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The unfortunate thing is orthopedics is a massive massive specialty in terms of our footprint in, in the healthcare uh footprint in hospitals. Um And it, it probably should be much better taught than, than it, than it is. So you guys going slightly over and beyond what, what you're presented in, in your, in your medical schools is I think it's, it's brilliant. Um And it will mean that by the time you, you keep this up, by the time you, you finish, you'll be at a very good, good knowledge. So, yeah, what sort of sessions have you had so far? The first one we had was um just a brief overview on career in orthopedics. So we had a consultant and ast three doing that, I have both perspectives. That's quite good. Yeah, that's all things very good because it often these things need a bit of a run up um orthopedist competitive, but I don't really worry about competition ratios and I, and I would advise you to all go forward not to be deterred by competition ratios for anything at any point in your career. Um Actually, the competition ratio is to get into medical school, which you already are a pretty bloody hard. So, if you've already mounted that hurdle, you shouldn't really be too worried. Yes, you should try to be competitive and you should try to work out what it is that you need. And, and unfortunately we have a really, you know, II, I'm not a huge fan of the way we select trainees in this country. I think we're, we're encouraging, uh, a bit of a cottage um industry and it becomes um quite financially um demanding. But if you start early and you start, particularly things that take a long time, the things that take a long time are things like your, you know, your research. It when you, particularly when you, you know, join the workforce, it's, it's tough work trying to do research at the same time as as doing, doing the job. But all the publications you have at any point, including your time at medical school, they all count, you'll be able to use them for your foundation school, your core, training, your specialty, training, your fellowship applications, your consultant applications. And so my top tip for that sort of thing is to take a long view, take a long run up and stop whacking on those things. Um You let me know when we're ready to shoot and I can start. Yeah, I think, I think we should be ok. So, um so everyone knows we're, we're recording this. So we put it on our website um when we get all that in um sorted. So what will happen is we'll have a link to this if you do wanna refer back to it. So, yeah, over to cool. Uh I shall therefore watch my language. Um I II I've got my email at the end of all of this if if you guys want to go ahead and, and drop me an email and, and chat about various things. So I I've been asked to deliver this talk on on how to look at radiographs uh pertaining to fractures. Um And so hopefully, by the end of all of this, um you will have AAA an approach, a systematic approach that allows you to describe any uh fracture on a, on, on a radiograph that you're shown throughout your medical school in your exams and actually into your post graduate training. Um So we're, we're going to spend a, a bit of time on, on, on developing that systematic approach. We will then you as much as I would like to in, in a, in a hour or so unlikely to turn you all into um M SK radiologists. But hopefully, by the end of it, we can develop some understanding of how to look at a particular type of um x-rays that you might see ii commonly in trauma, we'll also, I, I'll try to make the most of this will be didactic I'm afraid, but I will hopefully try to make it um interactive. If there are some brave volunteers, I'm not gonna pick up on anyone. But if there's some brave volunteers who will have a go at describing some X rays at the end of all of this, um that, that'll be brilliant. Now, presystematic. So if I showed you all this, um and I asked you to describe it, you, you know, you will have been taught probably ad nauseam how to speak about um and how to present and how to approach a, a chest radiograph. Uh I'm sure you will all go through your, your systematic approach and, and you're marked in your, in your, in your exams for being able to go through that approach. Um and, and picking up pathology as and when you, you, you pick it up and you might start and you should start with, with patient identifier, often they, they will be anonymized but in obviously, in the workplace, it's not anonymized but in the exam or, or, or in teaching um materials, most radiographs are all, I mean, GDPR, you have to um and patient confidentiality, you have to um uh anonymize it, but it's always important to, as you know, mention the patient details and demographics. Perhaps what time they were taken, comment on um adequacy of the film and then you go through your, your, your Pneumonic ABCD E, I'm not, I'm not gonna go through that. But the point to illustrate is that describing a, a fractured bone on a on a radiograph should elicit a similar kind of systematic approach. Um So for example, this is a AAA series of radiographs of a of a, of an ankle of a skeletally mature ankle. And I, and I'll come to that, this is a, a, an ap this is a lateral and this is a particular type of um view that we like of the ankle and you take it with the ankle slightly internally, rotate it by about 15 degrees or so. And the reason for that is it gives us this really nice view of the talus, this this bone here within the ankle mortis and that the space around the tail, that's the clear space as we call, it is quite nice and uniform. So II always ask for this and actually radiographers will know to do this if I'm worried about an ankle fracture because an important part of that will be to see how this has disrupted I digress. I'll come back to all of that later on. But um to start with the, with the systematic approach that we're trying to develop. One might say that this is an ap electoral and amorous view of a skeletally mature anonymized patient. And that's your beginning um spiel if you like and then how you then describe everything else beyond that is, is hopefully what we're going to try to develop we should talk about. Um So yeah, so obviously, patient details you, you should mention that skeletal maturity that's important in, in, in orthopedics. Often the scenario that I want to give you guys is pretend you're talking on the phone to me as the orthopedic. I'm the orthopedic registrar and you're talking to me about a patient and I have to visualize what it is that you are describing to me without being able to perhaps I'm at home or I'm on the trainer and you're calling me about about a patient. So skeletal maturity is important um in, in orthopedics because what we do about pediatric fractures and adult fractures are uh what we do about pediatric fractures and adult fractures are very different. Um how the fractures behave very d I'm sorry guys, is that loud? I'm in this booth and it's making a very loud humming