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My topic is common fractures and their management. So I have um questions built into this presentation. But um I usually use a chat function. I think Michael said, I cannot actually see your chat answers. But if you could try and answer them, um just so it will help consolidate your learning that would be good. And maybe Michael, if you could let me know when a good amount of people have replied, then I can get reveal the answer and move on. C All right. So um we'll be first talking about the upper limb, followed by the lower limb and I'll cover conservative and also surgical management. So, firstly, for the upper limb, we'll cover the clavicle, the humerus, elbow, radio, Annona and the hand and wrist. So the clavicle that's also called the collar bone. And it's an extremely common fracture which happens to people of all ages. So from very little, all the way to very old, it's just a very vulnerable bone just here if someone was to fall on to outstretched hand. Um Surprisingly, these are extremely painful, especially when lying down. So lots of people end up sleeping, sitting up in a chair. So clavicle fractures, there can be a variety of them. So if you look at the one in the um the top left, I don't, can you see my mouse Michael? Yeah. Yeah. If you look at this one, so the fracture is hardly visible. The fracture is about here, but the bone has remained within a good and a good alignment. But you c if you compare it to the fracture here, you can obviously see it and the bones have moved apart. And if you look at the one at the bottom, it's actually smashed into about four pieces. So there's the main fragment here. There's a small one here, another one here and the rest of the clavicle is here. So this one's a com clavicle fracture. So these three x rays are just to demonstrate that clavicle fractures can be of a variety uh of kind of presentation and that's how you decide whether to leave something to be managed conservatively or whether to fix them. So, treatment wise, you need to make sure they have regular analgesia as with all of your, the broken bones. If we think the fracture looks like it's in good alignment, just as that first one on the top left, did you can give them? This is called a poly sling and the fracture will heal adequately like this. It will heal quite a bit bumpy because we don't have much padding over our collar bones. Uh But they don't need an operation. Whereas someone else where those clavicle bones were like really far apart or smashed into a few pieces, they would require an operation, which would be this, this is a metal plate and screws, the metal plate and screws. They can stay in there forever. They don't have to come out. However, as I was mentioning, there's not much padding over your clavicle. So when you are holding a rucksack, it can be a bit irritating. So some people do opt to have them electively removed. There are a few dangers with clavicle fractures. So as you can see here with this X ray of a clavicle fracture, this fragment of bone is extremely close to the skin there. It's pointing up and almost tenting. This is what we call tenting of the skin here. And if things get really bad, the bone can actually poke through the skin and it becomes something called an open fracture, which is an urgent uh condition in orthopedics because if the bone is exposed to the air, it means bacteria can get in. So we have to do an operation uh hopefully within, within the first, either that day or the next morning. So first question, how long does it take fractures in the upper limb to heal if you could vote in your chapped function? And Michael will let me know when enough of you have voted. So a one week, b3 weeks, c six weeks or D 12 weeks. So currently there's like a mix between C and D. Ok. All right, thanks. So, um the correct answer is six weeks. So it takes six weeks for a good amount of bone to heal. And that's when people can start doing more rehabilitation. Um More range of movement um following their broken bone. So six weeks for the upper limb, the lower limb is about 6 to 8 weeks. So the next fracture we'll do is proximal humerus fractures or some people just call them shoulder fractures. They're extremely common, especially in the older population again, who fall with an outstretched hand. So yeah, that's like fall like this. You may see it in your larking notes as FH fo os H fall onto outstretched hand, um their treatment. So again, conservatively, it would be with something called a collar on a cuff. I'll show you a picture soon and surgically with a plate and screws. Usually these X rays, they just demonstrate again, the variety of uh broken bone classification that there can be. So the first one here, it looks, although it's broken the fracture is here, the bone looks relatively in a suitable position. The fracture fragments haven't displaced very far compared to this one in the middle. You can see the humeral shaft is actually supposed to be connected here. So this is um proximal humerus fracture with, with um quite a lot of displacement. And number three, this is just demonstrating that there's, this is a communed fracture. So there's a fracture along this bit, but the the head actually splits as well. So there's another