Name: Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (4)
Uploaded: 2024-05-31T00:00:00.0000000
Duration: T01H46M29S
Description: Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (4)

Name: Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (4)

Description: Online FRCS Course - Viva & Clinicals for Orthopaedic FRCS Exams (4)

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Transcript: Language: EN.
Segment:0 .
Um, great, so Gollum is next participant number four.
Yes, Hello. Hello, my friend. OK right. So you're in fact you've just done this a couple of revision cases recently, so the USA has asked you about the scoring that they've no noticed on these implants. So what do you understand by this? And what you'll explain to the show? So this is an explanation of the processes, and so it shows that it's modular and in the heat and also the Knick.
So there is no this can happen, which because of the socket and the paper neck of the prosthesis. So and they. Whereas paper is it that we have in these bunions and we have to temper that to fix. And so the proximal part or the end is more smaller than the base.
And to fix it, but still. Sometimes they get a micro motion which causes the splitting and causes the problem, which is called to turn our noses. OK, so when you get this micro motion, what could be, what can cause this? What can we do to prevent this sort of micro motion that we as surgeons can be? Yeah, the micro motion can be prevented if we're using the block, which there is no.
But of course, that is we tend to use modular. Now how can we, as surgeons, prevent our modular implants having this problem? Yeah, I'm Yes. But the model Black has its own disadvantages, but that we can use this to match it. Exactly and what the company or the rep is telling us. It's the exact paper to go to the head and also the material should be compatible to and not causes any galvanic problem.
So kavonic, what you understand by carbonic galvanic is there is a different charges and this happened due to dissimilar metals combination. And then the data causes erosion and causes because of the dissimilarity, the onions and the curtains. So they are not compatible, so they are causing more erosion on the implant.
OK and in terms of with other things that could cause where we're between the two parts between the two surfaces, what could that? What could be potential sources of that? The where is it? There is different types. There is the abrasion and adhesive. And the third particle.
And specifically this what sort of particles could potentially get in between the two surfaces? But in this one, there may be some. There is a lack of EXOGEN is coming and then once the and. Sorry, did he say oxygen? Yes and also I not understand.
You mean what is the type of? Like so. Let's stop there, shall we? We've been for five minutes now. So how do you think it went? And I didn't really understand the question, to be honest, to what you were expecting me to say, but I thought, you are talking about the taper in the. Yeah, so what about the taper?
Thank you. Well, from your point of view, you talked about typekit. And if they do that. Well Well, I mentioned some, but it was very randomly, isn't it? So let's think of the positives. So you talked about the typekit. Yes you mentioned also knows this as well. So we're talking about tenodesis. It's a big issue where modular replaced with modular implants.
Full stop. Something that we still haven't quite got to grips with. So it is a potential source for problems in the future in terms of revision. So we've got these sort of score rings here. OK OK. So what could have gone better governance? Now, I think you asked me that what kind of paper, but I was not sure what to say because typekit is stupid.
But maybe, maybe you didn't mention it. So this is what we call Morse taper. OK so in essence, when this situation, the key thing is talk about China analysis. So you did mention Galvani electrochemical transfer between dissimilar metals, so we try and avoid that fretting. So corrosion of my relative motion between two materials. So tolerant between male and female, more ciphers and possible type of mismatch.
Quite right. You mentioned that with regards to ensuring that we have the correct, the correct typekit template crevice, physicochemical interaction between metal and the environment leading to ultra mechanical properties. What do we do? You know, when you put a hammer off the and/or you put the total hit head on, the first thing you do before you put it on is you give the onion a good clean to make sure there is no blood on it.
That's the stop this of physicochemical reaction happening. OK Yes. It's about making sure we have. There's nothing on the tape. Right, right. Yes the most typekit mismatch. So we've got 12 14, which is what we use standard. It's really important, though different companies have different ideas of what 1214 is.
So your Depuy 12 14 will be different to your Furlong 12 14, which I've seen happen where people pull up the wrong one end and it does not go. It does not go well. So we're talking about the opening diameter and the closing diameter, so that's the opening diameter for the closing, and it's not enough. This is the male part of the taper. This is the female part of the taper.
Yes well, yeah, you could tell. The orthopedic surgeons are mainly men, as I say. So yeah, so it is key about that. And if you want to know the angle, this will. Is this angle here is one point four, 1.49. Well, that's the difference between different implant, different companies, actually. So it's really key, I say, to make sure you get those right. Right?
but Tony, it's a question to try and get you to talk about where in particularly California, where are we going? So government credit. So we need you to talk a bit about chronic. You understood what that was like electrochemical transfer between the two metals. You mentioned a bit about microprocessors. That's good.
So that's really key. So making sure you've got the right. The right. Male and female typekit. So in terms of improvement, I wanted to be a bit more precise with your language, if you can. And that's a great amount of practicing. OK that's how we can get better, isn't it? But you're doing really well.
OK so don't just be this. You actually said quite a lot in there, which was right, which which I'm really happy with. OK OK. Yeah thank you. My God. OK so when are you doing next week? Yes all right. OK thank you.
Thank you, David. Excellent question. So we'll move on now to number five, a.j., I think. Sorry yeah, I'm not jumping the gun for the rest. But the next question? OK so Simon, where are you? Yeah, Hi. Good morning, Simon. Hi, Simon.
Right? so congratulations, you're the new academic consultant. Can you tell me for a hip surgery? And tell me about the perfect surface? So a perfect bearing surface would be one with which is inert, which does not produce any conceivable world particles which are active especially, and that it has a good hardness and quality profile which is not susceptible to wear or oxidative stress.
And that. Can serve for a long period of time. And also, two surfaces have we got here. So these are two bearing surfaces, the one on the left shows a ceramic on polyethylene, while the one on the right shows a metal head with a metal shell. Yeah, it should be metal. Obviously, we couldn't.
It was too damaged to extract properly. Right OK, so what's the difference between metal, a metal and metal? Why do we find metal and metal? So method prostheses had have a good track record as they provide less. So where particles which are smaller in size and less susceptible to wear and wear and the activation of the track record or a bad track record so that they have a good track record regarding where, however they might lead to other problems, such as a.
What's to say, the tumor? So should the tumor is a type of alpha lesion, which is a aseptic vascular tick lesion with which, as the name implies, does not trigger an effective process. However, it activates macrophages and and causes soft tissue tumors, which which can lead to soft tissue to destruction of the local tissues and in around the hip joints.
There are specific guidelines about the MHRA criteria for specific procedures of methanol methods which are used in daily practice. And these include a yearly ion count, cobalt and chromium, and a yearly Oxford hip score, and also review to see if the patient is symptomatic or not. If they are in a high group or a low group, it depends on the rate of follow up.
