In fact, the flexor-pronator egawa test, I hope you guys be able now to recognize this as an emergency and deal with it. Do the initial management. That's our aim of today. I just have one question for you. Uh, so, guys, we talked about this flexor sheath. What do you think is the function?
Why do we have this flexor-pronator? Why does the tender run on its own? Why does it need this flexor flexor sheath to surround it? These are the options. Um, please. Oh, yeah, we'll start the poll, and this is anonymized, yeah, so please, yeah, it's all. It's all anonymized. Everyone have a go.
There's really there's no well, there's no right or wrong answers that anyone can see, but have a go, try and you understand some of the functions. And what's really interesting here is guys that out of all the lectures that we've done, we actually talked about this. So if any of you come to our previous lectures, this be quite new and this point is quite correct.
It's a serious thing to encounter during an on call, so it's definitely worth being aware of. I'd be honest, you're all my orthopedic training. I only saw this three times. Yeah, but you don't want to miss it. Yeah and especially if you work in any, and you might see it more often. And I probably if you are, you want to specialize in hand surgery.
You work in the hand unit. It might be a more frequent attendance. And OK, so we will give you guys a few more seconds to participate. We'd like to get at least 70% of people to answer. Yeah, I know my guys just have a good. Have a go at it. You won't lose anything. And we'll take your questions as well afterwards if you want to clarify.
Right, so we will end it there. Share the results. What do you think of that? Mr that's brilliant, brilliant guys. Really, really impressive and encouraging. 76 got the correct answer. 76% 76% Yeah, 76% of people, which is very good. So yeah, it does.
Match the function of the flexor tendon sheath. It helps the tendons glide smoothly because here between the tent, the tent between the tendon and the sheath there is synovial fluid. Yeah so the synovial fluid obviously will ease that movement. Yeah and just to make it more interesting, there's another function of this, which is nutrition. So the synovial sheath and the synovial fluid inside it, they are full of nutrients, so they provide one of the main suppliers of nutrients to the flexor tendons.
So that's why when this space is compromised and the scarred up, the tendon becomes necrotic and the tendons scars up as well. And obviously, once the flexor tendon scars up, it has very poor prognosis. It doesn't loosen up afterwards. You could have all sorts of manipulation in a surgical release, whatever never recovers fully. So you don't want patients to go that far.
So brilliant. Very, very impressive. So thank you, guys. So this is just one of four topics we're going to cover today. So just before I hand over to Nikki, I just want we are. For those of you who are interested in orthopedics. We are running two days orthopedic course. We are founded.
Myself and KneeKG and. And covering all aspects of basically coming in two days, it's an online course. So you all you can contact your here or go to the Academy if you're interested to book. And we are educational, but the very keen on obviously orthopedics that we specialize in, and if any of you is interested to stay Follow us. Please go and follow us on social media and on website telegram group, where about our other few educational events.
So I'll hand over to KneeKG now, I'll stop sharing. Problem so just before we do that, Mr rhino, there's a question that someone's asked. It may be very trust specific or hospital specific, but what they've asked is what kind of an empirical antibiotic would you use? And they asked the Ku Klux Klan or someone asked vancomycin. Yeah, Yeah. That's a very sensible question.
Yes, there it is. Hospital according to hospital protocols where I work before majority, it was augmenting camozzi slap or 4 o'clock since Allen. But that depends on the local hospital policy and the microbiology policy. So I would start with the broad spectrum. You won't go wrong with camozzi. Yeah and then you can consult a microbiologist if you like.
You can give them a call. You can check your hospital policy. But if you are in that column, the cloud covers. But it's very important that you check what's the most likely causing organism in this patient? Yeah if this patient is known to have other sources of infection in their body, they have whatever infection they have. An open wound where that will open wouldn't happen, obviously, if it happened in the sea or in the farm, what they are exposed to.
This is all criteria the Place Part of the selection of antibiotics, you going? But I think if you can go give it a class for the patients not allergic, that will be a good choice to start with. And then you can consult the microbiologist. You need to consult them anyway. Yeah so yeah, I think that's very good. And am I wrong?