noise. Give me a moment. Can you guys indicate if that's too loud? No, it's ok for we can hear you. Ok. I'll carry on uh skeletal maturity is really important because uh how I think about and how in all kids, we think about pediatric and adult trauma is, is is very important. So and I, and I think if, if, if you are able to say that quite early on at any point in your medical school, I think it lets the examiner or the consultant know that you are thinking about the fact that we do not think of them usually in, in the same way and, and there are certain types of injuries that we see in, in the skeletal immature that we see less so in, in the, in the, in the skeletal immature and how to determine that I'll, I'll come to you like the chest X ray. You should comment on the projection that you're looking at if it's a lateral view, if it's an anteroposterior view or, or, or, or any other type of view. Um It's really, really important as a, as a, as a convention, you always need two views of, of, of a fracture. If you only have a single view, the, the the kind of comment that you can make is actually quite limited. If you're going to make um comments on displacement and all sorts of other things that we're going to come on, you can't reliably do that with a single view. So again, in a, in, in a teacher session or in an exam session or in real life, I do this all the time when I'm, when I'm on call or people or show me x-rays, I always say, can I see a lateral? Can I another view is absolutely critical? It's crucial and it, and it, and it's, it's, it's a convention that you should all um get used to, to, to deploying. And then the whole point of this talk is to talk about how we talk about the appearance of the fracture, the fracture morphology. Oh You have to have some rudimentary um anatomy knowledge, we're not gonna be able to, I'm afraid go through all the names of the bones in, in the body, but you need to be able to name the bone that has been um, injured. Have an idea of whereabouts that injury has occurred. Has it occurred um near the joints in the, in the metaphysis in, in the, in that sort of cancellous expansion near the metaphysis. Has it happened in the in the shaft of the bone or is it within the joint or in the content or in the, in the, in the case of pediatric fractures? Is it involving the growth plate? So the so name the bone and the site of the fracture start with that. So we start off with patient details. So this is John Smith who's 69 years old. This is a an ap radiograph of uh this gentleman's um humerus. Uh I can see an api would like a lateral view. Er in addition, um the fractured bone is the humerus uh and it's in the uh it's the midshaft and so and so forth and this is what we're going to do. We're going to build um uh um each, each thing and then I want to know um what kind of fracture is it, is it a a an in a complete fracture? Ie the fracture has gone right through the bone or is it an incomplete fracture? An incomplete fracture is sometimes we call them green sticks or buccal fractures, something that we see in the pediatric population. And, and that's because they've got a really thick periosteum. So that's the connective tissue around the bone that allows, that provides nutrition to the bone, a blood supply to the bone and also allows the bone to grow in diameter. But, and, and in pediatric population, that's quite large and sometimes that allows them to have um these bendy type fractures. Um we call them um incomplete fractures. And then I want to know is it a two part fracture? In which case, we sometimes call that a simple fracture or are there multiple fragments? And we use this word um comminution or, or you know, is it comminuted er another way to say that is it multifragmentary? But we're going to use the language that is in common usage. And so the word is comminution and you guys are going to use that if there's more than two fragments. So three or more fragments, it is a comminuted fracture. And then what exactly does the fracture look like? Is it transverse ie does it go essentially perpendicular to the long axis of the bone? Right, all the way across. And I've got some pictures of things to demonstrate this in, in a, in a moment. Um Is it transverse, is it at, is it sort of obliquely at an angle or does it sort of wrap around the bone? And that those are those are really what, what you might see in a simple two part fractures. And then the key is describing, using the correct language to describe the relationship between the two fragments. And we talk about whether or not it's displaced or non displaced, whether translation has occurred and how that's translated, if there has been shortening or angulation, er and if you're doing really well, you talk about rotation and again, we'll come back to you. Uh We'll touch upon that later on. Uh This is just an illustration of the importance of two views. If you only saw the top picture, you might think um Prince William is, is, is is uh doing something um naughty, but actually the second picture gives you the full context. So it's really, really important two views. Um allow you to comment um on, on an X ray in an informed sense, we should talk about nomenclature. If, if this is not something that you're, you're aware of. Um this, this is really what we're talking about. So when something is medial, it's closer to the midline um as opposed to lateral, which is further away, uh proximal is further away. And I think the point of reference is usually the head, um superior and inferior is is, is, is is pretty self explanatory. Uh uh By the way, guys, if there's, if I say anything at any point that isn't clear by all means, speak up or, or, or write something in in the comment if I miss it, I hope, I hope somebody uh points it out to me. So the first thing, skeletal maturity, this is an ap radiograph of an anonymized uh skeletally immature patient. How do I know that you can see the growth plates, the piss? Ok. I most I II in a good X ray, you should be able to see the joint above and below, at least the joint below the nearest joint to the fracture. Um And if you can see a thigh cyst, then you can confidently um er say that this is a skeletally immature patient. And compared to the risk of a skeletally mature patient with a thigh cyst, it's just a little scar, you might even just about make it out. So that that's the first thing, skeletal skeletal maturity. I want you to get into the habit of saying that uh and then we, we need to start thinking about how to speak about fractures. So obviously, this is a normal femur fracture is just a straight line across that's transverse and that's important as well because it tells me a little bit about the mechanism and usually transverse fractures are the result of a direct blow, not always but usually the result of a direct blow. We're not really gonna talk about open fractures. That's uh that's an entirely different um session altogether. Um an oblique fracture. Remember we talked about imagine that line going obliquely. Sometimes