couple of fractures in here. So this uh shows you the variety of things. Again, things on this kind of spectrum, you can manage with a collar and cuff conservatively. But the other two, you'd be looking at doing an operation for them if you want to investigate your fracture pattern a bit more clearly or in more detailed, more details. What type of um imaging do you think that you could use? Would you like to have some specific shoulder x-rays? Would you order an ultrasound, a CT scan or an MRI scan and Michael if you don't mind letting me know again, that would be great. So a couple of people said CT someone has said MRI and another one has said x-rays. OK, thank you, Michael. Um So with broken bones, um if you want to classify these well, not classify but review them much more detail, then CT S are the best imaging modality for bones, MRI S are the best modality for soft tissue as well as ultrasound can be helpful in some aspects. So for example, ultrasound scans and MRI S, they both look at soft tissue. Ultrasound is less detailed. MRI is extremely detailed ultrasounds. You may use it for um things like achilles tendon ruptures because the tendon is very superficial. Whereas ligaments and soft tissues deep down, you would want to use something like an MRI. So for shoulders, if you're worried about the rotator cuff muscles or something, you would use an MRI scan. So going back to this question, you would use a CT scan to look at the bones more carefully. Uh this is some demonstrations of CT images. So CT scanners is a 3D view of which shows you in three different planes, the coronal or you may know it as the frontal plane, the sagittal which is also like a lateral view and the axial which is um a slice going all the way through. So this one here is the coronal view. So you can see there's a fracture fragment here and quite a lot of bone is missing in this triangle in the middle and this is the axial view of it. So the fractures going along here, if you look at this picture down here, this is the x-ray. So you can see we knew that there were lots of different parts of this fracture. However, when you look at this is um act 3D reconstruction. When they've made a 3D reconstruction, you can actually really see where each piece of the fracture is. This. This 3D reconstruction is actually of this X ray. So they're the same injury. So you can see it looks much worse now that we've got a CT scan. So just remember for bones to broken bones to be looked at in more detail go for CT scan because you see it in three different views. And you can also make these 3D reconstructions. Now, when we think about fixing it with an operation, we know exactly where each fragment is, where to put the plate, where, where to put the screws, which direction to put the screws. And there's actually lots of technology which is coming out. Now, computer software programs where you can actually put a computerized metal plate on your computer program with a 3d model of your broken bone. And you can, you can already plan where you're going to put the screws. You can plan how long your screws are going to be. So you can actually ask the theater team to get all the screws ready for you, which saves a lot of time. It's not very widespread currently, but something interesting which will, will come out shortly. Hopefully. So if you don't do an operation, you give them a collar and cuff. So one thing I wanted to point out is there's two different types of slings. The first one we spoke about was a poly sling this one which you use for clavicle fractures. Uh However, with proximal humerus fractures, you want to use a collar and a cuff. The reason we use collar and cuff is because as you can see the wrist goes up in the air, but the elbow drops and as the elbow drops down, it uses its own gravity to help realign the bones of the proximal humerus. So just remember collarbones, use a poly sling because there's nothing wrong with the proximal humerus and collar and cuff. You use this um you use it for proximal humerus fractures so that we use gravity of the weight of our elbow and arm to realign the fracture. These are example, x-rays of broken bones which have been fixed with surgery. So here you can see a metal plate and screws. So a plate sits on the outside of the bone, the lateral side and it all the screws go into the head as well as into the shaft. You can make out the fracture line about here, you can see just there and this is an example of intramedullary nail. So these devices make use of the natural medulla of a bone where you might be more familiar with it where the bone marrow sits in um in bones. So you use that one, it goes in through the top and not used very much anymore. And we we more often than not would use a metal plate rather than a a metal rod. So humeral shaft fractures, these are very common and more with young adults and they actually happen with arm wrestling. So you can see that this fracture is like um a spiral fracture. It's spiraling around. So as they are arm wrestling with each other, they then snap, they do happen quite a bit. So again, everyth this can be managed conservatively and, or surgically as with all um, fractures. This is something called AE slab. So you, this is the initial plaster you'll put in. When you see someone in