nm5197: okay i'm going to er work with you now for about an hour and i'm going to talk with you about trauma now this is not a lecture and i'm not going to stand here and lecture you at all i'm going to try and encourage you to talk with me so that we can develop and understand some basic principles that's why i want you all to sit down here so we're part of a little group and there'll be some fun activities for you to take part in as well now i've got some of your colleagues helping me and er we've picked a couple of patients who i think reflect er two different aspects of trauma one patient who had a hip fracture and one patient who was run over by a truck and we're going to talk about those two patients not to talk about how they were treated but rather to understand the disease that they had and you should start thinking right now about trauma as being a disease something which has risk factors something which has causes and etiology something which can be measured in the population something that can be diagnosed so we're going to speak about trauma as a disease and we'll focus o-, in the two cases on some of the etiological factors and some of the aspects of diagnosis and initial assessment so Tim why don't you begin sm5198: sorry can we have the machine on please [laughter] it would help hi everybody that's me wiggling my hips er i'm going to present a case to you on hip fracture er a very nice ninety year old lady er and this is the A and E A and E assessment that was performed and er documented the incident on the twenty-ninth of April this year she had a fall while she was walking and experienced some left-sided hip pain and she was categorised into the yellow category of in triage which is not that severe and at this point it wouldn't be irrational to assume that she'd suffered from a neck of femur fracture given that it's the most prevalent one whoops so here was the history er presenting complaint just painful left hip er if we delve into that a little bit more she tripped off the bus in town er and she fell onto her left side er she experienced immediate pain in her left hip without loss of consciousness drowsiness or nausea er she was unable to mobilise or weight bear on that leg and she denied any pins and needles and other symptoms so her past medical history we know that she's got osteoporosis she's had that for many years er she suffered a fracture before er namely a left proximal humeral fracture in October in last year she's an known hypertensive hypothyroid suffers from a hiatus hernia she's depressed and gets the occasional stress incontinence so just to give you an insight into osteoporosis er the definition is that it's a disease characterised by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and an increase in future risk of fracture er and it's important to note that er the deficiency lies in the quantity and the quality and the structural integrity of the bone and er not in the mineralization of the bone which we call osteomalacia and you can actually see in this graph here er if we consider Mrs M's case she's over eighty-five she's ninety years old so she's going to be on the brown line of that graph her femur bone mineral density is likely to be less than six-hundred and so her percentage risk of a hip fracture is going to be edging towards about thirty per cent but we'd need to confirm this on a dexa bone scan er obviously in fracture patients it's important to consider all the social implications er just initially er she's not smoked she doesn't drink excessively and she has a good diet these factors are essentially important because smoking actually accelerates bone loss and can negate the benefits of oestrogen therapy like accelerating oestrogen metabolism er diet i'm particularly interested in the intake of calories vitamin D and calcium here er it's actually recommended in post-menopausal women to be consuming fifteen-hundred milligrams of calcium daily and between four-hundred and eight-hundred I-Us of vitamin D which is quite sort of sufficient isn't it er normally goes into town once a week if you just read through that where's it say that yeah only daughter lives close by and takes her out weekly in the car unfortunately on this occasion her daughter was on holiday and that's why Mrs M went into town by herself on the bus er so her family work full-time she has an upstairs bedroom which is going to have profound implications on her management she lives alone in the three bedroom house er she was receiving day care but she cannot afford that anymore er and she was mobilising with one stick before so we'd like to get her back on her feet these are the risk factors that can be grouped into skeletal and fall related variables er and as you can see Mrs M is clearly disadvantaged already because she's er got osteoporosis so bone mass microarchitecture already down she's post-menopausal she's a female she's white er and she's had a previous fall before er however she's hypothyroid so she's likely to be overweight which she is and er her low body weight is likely to be her increased body weight's likely to be protective in the future er so that's one of the advantages er she's also relatively mobile she doesn't sort of run about but she does go into town a couple of times a week er she's never smoked never consumed alcohol in excess so we can er disregard the fall related ones as well er drug history the obviously ramipril ACE inhibitor paroxetine SSRI she's on detrusitol for her incontinence thyroxine fifty milligrams and ranitidine for a hiatus hernia but the fosamax is really what we need to home in on here that's alendronate and is a bisphosph-, sorry bisphosphate so if i just talk you through what bisphosphonates are they're actually er designer drugs based on the naturally occurring pyrophosphate molecule er now when they found pyrophosphates they were actually searching for an agent that would prevent er calcification in soft tissues and they found pyrophosphate inhibited crystallisation in the urine er pyrophosphate is actually cleaved by alkaline phosphatase er and that prevents it from gaining access to the bone collagen er in the case of the bisphosphonates you can substitute an oxygen in place of a carbon er in the pyrophosphate molecule which renders it er resistant to cleavage by the alkaline phosphatase enzyme so therefore enabling it to attach to calcium containing crystals in the bone and therefore increasing the bone mass in both the cortical and the trabecular bone the fist bisphosphonate noted was etidronate but that tends not to be used now because it can actually cause osteomalacia due to er osteoclastic effects as well so role in osteoporosis of the bisphosphonates is er in osteoporosis corticosteroid-induced osteoporosis Paget's disease and hypercalcaemia of malignancy the next slide er just to show you how alendronate actually has it's actions er you can see on the spine and the hip that it's improved the bone mineral density and in this study the dose was actually doubled after y-, after two years the er graph down in the bottom there the two of those graphs the NTX and the BSAP are biochemical markers that are released er during times of bone resorption that will the N-telopeptide and bone formation which is the bone specific alkaline phosphatase and you can see improvements in both those markers there with the alendronate observations and examination er general observations er patient was comfortable this is obviously following the A and E assessment er no pallor cyanosis no jaundice no lymphadenopathy and neck mo-, mobility was fine mouth was opening thyroid was normal er her left leg was shortened and externally rotated and as i'm sure you'll all be able to tell me it's due to the action of the quadriceps specifically the rectus femoris the adductors and the hamstrings which pull the leg in that sort of position er it's important to test for the pedal pulse there because fractures of the neck of the femur can cause er avascular necrosis because of the way that the medial circumflex artery goes around the neck of the femur into the head so the plan the most important thing there really is the X-ray just random bloods done as well and transfer to the orthopaedic ward er i've got the X-ray to show you actually we're looking in this area here obviously any guesses su5219: intertrochanteric sm5198: no it's not actually sorry namex [laughter] it's a subtrochanteric fracture of the left femur and here's one i made earlier i got off the internet because that one wasn't particularly good er that's actually a spiral fracture of the femur as well just to point out that's not really relevant in her case there we go subtrochanteric fracture of left femur what did they do about it she had surgery pre-operatively they checked her haemoglobin cross-matching obviously important if she has er a bleed U's and E's requested starve from midnight er she was given local anaesthesia and consent was requested so that's a cross-section of the hip joint there and if there's any surgical boffins out there i'm just going to read through the approach that was taken not that i quite understand it so it's a lateral approach was favoured and they reflected the vastus lateralis m-, muscle which has it's proximal attachment on the greater trochanter and it's distal attachment on the patella and the patellar ligament going to the tibial tuberosity the trochanter was exposed and a guide wire was passed into the head and neck then using a triple reamer it was reamed to ninety millimetres tapped and then a guide wire was inserted ninety-five millimetre DHS was passed through a hundred and thirty-five degrees and then a four hole plate was fixed with cortical s-, cortical screws er and it was noted to be a stable fixation image films were obtained and found to be satisfactory although there was some rotation of the head and the neck fragment then obviously wash out and closing and staples to the skin that's er a reamer at the top there shooting into the bone post-operatively regular blood tests were done er she was mobilised for weight bearing clexane also known as enoxaparin is a