it's Um And that's if it's not displaced and that's if it's displaced um comminution, lots of fragments. This is what we call a segmental fracture. But if you said to me that this is a culminated fracture of the midshaft of this patient's femur, I would also accept that because this is more than two fragments, there's three fragments there. But if you want to be more detailed when you have really large fragments, this fragment, which we call the intermediate fragment um um is, is, is something that gives you this segmental picture where ligaments and tendons pull a bit of bone off. We call that an avulsion fracture. Um Higher call that an avulsion fracture. A spiral. I've got x-rays that will demonstrate this is much, much better. And then in a pediatric fracture where you've got a green fracture where um the the fracture does not propagate to the other cortex. So one side is broken, the other side is intact and we're gonna practice all of these things. So um if I showed you this, you might comment on the fact that this was anonymized that they were likely mature. You might even say something about the exposure and say that the proximal um tibia of this patient is over exposed, but broadly, this is a midshaft fracture of the tibia and the fibula in a skeletally mature anonymized patient. If you're really keen eye, you might see there's little fragments there. Actually, it's not a perfect clean break. So you could even describe this as having a degree of comminution. So that's what a transverse fracture looks like oblique fractures, you know. So they, as the name suggests, they go obliquely across. And so this is an oblique fracture of this patient's ulnar or an oblique fracture of this patient's fibula. If I was describing this, I would say that this is an oblique view of a skeletally mature patients um forearm which demonstrates a relatively undisplaced oblique fracture of the ulna. This is an oblique fracture of the fibrial, OK, a spiral fracture. So you can see that the fracture has has sort of wrapped around the bone. It's spiral around the bone and this, this is a good x-ray to mention a few other things I would say that this is an ap radiograph cos I'm looking at it front on of a skeletally mature patient who has a spiral fracture of the midshaft of the left femur. And then we'll talk about how to layer that on in terms of the relationship of the two fragments. But while we're on this, I might as well just say there is and when we talk about displacement or angulation or anything else by convention, what we're talking about is the position of the distal fragment, the fragment that's further away, not this fragment. So where is this fragment in relation to this fragment? Remember midline is medial. So I would say the there is this is a midshaft spinal fracture of this anonymous um adult patient's uh femur, there is lateral displacement with shortening, ok, shortening. So this has been pulled up by the muscles that insert onto this bone. Because if you can use your mind's eye and you're an orthopedic surgeon and you wanna put these two bones back together. You might imagine that you have to move this bone down until like a jigsaw puzzle. The two key in together quite perfectly because you can see that that's the point of that spike probably belongs somewhere up there. And similarly, the point of that spike, the the point is that you can see that there is lateral displacement on, on this ap view. I suspect if you had a lateral view, there will be some um uh displacements in that plane that you'd be able to describe. But just to recap on that, when we're talking about displacement or angulation or, or the relationship of the fracture, what we're talking about is the position of the distal fragment in relation to the proximal fragment comminution. Again, we're all we're just saying simple things. This is an anti ap radiograph. So I'm looking to see there have no piss, the fiss is closed. So this is a skeletally mature patient. So it's an APA P and lateral radiograph of the tibia and the fibula of this skeletally mature patient which shows significantly comminuted fracture of the shaft of the tibia and perhaps you might say a transverse fracture of the fibula at the same level. If you said that to me, I'm happy over the phone. I'm happy. OK? Because II have a, I have a, in my mind's eye, I can see it, the next layer up from this talk would be to discuss or to think about the kind of energy that would give you a fracture that looks like this and, and, and just to tell you it's it's going to be a much higher energy than say something that looks like that. And they're both fractures of the tibia and the fibula. But yes, I would be concerned about an open fracture and various other things. So, but all I want to know is that this is a comminution. There's a significant comminution, lots of fragments. Remember I said that comminution can you can even describe it in a more granular way. So if you've got a large intermediate fragment, you might be very clever and say to me f I have a patient with a segmental femoral fracture. If you say that again, I'm very happy because I know exactly what you're talking about. And sometimes this in this little segment, the middle bit looks like this. It's a triangular um piece when it's like that you might hear orthopods using words like a butterfly fragment. OK. None of these are important. Unless you're really interested, you can describe all three of these as fracture commun er communed fracture of the relevant bones. But this is described often as a segmental fracture and this is a butterfly fracture, but all of them are comminution. And if you simply stop to that, I'm happy relationship between fragments. So, so when you see a fracture, I want you to ask yourself uh again, just to remind you, it's the distal fragment that we're we're describing. I want you to ask yourself, first of all, is it displaced or undisplaced? Is there translation? And if so in what plane, so if there's an ap anterior or posterior translation, you're only gonna see that on a lateral view cos the lateral view lets you know um anterior and posterior and medial and lateral translation, you'll be able to appreciate on an APV or on an anterior view on an APV, which is why I said it's very important you get 22 views. Um So is there a fracture displacement? Is there a translation? And if so how is there angulation? And if so in what direction is there shortening? And you're very good if you're talking about rotation. So if I was describing that, I would say there is a undisplaced transverse fracture of this patient's um tibia undisplaced. OK. It's pretty straightforward, think that's fairly self evident. If I was describing this, I would say that I'm looking at an AP on a lateral radiograph. Is there an open fires? There is not? So ap on a lateral radiograph? Of a skeletally mature patients. Um um uh So the fibs on the lateral side. So this is the right leg. You don't need to know that though. You can just say ap lateral radiograph of this skeletally