A&E, it's a sl me um, plastic sorry plaster slab, which starts here, it goes under the elbow like ae and then backwards around the back of the arm. When you can bring them to the plaster room, we change them to this something called a humeral brace and it essentially wraps around here, the humerus quite tight and it keeps the bones in a good position. And if we were to do an operation, er, we would use metal plates and screws. You can actually see this is the shoulder up here and this is the elbow down here. So if you imagine the, the length of the scar, the scar actually takes up the whole of the, of the arm. So we open it up, we see triceps move triceps out the way they're deeper muscles and we put the metal plate and screws onto the bone. Now, um, anatomy wise, I mentioned some muscles, but there's also a very important, um, structure underneath. So which nerve is at risk in someone who has a humeral shaft fracture. So this is just the fracture itself, not even having surgery. Uh, just think of it being a spiral fracture. And if there's any nerve that you know, that goes close by. So, is it a the common peroneal nerve. B, the radial nerve C, the median nerve or D musculocutaneous nerve and Michael, if you don't mind letting me know please. There's a mix of it answers. So a couple of people went for b um ok, someone went for D another one went for a, I mean, it's a mix actually really to be fair. And um yeah, it's a mix. Oh, that's good. More to learn. OK. So, um we'll just go through the answers. It might be a bit easier. So a the common para nerve that's actually located in your lower leg. So it's um usually injured around the head of the fibula or going slightly down. Uh The radial nerve is actually the correct answer. So the radial nerve is down here and it wraps around the humerus right where you might have a spiral fracture. So it starts off in the posterior compartment and then um towards the distal one third, it comes down to the lateral end of your arm and then it goes over anteriorly. The median nerve is um not located back there. It's in the front and anterior compartment. So it's not usually injured with this sort of injury. A musculocutaneous nerve, muscular cutaneous nerve is again, anterior which is around uh the medial side of the coracoid. And as it comes down, it enters into the biceps at the front. So radial nerve, um it may come up in exams just always think of humeral shaft fractures and radial nerve injuries. And if you are able to get to theater, if, if you see anyone doing this operation, you'll actually get a very good view of the radial nerve because we do usually have a look at it to make sure we move out the way before putting any metalwork on. So humeral shaft fractures, make sure you always test the radial nerve. It must be in every single larking you do of someone with a humeral shaft fracture the way to test it. Uh This is on the diagram just to show you here. So this is the shaft fracture. This is the radial nerve coming over here. So it initially comes backwards, it's posterior to the humerus and it wraps around laterally and then over anteriorly and it can get caught in the fractures. So you want to test a sensation on the back of the hand and most sensitively, I always check it in this bit. The first dorsal web space and motor function wise you ask them to, to um extend their wrist and also extend their fingers. So this picture just demonstrates on the left hand, this girl has a radial nerve palsy because she has something called wrist drop. You may have what may also come up on the exams. There's something called Saturday night palsy, which is the same thing. It's a radial nerve palsy from um people who go out on a Saturday night or whichever day of the week. It's just called Saturday night palsy. And when you get home, you rest your arms on, you may sit down on a chair, maybe fall asleep and your arms are resting on an armchair like this. And you get compression over time of the radial nerve and they wake up with a wrist drop and numbness in the back of the hand. It's called Saturday night palsy. So yeah, just try and remember these things, document it all the time for humeral shaft rashes. So the elbow, elbow fractures can happen in numerous ways. Um Mainly people fall on, fall directly onto their elbow. Usually they can be simple fractures such as this one here. This is something called an electron fracture or they can be fractures which involve the electron on the radial head, radial neck. They can involve the distal humerus. Uh The capitellum is here as well. So they can involve many different places. This is quite a simple one, but you can get some very smashed up elbows at the same time. Um As with most of orthopedics, they usually apply a back slab on in the first instance, for all fractures. The reason we do a back slab is it, it's only half of a plaster. So it's a slab which goes round, it doesn't circumferentially go round. It's just a slab which goes from top to bottom. The reason we do just a slab is to allow for swelling to occur. So when a broken bone happens, there's lots of swelling of the arm or the leg. And if you have a circumferential plaster going around and around, it will just constrict that and cause a lot of pain and discomfort and maybe compartment syndrome. So