Am I right in saying that Staph aureus is probably one of the most predominant bugs that affect? Yeah, absolutely. OK, so so let's move on to Miss Evans here. We if you can share your screen if you're ready. Thank you. Thanks very much. I will just go on Slido. Yeah all right, so I've got two things to talk about, so I'll just rattle them off because I think we're behind on time.
OK, so the first one, we've got an 18-year-old male playing rugby. He's had a tackle and he's got pain and he can't move his right shoulder. OK, so what are the important things that we need to look at? In the history and the examination, ok? And this guy's got a dislocated shoulder. This is something that you are going to see. Doesn't matter where you work, whether you're in A&E, whether you're a gp, whether you're doing some sports medicine, you're going to see a dislocated shoulder.
OK, so from when you look at the patient, what you'll notice is that the tip of the equilibrium is a lot, a lot more visible on the affected side because you've lost that normal contour that you see when the human is in place like it is on the opposite side. So what you can say is that there is some asymmetry of shoulders, and that's what you can see. And if we turn to the X-ray.
Here is the glenoid. OK and here is the humeral head and the humeral head, the articular surface should be up here with the glenoid. OK, so what do I need to know about the history? Well, I need to know the patient's age and how it happened. The most obvious things I need to know if he's got any altered sensation, particularly in the distribution of the auxiliary nerve, which is in the regimental bunch area of the shoulder.
Whether he's got any other symptoms that could reflect a wider brachial plexus injury and then other things I need to know is what his medical. Any of the medical problems know if I need to give them an anesthetic. And have you ever dislocated it before? Does he have a history of dislocation of other joints like his kneecaps or his other shoulder? He dislocated this one 20 times.
Does he dislocate it when he's in his sleep if he put his hand over his head? So there are things we need to know. Because it will affect our management if we take this as an isolated first event, traumatic dislocation of the shoulder, then. What we're going to do is hopefully reduce it. But one of the things that we kind of wanted to show you is like, why does it dislocate?
Well, unlike the hip, which is also a bone joint. The upper limb. Kind of sacrifice the stability for your range of movement, so your upper limb, you can do all these movements that you need to do with your upper limbs, your hands and everything you need to do that you don't do with your hips, hopefully. And so in order to get that range of movement, we have to sacrifice some of the constraints.
So if we look at the bony anatomy, we've got a humeral head with a bony glenoid and the bony glenoid is quite flat checked, a little bit like a pear, and it's quite flat and the humeral head sits on it. And that articulation itself, there's not a lot of limitation there. You've got these other bony constraints around, but again can move around that.
And if we look at the glenoid itself, we have to glenoid labrum and the glenoid ray labrum is a thick cartilage that goes from the rim of the glenoid. Into the joint capsule. And it causes a negative pressure effect within the joints that kind of sucks the humeral head in. So when we look at the static and dynamic restraints of the shoulder joints, then static restraints would be things like the labrum, the joint capsule, the capsule, the ligaments which I won't go into.
And the negative articular pressure. And then we've got dynamic restraints which go around the shoulder, as you can see here, which are the rotator cuff tendons, which are subscapularis bas status impersonators, those minor the long end of the biceps, which crosses. And through the superior part of the capsule to insert the superior margin of the glenoid and then the scapula muscles like the torso.
So reduction maneuvers now if you go into the internet and you look up how to reduce the dislocated shoulder, you'll see lots and lots of different ways and lots of people doing YouTube videos and things like that. These are the three most common ones, I think. OK and the Hippocratic message is the one that was all it used to be in all the textbooks where you put your foot in the axilo. The traction attraction is probably the most common one that you see in the emergency department, so you need two people.
You need a sheet, not a blanket, not a blanket because it stretches. You want the sheet because it's a lot firmer. Give you the traction and you usually pull your arm into about 30 degrees of abduction. Bend the elbow. The other person pulls and you try and push it in. Now, in the emergency department, you probably do this.