mature patient's femur there is a midshaft transverse fracture. You might even describe it as a shorter bleak, that's fine mid shaft transverse fracture, which is displaced. So it doesn't look like that does it, it's displaced, How is it displaced? So I know the fibula is there fibula is on the outside of your leg. So that's gonna be laterals here. So the the distal fragment, this fragment is medial. OK. And this fragment on the lateral view is translated posteriorly. So I can say the midshaft fracture which is transverse with medial and posterior translation. Is that all clear so far I'm assuming. Yes. OK. Now we're looking at a different set of radiographs. I can see a piss. This is the this is the ulnar, this is the radius. So we're looking at the forearm of a skeletally immature patient. We sometimes call this um both bone forearm fracture. Uh I would just encourage you to use the anatomical name. So midshaft radius and ulnar fracture which are transverse in nature with some degree of comminution uh in in particularly in the radius, the ulnar appears to be minimally or undisplaced. Looking at the lateral view, looking at the lateral view, there is angulation, right. So the hand is here again, you just have to get used to looking at these. It might look quite confusing, the hand is here. So I know this is the front of the forearm and this is the back of the forearm. So volar and dorsal, that's how we refer to the forearm. So I would say there is volar angulation ie the point of the angle. It's var yeah. So skeletally mature forearm with a midshaft fracture of the radius on the ulnar which appeared to be transverse. In, in nature, the ulnar is undisplaced. The radius is is minimally displaced but does have possibly some degree of comminution. And on a lateral radiograph, I can see an apex volar angulation. We're gonna practice all of this. Don't worry. And, and hopefully some of you might even have a chance to, to describe it. So this is a um a just a quick picture just to go through some of those principles again, assuming that's the bone that that's the femur, this is the knee medial later and up here is the hip joint. So that's gonna be proximal. OK. So we, we talk about, don't worry about this in dis distraction. Um So remember I said it's the later it's the distal fragment that you always describe when you're talking about the, the, the the position or the morphology of the fracture. So you can just about see here, this has moved ever so slightly laterally. So we call that lateral displacement, but it continues to be relatively well aligned. So, II, you know, there's no angulation here, there's m lateral displacement with no apposition. You might even say in terms of the ends of the fracture does not align at all. And we sometimes say that it lacks apposition and not only does it lack a position with lateral translation, it has also been shortened, you can tell it's been shortened because this bit is more proximal than this bit. So in fact, on a on a on your computer systems, if you were looking at this as a real x-ray, you can measure exactly how shortened it is. Again, angulation, it's what's happening to the distal fragment. If it swings out naturally, we say laterally angulated. If it's uh medially, we say medial angulation and sometimes you'll have a combination of angulation translation and shortening. You just take it in each one in turn. What can you see? Well, I can see it's angulated. I can see it's been translated in this plane. I can see it's shortened and so on and so forth. All of these come with practice rotation is, is quite a difficult one and often it's, it's on clinical examination that you can see there's been rotation, but sometimes you just, you can use your mind's eye um to see what's happened. So here's a spiral fracture of this femur. Can you see that it, it, it looks like if you want to put these two back together, you almost have to rotate one so that it aligns with the other one. So there's been a mal rotation to the, to the distal one. Can, I hope that's all clear. But the, the rotation is quite a difficult one and it, and it's not a problem if that's, if that's one that takes a little while to get, to get your head around. I'm happy to go through that again. But if you, if you just have a look at that picture and try to see in your mind's eye, if you were putting those two bones together like a jigsaw puzzle, you would probably have to turn your hand one hand or the other to, to make them align. Um I'm just gonna pause there. Any questions of anything I I've said so far. So would you mind just repeating? Would you say that was like a, would you, would you comment on like say left rotation or medial rotation of that? That last good question. That's a good question. I think you're doing very well visio spatially in terms of in your brain. If you can say where that's been rotated, often it's difficult to say because um usually both fragments will undergo some rotation, cos rotation is done is caused by the muscular attachment. And so this fragment will have muscles attached to it and this fragments will have muscles attached to it. And so if you're operating and often if I'm fixing a femur, I have to put a device around this one and a device around that one rotate both of them in opposite directions until they align. Nobody will expect you to, to discern or to, to report verbally what direction the rotation has happened. Simply that there is a rotation deformity and you're doing very well. Gold medal territory. I don't know if w where you are, if that's the thing most of you in London will know what that is. Um You're, you're in gold medal territory. If you can build your, your picture. This is a, this is AAA an xray of a skeletally mature anonymized patient. Um AP radiograph of the er left femur, there was a midshaft uh spiral fracture with um lateral displacement, shortening, um angulation and rotation. If you said that I would be jumping off my seat, any other questions about anything I might have said so far? Uh I it's a relatively broad thing to cover. Uh the point is not to make you all expert M SK radiologist. It's just to give you guys an approach to allow you to describe any, any fracture of a, on a, on a radiograph. If there are no questions, then we can, we can move on. Um We'll, we'll just talk about ones that you might see quite commonly. I if you end up working in A&E in places like that, you might see broken wrists, you might see broken hips, you might see broken ankles. And so we'll just spend a little time talking about that, uh, wrist, these are common injuries, they're common injuries and so that you'll, you'll encounter them. Um, when you're looking at a wrist, X ray, these are the questions that I want you to ask. So the first th this, the, whether it's displaced or undisplaced and whether they're shortened or not or lar deformity, we've already covered that as part of the, the mechanism that we're, we're talking about. The only other thing I want to know over the phone is whether the