low molecular weight heparin and that's used to prevent embolism analgesia was given morphine and co-codamol and she was discovered to be moderately anaemic so that warranted the administration of ferrous sulphate i just included senna and lactulose er not importantly but because of the opioid analgesia she was on she's obviously at risk of constipation er she is due to be going off to a rehabilitation hospital soon er where she will require rehabilitation physiotherapy and occupational therapy and they're really going to try and er mobilise her with one stick or possibly two sticks er i have been told by a physio that er walking with a frame isn't really getting an old lady into a normal straight back walking position so they will always try and get her to use her sticks okay er last slide prevention of hip fractures again divided into skeletal and fall related factors er you can see bang in the middle there oestrogen therapy in the form of HRT is of proven value er with regards to prevention of future fractures and er especially in post-menopausal woman the SERMs are selected oestrogen receptor modulators and they're under trial at the moment for stimulating receptors in the bone there by increasing the bone mass and they don't have the same effects on the endometrium as the HRT does er they've also they're also of benefit in lowering total cholesterol and LDL cholesterol and an example of an S-E-R-M is raloxifene the tibolone included there er combines oestrogenic er progestagenic and androgenic activities and it's indicated in the prophylaxis of osteoporosis quite a new therapy coming out er so obviously those are the drug choices for managing Mrs M's case in the future but er it's going to be essential to re-establish her mobility in the form of rehabilitation and er preferably getting her back onto sticks or soon there's going to be huge social implications her family all live quite far away and she's only o-, one daughter who lives close by er and hopefully she won't be going into town on the bus by herself again nm5197: so have you got any questions you'd like to ask Tim sm5198: bear in mind i'm doing dermatology at the moment i've just done my G-P casework nm5197: yeah so you've heard his presentation it was extremely interesting comprehensive did it er make you curious about anything sm5202: one of er Claire and i were in care of the elderly for our first place and he was mad he used to run around the wards and open up cardexes and see and make sure that all his old ladies were on vitamin D-three and calichew er do you know wheth-, whether there's any point in er pre-menopausal women taking it as in like prophylactic prophylactic things or is there no point at all [laughter] sm5198: no er i don't see why not though vitamin D nm5197: does anyone know the answer to that sm5201: is peak bone mass like an important factor for osteoporosis nm5197: can you talk us through that sm5201: well i mean er like women pre-menopausally if they're taking vitamin D or or calcium will obviously have a higher peak bone mass so even if they don't take are therefore predisposing themselves to fractures i can't really give you any more than that really sf5214: but if you're getting adequate vitamin D and calcium in your diet then taking a supplement probably is just going to increase your bone density nm5197: so er this is exciting it sounds like we're talking a little bit about calcium metabolism so who's excited about that anyone over this side or is it only on that side you guys know a bit about calcium metabolism right all the girls in the audience here at what age is your bone b-, bone mass at it's peak ss: thirty twenty-six nm5197: on this side only su5219: thirty nm5197: thirty about thirty someone else su5219: twenty-five twenty-six nm5197: right so you're talking about sort of er early adulthood and er in in the course of your whole life at least so that means that some of you are around about your peak bone mass now so it's all downhill from now on now the boys here what about your bone mass sm5203: pretty similar isn't it about twenty eight or something thirty nm5197: yeah any difference sm5203: oh yeah m-, males have a greater than females anyway don't they nm5197: right any difference though in the profile of bone mass as it changes with time between men and woman nm5197: yeah we'll let you come in on this side go ahead sm5203: there's a reduced decline over time nm5197: yes it doesn't go down as much we said it gets to a higher peak sm5203: and er women live longer than men anyway don't they so er they've got like nm5197: right so so in fact er men and women both have an increase in bone mass as they get older er from childhood and then in their late twenties or thereabouts it reaches a peak and in men it's much higher than it is in women and then they decline roughly parallel until an event that only occurs in women menopause so women end up with a a lower bone mass than men but it's only been going down proportionately until menopause and then suddenly it just collapses and why's that ss: oestrogen nm5197: oestrogen or nm5197: the lack of oestrogen okay so oestrogen in women maintains bone mass we could take through the biochemistry of that but let's not so in women suddenly a lack of oestrogen causes collapse in bone mass and that's why oestrogen replacement therapy is proposed for the purposes of maintaining the bone mass okay so that's it now in men it reaches a peak which is er larger than in women but differs between men and what sort of factors might influence that su5219: race nm5197: race yes su5219: smoking nm5197: smoking that's not one i know about it could be makes sense maybe su5219: activity nm5197: activity yeah men who are physically active sports people people who do a lot of weight training they lay on a much large bone mass in fact exactly the same applies to women anything else sf5215: family history obesity nm5197: yeah clearly there are genetic factors as to how much bone mass you lay down obesity er that's interesting now i have a sort of theory that obese people carry more weight so they lay down more bone but they are also people who tend not to be physically active so they don't get as much muscle er work and that seems to sort of roughly balance out so being obese doesn't seem to make much difference sf5215: i thought that it was if you were obese you had more oestrogen and therefore you might actually be at an advantage nm5197: in women only or in men as well sf5215: no women nm5197: yeah i don't know that's interesting anyone got any information about that no i'd like to know that's interesting okay er so men who are active men who are er physically active men who are er er black have a higher bone mass er at peak what about vitamin D and calcium though you mentioned that earlier on sm5212: people who live in the dark or sort or cover themselves up could be at risk nm5197: i don't want to know about that you carry on so certainly people who are deficient in vitamin D or calcium will not lay down as much sm5212: nutrition nm5197: oh so nutrition okay major major very very important environmental factor that applies to lots and lots of people in the world and that brings us back to the women again and whether having vitamin D and calcium pre- menopausally could increase their peak bone mass anyone know of a-, any evidence on that asked that question sm5198: Paul sm5212: yeah i asked that originally nm5197: yeah do you of any sm5212: no that's why i asked nm5197: there's been there's been some work that's investigated that and essentially the bottom line is that er vitamin D and calcium are both very cheap and so even a small benefit might be worth having but in fact that benefit hasn't been easy to show and it looks like at least in this country a great majority of people already max out on calcium and vitamin D in their diet and adding it to their diet doesn't provide any benefit there has been an argument that for some people living in this country particularly black people who tend to be more in in the north of England live in Scotland tend to be more likely to suffer vitamin D deficiency they might benefit and so widespread use might be indicated but it's not it's clearly not very important now what about vitamin D and calcium after menopause anyone know anything about that sf5216: well most women seem to be recommended to take it by their GP so i assume there's probably an evidence base nm5197: either that or a very strong pharmaceutical benefit to the pharmaceutical companies now actually there is quite good evidence but you should always think about that why would lots and lots of people be prescribed something is there good evidence to support that i mean many example of such mass prescribing that are not supported by good evidence but in this case there is reasonably good evidence that in this country again er women post- menopausally can benefit from vitamin D and calcium but the benefit is very small and so there's a massive prescribing going on for a very small benefit and the reason for that again is most people have an excellent diet but we're now talking about elderly people who were young and therefore at their peak bone mass often in around about the war years when diet was very poor and those people often had a low peak bone mass so they're more at risk so a small benefit in people at higher risk is worth having more than a small benefit in people at low risk we've done a bit of statistics haven't you you don't want me to talk about that do you but it that's the sort of time when thinking about relative risk and risk reduction and absolute risk reductions it starts to get interesting and that's where you'll need to remember all that statistics when you're working as a GP you start to answer the question should i prescribe this treatment routinely in my post-menopausal ladies sf5214: i can't remember what your list was for risk of falls but the same consultant that was giving a lot of vitamin D and calichews also on polypharmacy and he considered that did you ever come across this if a patient is on three or more drugs that's considered a risk of falls sm5198: