Home

1) Upper Limb Fractures & Conditions: SAQ & SBA Revision series 2024

Share
 
 
 

Summary

This session is an immersive review of some common orthopedic cases typically seen in Accident and Emergency departments, with particular focus on fractures and conditions of the upper limb. Led by PM, the president of the Left Orthopedic Society, participants go through multiple short answer questions and best answer questions, simulating the exam setup at Leicester. Attendees engage by participating in chat to answer these simulated exam questions thoroughly discussed as the session progresses. Key points include identification, diagnosis, and management of fractures like Collie's and Smith's fractures, along with critical concepts like x-ray terminology, physical examination of the wrist, associated complications, and nerve damage. This session, sorted by David, offers excellent revision for those studying orthopedics and provides practical insights for prospective examinations.
Generated by MedBot

Description

Join us on our UOL Orthopaedic Society's SAQ & SBA revision series which includes:

3 x 10 mark SAQ questions

5 x SBA questions

This week is on the upper limb!

Learning objectives

1. At the end of the session, learners should be able to describe the characteristics and diagnosis of common upper limb fractures, including Collies and Smiths fractures. 2. Learners should be able to interpret X-rays of upper limb fractures, highlighting the specific features that indicate specific types of fractures. 3. Learners should understand and be able to explain the protocol for physical examination of wrist and shoulder injuries, including checking for nerve damage and assessing range of motion. 4. Learners should be able to outline the standard treatment protocol for non-displaced fractures and the potential complications that could occur after the fracture has healed. 5. By the end of the session, learners should be able to describe the required imaging for diagnosing shoulder dislocations and the implications of nerve damage in these cases.
Generated by MedBot

Related content

Similar communities

View all

Similar events and on demand videos

 
 
 
                
                

Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Can you hear me? Ok. Uh Yeah, all good. Sorry, sorry about that. Yeah, the Wi Fi is terrible here. No, that's all right. Um, hi, everyone. Um, we'll make you start, David. Um, perfect. Hi, everyone. Um, my name is PM. Um, and, uh, I'm the president of the Left Orthopedic Society. Um, and today, uh, we've currently had this, uh, series sorted by David David's in third year. Um, and, um, he's sorted out this series and he's made the slide. So, uh, shout out to David. Um, so the way it works today is we're gonna go through, uh, three SA Qs, uh, very standard, um, way exams are built at Leicester. Um, you got 1010 marks for each S AQ and then we'll go through five S BS after, um, the chat function, uh, should be open for everyone to jot down answers in. Um, but once my share, uh, screen share, if you just uh monitor the chat, David and, um, and then we'll swap at, uh, the, the point we said we would, um, sounds good. Yeah, without further ado let's, uh, let's begin. Um, and we can all, uh, do the rest of can you uh is it, is it a full screen now, David? Yeah, that sounds great for me. Oh, that's good. That's, that's good. So today's session is on uh upper limb fractures and conditions. So case one. So a 71 year old lady presents in A&E after falling on some ice outside her bungalow, she put her arm out to protect herself as she fell apart from being a bit shaken and bruised. She complains in her, she complains in her, in her left wrist, a pain in her left wrist. She describes falling on her hand with her wrist extended. Um You order an X ray as you suspect a collie's fracture, your three features you might see on X ray. So if you guys have any ideas, you can just put in the chart, it would be great. What do you guys think might be seen on an X ray? So we'll give it, we'll give it a, a 30 seconds or so, just maybe jot down mentally as you would to do an exam or we can put it down in the chat chat function. Um And we'll go for the answers straight after. So, um is there anything in the chat, David? Uh No, no. So, so on the X ray itself, the shaft of the radius um is driven into the distal fragment leading to an impaction cos it's a fall on an outstretched arm, but there's there is gonna be some dorsal displacement of the distal fragment. Um the fracture can be displaced given that uh term that they like to use at medical school called the D fork deformity. It's not always that present in practice though. Um And there will be ulnar angulation as well. So these are quite, these are quite uh these are quite hard to get in an exam questions wise, but it's good to start thinking cos you might get a, a question like this on, on, on, on the um on the hip. That's what we got when we were in third year. So if I know your xx ray um terminology such as words like angulation, displacement, et cetera. Uh So what's the name for the fracture given uh caused by falling uh with your wrist flexed but not extended? Yeah. Smith's fracture. Yeah. Smith's fracture. Yeah. Yeah, that's good. Uh Yeah. So as you can see um in a Smith's, the distal fragment displace from to a volar aspect. So as you can see like this, whereas in a collies, the distal fragment will displace dorsally. So that's why you get the um the characteristic deformity getting collies. So uh briefly outline your physical exam, how you uh briefly out in your physical examination of the wrist. So four points above what you do um in your physical examination. So I think in third year, you go through um a hand and wrist exam and you should, and I think you've got to learn in for the rheumatology um hand exam as well when you do your oss. So it's good to know your hand exam. So obviously you wanna do the characteristic mm SK um inspect palpate, move, check for the neuro neurovascular structure. So yeah, so inspect, look for any swelling sis deformity. Um Those are the common ones you'll see um palpations. So feel for the bones and joints. If there's any diffuse tenderness, any pinpoint tenderness that's quite important, move the joint um ask them to first, always do um passive movements first to see how much active movement they can do. Um check the nerve. So you wanna check your uh median nerve, ulnar nerve, radial nerve in the characteristic Dermatal pattern they have in the hand just to make sure you remember um the pattern of what nerve does where um because that was a question that came up in our third year, last year as well. Um uh Feel for the pulses. Um because that's really important you wanna look for your radial pulse but also check peripheries are warm as well. So the x-ray comes back and you diagnose collies fracture along with the collies fracture. So just two other accompanying fractures you might be looking for. So if you guys think about where the um colleagues, yeah, someone says skateboard. Yeah, that's good. Yeah, that's good. So you just wanna think about, you know, falling on an out out stretched hand. What other fractures can occur when you fall on your hand. Yep. Someone says a distal ulnar. Yeah, that's good. Yeah, it's quite, it's quite a tight area in that, in that part of the wrist. So, skateboard fractures are quite important. Um II we may touch on that later on as well. Um So let's uh let's have a look. Yeah. So ulnar styloid fracture, um, radial head. Um I had a skateboard fracture. Um But yeah, that's uh that's, that's really good if people are getting those. Well, yeah. Uh So the fracture is not displaced. Um How would you treat this? And for how long? So the key is, if it was displaced, you'd want to, you'd want to reduce it. Um in A&E if you haven't already shadowed the on call, registrars at the L ri if you're, if you're on call, if you're on nimb block, um cos they do loads of those on a day, day by day basis. Yeah, perfect. Um Someone said immobilization for 64 to 6 weeks with the cast. Yeah, that's good. Sounds about that. Um So yeah, post reduction then apply the, the uh the, the hand in a blow elbow plast er plaster um with the hand um in a mid palm of flexion which is a bit like this. It's hard I screen. Um Yeah, so keep it on for 336 weeks. Sorry. And then go to Fracture Clinic. There's always that characteristic uh thing about six weeks in orthopedics. Um, it's not always needed. Um, but it's one of those things that's just, er, stayed as a status quo. So, apart from associated fractures name, the two long term complications of a Collie's