fracture involves the joint and we call that intraarticular if you can see a fracture line going into the articular surface or whether actually the fracture is purely outside of the joint. And we call that extra articular. And actually, I much prefer people and, and increasingly the, the, the, the, the movie is that we want people to describe what they're seeing rather than using eponymous terms. You'll hear people say things like Collie's fracture or Smith's fracture or actually just describe what it is that you're looking at. This is a normal radiograph guys. Is this a skeletally mature or a skeletally immature patient? Well done? Yeah, sally mature. Um I think it's beyond the scope of this talk to talk about um the granular details of parameters that we look at in the, in the, in the wrist. Broadly speaking, what we're interested in is the value of this angle, we call this, this the radial inclination. This is off the record. This is not really part of this to, but just for your own edification. Uh we're interested in the value of this angle. We call that radial inclination. If you drew a line from the top of the radial styloid, so that's the highest point on the radius, you drew it across and you drew uh and you drew a line um compared to the um the, the radial styloid, that's the radial height. Ok. And that's got a particular value. And then this angle here, the, the 00 sorry, sorry. This angle here on the lateral view of the, of the radius, the the joint is actually tipping forward. It's not pointing straight up, it tips forward. Um and we call that a volar tilt and, and that's really, that's really important. It's about um you know, 11 degrees or so. Um But broadly enough as if anything, you have to know what normal looks like before you start being able to spot subtle abnormal findings, um skeletally mature or immature patient. That last X ray I II don't know if you can see, can you see this? Is this a skeletally mature immature? Brilliant? Yeah, you can still see the fiss. Yeah. So if you're calling me about this over the phone, you might say um fad, I've got a, I don't know, 11 year old, he's come off his bicycle onto an outstretched arm and is coming with a deformed wrist. The X ray it shows that he has an extra articular fracture of the distal radius. Why is it extra articular? Well, this is the joint surface and you can quite clearly see the fracture is actually quite up proximal to that. It does not involve, not only does it not involve the joint surface, it does not involve the growth plate and fractures that involve the growth plate will come to in a moment called salter Harris injuries. So this is a purely extra articular fracture. OK. You might say they've got an extra articular distal radius and distal ulnar fracture with dorsal ran a dorsal translation. This is the back of the wrist. This is the front of the wrist and dorsal angulation. This is the distal fragment. It's do it's pointing in that direction. I already know where I in my mind's eye. I can already see it. I don't even need to see the X ray. Yeah. What about this one? Intraarticular or extraarticular? Sorry. Um On the previous image um say that again. OK. Oh, we'll we'll we'll carry on. Sorry if you speak. I might be able to answer it cos I can see the comments but they disappear very quickly. OK. Um Looking at this X ray is this would you say this distal radius fracture is intra articular or extra articular? Remember that? Remember the joint line of the radius? Yeah, it's here anything breaches that it's intraarticular. Oh, so you can see. Brilliant. Yeah, it is. Yeah. So if you're describing it to me over the phone, you can say there is a significantly comminuted, you can see it's just absolutely smashed to smithereens, significantly comminuted intraarticular distal radius fracture. Now, remember I remember remember the height of the radius is, is a bit higher than the ulnar, isn't it? Right? Compare that to where we have here. It's smashed. It's all the way down here. Look at where that ulnar is and what, why, why is that important? II would say that's important because it means that there is significant shortening and there is dorsal comminution, dorsal angulation, dorsal translation. So this is a, this is a terrible injury, terrible, terrible injury. Yeah, there are only two classifications you need to learn in all of medical school as far as our OK. Three, if you, if you go on to the one that we'll talk about and basically the three classifications you need to learn in all of medical school are the following. Um The first one is called the uh the Weber classification or the or the Danni Weber classification to give its full name and it pertains to ankle fractures. Um And, and this is what it is when you ever see whenever you see an ankle fracture, I want you to look at the fibula and I want you to work out where the fibular is broken in relation to this structure? Does anybody know what the syndesmosis is? You might have never heard of it? That's absolutely fine. OK. Well, I'll explain to you right. I'll explain that in a moment. So, um ii, this structure called the syndesmosis. I want you to look at the fibula. Um If it's below the syndesmosis, we call that a weber, a some people call it infrasyndesmotic. That's useful to know because those patients that's an inherently stable fracture, they can be treated in a boot, they can walk, they can do whatever they like. So it's important for management. Um We're not gonna talk about, about management at all in this. But, but that's why it's important if it's at the same level of the syndesmosis, we call that a Weber B or a crown syndesmotic fracture. And if it is above the syndesmosis, we call that a Weber C or a supra supra syndesmotic um fracture. So what the bloody hell is the syndesmosis cytosis is the ligaments that stabilize the, the distal tibia and the distal fibula together. So there's three components, there's a bit that goes around the front. You don't need to know these names. There's the bit that goes around the back and there's the bit that is in the middle. But broadly, all you need to know is the syndesmosis. It's the important ligament complex. Uh We call it a complex in, in terms of anatomy because a complex is a structure made up of more than one thing. There are three things we've just mentioned. So it's the complex, it's the ligament complex that stabilizes the ankle joint. Um specifically the distal aspect of the fibula against the tibia. And if you disrupt that ligament as complex, you have an unstable ankle uh and you need an orthopedic operation. So that's why it's important. So go from this, where the bloody hell is the syndesmosis and this is the picture I want you to take away in your head whenever you're thinking about where is the syndesmosis on an X ray? Remember that lovely x-ray. I showed you earlier on called a mortus view. It gives you this lovely clear view of the talus and this beautiful uniform, clear space around the talus and that's what a normal ankle should look like. The