sorry you were talking about the risk factors like on the vitamin D and calcium you're not talking about the thyroxine and the sf5214: not in terms of not on a biochemical level or any well in terms of her bones at all but sm5198: which which drugs are you talking about specifically then sf5214: any drugs just that if anyone's on any drug more than three drugs it's considered at risk of falls su5219: is it is sm5198: i just heard about cortical steroids i didn't really sf5214: yeah a-, any drug any sm5198: i mean obviously in this sorry to cut you off sf5214: no no sorry i'm sm5198: in in this case you have treat her known hypertension and her hypothyroidism you can't just completely ignore that can you and by correcting the er those problems she's less likely to have a fall on the long run sf5214: yeah i just wondered if you came it all in your reading that sm5198: no sf5216: is it clear which direction in whether it's that that predisposes people to falls or whether it's the people who are taking who are needing that many drugs are also more likely to fall because they're iller anyway sf5214: well yeah but this i mean he would literally walk round the er the bays and slash drugs off su5219: right sf5214: off and then the next doctor would come along and put them all back on again thinking about that but yeah and then he would just stroke them off sf5217: i don't know about all of the drugs on the list but the anti- hypertensives can make you dizzy can make you hypertensive sm5198: i think it's difficult to actually tell if it's an iatrogenic cause of a fall of whether it's been caused by the underlying hypertension or whatever else the underlying pathology that's there i don't think you could really tell that nm5197: so let me just explore that for a moment er you're asking whether the fact that she's on six drugs or thereabouts is itself a cause sf5214: a risk nm5197: of her falling sf5214: of her falling nm5197: and that might therefore cause her to have a fracture sf5214: yeah nm5197: yeah and er between you you explored two possible scenarios either that is the case that the drugs themselves are causing her to fall and we've had some suggestions as to how drugs like anti-hypertensives might actually do that by making people dizzy or whether the fact that a person is on lots of drugs is a marker an indicator of the fact that they've got lots of physiological disease and therefore they might fall in that second situation what would you call all those diseases that they've got ss: co-morbidity nm5197: co-morbidities yes and you'd call them something else if you were thinking of what this association between having lots of drugs and falling might reflect su5219: compounding nm5197: okay someone's got it compound that's what i'm getting at yes so there are two possibilities you've got an association between having lots of drugs and falling then it may that there's a causal relationship between those that the drugs cause the falling and that would be very interesting because then if you could take some of those drugs away in other words be the doctor who slashes them out then maybe you'd stop the falling occurring on the other hand it may be that something you haven't thought of like a whole bunch of diseases are confounding factors and they're associated both with having lots of drugs and falling if that were the case then crossing out all the drugs won't get rid off the falls it won't reduce the falls and so the reason that i bring that up is that we're talking here about risk factors and whenever we talk about risk factors it's worth you thinking about how did anyone figure out what a risk factor was for a fall and i can tell you the studies you're talking about er describing on falling have been done by looking at large numbers of people and measuring the fall rates in groups of those people and then trying to find differences between those groups and if you find the difference between people who have less than three drugs and those who have more than three drugs in their prescription chart then you might say ah there's a association between polypharmacy and falling but then you always need to think as doctors and scientists you always need to think is that association causal or is it a reflection of confounding by something that the investigators didn't think about and it's when you think like that that you'll know whether it's right to be the doctor who slashes the drugs off the drug chart or whether it's right to be the doctor who goes around and treats each of the possible causes i don't know what the answer is maybe one of you will figure it out because i can tell you no-one knows the answer to that question at the moment okay i want to ask you a question Tim you showed thirty per cent risk of fracture in this lady in one of your graphs can you put that graph up again that's great just tell us what that thirty per cent risk is what do you mean by that sm5198: she's got a thirty per cent chance of having a another hip fracture specifically hip fractures nm5197: do any of you want to ask him any questions about that sf5214: is that in a long time or in ten years one year sm5198: in her lifetime i assume nm5197: no i think actually those numbers that you're looking at are risks per year and an eighty-five year old lady who has that bone mineral density which is extremely low does have about a thirty per cent risk of having a hip fracture in a year she doesn't have to have had a risk a hip fracture already in fact having had a hip fracture and having it fixed halves her risk of having a hip fracture because she's only got one hip now to fracture because the other one's been fixed with a metal plate that won't break so in fact if you go out into the population and measure bone mineral density then you can plot graphs like this of risk per year of having a hip fracture now we've got how many people in this country ss: sixty million nm5197: about sixty million a bit less and er lot of them are old er you know what the demographics look like probably but there's lots of old ladies among those fifty-nine million if i were to tell you there were about a hundred and fifty-thousand hip fractures a year in this country that won't come as a surprise to you when you've seen those sorts of risk rates that's more than the knee replacements and hip replacements done in total in this country every year in fact it's about double those so hip fractures and hip fracture treatment are exceedingly important and internationally in this present decade of the bone and joint as it's called there's a great deal of interest in osteoporosis associated fractures and hip fractures are perhaps the most important of those and the World Health Organisation sees hip fracture or perhaps more generally osteoporosis associated fracture as the most pressing public health problem in the developed world for this decade and i tell you that because hip fractures aren't very sexy they're not really that interesting to surgeons and er people like me who are happy to fix them but we don't really get that much involved in the patients and in the etiology of that disease and in thinking about prevention but some of you may be interested in doing that and i think the chap that you mentioned who chased around with the calichew he's really onto a winner there there's an enormous amount of work to be done in improving the health of our population by thinking about osteoporosis related fractures i just want to ask you one more question er osteoporosis you gave a definition can anyone remember it now don't be shy i gave you a definition just a few moments ago sf5204: decrease in bone mass due to changes in the balance between er bone formation and bone destruction er leading to changes in the bone architecture nm5197: okay good lots of lots of right things in there i want to pick out just the very last thing you said about architecture now what's that what does that mean not you but someone else any idea you heard Tim talking about bone architecture you've just heard it again what's that all about then sm5212: is it that there are thinner trabeculae or something nm5197: yes so here's a bit of bone can you switch this can i have the er visualiser on please okay this is a bit of bone if you could look inside a bone which part of the bone would i be in here su5219: spongy bone nm5197: spongy bone yeah or another word more Latin su5219: trabecular bone nm5197: trabecular bone okay that's as compared to what sort of bone ss: cortical nm5197: cortical bone so whereabouts in your body is some cortical bone just show me a bit everyone show a bit of cortical bone come on guys you've got a whole body full of it here show me some cortical bone where have you got some where have you got some cortical bone su5219: i've no idea su5219: it's the outside of every bone isn't it nm5197: anywhere sf5205: yeah all bones su5219: skull nm5197: er yes er skull's not a very good example actually the really good example of cortical bone is the tubes of bone in your long bones so your femur femoral shaft tibial shaft the shafts of your long bones in you arms there are all cortical bone so what about trabecular bone where's that nm5197: sorry whereabouts nm5197: you don't know okay anyone else su5219: cortical bone sf5205: it's the bit on the outside isn't it nm5197: right on either end of the long bones yes er and also some bones are almost entirely made of trabecular bone actually the vault of the skull is mostly trabecular bone er and er where else is a good trabecular bone the body's of the vertebrae most of the pelvis that's mostly trabecular bone so this would be some trabecular bone and we'd looking down at what sort of scale how wide are these trabeculae what's the distance from there to there nm5197: you've done a bit of bone histology have you have you ss: yeah nm5197: so these are fairly straightforward questions really where's trabecular bone and how wide's trabeculae er how wide is it give me a guess go on nm5197: say again nm5197: i'm sorry sf5205: point one of a millimetre nm5197: point one of a millimetre a bit big nm5197: yeah they're only they're only in the sort