Ideally under some propofol if you've got someone there that can do it, because if you have an 18-year-old muscular guy who's waited for hours to see you, this is going to be a struggle. If we just give them midazolam and morphine, then you might not get enough relaxation to give them propofol. There's a good chance you'll be able to get it in. And then the other method is the one that I kind of use myself, which is Cocker's external rotation method and the idea is you don't have to put as much traction on the arm.
It's more of a leverage type thing and you basically. You basically externally rotate to you, unhinge and and lever it back in, and I tend to do this. More, because I get the ones that they can't reduce in emergency, so I take them to theater, they're under a jar and I could do this pretty easily. If you try and do this with any kind of force, then you risk fracturing the humerus.
So what do we do with them when we've put it back in place? Well, it all depends on whether they've got any complications and, you know, whether it's their first microfracture or not on the age of the patient, so. If it's an isolated injury, there's no fractures and no nerve injuries, and they're over the age of 20. Then you can probably just give them a sling and discharge if they've got anything else.
So if the recurrent dislocations, if they've got a fracture, either of the humeral neck of the glenoid, if you can see it or if they've got a greater lesser tuberosity fracture, we need to follow them up. If they've got a pattern of the current instability, if is any nerve injuries and rotator cuff tears tend to happen in the more elderly patients, so the young patients?
Generally will have a labral tear or a fracture. And where's the elderly because the rotator cuff are already starting to regenerate? They might take the rotator cuff with a dislocation. And I'm just going to quickly say, don't miss the post, Julie dislocation, so you'll hear it described as a light bulb sign. This is what it looks like. But if you have somebody in a sling with their arm in internal rotation, it might look like this.
So your clue is the lateral. So you can't try and get an auxiliary lateral if they've got a cursory dislocation. They're unlikely to be able to abduct their arm enough to get an axillary lateral. So they do a scapula lateral, which is this one. And if you look at this one, you can see the y of the scapula and the humeral head is pointing out the back. That's the key.
And these are often missed, and the problem is they're missed. And then we see them later on, and by that stage, they're locked in this position. So we have to do an open reduction. So here's my question. Which is following can happen with a shoulder dislocation. We know it fracture fracture, proximal humerus, auxiliary artery, rotator cuff tear or all of the above.
So guys told us they're up, we'll give you about a minute and a half. But we'd like a lot more people to engage at this time. Oh OK, so guys, we're going to finish up the poll just now.
Or that share these results. OK, that's pretty good. So the answer is E, all of the above. Don't fracture of the glenoid, yes, you can. That is called a Bankart lesion when it's just the labrum. And or they could actually fracture a small piece of bone off as well, so you can get a fracture right to the proximal humerus. Yes, you can get a greater tuberosity fracture.
You could get a lesser tuberosity fracture. You can have a surgical neck of the humerus microfracture or you can have. You may have heard of Sachs defect, which is just that the anterior superior part of the humeral head where you get a cortical compression, and that's whole of the topic by itself. So the answer to that is to. Axillary artery injury.
Yep, it definitely can axillary artery burns quite close. To wear the shoulder is and depending on the degree of trauma and displacement, you could absolutely get an injury rotator cuff tear, we've discovered that in the elderly, so the answer is eat all of the above. So well done. Everybody answered.
Apart from the two C and d, I mean, theoretically, they're both correct. All the answers are correct, but yeah, well done. You want me to carry on? Yeah, please. Yeah OK. With many questions, I can't see the chat in this. So there was a question, but I think Mr. arnault's answered it, and it was that would you inform ortho if you're going to initiate shoulder reduction?
And if anyone didn't read the question, the answers of the chart, but it just talks about if there's any neurological deficit. And if you have experience in giving sedation, I'm guessing this question in context of being an Eddie. Yeah And I guess the other thing is, if there's a fracture. So if it's a greater tuberosity fracture, then there's probably very little risk if you're doing much damage by putting it back in.