syndesmosis is around that this area. Ok. So if it's, if there's a fracture here, we call that a Weber. A I'm not, I'm not bothered if there's a fracture here. Hm Some, sometimes you need an operation sometimes you don't. If it's a fracture above always it's an unstable injury, you need an operation. And I can explain to you biomechanically why that is if you're interested. If you have a fracture here, what can sometimes happen or what, what does happen is the force goes through the bone causes the fracture comes down here, disrupts all the ligaments that we were just talking about and actually exits out through the medial aspects of the, of the ankle. Again, that, that we can have another conversation about fractures at different uh and what, what causes them and how they're, how they're managed at another time. But in your mind's eye, when you're looking at ankle x rays, I want you to think about this structure called a syndesmosis. What it is, it's the ligament complex between the distal tibia and the distal fibula. Um And there are three components at the front, around the back and in the middle between the bones. And it's around here below the syndesmosis with a at the level of the syndesmosis with a B at above the syndesmosis with AC OK. And that's, that's what it looks like in, in practice. OK. So this patient has a Weber a fracture, it's a stable fracture. You know that the ankle ligaments have been spared. This patient Weber C you know, it's an unstable fracture which certainly will have injured the syndesmosis. They need an operation. So broadly, a, you never need to do an operation. C you always need to do an operation. And B uh that, that's a more interesting group where you need to do some more um investigation to work out whether or not the ligaments are intact or not. But again, that's beyond the scope of today. So that's the first classification, the Gis Weber or the Weber Weber classification for sure Weber classification, sometimes you'll see fracture of both sides. So the fracture of the fibula. So I would still say that this is this guys, is this above the level at the level or below the level of the syndesmosis? Brilliant. Yeah. So it's a Weber bee fracture because the medial malleolus has been injured. II would describe this as a Weber bee bimalleolar fracture or even if you just had bimalleolar fractures, it's enough. This is an inherently unstable injury and needs an operation. Um But that's what we do when we're looking at ankle x-rays, we're looking, we're classifying them based on usually the position of the, of the fibular fracture. Any questions on that and the wrist, everyone's happy good. The next thing and, and I remember looking at these when I was at medical school and II II thought, oh God, that looks a bit complicated, er is the um injuries that you see only in Children is Pfizer injuries, obviously. Um when you reach maturity, your p is fuses. So these are not injuries that you can see in a skeletally mature patient, but it the let's go back to an X ray where there's a V um and I can perhaps um sorry. Um OK, so in here between these two bones, the, the radiolucent segment is your growth plates where you're getting uh formation of new bone that allows you to have longitudinal growth. Um but it's an area of structural weakness. As you might imagine that area is not as structurally robust. Um I'm sorry guys, interestingly when I'm in um presentation mode, I can't actually see the full discussion. I sometimes see a little comment pop up in the corner, feel free to speak up if you need me to um clarify. Uh but broadly, the vices is an area of structural weakness. And so you have a, a particular type of injury that, that affects these Children and that's called your growth plate injury, your physeal injury. Um and you might even have heard it called um Salt Harris injuries and Salt Harris um is the classification. So remember I said there were only three classifications you need to be aware of in medical school, ankle fractures, weber classification. This is the second one. Faisal injury, Salter Harris. So these are the normal vices. Um Yeah, the green is the normal vices. This area above the piss is your metaphysis and obviously the bit below the ps uh in this particular view of the, this is the distal tibia. Uh this is your epiphysis. Yeah, epiphysis, ps metaphysis. Yeah, as Salta Harris, one sometimes is very difficult to see is a fracture that goes not through the bone, either side but through the phys. So the red line here is your fracture and it goes through the phys and that's your Salter Harris ones, your salt. Uh And so it's easy to use the acronym or the Mnemonic Salter as asphalt straight through your type twos are where the fracture goes through the vices and out through the metaphysis or above, above the vices. Yeah, it'll take you some time and a bit of repetition and reading to get your head around. This three is where it goes through the fiss and out through the epiphysis spare in the metaphysis and four is where it goes through all three layers. So through the metaphysis, through the phys and through the epiphysis type fives, we don't, we won't really spend too much time, but that's where you have a crush injury. Uh They're pretty rare. Uh In fact, I've never seen them. Um but you need to be able to identify these first four on an X ray and if you do, that's fucking, that's absolutely brilliant. OK. So let's look at some examples. Any takers here, what type 12 or three or four? Yeah. So somebody said type two, remember type two. So actually, it's type two is where you've got a break in the metaphysis that goes through the fiss. What's actually happened here? This is a, a type one injury because what's happened is the fracture has gone through the fis oh sorry, through the fiss. And then you've had a slip between the epiphysis and the metaphysis. But actually, if you can see, I know these are not projected very well, but this is a type one because you've got no fracture in the epiphysis and you've got no fracture in the fiss I uh in the metaphysis. Um So this is a type one. Yeah. What, what about here? So again here. Good, well done. Yeah. So you've got a fracture that's gone through the five cyst out through the metaphysis. Yeah. The small bit is the epiphysis. So this is the metaphysis. That's a little metaphyseal fragment. So this is a salter Harris two. Yeah. This is a fracture through the epiphysis. Sparing the metaphysis. So it goes through the epiphysis and then out through the fiss, this is a type three, see a pattern. This is act but it still illustrates the the picture right. You can see a fracture that's gone through all three, all three. So uh yeah, so well done. That's a, that's a type four. So Pfizer injury and there are more complex injuries where you have a combination of different ones, but you don't need to worry about that. Ok. Um The other classification I want you to know is for the hips. It's called the garden classification specifically, it's for um what we call intracapsular