we do half a plaster. This is an example of a very um smashed up elbow. So you can see it hardly looks like an elbow, it looks very abnormal. Uh There's here a proximal ulnar fracture. So this is one end of it and this is the other end of it. The radial head is most likely fractured a bit, but it's also dislocated. The radial head should be here with the capitellum. So that's quite a bad one. Another thing you can notice on the X ray is air, there's air in here where there shouldn't be air. So it may mean that it's an open fracture. So potentially the spike of bone is probably sticking out. Uh What I'd advise you all to do is just try and look at x rays when you're on your orthopedic or A&E rotations. The more kind of normal x rays you can look at um the more you'll notice abnormal x rays. And people used to say that to me when I was a medical student, but you don't realize until much later when you can start noticing differences. And it's just because you've just looked at so many X rays in the past So just keep trying and um, x rays will get easier. I know that they're very hard and I remember what it feels like. The more you look at normal, the more you'll notice the abnormal bits. This is an example of a above elbow plaster back slab. This is something called a hinge elbow brace. So there's a hinge here and straps up there. They help someone um improve their extension and their flexion, but they stop them doing like valgus and varus movements. Um I if you want, if for example, someone has a an unstable elbow or wobbly elbow because of ligament injuries, you would give them this, this is an example of an operation. So remember that simple electron fracture we saw at the beginning where there was just a line here. This is a way you can fix it. It's, it's metal, it's called a tension band wire. You put two metal wires going in and then this one here is a flexible wire which is in a figure of eight position just like that and it just, it compresses it down. Whereas on the other hand, this is something you would do for that smashed up elbow. Uh So we normally use two plates. So on the humerus. So there's one plate here, there's one plate here and this is for the proximal ulnar. So either because it was broken or it's just um our surgical approach. So here's the quinone or proximal ul ulnar plate. Then these are the two on the humerus. For the humerus, you usually use two so you can close the fracture down and compress it and apply the screws. Uh Sometimes what I was trying to say is here, the electron plate, you'd put it there if there's a fracture here. But quite, uh commonly when we are doing humerus fractures, fixations and surgery, what we actually do is we break the ulnar. um and then we can lift up the, the e quinone with the triceps. And it actually gives you very good access to the joint. So you can make sure the joint surfaces are congruent and there's no steps in there. If you leave steps, then um haven't reduced it well enough. So that's why there are three plates on there. Something I urge you all to do is just make sure you know, your neurovascular status examinations of all the upper limb. It, it mainly focuses on four nerves. So the median nerve, the ulnar nerve, the radial and the anterior interosseous nerve, which is one of the branches of the median nerve and makes sure you know where to find your pulses. It's something you should always document when you're seeing someone um from A&E or in the clinic. Uh because these nerves can get bruised, they can get swollen and at worst case scenario, they can get injured. So this is um how I normally check neurovascular status of these four. So, movement wise. Uh The radial nerve does wrist extension. As we discussed, the median nerve is opposition. The anterior interosseous nerve makes an ok sign. And the ulnar nerve is a big star and also cross your fingers sensation wise. The radial nerve, as we discussed is the back of the um hand. And the first dorsal web space, the median nerve I normally do on the index finger as it's very sensitive. And the ulnar nerve I do on the ulnar border of the um little finger as again, most sensitive. Um And if someone has a nerve injury of those bits, then they won't be able to feel in that those places or they won't be able to move in the way that they're supposed to move. So the next one is radius and ulnar fractures. So these happen commonly a lot in Children actually, uh when they fall, they may break one of them or, or both of them, you can see actually how deformed this arm is. So people actually come in with like zig zag arms. Um Normally, what we'll do is we'll actually try and manipulate this in A&E. So either with gas and air or something called penthrox, which is quite similar or in some hospitals, they'll give them sedation and would improve the position and apply again, a back slab so that we can allow swelling to occur and be free. This is an above a back like we showed earlier, high elevation. This is something called a Bradford sling and high elevation is extremely important because the forearm can get very swollen. And again, we worry about something called compartment syndrome where the pressure in the muscles exceed the pressure in the the blood vessels. And it can, it can restrict flow to the muscles causing