of er ten to a hundred micron range so getting up perhaps so let's say that's about ten microns wide er and there's lot's of space in here in fact most of trabecular bone is just filled with space er filled with air su5219: no nm5197: no okay it's filled with air in the dry bones you look at what's it filled with in life nm5197: bone marrow which has got all sorts of good stuff in it and er you will have some of you seen bone marrow samples being taken what does it look like when it comes out has anyone seen a bone marrow sample done nm5197: anyone no-one's seen that okay you need to look out on a haematology ward it's commonly done it looks like blood with lots of fat in it so there's lots of fat in here lots of cells and a lot of blood in there and remember that's where a lot of the er synthetic activity for the haematological system goes on so in osteoporosis what happens is these trabeculae get thinner and your colleague i'm sorry i don't know any of your names was describing how that happened it's because this bone gets removed more quickly than it gets laid down and it gets very thin and then eventually some of the trabeculae actually lose bits of them so this trabecular here say which is going between here and here it might thin down and thin down until it ends up just being like that now that's a discontinuity in a trabecular how useful is that to you that trabecular how useful is it now nm5197: that's completely useless it might as well not be there because it can't work as a strut to resist compressive forces which is what the trabeculae do so in fact you can still have this bit of bone here but it can't do anything at all so osteoporosis is about losing bone mass so there's less bone and that's what we measured on those graphs but it's about much more than that it's much more complex than that it's about the bone being lost from particular places it's being lost from the sides of the trabeculae and it's increasing the number of trabeculae that are discontinuous and that's why these graphs look so dramatic because if you lose a certain amount of bone mass take it away take it away and it's not until you actually make those trabeculae discontinuous that it stops working and then you're going to fracture more easily so that's a bit about osteoporosis let's move on any final questions for Tim before he sits down one more thing i want you to do have a seat Tim is er i want you all to get a bit of paper and er draw on the bit of paper have you all got a piece of paper everybody draw on the piece paper a picture of a hip i'll only give you about twenty seconds so get cracking to help you i've drawn one here so you can just copy that now i'm a surgeon and i'm an orthopaedic surgeon and er i'd have to say that i a little bit when i detect Tim's er er how should i put this er er lack of respect for anatomy Tim clearly doesn't think that anatomy's very important er or indeed a subject that any of you should know anything about so i'm going to show you why Tim really did need to know about anatomy in order to know anything about how this patient was treated and how the surgeons if they hadn't done this bit of anatomy would have completely screwed up the manage of this patient and you'll see why that term's particularly relevant in a moment so er here we go here's a picture of a hip what's this bit called ss: acetabulum nm5197: and this bit ss: femoral head nm5197: and this bit ss: femoral neck nm5197: and this bit ss: greater trochanter nm5197: and this bit ss: capsula articularis nm5197: and this bit ss: shaft nm5197: so someone said intertrochanteric fracture earlier on what does that word mean ss: between the nm5197: and so a fracture that goes like this would be an intertrochanteric fracture okay er Tim reckoned that that patient that we just looked at had a subtrochanteric fracture so where would that fracture be nm5197: so down here somewhere okay and er another term that's often talked about is a subcapital fracture what would that mean nm5197: so that would be usually in the neck about here somewhere so they're three pretty common hip fractures this one actually the subtrochanteric is quite rare in comparison and these are roughly equally common er these ones usually occur when people fall down and land on their hip as our lady here did and these ones usually occur spontaneously so they're just walking along and all of a sudden they fall down because their hip breaks and these ones are much more associated with osteoporosis than these so this is the the way that those patients with discontinuity of their trabeculae will probably get a fracture be walking along one day and their hip will break and that will cause them to fall now let's just focus on these two for a moment so on your diagram show me in some way the blood supply of the femoral head i'll give you a few seconds to draw that and then once you've drawn it you can come and show everybody what you've drawn nm5197: okay er who'd like to come and show us what you've drawn come on i don't want to pick someone let's have a volunteer yeah come what's your name sf5205: nm5197: okay show us what you've drawn sf5205: nm5197: have you got a drawing sf5205: sorry nm5197: have you got a drawing sf5205: er yeah nm5197: bring it with you go on show us on the er on the demonstrator sf5205: on this thing nm5197: yeah sf5205: er there's one here to the head of the femur and er the medial circumflex femoral artery i think comes round here nm5197: that's brilliant okay have a seat thanks okay Tim let me see yours you're the anatomist sm5198: the medial circumflex artery goes round here and then the two arteries bunch up into the femoral neck into the femoral head nm5197: good and what about the one that er showed coming in from the medial aspect sf5206: that's obliterated at the back at five years old nm5197: say that again sf5206: that's obliterated at about five years old and then it becomes a ligament at the head of the femur nm5197: yes so there's a ligamentum teres which is the ligament between the acetabulum and the centre of the femoral head and in children there's a little blood vessel in there actually in children it's quite a big one and an important one but in adults it it does get much smaller and is probably not very important in most elderly people you're absolutely right so Tim who was pre-warned had drawn some blood vessels that came up here and supplied the femoral head and er actually they're plastered down on to the neck of the femur there what would plaster them down nm5197: not the capsule because the capsule of the hip joint would be like that and so there's a a potential space there with a little bit of synovial fluid in it so they can have that part plaster those down on to the femoral neck su5219: is it the periosteum nm5197: periosteum what's periosteum sm5203: it's er nm5197: it's the bit that plasters down the blood vessels so it's er it's the material which is all over the bone er but that's actually quite thick usually er in the er around the femoral neck and doesn't go any further than that why not nm5197: say again su5219: because of the articular surface nm5197: yeah because there's an articular surface here of hyaline cartilage so er runs over the femoral er neck on either side er all the way round and is plastered down onto the femoral neck and that holds those blood vessels onto the femoral neck now apart from this little teeny weenie blood vessel that maybe is there er in adults but probably not in most adults essentially there's no other blood supply to the femoral head than these ones that are coming in here now that's actually quite an unusual situation isn't it because if we think about your hand for example its blood supply is er there there are various bits to it so tell me about some of the blood supply to your hand ss: radial artery nm5197: the radial artery that's coming down on the radial side ulnar artery over here they they come together in anastomosis in the centre and there's a whole bunch of little vessels under the skin er all around the wrist so that even if you lose both the radial and the ulnar artery there's still a potential for some supply to the hand so you've got lot's of options for how you get blood supply to your hand but in this sort of situation if the patient has a fracture which runs across there you can see how all those blood vessels that are plastered down onto the femoral neck would be ruptured by such a fracture and then what would happen to the hip nm5197: it would die and that's called avascular necrosis and in those circumstances this head would be no use at all because it's all going to die and fall to bits and so that patient would need some sort of hip replacement and who was the hip replacement guy so that's the answer to your question there but what about if the fracture was here would the blood supply be disrupted ss: no nm5197: no it won't because the blood vessels come in from here and then ru-, run up the femoral neck and the fracture down here just the same that's not going to disrupt the head so it's possible for the surgeons to fix this with a screw device that held it all together and they can expect this bit to have a good blood supply and this bit to have a good blood supply and therefore here and that's what should happen in our patient here and clearly if they've not understood that they hadn't understood how the blood supply works then they wouldn't be able to choose which operation to do and so assessing this person's fracture involves thinking about not just what you can see on the X-ray of a broken bone but thinking about the anatomy which may have been disrupted and that brings us on nicely to our second case who's going to begin okay go ahead can we have the off please sm5199: okay so our clinical case presentation is on multiple trauma Adeline and i spoke to Mr H who is a twenty-two year old army tank operator er who has no significant previous medical history that i need to tell you about at the moment er he's a motorcyclist er and he had to er effect a sudden deceleration when he was driv-, er cycling along er which apparently if you do it too quickly on a motorbike