fractures. So what the hell is an intracapsular fracture? Well, look at this X ray, this is telling you not x-ray, I beg your pardon. Look at this picture. Um you do not need to learn the names of these ligaments, but these are really some very, very strong ligaments are the biggest ligaments in your entire body. Um In fact, the iliofemoral ligament is your, is the biggest ligament in the entire body and the strongest ligament in the entire body. Um These ligaments surround the, the neck of the femur and they're important and they form the capsule as well. And they're important because the blood supply to the femoral head travels inside the capsule. And so when we talk about intracapsular, we mean fractures that are in this area within the capsule, extra capsular. So think of that imaginary line of attachment on the front. This is by the way, what it looks like on the back, but usually you look at an X ray ap so on the front, the capsule actually attaches in this imaginary line and we call this line intertrochanteric. So this is your greater trochanter up here. This is your lesser trochanter. And so this is your intertrochanteric line. And so when you're looking at a normal X ray, the, the, the l when you're wandering is the fracture displaced? Is it normal? I want you to imagine this line, it's called your Shen's line, Shen's line. So if you drew a line along the medial cortex of the femur, it draw, it draws a really nice smooth arc all the way to the superior pubic Remus. Yeah. When you have a displaced fracture, you do not have preservation of shen's line. Again, you're doing really well. If you're showing x-rays and say there is a hip fracture with disruption of Shen's line cos it means you understand that a normal radiographic um parameters been dis disturbed. So this is the classification of an intracapsular fracture or at least a picture of it. Uh And there are four types, you can have a little partial fracture where it's not gone all the way across. So here the red line is obviously the fracture. Um you can have a, an undisplaced fracture, but it's a complete fracture. So those are type one and type two garden, type one garden and type two. Type three is where you have some displacement and type force when you have full displacement. And remember what I said to you, the blood supply to the head actually goes back up to the head within the capsule. And so these fractures three or four where you've had a displacement of that fracture. It has important implication for the blood supply to the femoral head and it has implications for what operation we might do. So I want you to learn the garden and classification of intracapsular fractures. OK? And again, this is what they might look like. Again, apologies if, if that's not projecting very well, but a type one is a, is an undisplaced fracture, an incomplete undisplaced fracture. Type two is a complete but still relatively undisplaced. Type three, there's displacement and type four, there's complete displacement. We we only really need to touch up on those. But what the key here is to get you guys to practice presenting is anybody up for looking at some X rays and, and, and trying to do what we've been talking about trying to um apply that the systematic approach. Patient details. What kind of, what projection is it? What bone is it? What part of the bone? What does the fracture look like? What is the relationship between the fracture uh between the fragments? Does anyone prepared to do that? Do you want me to go through and present them all? So Mohammed, have you got a microphone? No, hello. Mm What's happened now? So can you hear me? Oh, I can, yeah, I can hear you. Is that Mohammed? Yeah. Go for it. Mate. What uh la lateral angulation and then shortening. So remember we don't, we start off with the simple things. We need that systematic. If I showed you a chest X ray, you'd tell me this is a AP or pa chest radiograph of a. So, yeah. So I want you to develop that patter that spiel. So what am I looking at? OK. Pretend I'm on the phone. Yeah, we're looking at the, the right clavicle. Yeah. Well done. So an ap radiograph of the right clavicle. Yeah. Yeah. Uh And uh there's, there's a fracture in the, I forgot where, where it was for just when you say it's in the middle. Yeah. Midshaft. Yeah. Well done. Mid mid shaft. Yeah. And there's a lateral angulation of the, of the part of the clavicle that's towards the midline. It's angled upward So this is a difficult one, cos all the other ones were on the limbs. But if you imagine the middle line is, is your, is your proximal. I'm only when you're describing the f the way the fracture looks. I want you to tell me what the position of this fragment is to this fragment. Yeah. So OK, perfect. So the fractures distal, is that what you'd say? What does the fracture look like? Is it oblique? Is it, is it transverse? Is it spiral transverse well done? Brilliant, well done. So it's a we're building this up. Now. We said we're looking at an ap radiograph of this illegally mature patient's right clavicle. There is a transverse midshaft clavicle fracture. Good. Yeah, they're shortening as well. Fantastic. They're shortening. Yeah. This bit is, is closer to the midline than this bit. So it doesn't align. So they're shortening well done. And really, I think that's pretty much all you can say on that. Um What you're, what you're seeing here is the insertion of the external cleidomastoid pulling this fragment up. But all I want you to say there is a midshaft clavicle fracture with shortening. Brilliant. Yeah. Anybody wanna have a go at this one? I can have a go brilliant, go for it. So this is an anonymous radiograph of the right clavicle. Um He islet mature. Yeah. Fantastic. And so this is a commun mid fracture with um quite significant displacement. Uh uh Would you describe it as oblique as well. You, you can do that. It's combated oblique fracture. Um And it's inferior, inferior displacement. Yeah. And, and would you say it's shortened? Oh yes, so sorry, shortened as well? Fantastic. Top up. Hold on. Yeah. Who wants to go have a go describe in this, you know that it, I can try you on, please. Um uh uh Before I do is the, is the picture on the right after it's been reduced? Which one am I? No, no, no. It's a good, very good question. This is a, this is a lateral radiograph of the same fracture. So that's why you two views give you a slightly different appearance. Uh And it, it might make you think sometimes it's reduced. You were just seeing it in a slightly different angle. But this is OK. So the right one is the left one is ap that's correct. Yeah. Yeah. OK. So, um this is an anonymous x-ray um of skeletal maturity of the left um femur. Um There is, what did you call that left? What? Sorry. Hum. Well, humorous. Yeah. Yeah. Well, yeah, that's hum um I would say this is um it's not exactly AAA mid um humeral shaft fracture. Yeah, mid, mid is probably over here. You, you can just say of the proximal um shaft honestly. Yeah. Hold on. I would say it's a, it's a crash or