muscle ischemia. If we were to do an operation, again, we would do metal plate and screws. So normally we do this via two scars. So one scar on the front of the arm for the radius and one scar on the side for the ulnar wrist fractures. These come up quite a bit in examinations. Even in MC qubits, they're very common happen in all ages, very young, uh all the way to the very old. And again, as with most of the upper limbs when they fall onto an outstretched hand. So again, just showing you a variety of fractures and how they can be ok or be terrible. So this one you can see the fracture line is here and this is the lateral view here. Uh It doesn't look that bad. You can improve the position just by manipulating an A&E and applying a plaster. And this fracture is what we call extra articular, it doesn't go into the joint. So this may be ok just with plaster if it stays nice and stable over here on the right you, this X ray looks extremely abnormal. Um So if you look at, this is a sideways view, the lateral view, this is the uh radial shaft, the ulnar shaft, but there's no wrist attached to it. The wrist has actually broken off and fallen backwards. It's fallen dorsally. So you can see this is the fracture line here, this is radius and there somewhere as the ulnar and it actually needs to be pulled back on the top. This is the AP view of it, which doesn't really show the extent of the injury. That's why it's very important to get two views for X rays and fractures. And if you look at this one down here, this one, I hope that you can just appreciate that it's in multiple pieces. So something called a comminuted fracture. It's uh you know, smashed kind of everywhere, there's many lines. And as we learned earlier, we would get a CT scan so that we can further evaluate all the fracture pieces and where we can put our plate and screws and how long the plates need to be. Oh, yes, this is a common question. So, um this X ray here is a, which one shows a Collie's fracture? Is it here A, is it this one B or is it this one C? This is always a question which medical students uh just tend to ask me they're like, is this one a colleague's fracture? So I think it's something that you guys usually pick up on and learn. So I if you vote A or B or C, which one shows Collie's fracture? And Michael will uh let me know again how many votes Michael? Um People are going for see someone's asked, what is it called these fracture? OK. That's a even better question, right? Um The answer is this middle one B so A Collie's fracture is a distal radius fracture which has dorsally displaced. So you can see the fra this is a sideways view, the lateral view, the fracture is here and the rest of the wrist has tilted backwards. So that's dorsal displacement. When you discuss whether something has displaced dorsally or vally, you, you talk about the distal, the most distal fragment. So you don't talk about the shaft. So this is the radial shaft. This is the fracture here. This is the rest of the radius. This is the rest of the wrist and the hand and it's, it's tilted dorsally. So a col fracture is uh a distal radius with dorsal angulation and they happen in osteoporotic bones. In particular, if you look at this one, a this is actually the opposite of a collies. So I hope you can see that here is a fracture and the this bit of the radius has tilted forwards so tilted volarly. So that's called a Smith's fracture. Opposite of the collies and c er this was a, a bit of a trick one. This is actually a, a child's distal radius fracture. It's um they not, they have a growth plate here. And this is the epiphysis which is completely slipped off the growth plate. So, yeah, child fracture because you can, there's a growth plate of the ulnar. So what I want you to remember from this slide is a collies fracture is a dorsally displaced distal radius fracture. I would be very surprised if they asked you about the Smith one. So dorsal displacement of the distal radius, the way that they present and which may come up in your exam is something called a dinner fork deformity. So for your reference, there's a dinner fork picture and you can see they present with their arm shaped and deformed like a dinner fork. And that's because as you're coming down the shaft, this radius fracture has dorsally displaced. So it's tilting backwards which you get this bit this bit from then the rest of the fingers go forwards. So dinner fork deformity collies fracture, dorsal displacement of the distal radius. Again, we could treat things with costs. You can treat them with surgery. So this is an operation where we just put metal wires through the skin into the bones. It's a quick operation. The scars are very tiny and we pull the wires out. After six weeks, we leave them sticking out, we just pull them out after six weeks or use a metal plate and screws for especially for those ones which are quite smashed or where the fracture had fallen off the back. This is a a lateral view of a fracture. Again, the distal radius fracture, it's similar to that one where the fracture had, the bone had broken about there and then it fell off the back. This is the wrist and the hand. So this is where your median nerve usually sits. So if you can imagine where you had that spike of bone, the median nerve is really