you're going to fall to one side or another he was unlucky and fell into the oncoming traffic on the other side of the road and was hit by a van er he actually rated his pain on the impact as only six out of ten and compared it with when he broke his arm as a young child er he he said the pain was actually worse when he was just lying in bed in the rehabilitation ward er than it was when the accident actually happens which i thought was quite interesting er pre-hospital er management when the ambulance crew arrived on the scene er was purely moving him onto a spinal bed and er giving him analgesia and a leg splint before bringing him into hospital er when he came to A and E er the primary survey of A B C D E which is probably familiar to a lot of people was er performed his airway and breathing were non-compromised circulation wise he was tachycardic he was pale and he had er a borderline impaired capillary refill which are signs of hypovolaemic shock which we might talk to you about later if you're lucky er disability wise his Glasgow coma scale was fifteen throughout fifteen out of fifteen and then the er er hospital staff moved on to exposing to look for further injuries er and this secondary survey revealed a continued hypovolaemia er substantial perineal laceration and bruising which apparently er the perineal area is one that's very easy to overlook when you're assessing trauma cases er and he also had suspected damage to his pelvis and his left leg so he was zoomed off to CT which gave this groovy picture er which er i've been asked to ask you to tell me about anybody er there's two main things really i think compare the left to the right sm5199: anybody want to tell me su5219: is it a comminuted fracture of the left er anterior superior aspect sm5199: er i don't know whether it's comminuted or not but there's definitely a fracture there yeah er it was s-, severe disruption to er the left sacroiliac er joint in fact and apparently there's er some lesser damage to the right one as well there's also er at the front disruption of the synthesis pubis er nm5197: let's just er nail this word comminuted what does that mean su5219: in loads of pieces nm5197: right so that's a that's a sort of big word really but i think it's just about confusing patients because i don't think we use that word in any normal life and you might as well just say lots of bits or multi fragmentary or smashed to smithereens almost but er comminuted is a word that doesn't really mean anything extra which is i think is why there is a little bit of uncertainty between you as to whether it was comminuted or not so even among doctors people don't really know what it is er general point try to use the simplest word that will address the situation nm5197: er i understand you won't always be taught the same things by your teachers you need to get used to that but i would sm5207: nm5197: say that again sm5207: you go into hospital nm5197: oh no not at all i mean er i work i work with sixteen other orthopaedic surgeons and i would think that er three-quarters of them would use the word comminuted routinely every day but some of us don't think it's a very useful word and i'm alerting you to the fact that in your practice when you become doctors you will need to think about what sort of language and on the whole the simplest language that conveys the message is the right thing to do but you'll therefore need to think about everything you hear not just now but throughout your working lives and think what does that really mean does that actually convey anything to me other extra to some straightforward word and you'll find that some doctors are dreadful at this and they will use highly complex words for no good reason at all and you'll find that other doctors er will rebel against that and use very straightforward words and you need to find your own place in that what i'm saying to you is think about it a bit don't be surprised when your teachers use take different approaches to that and you need to work out what yours ought to be sm5199: thank you er after the CT was performed he was taken straight to theatre and for those bud-, budding surgeons among you they sliced open his tummy er they found significant retroperitoneal haematoma er bleeding into the abdominal cavity er severe disruption of the pelvic floor apparently his er er rectum had become completely dissociated from the supporting structures but other than that there was no major other major pelvic or abdominal damage his livers his kidney his spleen were all still intact er while he was still on the table er further surgery was performed to find er to fix the bits that they'd found that was wrong there's simple language for you er so they sutured the er mesenteric er artery they found that had caused the majority of the bleeding er they gave him a colostomy to defunction the damaged lower bowel er they also inserted a suprapubic catheter because with disruption of the synthesis pubis there's er a large chance for er er laceration of the urethra so they decided to put a catheter in they packed the perineal wound and er they fixed the pelvis externally as well er i've got a nice picture of that er this is indicated again where the synthesis pubis has been disrupted to stabilise the pelvis and stop the two halves rubbing together to cause more damage and now purely because we're half way through the talk i'll hand you over to Adeline sf5200: thanks okay right so they then went on to take a look at the damage to the femur and saw that there was a closed transverse fracture to the shaft of the femur and because it was er because he was actually suffering from multiple fractures this was an indication for stabilisation with surgery rather than er simple plaster of paris so a nail was inserted and this is an X-ray of the fracture to the femur the er i think i'm going to be ask some questions about this in sec but first just to say that the sciatic nerve was left undamaged and as you can see there was obviously no damage to the joint and both of these indicate a better prognosis than if either of those had happened sorry did you want me to stop this so you could ask some questions nm5197: no carry on okay sf5200: okay right as you can see he was given quite a bit of blood products while in surgery to combat the hypovolaemia that he was suffering and then post- surgery over the next week or so he was er he was weaned off the ventilator which i've heard can actually be quite a traumatic process and he was treated for a left sided pneumothorax which was discovered on chest X-ray rather than actually clinically he developed a spiking temperature and MRSA was er cultured from a throat swab and Candida from his central line and he was treated accordingly by isolation antibiotics and antifungals he was then moved to Coventry and Warwickshire for their expertise in pelvic repair and here he initially er underwent examination under anaesthetic and this perineum they removed the stabilising bridge that had been put in place previously not because it was no good but because it's not a permanent procedure and they replaced it with something more permanent er fixation with a screw which actually went from the ileum through to the sacrum er to stabilise the sacroiliac joint which was the site of the ma-, the major injury they also removed quite a lot of necrotic tissue from his buttock muscles because obviously he was at risk of infection from that then during the next couple of weeks he made a number of trips to the theatre er of which i think Macbeth he particularly enjoyed and less enjoyable er was the further tissue removal from his buttocks and thighs the colostomy er examination which then revealed that yet more er skin and tissue had to be removed they re-dressed the wound er on a separate occasion and a skin graft was performed to replace some of the tissue which had been the damaged tissue which skin which had been removed earlier just very quickly er i'm going to mention some of the possible long term complications i don't really need to go into these in detail because you're probably quite aware of them physically the the most obvious is the mus-, musculoskeletal damage which if if we're not careful with his er rehabilitation could lead to long-term immobility and disability the genitourinary and GI complications as yet aren't particularly clear and probably won't be until they reverse the colostomy et cetera and then of course there's the er possibility of social and psychological complications things like anxiety and depression are very common in this sort of situation and so er we've split the rehabilitation up into surprise physical social and psychological and again you kn-, you all know about physiotherapy occupational therapy walking aids et cetera socially good communication with his family and employment er his employee employer's particularly important so that he can get back to if possible the work if not the work he was doing before as close to it as possible and evidence had shown that er a more psychological base to rehabilitation is of benefit one last thing to mention that i think's important i've sort of noticed while in hospital not just looking at this case is the two extremes of patient attitudes following something like trauma er at one extreme you have the sort of patients who really want to hand everything over to the doctors and don't want that that much involvement in their care they don't want to take it on board and at the other en-, the other end you have those who really want to be empowered and want to do as much as possible for themselves and i think from speaking to him although at the moment he's still in obviously quite a state of shock he seems to fall into that end of the spectrum and he's a pretty motivated individual and that obviously bodes very well for his recovery okay thanks nm5197: do you have any questions sf5218: how can you wean somebody off a ventilator sf5200: i think it's er yeah an unnecessarily complicated way of saying take it out and see if they can breathe without it or take it off see if they can breathe like without it on but the but