But if you have a surgical neck fracture that's displaced and you try to push it back in, you could displace that fracture and make the problem worse. That would be the other reason I would call ortho. Yeah, OK, good. I'll quickly cover these ones then. So they first talked about an orthopedic emergency. For me, this is a bigger orthopedic emergency, so typical story would be a child at the age of six falls off some monkey bars or something like that, and they've got a painful, deformed elbow.
And here we have a epicondyle of fracture. OK when I was a medical student and junior occupied, I could not get my head around this little practice at all. So I've tried to make it quite easy. But essentially, it's a break at the distal part of hubris. And it's either displaced, a bit displaced, really displaced or absolute mess. All right, so that's what we're going to look at.
So your history? Typically, it's a kid that's fallen off something. They've got a painful, swollen elbow that they don't want to move. You've got always going to think of non-accidental injury when it comes to children's fractures. So if you've got a delayed response or a history that doesn't fit, you've got to think about it. But generally, these are not due to niye, they're due to kids falling off.
In your examination, your main point. What you need to tell the orthopedic surgeon on the phone is whether the fracture is open or closed. And because some of them are open, if there's any skin puckering, so if you can imagine this proximal fragment can actually tent and tear through the anterior part of the biceps and kind of buttonhole through it. And then when it goes, when it moves, it pulls a piece of skin back at it.
That type of fracture, you're not going to be able to reduce it without opening it because you can't get the fracture piece back in. All right. Next thing, does the child have a radial pulse really important? You need to feel a pulse, ok? If there is a post, great, if there is no pulse, the next thing is the hand warm and pink or is it white and cold?
OK but that's what we're going to go with that one. And the nerves are the most commonly injured nerve is the anterior Rochester branch of the median nerve. OK, without going into all the different nerve examinations, children. The OK, so the way that you can test the major nerves in the hand is I get them to make an OK sign, which is your median nerve.
And until you get them to make an L side, which is going to be your radio and you post your interest. Yes and then I get them to do star, which is your ulnar nerve abduction. Some people do cross over their fingers through scissors, whichever you want to do. So you can get some kind of idea of the assessment. And the other thing is if you think there's a nerve injury.
You can look for the sympathetic part by putting a wet swab on their fingers and see if their fingers wrinkle. That's another test that you could do in a bind. So let's have a look at some things, so Gotland classification one, two three, then somebody added the four. OK, so one is on display, you're probably not even going to be able to see it.
The only thing you might see is a poster area of fat cat sign, which is what this X-ray shows here. OK this little bit at the back. So an A fat cat size can be normal a posterior fat pad sign. There is an injury in about 80% of the cases, so child painful elbow all posterior slap outside, it's got a super alert until proven otherwise. OK, so that's type 1.
Type 4 is where, like the one we've just seen where there's no connection anterior or posteriorly and it moves all over the place and it's going to have to go to theater. All right. We have the ones in between. So number two and number three? Number two is quite displaced. Number 3 is more displaced.
Number two helpfully is divided into and b, which depends on whether the piece is rotated or not. I do not think you need to know that at this level, all you need to know is whether some things are one. Or whether it's something else, to be honest, so were to when you get the slight tilt, we talk about the anterior humeral line, which goes down the anterior aspect of the humerus and should cross through the Allen.
So there it is in this picture. And here it is in this picture through the middle of the Allen. But if we look at this one, this one and this one, you can see that it goes the line. The anti-human line goes in front of the Capitol Allen. So we've got. Usually a 2 type injury. Now some of these are acceptable, if they're tilted back any further than what we could do is a close reduction, which is where we just push it back into place and put them in a plaster.
Sometimes if they're a bit rotated, we put wires in if there are three like this one. And then we're going to take it to now. I will go through the whole business of what we have to do from your point of view, seeing this patient in emergency, the thing that we want to know is the Australian examination. Give the kids some pain relief, give them a back slap because you can imagine these bones moving around is going to be painful.