tenting around there. So you, you want to check your neurovascular status and document it. Um again, right lower limb. So my lower limb section, it mainly focuses on neck of femur fractures, which is a massive thing um at your level and examinations and we'll fo we'll do a bit on ankle fractures as well. So neck of femur fractures, the this x-ray shows very nicely where the femoral neck is. So this is the femoral head, it's a ball and socket joint for the hip. So the femoral head and the acetabulum, this bit's the femoral neck. Then you have here your greater trochanter, this little one, your lesser trochanter than the femoral shaft. So you may have heard of neo feur fractures being either intracapsular or extracapsular. Uh So these ones here are intracapsular and all that means is that the fracture has occurred within the hip capsule. So every joint in your body has a balloon shaped capsule and inside it is all the synovial fluid uh just for every joint. So the capsule it usually inserts about here and it comes around like a balloon up to the acetabulum and again round here and it stops there. So all these fractures of the neck upwards are intracapsular. However, if it's just below this and going towards the trochanters, the lesser trochanter and the greater trochanter, they, they're called extracapsular because they're not contained in that balloon like balloon like capsule. The reason we worry about it is because of the blood supply. So these are the most common vessels which actually supply the femoral head. It's quite important to know. Uh for memory. I don't think they came up in my, the blood vessels itself didn't really come up on in the exam. But um a subsequent question which will come up, which, which I'll ask you in a minute. So, yeah, if you, if you just remember the, there's an, well, the biggest one is the medial circumflex artery from the Profunda femoris. That one is the main blood supply of the femoral head. You have these retinacular vessels which travel up as you can see, traveling up to the head. There's a lateral circumflex which has a bit of supply and also the ligamentum terrace, which has a bit of um supply from the artery inside there. So my main, my first question, which again, um a lot of medical students usually get taught quite early on in medical school is which risk is associated with intracapsular neck of feur fractures is it a avascular necrosis b nonunion or C malunion and Michael? If you don't mind letting me know how's the answers? Doing Michael? Currently there's no answers. Ok. That's fine. So, um the thing I was trying to uh get, get across is with the femoral head. If you have a fracture, it can affect the blood supply. So you can see all these vessels going up and they're going up to the femoral head. And you can imagine if you break your femur here, femoral neck, here, you cut off all of those blood vessels which are traveling up. So if you break it here, they all stop. So this is what you get. It's something called avascular necrosis. So it's necrosis is death of death of the bone and avascular means because the blood supply has been cut off or impaired. So, something to remember is intracapsular like a femur fractures. They can cause um avascular necrosis. There are other bones in your body of which avascular necrosis can occur. There's three that I'm aware of and it's, it's because of how the blood vessels go there. If I show you this one, normally, blood vessels travel from the top to the bottom. But you can see with the femoral head, uh this is the main, the femoral arteries coming down and then these blood vessels have to go up again to supply the bone. So we call that a retrograde blood supply because it's going backwards on itself to supply the bone, the other bones which do this. So this is the femoral head. This is a scaphoid. So you may uh scaphoid fractures are a big thing and it's the talus bone. Uh the talus is located within the ankle just below the tibia. So the femoral head, the scaphoid and the talus bone because their blood supply is a bit funny. Their blood supply is retrograde where the main artery goes backwards on itself to supply them. They can all have avascular necrosis if they have um a fracture which cuts off the blood supply. So, um this is a pelvis x-ray and one of the hips is broken. Hopefully, you'll be able to see um some of it. Uh What I'll do is I will tell you some of it and then we have some questions after. So this is an intracapsular fracture. So as I said, the capsule inserts itself about here. So just just above the trochanters, the greater trochanter, the lesser trochanter. So this fracture is intracapsular, which is within the capsule. So as I just mentioned, uh the blood supply is cut off traveling upwards and they can have avascular necrosis. You can, one thing I should point out is all hip fractures. We operate on them because number one, it it severely impairs somebody's mobility uh being that they end up being bedbound if we don't fix them and bed bound for 6 to 8 weeks for the bone to heal is a detrimental amount of time for someone who's elderly. Uh usually these fractures happen in elderly people. And if you make them bed bound for 6 to 8 weeks, all their muscles with a will atrophy, they'll become very deconditioned. They can have