If the patient becomes symptomatic or in a high group Mars or induction sequence MRI signal back silent. So tell me you mentioned the special metal is supposed to be a perfect ring bearing surface, but why do we get these small sort of small particles forming? Is there a problem with how we're doing this? So how are we doing metal or metal and bearing surfaces? So the ideal procedure would be that for the smooth surface, however, these are prone to the do not.
Sensitivity, as we mentioned before, might lead to as parities and disparities might produce where particles which again wear off or decrease the articular surface surfaces producing these small particles. And this can be the way it can be, either from as the manufacturer intended to be. So with type one, where the type 2 is between articulating and not articulating surface type 2 body versus, for example, if there are fragments of cement or bone in the joint effective joint space and the type 4 would be that of between 2 and 4 articulating surfaces.
OK and so we mentioned also a ceramic body or something. What's the benefit? The benefits of ceramic and poly? So ceramics ceramics have some properties which are beneficial, such as they are very stable as the well again mentioned before, there is a fluid still around the bearing surface, which enables it to work for better lubrication and decreasing coefficient of friction.
They are hard so that the surface properties they do not form as parities as readily as the metal part and. That's right. OK, let's say I agree with that. OK, so I'm OK, how do you think that went? And I felt disappointed, but I tried to pick up by filling in with some things I was aware and the proper service properties and look for quite a lot there.
So positives? Tell me the positives. Yeah, exactly. So we covered quite a lot. We went through a lot. Maybe not. Yeah, it was about it was flowing and. Mentioned most of the things I think are good.
OK so, yeah, he did. I was very pleased. You talked a lot. You talked about different things like wet ability, toughness, hardness. You mentioned all the key things I wanted to talk. I wanted to mention, which is why actually, I didn't actually say much, which is great. I love that's what examiners want to do.
They don't want to have to talk. If they have to talk, they're just trying to bring you back onto the scheme or just probing your knowledge. OK, so actually, your knowledge, was pretty good. So I was very pleased with that. Don't obviously will happen. The real thing, but don't mention, as we discussed earlier.
So the new question popping up, so to speak. But yes, overall, very pleased with how you answered that in terms of how you can improve. How do you think you can improve, simon? I think it's filled with disjointed and not flowing enough. I didn't get to that sort of steady flowing phase when you read, you know, something I guess, but covered most of it, I guess, when you sign it next week.
So just a little bit of structure, that's fine. We'll need a bit of structure. Don't worry about that practice in practice talking. That's the key thing. So you've got the week to ball your other half silly or and your study silly with different topics. So this week you should just be talking, talking, talking to talk the hind leg off a donkey. And that will help.
Trust me, we're up on the day. So it's just the idea of talking about these concepts and that's coming on. Courses like this allows you to give you an opportunity to discuss that in a non-threatening environment, hopefully. But actually, yes, as I say, I was very good mountain knowledge, a very key that lots of good knowledge there. And I say yes, structure could be better, but that's a minor point.
So I mean, the reality is you cover the key things I would have covered with it in terms of. So characteristics perfect, very surface, durable, combined properties of where friction lubrication, which you mentioned straightaway, local official friction against fantastic and we talked about metal and metal. So be careful about saying it's in an ideal world. It's supposed to be a fantastic bearing surface, but in reality, it didn't end up being a lot of that's due to, as you said about expertise.
But also one thing we don't really talk about actually is really key. We understand there's a fantastic talk on all four Academy about where by our colleagues. So we've got to go watch that on the YouTube channel. And he describes the problems with metal and metal, and it's the mismatch. So it's the fact that you need to have a little bit of mismatch with the cup and the head.
But if there are two perfect or they get trapped, you get salt pinching and that creates those, that's where problem. OK well, as I say, you described it brilliantly on his talk. So advise you. Go if you're bored and you wanted to watch a YouTube channel, watch that one. And because there's some very important wear and try biology concepts in that as well, and you can watch out at your leisure and it describes it really well with fantastic two key explanations and nice, simple terms.
OK, so you mentioned about metals and the properties of metals ceramic, which I was very happy with. So good hardness, scratch resistance, a piece of wear related to self-heal? Yep Yeah. For those I say overall, really good, strong, rather strong answer, in my opinion. So I'm not I'm not wasn't worried, Simon, for that point, which is why I let you talk and I'll just to highlight a few points, which is what we want to see.
OK so as with everyone, the exam in the next week or so, I do recommend practice talking through basic sciences. We don't talk basic science all the time. You talk clinical stuff a lot, but with your colleagues, with your study groups discuss different concepts and really important. Basic science is try and see if you can apply them in a clinical scenario. That's what the exam is, what the exam is want you to get to at the end of your answer.
OK that's what I was trying to do with a lot of these questions applying them in the clinical scenario, which is really key thing that pushes you. If you can get it, you can get the bit if you can regurgitate the textbook stuff. It's a good six. If you can get to a clinical scenario applying the clinical scenario, you're putting seven.
Eight OK, so and if you can use those key concepts like ground reaction forces, how they work and how it works for someone walking using an air first splint, that's what they want to see. OK and again, likewise talking about biology in terms of how it works for us as surgeons, why it's important for us to surgeons. Again, a really key concept. And likewise as well.
Well, I talk about consent as well. So think about some of the topics, such as the medical ethics and consent, because there will always be a question like that. They will always evil or false or an ethics question or in there. So just don't ignore them. Do read them. You don't have to read them in depth, but don't ignore them because they will turn up.
But I don't I think that's me done, isn't it for us, is anything else? That's it. You're done, David. Brilliant and thank you for sticking to time. Much appreciated, David. I think you covered quite a lot within one hour. You can't cover the whole. But first, the basic sense is in a way that needs a whole week.
But you've done very well, David. Thank you very much. And yes, that later in the afternoon for a clinical, complete clinical. Yes, David is going to join us later on in the day. Yes for the upper clinical session. Upper limit clinical sessions. Sunny, hi, well, I'm only nine, I'm here.
Oh, hi, Sandy. Yeah, Hi. I think I remember. Anyway, so my name is that I'm one of the lucky few. So this is. The right finger injured while playing basketball, and this is a lateral X-ray of the ring finger, it demonstrates the volar subluxation of the two.
I can't see any associated fracture with that as well. I'd like to clinically assess this patient with the history and examination. I'd like to find out his hand, dominance, age as well as occupation. And then I'd like to find out more about the exact mechanism of the injury. His right hand dominant University student and he injured his finger.
OK, OK, OK. OK, Yeah. So that's an examination. Just checking. It's closed, neurovascular. The intact everything. OK, then only OK, fine, fine. In this case, my initial management would be to reduce this in the accident emergency department.
I would gain verbal consent and apply a ring block and apply gentle traction in order to reduce this. You managed to reduce it nicely. And what is your concern? How would you fix or stabilize the joints or the fingers? So I'm concerned about the possibility of central slip injury and I would in the initial setting, I would check the stability in flexion extension.