The position of your backside doesn't really matter. You might have to have it by extension, doesn't matter. It's just to hold the fracture still and give some kind of pain relief. Keep the kid fasted. Find out when they've lost eaten. Call us if you've got a white hand, we're going to need vascular as well. I make sure you document everything OK.
It's really important that you document everything that goes on with these children. So here's a quick flowchart, you don't need to know all this, it's the interest anyway, because I think it's really interesting. So you've got the worst case scenario that you want to in the morning, you've got a displaced type III or type IV epicondyle a fracture with no pulse.
Now, have you got a pink hand? In which case you call orthopedics and say, I can't feel a pulse, but his hand feels warm and it's pink. And we'll probably come in and see it, and then we'll probably look at it every hour or even every half an hour because we'll be quite worried about this. We might even try and get to see it at 200 in the morning to look after it because the problem is it might be pink and warm when you ring us.
But by the time the kids, you know, been to X-ray then transferred to the wards, it could have gone white and nobody's checking on it. So what those ones will do will usually reduce them and pin it and then see whether we get a pulse back. As well, sometimes because of the point of the fracture, you get spasm of the artery, so that's why you lose the pulse. So hopefully when you reduce it, give them a bit of time, the pulse will come back, ok?
Worst case, no pulse and white hand. All right. Call us, call vascular. We're going to take that kid straight to theater and we're going to reduce it and see if it comes back, if it doesn't. We're going to open it up and the vascular surgeons are going to explore and repair the artery. OK so here's my question which nervous, most commonly injured in pediatric supercontinent fractures?
Is it a the post their interest? Yes B the a c, the radio d, the median or E the ulnar nerve. Oh so we did just answer that, guys, this is just a quick test of who was listening. But everyone should answer this. It'll allow you to jog, you've just gone through, but this is something that you'll get asked again and again and again, I can tell you at like core training interviews and three interviews, maybe afterwards, probably afterwards that.
Yeah, and then and then the day you'll encounter it. Even up to your consultant interview, probably, yeah, Yeah. OK, so got a couple more people, guys. Go on. Give it a shot.
OK all right. Five more seconds, and I'm going to pull. All right. Can everyone see the results? We can. And I have to say I'm disappointed it was mentioned. So the answer is the a interruptions.
OK and it's just the way the fact that where it comes off the median nerve, as it goes around the elbow, it's just more prone to injury from a fractured displacement than the other branches in your head. You might be thinking, oh, its posterior nerve, because that is that's near the elbow, but it comes off a little bit. You remember round as around the radial head, first to come off.
So it's not the posterior atrocious and it's not the radial. The ulnar nerve is coming down the other side. I agree it does run behind the medial epicondyle, but the way that the fracture usually displaces. It is usually a little bit superior to that, and it doesn't tend to catch the fracture tends to go away from the fracture away from the nerve of anything.
So it's not the ulnar nerve. So your choice is the median nerve or the anterior trough where the median nerve goes, it takes it out of the way. But where the anterior interosseous branch comes off, it goes right by where his fracture normally displaces, so the anterior entrusted to serve the OK side. So usually they can't flex their index finger. Yeah, yeah, they do that.
Instead, they can't flex their. That's what you want to look for. OK, thank you, everyone. That's brilliant, brilliant. Thank you. But then potentially all these nerves can be injured, but the question was the most common injured nerve. Yeah, Yeah. But obviously, potentially all the nerves, KneeKG.
All of them. Yeah, Yeah. So you check all of them. But the most common question? Yeah so we have is that one more topic that we've got left, Mr. arnault? Yeah OK, so that'll be with you. So guys, one more topic and I've I'll add the feedback at the end of that.
And please do keep your questions coming. This is the first lecture that we've done with Mr. Thomas. So they've tried to gauge a little bit what they would feel for medical students would be at an appropriate level. Of course, they can go as advanced as you like, but if there's any questions that you have or anything you'd like to add, put it in the chat and we'll try and we'll try and address it.