chest infections, blood clots. So you operate on all, all neck or fever fractures. Unless someone's extremely unwell, you can fix them with screws uh by keeping their own femoral head or you can replace their femoral head by doing half a hip replacement or doing a total hip replacement. And we decide on that depending on how. Um well, uh the patient is. Now, in comparison, this is extracapsular fractures, extracapsular because I was saying the capsule inserts about here just above the trochanters and these fractures are usually around the trochanter area just below the capsule. Here's a fracture here. Extra capsular fractures. You're not worried about the blood supply. You can fix them in two ways. Number one, the dynamic hip hip screw DHS which you may have heard of again. An operation or a number two is an intramedullary nail just like the humerus. You make use of the intramedullary canal and put a metal rod through it and secure it with um the screws. So this is a type of fracture which I'll just go through with you. Uh This is again, we mentioned the capsule at touches just above the trochanters. So already, you know that this fracture is going to be one of the extracapsular ones because it's outside the fractures here, it's outside of the capsule. Now, the fracture is either in intertrochanteric or subtrochanteric. So, intertrochanteric means it goes from the greater trochanter to the lesser trochanter. Subtrochanteric just means the fracture is below. So sub just means below the fracture is below the trochanters. So this fracture is actually below the greater trochanter below the lesser trochanter. So that one's an extracapsular fracture with a subtrochanteric fracture. Just to be specific. Uh This one is quite a difficult one. We'll leave that one. Uh Can a one see this fracture? Uh This doesn't look how it should do. Uh Do you think the fracture is intracapsular or extracapsular? Uh If you don't know the detail, that's fine, but if you don't mind trying to vote, uh then Michael, please just let me know how it goes. You can just write inter capture or extra capture if you like. How is it going Michael. So that was quite, actually there were quite a lot of uh things that I was missing. Um Apparently it's like split between C and D. OK. Yeah. Well, that's fine. Um That's seeing uh being extracapsular. That's, that's completely correct. It is extracapsular and that's the main thing. It's good. If you learn from this talk, the fracture I appreciate is a bit difficult. It's in quite a few pieces, but this is the greater trochanter, the lesser tranter is actually here, you can see the shadow of it is broken off as well, but the fracture goes from the greater trochanter to the lesser trochanter. This means it's intertrochanteric because it goes between the two subtrochanteric is below the trochanters. So subtrochanteric is here and subtrochanteric fractures are usually transverse horizontal. Whereas intertrochanteric fractures are usually diagonal. So that one's extracapsular intraenteric and with extra capsular fractures, we fix them with a dynamic hip screw or with an intramedullary nail. Uh Here's another one. So the arrows are very helpfully pointing out where the fracture is. Uh So it's just here and I'll give you a clue. It's at the base of the neck. So if you don't mind voting to see whether it's um intracapsular subcapital, intracapsular ba cervical, extracapsular, intertrochanteric or d extracapsular subtrochanteric. So it's basically mainly intracapsular. Great. Yeah, that's correct. So it is an intracapsular fracture. Now, we have two options here. So I've done uh subcapital or ba cervical. So uh it's just about learning terminology really. So capital is the head. So subcapital means just below the head and below the head is about here. Ba cervical means the base of the neck. So that's where this fracture is the base of the neck of the femur is here. Uh Just um things to get used to. That's all. But you're all correct in that it's intracapsular. Now, as I said, we worry about intracapsular fractures because the blood supply gets impaired because those vessels are trying to get up there, but they can't get up so they can have avascular necrosis. So we usually just remove the head. We take out the femoral head and we replace the joint either with a hemiarthroplasty, which is half a hip replacement or a total hip replacement. So, just uh before we move on to ankles, the main thing I want you to get out of this is there are two types of femoral neck fractures. They can be one intracapsular or two extracapsular. For intracapsular, you worry about the blood supply and getting avascular necrosis. So on the whole, when we're surgically managing them, we just remove the femoral head, which is broken up already and we do half a hip replacement or we do a whole hip replacement. Whereas extracapsular, which are either here, intertrochanteric or subtrochanteric. You don't worry about blood supply. You just fix the bones back into place and you fix them with a DHS or intramedullary nail. Um Those questions do come up in your exams and um that's kind of a level you just need to know them at which is fine. You don't need to know these subgroups. Uh usually to ankle fractures just a little bit for the end. This is a normal ankle