If it's stable, then I would place it into a body splint and then see him in clinic in order to assess the central because it will probably be very swollen. What do you anticipate from both of the application of the joint what you anticipate for patients to join? I think it's docile, do you think they are the same pathology or same, you know, so say you're more likely to get a volar plate injury with a dorsal dislocation?
Yeah and then and then a central slip with the volar dislocation. OK so with this centimeter. So this is I think I would like to give you another scenario, because it's one that is OK with a simple be careful with. But instead we have to utilize an exemption for some time. This is the simplest part of the system. Is you anything that you need to Achilles tendon?
You have to put the requirements to this one extension, ok? If it's coming with a wooden fragment, you should exit surgically. Yeah OK. OK this is important because everyone is giving one strapping and said, no, you should be different from others. You should know that this is the standard.
OK OK. I assume you know how if you can take a screenshot of this one, and let's put it this way. OK OK. So this is. As mentioned in extension, then we wouldn't start again, the fiction of the government. OK it is important to know that with those of you should do the other stuff early mobilization to stop stiffness, inflation because of the work.
OK OK. No different time. This is a lateral X-ray of a finger. It demonstrates a bony abortion of the disk of the dorsal aspect of the base of the distal phalanx. It's significantly displaced, and the distal phalanx is held in this place, so the bony abortion is displaced.
OK and if I see the other way around, would you agree? Can you see that sort of I don't know if you can see the arrow here, if they draw a line like that, this line should go to the telescope. So yeah, this one is it's Yeah. Yeah Yes. Sorry, Yes. So the distal phalanx has some blocks vertically as well.
Again, I'd like to assess this patient clinically asking for same questions hand dominance, age and occupation and any relevant past medical history. If this is a closed, neurovascular, intact injury in the initial index finger, this in the NetVault. OK she didn't know. OK, I think in the initial setting, I tried to reduce this and apply a mallet splint. I would with a mallet splint and check on X-ray to see if it has been reduced.
But this is likely to be an unstable injury. And I think this would likely require a how we want to speed stability of this joint. Um, you know, in the issue of injury or in. So I think it's more than 30% of the. Of the people, are you sure about that? I'm not entirely sure, but it looks like it's more than 30% of the articular surface has been involved.
If you would like to treat conservatively how much the degree of strength you would, you would put it, I put it myself or visit. I don't say anything. How do you put this thing? You try to put it in hip extension or neutral or niche? Well, I would have thought neutral. OK, and we have to put it in those water.
I on the. On the on, the management just goes over the top, so OK, so put it on the Bowler side to avoid it from flexor-pronator, you try it right, conservative, but it's still the same. How what do you manage that? You accept that? Uh, no, so so it's likely to result in a. So it's likely to result in poor function that way.
So what is the poor function if it is a long standing mandate, what will happen? So inability to fully extend the finger. Do you think any long term impact on the food system is? Uh, it can lead to a swan neck deformity as well. OK yes, and surgically, what options you said you?
So I think fixation with kiwis would how do you fix it? Well, you can reduce the bony fragment with the k-y in place. Any technique or anything because it's not like the steroids. This has different rules. I think it's a dorsal blocking kind of wire that's applied. OK, I think I don't know the kind, but it seems like, what do you think?
Yeah, I think I'd need to revise this again to say something. No, that's a great one. That's a good question. I had this question and I missed my exam, by the way. I asked about the size of the well, I said, look, the size and the size and strength we use sat with the wire, if you would like to do in. This is just the smallest lawyer. Maybe do it for 1.1. Don't see 1.61 0.6. It must be this classification.
There is classification. We to. I would show you, at least with me about this one here. If you can take a screenshot, this will give you maybe more marks than others.
We can't see anything at the moment. Yeah, I'm doing it, that's fine. OK, sorry about that. Sorry can you see this one? Can you see this? Just remember one of them. They are used to in. So we trust the majority of them will be done from there and the rest will be perceived, as you said.
Remember that section below? Don't say production. This is not a very good option. I rarely do it. It is not advisable. Any questions? A 28-year-old gentleman who fell down in Garden and sustained this injury. What can you see?
Then the idea that you could have of the left hip showing a total hip replacement, all cemented with a better periprosthetic fracture. Vancouver type B. Uh, yeah, I would like to assess this patient, I cannot comment if the implant is stable or not to say if it is a B two or three, However, there is a good bone stock, but I don't think the stem is in place, so it is a v. I would like to assess this patient clinically ASAP.
I will take a history about the ford, any other associated injury like a head injury, and I would like to take this about past medical history, especially concentrating of and she is on steroids and blood thinning drugs to optimize her. I believe also check the locally about if there is any signs of infection of the soft tissue, this neurovascular bas status.
And so you're going to take a history. All right. So what are the risk factors in history for getting very prosthetic fractures? Uh, risk factors, it might be something like a fall from a standing height can lead to a peripatetic fracture example is affected or if there is a twisting kind of an injury, if there is an infection that leads to osteoarthritis of the implant and disease has predisposed to the implant being weak or rising to a purpose fracture.
This is a worst case. OK, so you told me sometime back about Vancouver. So what is Vancouver classification? The classification of a peripatetic production type A is related to a type age for the greater tribal structure or a L for a lesser character, type B is according to the employment fixation and the bone stock, while B one is good influence still in place and bone stock is fine with the minimal and displaced fracture.
B two is implant is moving, but a good for stock B three implant is moving at a bad bone stock and C is a fracture distal to the stem. OK, so what are you going to do now? You said there is a tiny periprosthetic fracture in this patient. What's your management? Ideally, I would like also to have a CT scan with a metal substructure, if possible, to assess for the bone quality and to plan my surgery based on it.
It would be with this kind of fracture with the age of the patient. It will be according to the bone stock, and the appearance of the soft tissue could be either to fix it with a cable plate and the screws arising from as proximal end to about 4 centimeters below the fracture site so as to avoid stress Pfizer or to do a revision revision Di hypotheses first step with the bone.
You know you got two options. Either fix it or replace it. What are you going to do? I for this patient, according to the liability, according to the bone stock, I will be eager to fix it. Fix it and why would you fix it, why not replace it? Because it is the implant? Actually, this patient that is I can see all of I just bring my answer back.
I can see there is some loosening around the proximal fragment around the shoulder of the stem, with some loosening also on the medial in the medial part. So I think this might be a predisposing factor for being fracture, so I would be replacing it. We would be replacing it. All right. So you think that does the damage lose, isn't it?
Yeah, so what approach will you use? I will be using a mower. I will be using an extended lateral approach. Oh, I think your time is up, Sheriff. So let's go to the slide again and we'll just read it for you, ok? So when you saw this, can you see the slides next slide? Yeah about assessment, Sheriff.