Thank you for explaining that here. Thank you, Nikki, for touching on the topic of this distal humerus fractures. That's another orthopedic emergencies that you leave everything and go immediately to assess. Um, can you see my screen destroyed? So now we're going to step back a little bit from all those orthopedic emergencies. All the rush of adrenaline, of all of those into another orthopedic emergency.
That's probably not as urgent as the previous ones were discussed, but it is very common these outrageous fractures, so this actually can become about fifth of your orthopedic trauma attendance and tendencies at your fracture clinic or emergency department. So it's very common. So what I want to get to obviously this debate is fracture is a huge topic.
We could spend conferences on this, but we try to cover some principles and a few minutes. So from my point of view, what I want to guys to pass on to you is that you need to be able to describe these fractures and classify them as simply as you can and to help you with that, just focus on two issues. On on your fractured description, number one is the direction of displacement and no to articular involvement, just focus whenever you see the stress fracture, no matter how awful it can be, how confusing it can be.
Just focus on those two aspects direction of displacement and articular involvement. Yeah so when we talk about forearm, wrist and hand. We don't use the terms, such as posterior, anterior medial, lateral thiswe terms we do not use because there can be very confusing. There are depending on the position of the arm and what's posterior could mean different things to different people.
So we used terms such as dorsal. OK for the extensor part. And volar for the flexor-pronator. And we used the other terms is radius. If we're talking about the lateral aspect, the thumb thumb side or ulnar nerve. OK, so Dawson, volar radioulnar and articular involvement, OK, so there are four main types that we focus on kohli's fracture, Smith fracture and Barton fractures.
OK, so Collins and Smith are extra articular fractures. Barton is intra articular fracture. I think if you know this stuff, when you go for your orthopedic or trauma elective, you'll be on the top of the class. So we start with the Cordis fracture cause fracture again. Displacement? yeah, so displacement. You describing the distal part of the fracture? Yeah always refer.
Don't get confused. Sometimes could be confusing. You see fractures, fragmented and pieces everywhere. Just focus on the distal part of the fracture. Where is that going? And here it's going. Dorsally is displacing dorsally and it's extra articular. OK, so here we have a fracture that is displaced dorsally and is extra articular, and this deformity creates this so-called dinner for deformity.
Obviously, this is quite extensive displacement. You don't always see it, but that's how they present. OK, so now one question I want to ask you guys about is how which you could think about and if someone knows the answer, please write it in the chat box is how do you know? You know, sometimes could be confusing if this is a vowel or displacement or dorsal displacement.
What are your landmarks to define this as dorsal displacement? Why is it not vowel or how do based on the X ray? If anyone knows the answer, please write it in the chat box. OK, so that's how I look. And while you guys, I think we'll move on to the next fracture, Smith fractures a Smith fracture.
The fracture displaces violently on the other direction to call his fracture, but it's still extra articular. see, the articular surface here is not violated. It's still intact, OK, but the fracture has moved violently, and the same question applies how do you know this is volar and not dorsal? So please, guys as well, try to write the chat box if the answer, we will come to that.
So someone wrote down thumb, which yeah, Yeah. Perfect so you know, it might look simple to many people. might. It might be clear to many people what's but believe me, there will be those times when you are stressed in a trauma meeting and the fracture is not very clear. Multi trauma patient. And when you get confused, what the direction of displacement.
So using landmarks is the thumb. The thumb is always on the volar aspect. If you look at the hand, always the thumb is in the volar aspect. So that's one landmark. There is the r mode. If anyone knows, please write them down. Did so, Smith fracture is the second fracture. Now we'll move to the articular fractures, and these are more simple.
One name Barton fracture, so there's dorsal Barton and volar Barton. Again, the same displacement is the displacement dorsal or is the displacement volar. And as you can see here, there is a fracture line and then it sustains here into the joint line. So, for example, you could see on this x-ray, this X-ray is a cone x-ray, and it's quite common in cases when you suspect Inkscape forehead fracture and stuff.