x-ray here is the medial malleolus, this bit, this is the lateral malleolus. So this bit and there's something actually called the posterior malaris and that's here, the back of the distal tibia, you can have fractures of the ankle which are uni malleolus. It only affect one of those malleolus. So this is a fibular fracture which is a lateral malleolar fracture, but nothing else is broken. This middle one shows a medial malleolar fracture. And the third one shows a posterior malleolar fracture. They don't, they don't always happen just by themselves. Usually there's um at least a couple of fractures. So we move on to something called bimalleolar fractures, which just means two of the malleolus are broken. So, very commonly, this is a bimal fracture of a medial male and a lateral male. This one has stayed relatively looking kind of like a normal ankle. This is the joint, this is the talus, we spoke about earlier and the joint seems all right. It's quite congruent when you compare it to the middle x-ray, they again have a medial malleolar fracture. They have a lateral malleolar fracture. But you can see the bones. This one is completely tilting, the foot and ankle are tilting outwards laterally. So this one, you actually have to manipulate an A&E and put a plaster on it. And the third one is even worse. This is actually dislocated. It's a fracture dislocation. You can see the fibula was broken. The lateral malleolus, there's a medial malleolus fracture and this bone is supposed to be on top of the talus. So it's dislocated fracture dislocation. And again, you manipulate these very quickly in A&E and put a plaster because the foot very quickly becomes purple and, and cold. So you need to make sure you restore it for the blood supply is how we commonly fix bimalleolar fractures. So we put a metal plate on the fibula with screws and we put the medial malleolar screws. We put a screw going across because there's something in the middle called the synd osmosis. And the Synd osmosis is a ligament which goes, it's the intraosseous membrane, it goes all the way up. And when you have B fractures, sometimes that ligament is also ruptured. So you would um test it. And if the gap between the bones look bigger, you put a screw across. Now this is trimalleolar fractures. So it means that all three of the malleolus are broken. So here, hopefully you can see there's a fibular fracture here, a medial malleolus fracture and at the back, there's a posterior malleolus fracture. And again, the f ankle is dislocated. So this is the distal tibia here, this curvature and it should actually be sitting on top of the talus here. So we'll reduce it in A&E and operation wise. Again, metal plates and screws so much like the biomer fracture where you do a, a plate on the fibular screws on the medial side, but there's a plate. This is at the back of the ankle. You can see here, it's at the back of the tibia. Ok? I think, oh yes, conservative management. Some fractures are managed conservatively if they haven't really moved out of place and they look ok, they can be managed with a walking boot like this, a back slab or a plaster. And we worry about blood clots, deep vein thrombosis. So you make sure you give them low molecular weight heparin because they're not allowed to walk on the leg. All right. So, hopefully, um, you found this helpful and we've gone through common upper and lower limb fractures and how to manage them. We discussed different casting and splints and, and some cool operations. So please let me know if you have any questions. We've got some a better time. Thank you very much. I'm just gonna put the feedback link onto the chat box for people to fill out so that they can get their certificates for attending the series. That's all right. Oh, yeah. Thanks Michael. If you don't mind filling out the feedback, we would be very much appreciated. And does anyone have any questions at all? I can now see the chat. So there's one question about how do you treat malunion or nonunion. So, first of all, malunion is when the bone, the fracture has healed and it's wonky, it hasn't healed in the correct position. Uh So the operation you do for that is you actually have to break the bone. So you do an osteotomy. So you break the bone and you move it back to the correct place and then you fix it usually with a metal plate and screws again and wait for about six weeks for it to heal. Uh Non union fractures. Yeah. So nonunit is when the bone, the fracture just doesn't heal and we usually leave it at least six months. And if it doesn't heal, we do an operation. So you do a very similar operation with plates and screws. It's just, you have to scrape out all the soft colors that the body has tried to heal. Someone mentioned about x-ray angles. It's not something you need to know um at your level, x-ray angles. Uh The level I pitched the tool at was more what you just need to know. Um There are many good resources online if you want to know the minute details, but um not for your level. All right, my, I'll leave it with you. Yeah, sure. That's fine. Um I think people are heading out, but thank you for presenting this and we'll let you know the responses to the feedback forms once we get all of it done. All right. Thanks very much. Thank you. Bye bye bye. Thanks.