So so you should say this is a very periprosthetic fracture of left hip. All right. In one line. Hip replacement. So how can you assess this year to see how did this problem happened? OK what is bothering him and what is being done for it? These three questions to address first, about risk factors of developing these.
These factors can happen because of inadequate technical like trimming or using a bigger system or bone itself is weak because of osteoporosis or if there's a later wear and tear or sometimes infection. OK, so in streets, these are the risk factors, but you are to ask generally some history, which is important, like whether any perioperative complications like a wound like out, wash out or a course of antibiotics.
Was this hip replacement a happy hip in the sense patient walked comfortably for years together and suddenly this happened? Or is to give him pain on the leg some four years together? This is very important because it gives you the plan of treatment. So once you take a history, this is a relevant history pertinent to the case. You go to examination, you say I'll examine as per a principle.
And so the patient is safe, does not have any other injuries. You will examine the limb. So how you examine you look for the scar and see if the signs of infection that you feel there is a local tenderness and a cyst compartment distal neurovascular status. OK, so next step, if you see the patient and you follow the framework is you're going to provide him, admit him, providing analgesia and DVT prophylaxis.
OK and this is not a very straightforward case. You might be a hip surgeon. And again, going to exam you are a general surgeon general, orthopedic surgeon. So you say I would this this, this is a complex case. I would take a second opinion, but principles of the treatment are this if the stem is loads, which you cannot make out on an x-ray, then you replace it.
If stem is well fixed and you fix it and augment it with the long grafts. All right. You can do. You need to mention that you will do a speaker to rule out any infection. This important factor x This you like to use some people for more information will get cities. But one valid point to tell that even you feel it needs fixation will say that I'll keep backup replacement because whether it be two or three, you can.
Most of people sometimes you can only make out in the operation theater because on axilo it might be no hostility declines. Nothing but in theater, it's completely lost. So to get back up for the theater and that would that, that's what you would actually do. Thank you. I would want to ask something because you're using it to do a CRP to check if there is signs of infections that come at, however, the patient who is a trauma or CRB will.
No, no, no see Sheriff. Either you can sustain trauma and fall or you can fall in sustained trauma in this patient patient fell and then could fracture. All right. OK, so it might be pathological, isn't it? The way I'm describing it. So like some, sometimes you might drive, it might sustain trauma and get structure, or you might get fractured and fall.
You're with me. Yeah, Yeah. You might fall and get fractured or get fractured and fall, so it's two different. One thing is traumatic. One second thing is pathological. You got the difference, isn't it? Yeah, Yeah. Your bas status station chief, but you know, there these are very important points, which you are to really tell.
And if you go to what I told you and go in that stream, that leads to seven or 8 and. So the seven eight you can get only when you ask for a second opinion, if you don't, it's a problem approach will take will be in consideration of with the previous approach which surgeon has taken. Generally, isn't it? Yeah you might change, but you say I will just see what was the previous approach taken so points to learn in this state in history you to.
About apart from generally, you have to ask whether it was happy or not, number one, number two, perioperative complications in examination it health protocol you didn't mention, you have to mention that. OK examining the part and distilling bas status. OK and management primary management. You should say I'll provide analgesia prophylaxis, definitely to management.
I'll ask for a second opinion, but principles of management are these. and then when it runs out of question, you score 7 plus. any questions from your side? Thank you very much. Mm-hmm so no banker classification, you say the ABC.
Do to classify it? Oh, I spoil. Yeah so there is a further supply into 1 to 3. One is cortical penetration. These incomplete fracture and see is complete fracture. 3 is complete fracture. I would read about this now. Yeah so either of these a bc can be the cortical perforation or incomplete fracture or complete fracture.
OK, thank you. So can you tell me in two minutes what I said? Yes, so what I have said that initially, while assessing the patient, I would need to check if it was a happy hip or an unhappy hip. I would need to match this patient initially, according to et Les protocol, after excluding, there is any other life threatening or Olympus threatening injury.
I would like to check locally if there is check the wound, the surgical wounds that she had any signs of infection locally, any bruising, the distant neurovascular status of the limp and the comportements. Then I will need to check from the history about the complications that has happened. As I said, if any antibiotics that is used in post-operatively or as I said, it is a habit, then initially I would like to do check the patient biomechanically by having bloods, including full blood count is CRP group and safe and have an X-ray and CT scan.
I would like also to be aware that might be an infection going on there. This patient needs to be given the appropriate analgesia before starting to have any of this investigation or movement for an X-ray or a CT scan plus formalin especially chockablock. And then most, most discussed with this patient. About that, you will need a surgical management. However, I will be discussing it with our MDT team to have a second opinion about the appropriate management, which will be according to the CT scan.
However, the principles generally would be easier to replace or to fix it. Uh, according to the bone stock and after discussing an M.D. 80. The approach that I'm going to use will be the will be most probably the approach that she has a total hip replacement, that was it before, but this is liable to change as it is needed. Sticking with pediatrics.
We've got a two-year-old girl and she's been sent to your clinic with a fixed flexion deformity of her thumb. So I've got some pictures here, so I'd like you to tell me about what you can see and what you know about this condition, and then we can talk about what we're going to do about it. So these are clinical photographs of the two-year-old girls left, some showing a flexed.
So a flexed attitude of the entire pharyngeal joint, and it seems like this also highlighting of a node or not as node, so this would be in keeping with a petrosectomy thumb also known as congenital trigger thumb. Yeah and yeah, and the. The so, yeah, you get the nutters node forming in the flexor tendon and it can get caught in the.
So they think that it's either the not as node or it could also be a hypertrophy of the A1 pulley or the oblique pulley of the thumb. And so then you need to classify this using the Watanabe classification to see if it's just a triggering of the thumb or whether it's locking and needs to be passively extended or whether it's fixed locked and that cannot be passively extended.
OK, so this is fixed, what shall we do? So if this is fixed, then and the child is two years old, then? My understanding that so I would want this to be treated by a pediatric orthopedic team, but the principles of my management, once it is a fixed trigger, some would be for operative procedure in order to release the A1 poly.
OK, so talk me through your operation. So in an appropriately marked and consented, so consenting the parents, obviously I would have the child under general anesthesia and the hand on a hand table, and I would make a, I would say, a longitudinal incision of the. Over the nutters node.
Sorry I would want to make sure that my incision is more based, more on ungainly, I think so that I avoid the radial, the radial neurovascular bundle, digital bundle and then I would want to dissect down onto the pulley to release it, always being sure not to also reduce the oblique pulley.
So I don't get. And bolstering of the tendon, I will then ensure that the tendon is running freely when I passively extend the inferential joint and then close the skin and just press the finger. OK, and what are the potential complications of this operation? So it's an injury to the radial neurovascular bundle of the digit, as well as injury to the tendon.