When they do not X-ray the hand. So how do you know what's volar and what is dorsal on this x-ray? Again, please, guys, if anyone knows the answer, please write in the chat box. Very, very important, because you need to know, is this door selling this place, you need to be able to describe it either to your seniors, the trauma meeting or when you're offering this patient.
If you are in any or, you know, if whatever you speciality, even if you are a physiotherapist, you're talking to it, to the surgeons, you need to be able to describe it accurately and you don't want to be describing it as a wall of displacement here. For example, I won't look good. So dorsal part we spoke about, and this is boilerplate Barton Barton with the fracture has line is in particular you see here it's quite impressive displacement and the fragment has displaced forwardly.
So do we have any answers about them, any more hints on the X-rays at all? No, not. Not yet. So we could maybe comment on that a little bit. Yeah so the correct answer about the thumb, obviously, and we can see here, for example, the thumb is always volar and the fracture has moved towards the thumb. So it's volar.
Yeah, so that's when I speak. Other thing is, for example, if you cannot see the thumb is missing out of the x-ray, which can happen. Is you look at the metacarpals, Yeah. So here, if you look the metacarpal bones, the dorsal aspect of the metacarpal bones is straight. Yeah, as you can see here, but the volar aspect is curved concave. Yeah so the volar aspect of the metacarpals concave, the dorsal aspect is traitorous, another sign.
Can everyone see that? I hope. Yeah, I hope it's clear. Yeah if want me to repeat it, I can, if not clear. Now how about this, ray? Now, how do we know here? We cannot see the thumb, we cannot see the metacarpals. Anyone?
0 here in the chart, because I can't see no, no good. So, yeah, so the hint is. Is this going? The basic form born, Yeah. The policy form bone is assessable with bone that's in the wrist. Yeah and it's formed an insertion or not, an insertion, it's within the tendon of the flexor carried by a lattice, but that's bone is always on the volar aspect because it's in the course of the flexor carpi ulnaris.
So it's in the flexor side, it's in the volar side. Yeah, unless it's dislocated, which I don't sure I've seen ever seen it. So it's so the basic form bone is your landmark. If you cannot see the thumb or metacarpals, the piece of foam bone is always on the volar aspect. OK, so that's how I know this is a dorsal displacement. Great I hope that was clear and helpful to you, I think.
I'm just going to go quickly through the principles of management of the structures, so generally if the fracture is displaced, it will require reduction, most commonly if the fractures are extra articular. So Collins and smith, for example, or more commonly colleagues, you could do a closed reduction and you need to stabilize them. Yeah, you can either stabilize them in a cast or if the cost is inadequate, you could put keywords in.
Yeah, we won't go into details. Exactly that's different. Lecture take longer time to explain the various reasoning in the draft trial, and so many other trials have come up. It's a matter of debate. What's the best way to fix these fractures? But that's the general principles. If there's articular fracture, it will require surgical fixation because the principles of articular fractures, they require anatomical reduction.
Yeah so intra articular fractures, they require anatomical reductions. They need an operation and they need something like this play to fix. OK, so that's the other guys I wanted to say about this radius fracture strike to keep it as simple as they can without going into too much details. Obviously, if there are any questions, we can always address in the future, lecture cover other parts and maybe more of the algorithms of treatment of bas status fractures.
So now this is my cue. Please try out, guys, I think we touched on the de La fracture, but I think it would be just good to re-emphasize the same points. I think you guys are must be masters now in neurological assessment. just the opposite. I was just going to say, just speaking from experience, there is always at least one of these questions, if not more in every single one of our papers that we seem to have.
So it's definitely worth just practicing them over and over again. Yeah yeah, know they recur at every level. These assessment questions will recur at every level and they know they'll catch you up. OK it's quite interesting the answers, but guys, this is at the end, everyone should answer this.
It doesn't matter whether you get it right or wrong, because we'll see it as a whole group, but you should give it a shot because it's your last chance to have a question a shot before we finish up. Yeah, and I encourage you all guys, because when you answer, even if you get it wrong, you tend to remember the correct answer better than when you attempted just attempted anonymized you want. You know, it's not a real test.