now er i think there's a more sophisticated type of ventilator which er is able to respond somewhat to the er i'm not sure of the name of it but it's able to respond to the amount of breathing that the patient can do and yeah respond accordingly so the ventilator is in a sense telling what the patient can do and not taking too much away at once am i right er yeah nm5197: yeah that's a good description sf5200: but i think that's quite new and not all ITU's have them i don't think but as far as i know anything else sf5208: i was just wondering about the if had quite a significant amount of tissue damage due to the fact i guess the fact he and that sort of thing that went on for him i mean i'm assuming that because of the multiple trauma he's unable to move himself and and they're afraid to move him because of any more damage and because he's had this bridge what sort of things can he do to avoid tissue damage like that because i mean sometimes they have these mattresses that you know that they're er to avoid but i'm assuming that you couldn't replace them with those and that's how he got this tissue damage sf5200: i think a lot of it probably er occurred around the time of the injury but sm5199: er i also think that the presentation probably gives a bit of an exaggera-, because he went back for further debridement and further debridement it we didn't actually write down how much was taken each time so it could of just been a little bit each time certainly the photos er of sur-, the surgery that i saw in his notes er there weren't great big areas hacked out of his buttocks at all [laughter] it er it did look er like quite a lot of tissue was still intact so i i i don't think the tissue damage was as major as possibly the presentation made out er sm5209: was there any grafting done to the buttock tissue or i mean some muscle was er removed as well so how did they rectify that sm5199: again i don't think they took away enough to be to give a significant loss er but don't quote me on that one sf5200: no all that was mentioned in his notes was that he had a skin graft and he was pretty unaware of exactly what had been done and he's a little too shocked to really take it all on board and ask too many questions at the time so he hadn't really asked the doctors for details of his injuries nm5197: see about half of the muscle here has gone a little bit more than half maybe two-thirds which muscle is this nm5197: gluteus what sorry sf5200: medius nm5197: gluteius medius good yes so where's gluteus maximus everyone stand up put your hand on your gluteus maximus nm5197: right round the back here the gluteus maximus is the back part of the buttock and most of it's comes off the sacrum and most of it's sf5217: can i just ask he was on a motor bike wasn't he nm5197: yes he was sf5217: was he wearing motor cycle leathers and do they actually make much difference to whether he'd lose much of his bum or not when he's skating along on it sm5199: i don't know whether he was wearing leathers or not no su: i can vouch for the fact they do make a big difference i mean i don't know about in his case but yeah i've come off motorbikes and they make a very big difference yeah nm5197: i think that's certainly true they definitely an enormous difference er especially if you see the leathers after the accident when someone has had an accident they've been going sixty miles and they've come off their bike and they're skidded along the road you look at their leathers afterwards you realise how they've benefited from their skin not looking like their leathers in fact this chap's injury was primarily caused by him being run over it wasn't the fact that he came off the bike that did him much of the damage he was actually driven over by a large truck and the truck came diagonally across his body er that side so it came one of the sets of wheels came between his legs ss: oh nm5197: across the middle of his pelvis and came off over here and you could see when he first came in the tyre tracks ss: oh [laughter] nm5197: and er because the injury was actually therefore caused by pure crushing and that's what damaged the muscle on the side and that muscle was just killed its there there was nothing that could ever be done about that because he was going to lose that sm5209: er his rectal muscles were completely removed from the surrounding structures and he was on a colostomy i-, is there surgery that can repair that so that he won't have to be on the colostomy long term nm5197: er yes but let's go back a few steps so he'd been crushed and he'd lost about half two-thirds of the gluteus medius so what sort of functional deficit might he experience ss: adduction nm5197: he's going to lose adduction so how will he notice that what you can be sure of is he won't come into the clinic and say doctor doctor i've lost my adduction power how would he complain what would he say nm5197: so what would he complain of nm5197: he's on the end of the phone now and he's trying to describe to you what the problem is what would he say su5219: can't walk properly nm5197: can't walk properly okay what happens when you try to walk sf5216: he won't be able to support himself on one leg nm5197: now that's exactly what he won't be able to do he can't stand on one leg because if he tries to stand on his left leg he hasn't got enough adduction power he can't tilt his pelvis like this to bring his centre of gravity over that one leg and so when he tries to stand on one leg his weight will still hang over to the right side and he'll fall over so he won't be able to stand on his left leg and when he walks every time he's in the stance phase on his left leg he'll be falling over so as he walks he'll do something like this okay so he's going to have a functional deficit and there's not much we can do about that but what we're trying to do is just to get his pelvis sufficiently reconstructed thank you very much get his pelvis sufficiently reconstructed to make it work later on okay let's talk a bit then more about the injuries can you get back to his er his initial X-ray great so have a look at this and er here's a pelvis which you can compare with that one that's er a reconstruction from the CT scan and he's got er a lot of fracture around here a multi fragmentary fracture in this area this side of his pelvis this of the ileum is just smashed into lots of bits but that's not really a his big problem although that reflects how much damage has been done there and hence why gluteus medius was so crushed his big problem was that his whole pelvis was completely disrupted it was taken into two pieces one bit went that way and the other bit went that way when the tyres when over the middle and it separated here what structure is this ss: sacroiliac nm5197: sacroiliac joint and here nm5197: right and in fact we know that this part of his pelvis went backwards with respect to this part as well now that's actually quite a technically difficult problem for us to manage but what you need to think about just now when you first see him is what are the implications of that that's what the picture looks like but what will that mean so what sort of big stuff is in here that might get damaged when the bones do that sort of thing nm5197: his bladder okay where's his bladder nm5197: okay it's about here sitting behind the synthesis pubis and you can imagine it when his bladder fills up it comes up like this and his urethra is at the bottom of the bladder and comes down between the two rami of the pubis and that's why his urethra was damaged and that's why he had to have a suprapubic catheter okay what er other big stuff's in here no we're not talking about here we're talking about matter su5219: intestines nm5197: intestines yeah lots of intestines all wriggly stuff in here lots of intestines any of the intestines damaged nm5197: what did you hear in the presentation su5219: his rectum was damaged nm5197: his rectum was damaged actually his rectum was damaged right down here where he had a great big wound where his pelvis had sort of been not just the bone of his pelvis but the whole soft tissue structure had been split so a great big wound down here which went into his rectum so that was the damage to the rectum what about further up here i think Adam mentioned it in the presentation su5219: mesenteric vessels nm5197: mesenteric vessel so one of the mesenteric vessels what's the mesentery su: something that suspends the colon into the rectum nm5197: okay so there are there's a a thin relatively delicate structure which joins the whole bowel the whole length of the bowel onto the back of the abdomen onto the retroperitoneal area and all the blood vessels which supply the bowel come from the back there and so they're thin relatively fragile structure the mesentery's got lots of mesenteric vessels in it and one of those was ruptured so he was bleeding from that and that required surgery and we've heard about that during his abdominal surgery what else is in here su5219: aorta nm5197: aorta yeah aorta where does the aorta stop how far does it come down nm5197: someone L4 T10 nm5197: about T10 and it's at the level of the so it's up here somewhere so down in here there's not really any aorta but what are the two big vessels that come off the aorta ss: iliac nm5197: the iliac arteries and then subsequently the external and internal iliac arteries and where do the external iliac arteries go into the nm5197: they become femoral arteries and go into the leg so where are they on this model they're lying over here like this and each one's about the size of my finger so big vessels and you can see how maybe some of that disruption you can see on the left hand side might be getting quite close to where the femoral artery is on the left okay what else the internal iliac arteries where are they nm5197: they're in here they're in this space so they're winding around in here and the internal iliac arteries are not much smaller than the external they're really quite big structures and what runs along beside them su5219: veins nm5197: veins what are they called nm5197: the iliac veins the internal iliac veins it's easy isn't