As you're doing it over release of further police, including the oblique police, which could result in bolstering other things would be a recurrence of the trigger some as well as infection. Yeah, OK. All right. And just quickly tell me what the pathophysiology is of the pediatric trigger, some compared with the adult trigger finger.
And, Uh, so I am an adult trigger finger. You would get. So you've got no sign of itis developing, and so that causes the inflammation within the tendon and the blocking whilst in a pediatric trigger finger, then not us know it.
I can't remember exactly how it develops, to be honest. All right, that's five minutes, so how do you think you think you did? So I felt it started well because I felt I knew what I was looking at. I kind of had a good idea of the classification and thing, but I felt I then struggled a bit when it came to the details of the management.
No, I think you did well. I think you did well. Let's just go through it. So you're right. It's selection of the IP joint. It starts as a trigger and then it becomes fixed election and in a child. So this is the difference. So in a child, you've got a problem with the FPL tendon, so you get thickening of the tendon due to the abnormal collagen degeneration synovial preparation, which causes an increase in the diameter of the tendon compared with the size of the A1 pulley.
So you get disruption of the gliding now, as you said in the adults. They get proliferation of the synovial, the son synovitis sheath, which causes the problem or problems at the A1 poly themselves. So that's the difference between the two. The naughties node is where you get the nodule, and we drew that out, I think, and you pick that up quietly. Well, when they get to the age of two, it's unlikely to resolve.
So we're going to do an a-1 pulley release. So even though there's different pathologies for the child and the adults, we're going to do the same operation. You're not the first person to say they're going to do a longitudinal incision. Personally, I would do a transverse incision to try and keep it in the crease and just make sure that I have ragnar's retractors in to make sure I can see where the tendon is, where the pulley is and look out for my radial digital nerve.
That's the one that normally gets injured. So adverse outcomes. I think you mentioned most of them infection. Not really seen any infections, but it's their scar contractors bolstering of the tendons FPL rupture incomplete release is the one that we should think about whenever we talk about trigger finger release or some release and radial digital nerve injury. All right.
A little bit of a paper for you. So here's what you're talking about a 30 degree deformity, 30 or more degrees. So if there's less deformity, they're more likely to resolve spontaneously than if they're 30 or more. Degrees of fixed flexion and for each additional degree, then you reduce the likelihood of spontaneous resolution by 3% There's no detrimental effects of nonsurgical management, so you're quite each case you're able to do a trial of non operative treatment.
And the idea is that if you do wait, so if you've got a child of one with a fixed election on one side, if you do a trial of non operative treatment and they develop one on the other side, then you can treat them both at the same time. OK, so well done. Any questions? So just to confirm, even if it is fixed election, you still try to.
Non operative with physiotherapy and parenthood stretching some things if it's fixed. I think if the I think if they're under 18 months, it's probably worth it. I think by the time you're getting to 18 months and two years old, like this child, it's probably not going to get better. And I would do a release at this stage. But if they're very young, then there's no there's no side effects of treating intraoperatively to start with.
OK so the next one I have is your child foul was playing football. And complaints of terrible pain, isolated injury, neurovascular, in fact, you are seeing this patient in EEG department proceedings. So there is AP and a lateral view of X-ray of an immature skeleton.
On the. AP view that there is evidence of a bone fracture involving the lateral aspect of the distal humerus, so probably and on the lateral view that is subluxation of the vessel humerus. So I'm thinking there is a fracture of the lateral epicondyle with fracture dislocation.
OK, so how are you going to manage this. So I will get a focused history and thinking that it is an isolated injury. I will focus his three points that you want to ask. So the mechanics of injury, while so it is said while playing football, so what exactly happened whether he fell directly onto the elbow or there was a personal injury, so mechanical impact on his outstretched hand?
Yeah, the timing of injury when this happened four hours ago and what was done immediately. And I would also ask about his past medical history, also about his immunization status and also when he had his last meal. I will then look do a clinical examination to look at the soft tissue and up to see if it is an open or closed injury.
It is close to fracture. I will. A bill, a neurovascular examination of his elbow intact, and presuming that because he is only seven years old, I will also see who has come with the patient, whether it is his parents or the other court from the floor from the program. So the parents brought him straight away.
There is no concern regarding the non-accidental injury. OK so what night? So my initial management would be to. Give him adequate pain medication and. after giving him analgesia, and if there is a anesthetic support or pediatric support, then I would give him some sedation to try and reduce the injury and give it elbow, elbow, peel-back, and then do it X-ray after I will assess the post-production.
You mentioned about reducing it. How are you going to do that? So So given that is more of a. Lateral on a capital structure. I would give a linear direction and try so the patient is now in the elbow sense of the virus, so give him linear production and try and.
Give an opposite direction course. All right. While just standing by that, it wasn't successful. So on this AP view, Yeah. What do you see? You mentioned about the fracture. Is there anything else which is abnormal?
so you mentioned about this park, which is broken, and I agree with that. Anything else? Which is abnormal. So I'm thinking that whether the tip of the political unknown has also fractured along with that. But the radial head seems to be intact. Yes OK, so you've tried and you couldn't do anything, you could be exactly the same network.
So I would discuss this X-ray with y. Assuming that he is still neurovascular, in fact, I will. I will discuss him with my, Uh, with a pediatric orthopedic on our team. Well, you are on board consultant and it is so, so the moment. Normally happens, isn't it? Yeah so the principle of management would be to initially to ascertain the fracture pattern.
If we have doubt regarding the fracture pattern, we can request for further imaging, which could be a CT scan of the elbow. They got the CT scan now. So um, so looking at the CT scan, I think there is a fragment of the capital as well as the lateral epicondyle. And I'm not entirely sure about the radial head inhalational.
OK, so radiant had an omnipresent they are, in fact, so that is at least two to fragments for the lateral condyle, so potentially capitalism and and lateral epicondyle. OK, so next. So if I have tried to reduce it in any and if it is not producing and I would assume that one of the fragment is kind of insoluble there, just to be clear, when you say you tried to use what exactly you're trying to use, are you talking about this fracture?
No, the elbow joint is sublets, so that is the reason why. Thank you. Thank you. That's what I was trying to establish here. OK, so all right. So you think there is some disruption in the elbow to be specific? What part of the elbow joint? So, so so the fumero are not joint this dislocated.
I'm looking at a joint. Ok? so let's go back now. You've tried reduction of the ulnar humerus joint, which was unsuccessful. Now what? You've got this imaging CT scan is being done. Yeah so tell me, how are you going to manage this? You've spoken to the patient.
You have obtained the appropriate consent and everything is done. The patient is now now. So I would position the patient supine and. Oh, and yes, we will. Can will use a tourniquet. What will not inflate it unless required? I will position the patient supine on a side with the side table and.
Erm, the principle being and have an extreme position so that I can get a 360 degree access to the elbow and the principal would be to try and reduce it close and then figure percutaneous fixed the lateral line. OK, so once the patient was anesthetized, you managed to get the reduction closed of the glenohumeral joint.