No one is marking you. OK, so I'm going to close the poll in five seconds, guys. 5, 4, 3, 2, 1 OK. Three excellent. Thank you. So 72% of participants attempted and now got 39% answered correctly, which is making a fist.
And what's obviously we discussed earlier with KneeKG is making the OK sign. It's the same principle. You're assessing the flexors of the hand. That's the median nerve. Yeah OK, so making a fist or OK sign? That's the median nerve. Now the second common answer some people picked here is thumb extension and extension.
Generally in the hand is the radial nerve or the extension of the thumb. You know, thumbs up or else sign, as KneeKG showed earlier. Thumbs up sign. These are extensions. And these are radial nerve or posterior interests. Snare if you want to be more specific, so so these are radial nerve, unfortunately. OK, now finger movements sideways.
Yeah sideways like this, whether it's opening, spreading or sizzling. This is ulnar nerve. Yeah, because the assessing the intrinsic muscles within the hand. Uh, intrinsic muscles within the hand, Yeah. So, yeah, so again. Extension generally is radial nerve with a thumb extension or fingers extension inside.
OK, sign or a fist is median nerve and finger sideways is ulnar nerve, yeah, so well done. 39% to got the correct answer. And generally, guys, obviously when you are assessing a patient. So broken, they're fractured or destroyed, just fracture coming with acute pain. Sometimes it's difficult to assess the motor function. You ask them can you do this, this, and they can't because they are in pain.
And in orthopedics, you want to gain the trust of the patient. You don't want to cause unnecessary pain. Yeah so if they are unable to move, don't force them. Don't make them move. Yeah, they cannot move. They're in pain. Don't make them. So instead, you can assess the sensory components of the nerves.
Yeah and for the sensory components, there are specific areas. So for the medial nerve is the visual aspect of the index finger. For the ulnar nerve is the volar aspects of the little finger. And for the radial nerve is that dorsal aspect of the first web space, so you could just light touch. Yeah light touch, that's what you do.
Just light touch, that's how we touch the sensation. And that could be another way of assessing the motor. Sorry, assessing the nerve for any nerve dysfunction if they are patient in too much pain and they cannot move. And that's all I wanted to talk about today again, guys. Reminder, of course, with the academy, please. And please, we would welcome you guys to stay and follow us on social media, on Telegram as well.
And we have a YouTube channel as well with educational videos for you guys. So please stay in touch with us. Always and myself and other faculty of the Academy will be very keen to hear from you and communicate with you for what you need to learn about in the future. What you want us to talk about, what complex concepts you find that you want simplifying and Shaair as well.
Will will help us stay in touch with you, hopefully. Yes so thank you so much, Mr Arno, and I think that was really good going over some concepts. And I think it always really helps to have a senior clinicians here to do some of the teaching because you can drive home some concepts that we may not be able to cover in detail. So thank you for that. And guys, just mentioning about the course, there's plenty of time to the course, but start registering.
We may run out of spaces and you know, we're really trying to gauge what people are interested in. But the good thing about the course is that it's based on the BOA undergraduate syllabus. So what we're covering is pretty much at least a very good standard of what needs to be taught. And then anything above and beyond that, let me know or orthopedic if you're interested in that. And we can certainly discuss that because what we've looked at from a lot of our polling is that undergraduate teaching in orthopedics, especially for people that are interested in it, is probably not as much as people that want to do orthopedics would like.
So if that is something that you're interested in or it concerns you, or maybe you want to do plastics or Ed, and there's elements of orthopedics that match into what you want to do, then let us know. And I'm always free to be contacted on any of the social media handles that you may know from. And that's it. We hope to have more lectures. The feedback is posted in the chat.
And thank you so much and I hope everyone has a lovely evening. Thank you. Here, I thank you for having us and all the best to the 6 PM series. Thank you, guys. Thank you. Thank you. Thank you. Bye bye.
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