it and the arteries are sort of stretchy they're very elastic so if you take the pelvis and go like that the arteries stretch out and it's quite difficult to injure them the veins are not like that at all they're very very thin walled structures if you do this they will just tear and so the veins are all lying in this sort of place on the side big ones where they come off the er er before they before they join the to form the inferior vena cava and these veins are therefore right in front of where the sacroiliac joint disruption is can you see it on that picture by the way where it says degree there's a whole bit of bone missing because that's all gone backwards the sacroiliac joint's completely disrupted and so those big big veins have very very likely been damaged in here and many other structures as well now did you get the impression that he almost died or did he come through this no trouble at all sm5199: stiff upper lip and all that nm5197: stiff upper lip sm5199: yeah er i never got the impression that he almost died did you sf5200: some well if i'd just read his notes i would have thought he'd come pretty close to death but from speaking to him i didn't get that impression he he didn't sound like he thought it nm5197: that's interesting how much did he know about what was going on when he was initially being resuscitated sm5199: not much nm5197: no quite a long time ventilated and sedated in the intensive care unit so he probably doesn't remember any of that so in fact i can tell you that he did almost die and we'll see a few bits of direct evidence for that in a moment but lets go back a little bit er to some of the things we were thinking about with the lady who had the hip fracture we talked about her being elderly female white we talked about bone mass we talked about osteoporosis so what sort of risk factors did this chap have for trauma ss: motor bike nm5197: rides a motor bike he's a young man young man sf5218: speed he was travelling nm5197: say again sf5218: the speed he was travelling nm5197: er yeah and how fast was he going actually in fact he could have been going very slowly couldn't he because er his main injury was being driven over su5219: his occupation nm5197: what's his occupation su5219: tank operator nm5197: no he's a soldier so he's a sort of rough and ready sort of chap i can say that because i was in the army too what else what other risk factors might you be interested in maybe you'd like to ask the chaps about them sm5210: they said there was no relevant past medical history nm5197: no past medical history what what would be relevant sm5210: depends whether or not there's systemic illness so if he was diabetic or nm5197: a bit more broad su5219: psychiatric nm5197: psychiatric history certainly what about previous trauma trauma is a repeating disease my best is a patient who was shot five times on five separate occasions right on the third occasion when i saw him he was shot in the heart he had a bullet that went right through his heart we managed to keep him alive he survived i then saw him two subsequent times having been shot again on two separate occasions this is a person who got shot five times to my personal knowledge i don't know whether he's still alive or not but trauma is something that happens to people again and again and i want you to think around the idea that this is a disease it's not an accident it's not just hard luck some people are trauma patients they get it in the same way that some people get hip fractures some people get run over by trucks and the people who get run over by trucks are young men who are physically active and often have a particular sort of er er maybe we'll call it outgoing but it might be aggressive er personality they're people who get involved in activities which are more likely to result in injuries and some things you haven't mentioned at all they're people who drink they're people who take drugs they're people who are antisocial in their behaviour these are trauma victims and just the same way that not every person who gets a hip fracture is a little old lady with osteoporosis not every person who gets run over by a truck is in like this but you can categorise what these patients are like and think about the epidemiology of trauma in just the way you can think about the epidemiology of pneumonia okay er these patients who get trauma as a disease what kills then su5219: infection nm5197: i want you to think of the most common cause of people dying from trauma in this country su5219: infection nm5197: so a few possibilities infection is not the right answer su5219: shock nm5197: shock is not the right answer su5219: hypoxia nm5197: hypoxia yes talk about about that a little bit more sf5217: well the breathing or circulatory failures then they won't get enough oxygen to the brain and they'll die nm5197: yes that's not really hypoxia although that would be a cause of everyone dying really not enough oxygen in their brain but er i think you're on the right track but it's a little bit more straightforward su5219: airways nm5197: yeah most people die as a result of trauma from airway obstruction so of the people who have trauma and die it's airway obstruction that's the most common cause i'll tell you a little story one of my colleagues a consultant orthopaedic surgeon very famous scoliosis surgeon working in Oxford was killed when i was a medical student in Oxford and er he was killed in pretty similar circumstances really he was on a push bike and was run over by a er bus and er the bus didn't actually do very much damage but he banged his head on the road and so he was a bit concussed and he was taken by an ambulance to not the nearest hospital but the hospital that happened to have a C-T scanner at the time and on the he was taken there because a junior doctor jumped in the ambulance and said ah this chap's got a head injury we need to take him to a C- T scanner and in fact er he died when he got to that hospital because no-one thought about common causes of death they were all thinking about what was going on inside his head and he died on a trolley in the accident and emergency department because no-one thought about the fact that he became unconscious because he had a head injury and he developed respiratory obstruction and he died so airway obstruction commonest cause of death in people who suffer injury in this country second commonest cause su5219: blood loss nm5197: bleeding exactly could you just talk about hypovolaemic shock sm5199: yeah okay it's only quick i think and i wasn't expecting this er er hypovolaemic shock you're losing blood volume er which gives you a fall in venus pressure and therefore reduced cardiac output er your arterial pressure will also fall er it's detected by your baroreceptors which er increase your heart rate er and as a result of that your total peripheral resistance raises as well in an effort to get the cardiac output up and er also venoconstriction but er obviously the main er way to treat it is by replacing the volume that was lost and is there anything else you want to know nm5197: no that's fine any questions sm5199: good nm5197: so er when er do sit down Tim when someone takes a blood sample with a syringe er we lose some volume there does that person develop hypovolaemic shock ss: no nm5197: why not sm5213: does it have to be more than seven-hundred and fifty millilitres nm5197: how much su5219: is it seven-hundred and fifty millilitres nm5197: eh er so what we're saying is that there's some sort of threshold once you've lost more than a certain amount of blood you're going to develop hypovolaemic shock which is in a sense a disease isn't it caused by bleeding some people are going to be able to respond their haemostatic mechanisms will be more effective than others what sort of people are likely to have relatively ineffective haemostatic mecha-, mechanisms nm5197: elderly people yeah nm5197: say again sm5203: people with kidney disease maybe nm5197: yes that's usually not much good any way what else nm5197: children yeah children don't have very much reserve so they can lose a small amount of blood and be very severely affected so how much blood did this guy lose nm5197: what what was the answer su5219: we don't know nm5197: oh we don't know how much does he have replaced nm5197: seventeen units how much is a unit su5219: five-hundred mils nm5197: five-hundred mils okay and how much blood's in his body to start with nm5197: five litres okay so he's er er had replaced how much in total nm5197: eight and a half litres okay so we don't really know how much he lost exactly but we do know that by the end of it he had another eight and a half litres put in so unless he's become very very big then probably he's lost something in the order of except it's not an exact match it's something in the order of one and a half blood volumes now that's an enormous amount that's a gigantic amount if i put seven er eight and a half litres of blood on the floor here we'd be awash with blood it's a gigantic amount of bleeding and a large proportion of people who lose that much blood will die just from the fact they've lost all that blood even if you replace it complications of the losing of the blood is enough to kill you so in fact he did come very close to dying with regar-, regardless of anything else just because of his blood loss now let's think a little bit generally and he'll be a good example here where do you think people can lose blood after major injury sm5211: where where to nm5197: yes where does blood come from sm5211: from the bones nm5197: from bones okay so he had some fractures so he had a fracture of his femur and he had a fracture of his pelvis so talk about the pelvis in a minute but the long bones the femur the tibia the arm bones these can all bleed quite a lot and big amounts of blood can be in the cavity around that bone er femur for example easily fit two litres of blood in your thigh around your femur so a lot of blood can be lost there pelvis he had a big fracture of his pelvis you you'd expect him to bleed from the fractured surfaces but much more importantly is the bleeding