So so once the ulnar claw model joint is reduced, sometimes the fragment will fall back in place and then you can. Under the same guidance, you can use percutaneous screws to fix the lateral epicondyle. OK OK, what configuration you want to use the screws in, so we took use to. So there are two separate fragments, so you can use one screw.
So two screws in the capital fragment, which which can be headless screws and then another screw in the lateral epicondyle fragment. All right. OK your approach when you're doing anything particular that you want to be careful about. I'm asking about the bottom line. So so I will try and do a limited lateral approach when doing the.
So I will be worried about the. Um, where is the blood supply? Mostly with this part. So my main concern would be for the capital, which can cause avascular necrosis of the capital. Yes what are you going to do to minimize that? So it comes from the regulatory, which is coming from medial to lateral side.
Um, I'm not entirely sure what you think. Thank you very much. OK all right. So I'm giving you performed. Yeah, I think. I did I was a bit focused on the fracture, and I think I did mention that there is a posterior dislocation of the elbow.
But yes, it could have been more, more systematic and more slick. That's fine. OK right. So your initial approach, the patient was fine in the history. You did the examination and in the examination part, you could see that it is obviously deformed that elbow and the X-rays showing exactly the same.
And you can clearly, apart from some time, there are features that we just get tunnel vision into. So we are always focusing on the obvious fracture, which is there. We're not looking at this part, which is also subtle. Axilo, partially dislocated. OK so ideally, you're not attending to a seven-year-old. You do not attend any reduction in Ed because of the number one, it's unlikely to get reduced.
Number two, it would be very painful and very distressing for the patient. So we take the patient dictator. But that's that now coming to the. Aspect of it took you a bit of time to get because the type here immediately gives you a clue that there is a complex fracture, but there is also ligament problem here because of the dislocation here.
So you need to come to the point of getting further imaging rather quickly. OK, then you should see this kind was done. And this demonstrates the split there as well and the fracture. And you can see that the ulna, which is not congruent there. Now, the question I asked was the blood supply, that you need to be aware the posterior, it is the posterior part, which is where the vascular supply is arranged.
So we always try not to revitalize the soft tissues. Posterior incision should be slightly more the pan and then stripping of the soft tissue should be all on the interior side rather than posterior. And this is basically to avoid the risk of extended. It can happen, but at least you have tried your best to minimize the risk of avian. Right, OK.
And you talk we already talked about those divergent screw configuration, so that's good. So what would you take the patient on the same day? Yes, because it's dislocated. Yeah and if you don't produce that, it will cause further problems in terms of increasing swelling potential compartment syndrome, potentially a vascular compromise. OK thank you.
One aspect is that if you don't have I mean, we nowadays we do have the facility of scan available in every hospital, but the other traditional option used to be the program. So you can do that operatively and that would outline the articular surface for egawa. So when you're shown the CT scan, would you say it is capitalism and lateral epicondyle? It's a lateral mass fracture, Yes.
Yeah so I mean, we're running slightly short on time, but had you come a bit early to the diagnosis with the imaging and we would have discussed about the potential complications of this injury. I think we're going to move on now. Any any burning questions for this case. Thank you. OK well, my question is this little epicondyle fracture is usually inverted, the fragment is flipped, so do it need always open reduction?
I think it could not be managed with claws reduction if the fragment, that's what exactly I did. So the only thing going to be OK after anesthesia. However, that fragment was not getting reduced. So many open approach, as I said laterally, but more anteriorly to avoid the vascular supply to the posterior elements, which is where the blood supply comes from. And then reducing it under direct vision.
OK so who's next, then? Yep, that's me. All right. OK, so this is your case, taking your file next? Yeah the good answer, a.j., by the way, thank you. All right. So you're a critic. You got a 60-year-old gentleman with bilateral hand problems. He's come to you from the rheumatologists.
So tell me what? You're going to ask this gentleman. So I will take a detailed history. I will ask about what's in your detailed history. I will. I will. I will. I will ask about with any pain. And if there is pain, what is the location and nature?
What makes better? What makes it worse? He's got rheumatoid arthritis, he's in a lot of pain. Yeah OK, and then I will assist the function of the hand, including grip as well as pinch and then weigh what you still need to be on you. Sorry it's a political you're taking history. Tell me about what you want to know from asking what questions you can ask him.
Yeah, I will. I will ask the patient about the function profile to what extent this problem affects their daily activity, whether she's what daily activity that we want to ask, whether she's able to use a brush to brush her hair or dressing or taking clothes off or walking driving. And then I will assess ask a patient about the swelling with other hand, swollen up and what makes better for swelling, any deformities win-win where whether she's compliant to medication or not, and to what extent the medication also improve her symptoms.
And then I will assess for in other co-morbidities with rheumatoid and what treatment is going. Is it DMARD or not? He's on his medications yet. Yeah then I will. I will assess the neuromuscular status for arthritis. I will ask about any numbness in the hand, and I will conclude my history by asking patients what expectations she had she wants without what occupation she is doing at the moment.
If she does anything and what she expects from the surgery, if something she is going to undertake at the moment is really frustrating, but he's really sorry, he's really frustrated because he struggles with buttons, particularly when he's doing his shirt buttons. Yeah, and OK, so I will. So this is struggling to get his hand and particularly as he can't get his fingers straight anymore.
Uh, OK, so I will assist with I will treat this patient, optimize the his. Tell me about your examination. What are you going to do when you're examining him? OK, so I will say the clinical picture shows I will assess the. Look for from the front, as I can see, there is. Radial ulnar deviation of the metacarpal.
With with I can't appreciate any Cabot Alma, probably in the right hand, a bit prominent compared to the left. OK there is no obvious subluxation of the extensor tendon. I can see there is a swan. I will assist the middle finger in the right hand and the ring finger for boutonniere deformity.
Tell me what's one thing neck is, is a hybrid extension of the Pibb with flexion of the Dib and I can. So again, why don't you guys one? What is this one that causes the imbalance of the tendon of the flexor and extensor or intrinsic tightness in this? It could be many reasons, but usually in the rheumatoid and it related to subluxation.
Volatility of the travel ban and which is. And you notice as well that you said that about the only deviation. The thing is when the notification is trying to straighten his fingers, he struggles to get them straight. Why might that be? This, usually as a result of one Jackson deformity, could be one that it could be.
So it could be a tradition of the ADC tendons or attrition or rupture of EDF ICU as well. OK it can be on that. You can see the tendons, though still there. Other things could be stopping the fingers from extending properly. In early, it mostly could be synovitis of the metacarpophalangeal joints.
Is that as an inflammatory process going on that affects the function of the joints? What would be the right? So again, only. Yet it could be that the extensive turned drifted ulnar nerve because of the sagittal band rupture. Yes all right. So tell me what special tests?