burst fracture because of the hyperintensity around the joint. Um There lateral um displacement. Well done. Yeah, we're describing it in relationship. We're describing the position of the lateral of the distal fragment. Yeah, you can see the distal fragment is laterally translated. Well done. Good. Um With shortening. Fantastic. Yeah. Um Yeah, that's it. Yeah, I think you got most of it. Yeah, you, you might have said it's a transverse fraction. It's a displaced transverse fracture with lateral translation and shortening. Yeah, it's well done. Anybody wanna have a go at this? It's OK. We're nearly there now. Anyway. Uh II would say that this is sorry, we would say this is maybe a, a non anonymized um radiograph of a uh skeletally mature. I would say um uh individual with the mature or immature. Sorry, I missed that. Uh So II feel like II can't see the separation in the er epiphyseal plate. So I feel like skeletally mature as an adult. So this is the fastest. This is the oh OK, skeletally immature. Um um you with a commuted fracture, mid mid humeral commuted fracture. Wh whereabouts on the humors? Uh I would say, yeah, mix mid me to dis Yeah. If you're saying that to me over the phone guys, I'm, I'm happy. Yeah, I've got a, a combated miha fracture of the right humerus of a SCLE immature patient. And then we can talk on lots of other things about examination and, and management and so and so forth. Uh If you're showing this in an exam. The savvy amoxi will also say I would like a lateral radiograph to comment reliably on uh fractured um er position. Yeah, I, I'm coming up to my um Fr CS exam and even I say at that level. Yeah. So you always have to indicate that you understand, I think this might be the last one if anybody wants to give these a go. Um Before we move on, I just wanted to know if you can call it segmental as well. Yeah, you can do, you can do um segmental often is really quite a nice discrete three parts usually. Whereas I think here you probably if you did a CT scan, you'll probably have lots of fragments. So segmental might slightly underestimate um the severity or, or the degree of comminution. But you're certainly thinking along the right lines. Um You might actually say this little piece here looks triangular. Um You, you might be perfectly entitled to say that this is a, a a AAA midshaft comminuted fracture of this skeletally immature patient um with a medial butterfly fragment. Yeah. You remember the, remember the fragment was that nice triangular piece that looks like it wants to just slot in orthopedic surgeons. We really basic, we like fixing nice jigsaws and when the pieces all look like they're, they, they fit together, it's very rewarding. Uh Last one. Does anybody wanna give this a crack? I kind of no one else is. Yeah, please help. Um And so am I right in saying this is the left foot? It is. Yeah. Yeah. So um a oh I don't know if this would be ap would it, it would be a Yeah. So ap radiograph of a sle skeletally mature left foot with um oblique displaced fractures of the 3rd and 4th m er metatarsals with um so medial displacement and oh you nearly nailed it. So this is lateral, right? Because you said this is the left. Oh Yeah, because it's distal, isn't it lateral? Always looking at the distal front. But other than that, you did really, really well. And then the oar you're going to say like a lateral view of the foot in order to um comment on the angular deformity in the sagittal plane. But that's a talk for a different time. Anybody have any questions about anything we've talked about today? That's, that's your, that's a lot folks. Any, any questions I just wanna say, thank you for that. Not at all. Not at all. Thank you. Are you guys happier describing x-rays now? Oh, yeah. Thank you. Thank you for that was amazing. Um Really engaging. I think everyone, everyone loved that a lot. Um We've got uh Ford's email he put in and it'll be on the recording. We've got a um feedback form as well. If everyone could fill that in and you guys will get your certificates and we'll send this feedback to you for it as well. Ok. Yeah, that would be helpful. Um Yeah, feel free to email me guys if you've got any questions or give you general advice about things. Um but I think I had my email address up there. Am I still sharing? I'm not on mine. No, not sharing anymore, but you've got my email address. Have you? Yeah, yeah, it'll be on the recording that everyone has access to. All right, is it all right? If we get a copy of the powerpoint, I missed that. Say that again. Is it ok? If we can get a copy of the powerpoint? Yeah, that's fine. Um, I can email it to somebody, we can work that out. It's not a problem. Yeah, if you email it to me for and then I'll send it on the group chat. Mohammed. Uh, and then everyone can have access to it that way. Yeah. Ok. Ok. Well, thank you. Thank you, Doctor Mohammed. I appreciate it. Pleasure. Pleasure. You know, the, the thing to say is a very well studied phenomenon is if you, if you're prepared to give up your evenings as a student, you're probably gonna do just fine. There's a very direct line between people who go to these sorts of things. Attend webinars, go to courses and performance at any sort of thing, whether it's exams or whether actually it's things like interviews. So if you guys stay motivated, you'll be absolutely fine. I have to say I don't remember having this kind of motivation when I was a medical student. So you're much better than I was. All right. Thank you so much. Uh, everyone for attending and for, for actually doing the talk. Um If no one's got any more questions, I think we'll leave it there. Thanks. Thanks so much. Bye-bye. Bye-bye. Thank you very much. Cool, well done guys. Um Cool and hear you. So that sort of, that gives you a bit of a taste of how, how I wanted to sort of run the sessions. It's just sort of introduce them, do a little outro and then that's it really. Um I probably won't be attending the next few sessions, so you guys will be taking the lead completely on these. Are you guys? Ok with that along with Michael as well? Yeah. Yeah, cool. So what I'll probably start doing is, um, once I arrange sort of with the next speaker, what they'll be doing, sort of, I'll just hand it straight off to you once they've organized a date and time and then you can get in touch with them. Um I think you guys have a group chat with just the events guys, right? Yeah. Um So you can put it in the group chat. Um And then just go from there, you guys decide on meetings and sort of, do you know how to make people co hosts and stuff? And I feel I could figure it out at some point. But yeah, II just went on. So participants where it says show everyone and then just do the three dots. Um make cohost um like if we make Yash who's still here cohost, you just press three dots and then making cohost basically. Um Yeah, and then they will be able to access, like do the recordings and things. Oh, I am still recording for the next one for the Zoom thing. Right. Um, are you still making the?