from those blood vessels that we talked about where else su5219: into the abdomen nm5197: into the abdomen he was bleeding into his abdomen he had a mesenteric vessel rupture so bleeding in the abdomen su5219: wound onto the floor nm5197: good onto the floor and it doesn't matter how it gets out but somewhere onto the floor and probably quite a lot of blood was left on the road in this case so somewhere out in Worcestershire there's a very bloody road and that bleeding could be left at any point along the track and usually some everywhere so you leave some blood on the road leave some in the ambulance leave some blood in the A and E department floor leave some blood in your clothes leave some blood in your car blood gets left in lots of places where else su5219: intracranially nm5197: inside your head how much blood can you lose inside the head su5219: probably not a lot nm5197: yeah i mean about er two-hundred mils will kill you because of the pressure effected that volume of blood if you you bleed quickly into you head like that think about an extra er sorry a subdural haematoma or an extradural haematoma those sorts of acute bleeds can lead to death with only a very small volume of blood so no not much blood loss inside his head and we're not going to explain anything like eight and a half litres in his skull su5219: into the chest nm5197: into his chest yeah so er into his chest so into the pleural space er he can't really lose blood into the pericardium because a smaller volume there would kill you again er two-hundred mils easily enough to kill you a hundred would certainly make you very ill but quite a big volume in your chest how big's the volume in your chest nm5197: ten litres you're a big man su5219: about five nm5197: yeah about five litres is the maximum er think about two litres in each side of the chest because you can't obviously fill the whole chest up because you've still got some lungs and other stuff to fit in there so er again some litres inside the chest where else su5219: into the gut itself nm5197: into the inside of your gut su5219: uh huh nm5197: yes certainly bleeding can occur there but to be a large amount it's either going to stay in the abdomen and just fill up your abdomen with blood or it's going to come out er at one end or other of the gut in which case it's on the floor su5219: the retroperitoneum nm5197: yeah the retroperitoneal space that's really about bleeding in the pelvis that's where it goes when you bleed in the pelvis so into the posterior wall of the abdomen well the answer is that's it it's really pretty simple they're the only places that you can lose blood so if you've got a person who's suffered a big injury and you can secure their airway and make sure their airway's not obstructed and be certain that they're not bleeding in any of those places then you will avoid about seventy per cent of all the deaths that occur after trauma so for all those young smoking alcoholic men that get trauma that's the sort of way to minimize the impact of their disease now we could talk about this chap all day and i'm sure some of you would be interested in doing so in fact how many of you would be interested in doing so not tonight but i'm interested to know how many of you find this sort of patient the one we've just discussed interesting how many of you find him so interesting that he's the sort of thing that you would choose to make your professional career around about six or seven of you then of those of you would you be interested in the initial assessment and initial treatment in other words the emergency room medicine the ER type stuff or are you interested in the subsequent management in other words how to fix him up and and make him work nm5197: so how many of you interested in the ER bit and the subsequent management okay that's just my own my interest to know that good we've talked about two different sort of extremes in trauma we've talked about a little old lady with a hip fracture and we've talked about a young man run over by a truck and er they don't cover the whole spectrum of trauma by any means but what i've tried to do is just to illustrate to you some of the complexities that you need to think about when you're considering what fractures and other injuries er mean to patients and in particular i'd like to take you to take away the thought that trauma is a disease and you can think of it in the same way you think of any other disease so you can think about risk factors you can think etiology you can think distribution and just in case your examiners thought the same way i'd like you to spend just one minute writing down three bullet points that would be the main headings of your essay answer to write on the epidemiology of trauma i'll give you one minute to write three bullet points on the epidemiology of trauma this is not a real exam i can see someone looking over their hand at their neighbour there okay so give me some bullet points sf5217: risk factors nm5197: say again sf5217: risk factors nm5197: risk factors okay so we've seen how risk factors could be applied across the board okay sf5218: statistics nm5197: statistics what does that mean sf5218: you need information you need nm5197: yeah sm5210: could be quantified and analysed nm5197: yes su5219: nm5197: i guess you're talking about descriptive statistics you're talking about how many cases are there or the incidence er that may be associated then with risk factors you might talk about how some of those graphs show how the risk factors affect the er prevalence su5219: prevention su5219: trauma as a disease who gets it nm5197: isn't that the same thing okay su5219: prevention nm5197: some one says prevention okay so that could be a whole topic on it's own and you could pick either of these and talk about prevention we talked quite a little bit about osteoporosis and we need to take the next step when talking about treatment of osteoporosis but of cause prevention would mean identifying at risk people and then treating them with effective treatments and we mentioned early on that maybe some treatments that we use aren't really effective su5219: mechanisms nm5197: yeah mechanisms and we just talked a bit about why people die er we could easily have talked about why people get hip fractures and er in one of your slides you showed hip hip protectors and there's been a whole load of interest in the fact that people get hip fractures because they fall over and land on their hip and those intertrochanteric fractures seem to occur like that so there's been a massive amount of interest in inventing devices that you wear inside your pants that are sort of like cushions that protect the trochanteric area so that when you fall over you don't fracture your hip it works actually if you can get people to wear them but people don't like wearing balloons on their hips one thing it doesn't very look very nice so actually the research has moved onto in elderly people's homes should we put very thick underlay under their carpets the problem is that in fact in most elderly people's homes they don't have carpets at all they have er smooth floors because carpets make people fall over so we're not quite sure whether having the rough surface of the carpet is er outweighed by having the soft cushion underneath it of course you can make it very soft and it becomes like walking around on a bed on a mattress with all these little old ladies we're not sure whether that works at all any other bullet points su5219: complications nm5197: complications yes er we'd be talking then more on the treatment end wouldn't we what about assessment diagnosis er we've talked about various tests that were done and it would be well you could talk about how you assess someone who's suffered an injury su5219: costs nm5197: costs very good trauma is probably the most expensive health problem in the developing world and is almost certainly the most expensive health problem in the developed world and for two different reasons in the developing world there's an awful lot of it which is why it's so expensive and then in the developed world it's costing an enormous amount to treat it because we can do lots of very very expensive fancy stuff but it's also expensive because on the whole people don't get that much better afterwards they don't get back to their jobs they don't get back to their normal lives a lot of these hip fracture patients never get to their house where they were living alone with their family looking after them this young guy probably will never work in the Army certainly again and probably never work in a physical job again so it's very expensive because then we've got a whole life time of expense in front of us su5219: when you say it's the most expensive what er proportion of the NHS budget does it er nm5197: well in fact treatment terms it's a small fraction of the NHS budget and less than one per cent of the NHS budget is spent on trauma and that's because the actual treatment bit doesn't cost very much in comparison to other hi-tech treatments for things like heart disease and cancer but it's expensive to the s-, to society because of the loss of income the fact that you have to spend a lot more money on these people in the future to look after them and the other heading i would talk about would be er social impact we touched on these little old lady is going to be desperately er disabled in the future certainly in the medium term if not in the long term and that's going to have a big impact on her and her family one of the questions i wanted to ask you Tim is i wonder how her daughter feels about the fact that her Mum's been living on her own in a house which she had an upstairs bedroom she had some help but they ran out of money and so now she doesn't have any the daughter used to take her shopping but didn't on that occasion because goodness me the daughter wanted to go on holiday and the one time her daughter doesn't take her shopping her mum goes out and breaks her hip so when you imagine looking after that patient maybe you need to look after her family as well okay i'm going to stop there i hoped you've enjoyed that session