What are you going to do for this patient because you talked about testing function earlier? Yes, I would do a great function. Um, so what types of groups, what talking about, what is the function by grab like a doorknob door knob to assess whether patients can do door knob or not will assess the bench side bench. As will a side bench and pencil bench and Chuck bench as well, and will check for intrinsic brightness by panel test, and I will do also for.
In other forms, I can't appreciate any about any deformity. If there is, I will do Allen test as well. OK, good. Right? all right. So you to get some X rays? Yes yes, please. Yeah what can you see here?
Well, these X-rays cause so the X-rays shows. Degenerative changes in them and. And metacarpophalangeal joins significantly with also Pibb. So it's significant changes, globalized in most of the hand joints, and there is ulnar nerve translocation mile Delano translocation of the bus.
Um, I can't see a significant day. What do you what do you think about the MCP joint? So they are there right now? This is. It's almost fused or degenerative changes of the MCP with subluxation as well. OK, fusion, do you say no, I mean, degenerative, like articles joint or are they cellblocks?
That looks like supply. There are some patients saying he's struggling to extend his fingers. It is a bit of subluxation of the CPGs. So what's your sort of differentials as to why he's got these problems with his hands? You can see the tendons trying to move, but when it comes to empty PJS, they're not wanting to extend very much.
And so because of I think. The degenerative change of the joint itself or inflammatory process, with significant sign of synovitis in the joints that affect the range of motion of the joints as well. The investigation is needed to help you.
And as our investigation. I'm not sure. I will. That's a clinical to assess if there is any tendon rupture or alteration of the tendons examining in the tendons appear to be intact or not ruptured. But they are. There are some blocks out into the ulnar side.
Yeah, which is I will do MRI to assess the surgical band, whether it is rupture and not which in case I will consider reconstruction of surgical band. OK right. OK, so tell me about your management options. What what are your major options for this gentleman? So the options are non operative management, including a mid-tier approach that include physiotherapy, activity, modification, optimizing the medical treatment and orthotics.
Yep, that's it. Yeah so you just focus on a specific problem, which he's talking about and then individualize each problem as well, it's a function of each. So I'm not going to treat all of the problems here. It depends on the function itself. Yeah OK. All right.
Sorry I'm sorry that we're running short of time. Is that well done? So how did that go for you? That's kind of like, I don't know, it's sometimes hard to rheumatoid lots of things, but I'm not sure. Yeah so obviously I should talk about this spine. Yeah all right. OK so rheumatoid, it's a large topic, so rheumatoid and scares everyone because you think you have so much to talk about.
Focus on the problem. You did that right? You ask the patient what their concerns are, what their expectations are. OK, so this goes. Bas status is trying to do his buttons because his fingers can't extend properly, he's struggling to do them, so you've got to think about why these fingers are not extending.
So you did you talk about pain? Talk about functional assessment activities of daily living. C-spine don't worry too much yet, but it is important the anesthetist wants to know if they're going to put them to sleep early on and break their neck. Previous interventions and obviously, these disease modifying antirheumatic drugs. That's the key thing in the history, and we mentioned all those c-spine think about for next time round.
Good the steps look, feel, move, hopefully will identify most pathologies, look for AIDS of tenderness, assess any abnormal tissues or swelling. So you'll find it's a bit bulky where several bands have had an attrition and perhaps a move of the joints stability of the joints. And we will find that actually because of the subluxation, those steps are subluxation, so they're not stable intended function.
So tendons are actually will function fine. So Ron Jackson happens a bit later on, if you would more let this end up to n up having Lamar Jackson. So were we allowed to see patients or go to the exam? This is what we suggested. You should have in your pocket. So to help do the functional tests. So a pen, a key and a coin.
So picking up coin. So as you mentioned, the five key lateral pinch grip. And pinch grip, which you mentioned how gripped you mentioned Chuck grip and hook grip as well. Those are the if they want you to examine the rheumatoid hands. Those are the five things you should. Those are the five functional things you should think about. OK because you don't have time to do a full exam of the hand, look, feel, move and get them to do those power trips as best as you can.
OK, something we all need to. We have to practice to get as thick as we can was to do it within a few minutes. OK but it is possible. All right. Well, I'd like to approach management. Principles for rheumatoid is really difficult. You've got you've got to assess the whole patient with MDT approach, optimize medical management, physio focus on the main issue.
You can't treat everything. We try to treat everything where we lose. So no operative injections. You mentioned those good operative on the situation, but you're focusing in general. We talk about rheumatoid. We might think of risk for a disease if they've got problems with the carpet centralization procedures, satchel procedures, lateral band reconstructions like in Swan making, which I was very impressed with.
Example, will asking you what's one that is this way? What happened? And obviously, with the subluxation, you can also possibly think of MCP replacements if they've got arthritis there. But you wouldn't necessarily do that in this gentleman. You would struggle because of the instability around those joints. They will fail, so you need to do something about the special bans.
So it's a double edged sword. What are through these options. We can consider, except of frist after this is any other finger we can do, you can. So PRP, so you would fuse the pill, you confuse the dip. You could replace the PRP occasionally confuse the PRP MCP. You would try and replace, but mostly wrist fusion. If you're talking about someone, if they've got severe capital, then you could be yourself and you've got all these lovely, different ones.
You can try. But ultimately, the most predictable one in terms of outcome is a fusion, sadly. Yeah, but it does take a lot of counseling for a patient to get to that stage. The good thing for the good thing is the medications are so, so Def much better. We rarely see rheumatoid patients, but when they do, they've got these quite complex issues where their fingers are subleasing and they're struggling with function with functional functional activities.
So we focus the key thing is to focus on those. OK Yeah. But yes, otherwise good approach is the real approach. It's very difficult with rheumatoid hands, as I say. There's lots to go on. There's always lots to see. There's lots to talk about. I think I was happy with your approach there. I know I hurried you along at the time.
OK, I'm going to apologize. We have overrun, but well done. Well done. Thank you. Thank you very much, David. That was excellent. And obviously clinical. Did they do drag on? That's the nature of it.
Because of that, a lot more interactions and questions. And so but that was really great. Very good cases. Thank you very much, David, for all the effort you put into for this session. My pleasure. All right. Good luck, everyone next week. Good to have you.
Thank you very much. David, I think you have a nice Easter. Thank you. OK, guys, now we'll move on to the last station, I would please. So we have this last station today is lower limb clinicals. You must be all guys exhausted, but I think it's good to build up the stamina and the resilience for the exam and stay focused to the end.
So thank you. Thanks, Ferre. Sorry about the delay. No problem. OK, can you just in one word? Tell me what the problem is here? And this is a plane of arrogance, deformity involving the right tell me the ideology of the religous foot.
What could be the potential causes? So it could be post-traumatic with having had fractures in the midfoot. It could be a tibialis posterior tendon insufficiency. Other things would be diabetic with a Charcot foot and they could end up with a rock bottom foot.
Other things would be inflammatory. Arthritis could also cause that infection and metabolic. Anything more than this is all you mentioned and lightning are all acquired one something anything before. Oh, of course. So yeah, there are the congenital ones that play a fixed for deformities, such as your congenital vertical tails.
And I think it's a coalition operation. OK well, OK, so this lady comes to you complaining of pain and ongoing difficulty with her gait. And this is the picture that you see. How do you want to proceed to take relevant history to start with? So I would want to ask her how long the pain has been going on for about a year now?
And was it precipitated by any injuries or any inflammation within the foot? He doesn't know what inflammation means. So did you have any episodes of redness and swelling and pain, the proceeding? No OK. No injuries. OK Oscar is the. If she's had long standing loss of her arch or whether she's gradually developed this deformity, she thinks it's gradual, so symptoms are worsening gradually.
OK, I just want to know what kind of effects the symptoms they're having on her. Lifestyle and her so he notices some weakness. She cannot go on her tiptoes there, and generally she has pain on the side of her foot. OK it's been finding that this is causing it to make it difficult to walk long distances walking on the ground.
He struggles to walk. OK and her age and occupation. She is an office worker. She's 45. OK and does she smoke? No does he take any medication, steroid medications that he's otherwise fit and well? OK and. What are her hobbies in terms of her, her overall sporting activities?
She doesn't get involved in sport activities. No jogging and nothing. OK all right. What are her expectations? If he wants to get rid of her symptoms, which is mainly pain and difficulty in walking. OK all right. And I think at this stage, and she has never had any previous surgery to the foot.
No, no. OK and yeah, and no neurological. So no numbness or tingling or anything like that? No OK. Can I move on to the examination? OK what are you going to do? The focus relevant examination here. So I will first assess her gait. So kind of.
And Tom typekit on the right side. OK and I would want to see her single leg stance, whether she can go on tiptoes a single leg. She cannot. OK and so then I would want to lie her down at other exacerbating school, actually, while she stand there as well. That's normal. OK, I wouldn't lie her down so that I can examine the foot.
I would want to check if there's tenderness on the medial aspect of the foot of the post tendon. She has tenderness there. OK and I would want to see also then, if the deformity is. If the arches reconstructed when I do Jack's test. So it is not OK, and I want to then assess if this is a predictable deformity in terms of the hind foot rather and the fall for a deduction, whether that.
Correct so how are you going to check that? Yeah, so for the time for this, I will want to invert the hill and see if that's correct. And then I will see if the four foot remains. Whether the Pope would remains too connected or whether it correct what I infer to hear, so there is a picture there.
That's how the foot is lined when he tries. When when you try to bring the hind foot into the neutral position to the floor for it remains to be naked. OK all right. That's all right. And then I want to test for it to be able to steer posterior. A strength as well, so I will put the position the foot in a inverted position and then I will ask her to push against my hand to try and maintain that inverted position.
OK all right. So she can do that, but with struggle. OK OK. And so. So describe to me this hind foot and four foot rotation in relation to each other in this particular problem. So you've got a. Hind foot, Vargas deformity and your that is causing the medial aspect of the forefoot and midfoot to.
Uh, to be in contact with the ground and in order for the lateral foot to make contact with the ground, it needs to in it in response to bring those raised to the latter race to the ground. OK what are the structures that maintain the medium large of the foot? So the media arch is maintained by the tibialis posterior as well as the planet's longest and.
Some input from the. Uh, the plantar fascia. Anything else? And the spring ligament, which yeah, and that runs from where to where the spring ligament that runs from the sustained Allen tail to the navicula? OK all right. OK, so let's proceed now.
So you have now established her clinical findings or next? Then I would move on to getting radiographs, lateral and radiograph standing radiographs. OK and I don't have them, but it's done, and that basically shows best planets. So what exactly are you trying to find from the extremes? So from the trade, I will be looking at the subtalar joint for four degenerative changes there.
And I also want to be looking for Taylor tilt of the Taylor tilt on the AP view. OK as well as the Mia angle and the calculated pitch. OK all right. Tell me about Mary's angle. What is it that we did? Yeah so that is the long axis of the tolerance and the long axis of the first rate, which should be, if not parallel within 5 degrees of each other.
And if it's deranged in either direction, you can either have a crevice or a plan. OK, now coming to the treatment options, what are the surgical options here? So surgical options, if there is a grace, didn't show any arthritis. OK, but it does clearly show the best as deformity. So then you could be considering a reconstruction, a transfer of the F reflects a digital and long standing to tiberias posterior.
To reconstruct to reconstruct the. OK, you won't reverse the default. They're going to do it and then transfer FDR arms. Other than that, you'd want to consider. It's not fit, make it for foot deformity and incorrectly kind foot.
Then you'd want to consider a lengthening of the lateral column of cranium in order to correct the abduction of the forefoot. And yeah, and that's we're correct in that plain and. So what do they do for fun, because if you correct behind it by transporting the tendon, then the forward would remain still to naked and it will not provide her with a plump degree gait.
Yeah we're going to stop that, thank you. Well done, Andrew. I think we approach this very systematically. I'm just got slightly confused on the treatment of they are not easy. And they have especially this fear and put an end to and we are not very much seeing all these cases on a routine basis become slightly confusing.
However, your approach was very good. You started with identifying the problem straight away. You could simply add it, saying that this is too many to assign, which is present in no matter what gets put etiology wise. You mentioned, pretty much all of them. So don't forget about the congenital causes as well. So where people pay less and some neuromuscular causes like cerebral palsy, lesion, you mentioned and you've mentioned about the examination.
So you've got a very clear concept of how those two elements, the hind foot and the four foot act in relation to each other as the deformity progresses. Coming to the investigation, you talked about temporary perfectly, no issues, do the treatment by classifications? There are four stages and you and you basically manage according to that stage of the deformity or the condition.
So here is the summary. Do you see that picture of the foot, which is after correction of the hind foot? The four foot is to naked so that great toe or the medial ray would not touch the ground, and it is essential to have it touching on the ground, isn't it? Yeah, you would me so far. Yep, Yeah.
So what you do you do in an osteotomy what we call it, as a cutting osteotomy, and that's the plan to flex the first ray so that it is touching. And that's basically on the category of the stage to see where the power cord is to be naked. So this is a summary you can see by stages and you do the treatment accordingly. The I've.
Thank you. No problem, that's why it gets tough in this, this is very well described in the Miller book. If you go there, it's just in a state wise fashion, it's very clear that they can ask you about this. This is a common case that can be presented in the exam. Any questions. So far from this?
OK, let's move on to the staircase now. Thank you. Yeah, next one is candidate number four Ghoulam. OK, so we have a female patient, she fell.

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