fracture. Yeah. Someone said posttraumatic arthritis. All right. Yeah, that's good. Yeah. So, so carpal tunnel that can happen, um, osteoarthritis. So that's good. Er, you can rupture the E PL, um, as it runs very close to the um, distal radius, uh Mao Mao Union, um, and prominence of the distal ulnar for exams and stuff like that. I'll be honest, always just go for complications after fractures of oa mal union if it's the hip potential avascular necrosis. Um, those are the common ones you should be thinking of. But, yeah, for collies, it's more carpal tunnel as well. So, hold on guys, hold on. So that's quite a quick, uh, quick run of case one is anything that anyone wants to go over in case one. So to summarize, we had a, a distal radius fracture. There's two types you can get, um, poly fractures when the wrist is extended on out stretched arm. Smith fractures, if it's flexed. Um, you can also then get, um, you can fixate it whether you, you, so in, in, you want, in A&E you wanna reduce it, you wanna do a post reduction X ray, you then wanna, um, see, well, refer to orthopedics. If you're on a, a non orthopedic team. Um, after that, you'll um, either see what they'll, they'll go to Trauma MDT and they'll see whether it needs fixing or not. They'll usually go home and come back if it needs fixing. If not, they'll just be immobilizing the cast for six weeks and seeing fra, so that's a bit of a summary on uh on fractures and you've gone through the complications. So, case two, that be something different. So a 22 year old presents to A&E after a skateboarding and fell on his left shoulder, he complains of severe pain and immobility in his left shoulder. Uh on examination, his left arm is A B ducted and externally rotated. What's the most likely diagnosis? Someone said unter shortage. Yeah. Have a look. Yeah, anterior shoulder disc. So we might, we might go through his dislocation at some point if we don't go through the question. But yeah, so that's good. Well done. Um The TN O TN O reg uh request some imaging, what do they request? So always, when you wanna answer a question about imaging, you wanna say what image and in what plane? So the other one X ray. Yeah, we can and ap and natural. Yeah, of the shoulder. That's good. Yeah. So you want an AP um and ap and a lateral view um of the X uh X ray of, of the shoulder. Uh Sometimes you can see them in upper um chest, X rays as well. Um but, but yeah, so you can, I can accept scapular Y view instead of lateral. Um Yeah, if you got ap and lateral, that's quite sufficient for third year exams, Shreya said would you need a Y view? Um So ap and natural is sufficient enough. But um yeah, you can do a vi Y view as well instead of a lateral view. Um Does anyone know when A Y view might be useful? And what kind of dislocation? Yeah. A posterior. Yeah, that's good. Yeah, posterior view. It as that characteristic um causes of a posterior dislocation isn't there that we're honed in on at a medical school? It's like an electric shock and things like that, isn't it? Yeah. And seizures as well. Yeah. Yeah. Yeah. Um So which nerve is most likely to be commonly affected in patients with this condition? And what sensory and motor deficits will the patient experience? So, yeah. Any time we talk about nerves or think about motor and sensory, try to be as specific as you can try to think about dermatome, myotomes, et cetera. So take some time on this question um and try to visualize it. OK. Any answer in the chat. David. Yep. Someone said axilla. Yeah. Yeah. That's, that's right. Yeah. And the regimental badge area. Yeah. Mm mm Yeah. Yep. So axillary. Um So that will cause yeah sensation to the regimental badge area and loss of abduction due to paras of the deltoid and terry mind. So, yeah. So um it's quite important the axillary nerve. Um it's always good to know about it in, especially in shoulder trauma. Um But yeah, so, abduction uh because the deltoids require, do you know the muscle um that's required for the first part of abduction. That's a common um SBA question that co that's come up a few times one of the rotator cuffs. Yep. Someone says super Spinatus. That's good. Hold on. Yeah. So it's also noted that there's a Hill Sachs lesion pre present. What is a Hill Sachs lesion? So I remember trying to get my head around this at medical school um in third year, once you got your head around it, it's OK. Um Someone said a lesion on the humeral head. Yup. Yeah. So it's basically, it's a poster lateral humeral head, depression fracture resulting from the impaction of the anterior glenoid rim. So when, so basically, when there's a dislocation, I tried to describe it, the obviously the head comes out but in that process of that happening, um there, there's always a slight, there can be a slight fracture on the posterior lateral humeral head as it's just clipped the glenoid, the anterior glial. So try to visualize orthopedics that makes it a lot easier but well done if anyone's got that. Um So what other lesion um is, is associated with a hill sex lesion? Describe what it is. Mm So if you ever see a shoulder arthroscopy. Um We don't get much exposure to shoulders when we're in. Um Unless you would like a shoulder consultant on a shoulder arthroscopy, you'll see it with someone with rotator cuff damage or with recurrent dislocations before they have a stabilization procedure. So anyone, someone's Yeah, someone's Yeah. Bangar. Yeah. Yeah. Yeah. So Bang. Yeah. So people call it bony bang. Bang. Um What is it? It's basically uh the glenoid labrum. Um it is torn following impaction of the human head against the glenoid. So yeah. So it's, it's, it's basically it makes the stable, quite un the shoulder, quite unstable because the labrum is obviously involved in keeping the, the glenoid and the humerus articulating. So it deepens that and obviously the glenoid and the um humeral head don't articulate. I think it's about 30% articulated articulating service. That's what allows our shoulder to have so much movement. So, yeah, Bangkok lesion and Hills are very important to just uh just have awa awareness of what they are. So the patient returns to A&E multiple times with recurrent shoulder instability. What's the definitive treatment? Am I giving this away? Am I bad? So, yeah. So, surgical stabilization. Um I don't know if anyone has seen this procedure. It's quite cool. Um What they do. Sometimes it's tend tend to be done with a rotator cuff repair. It usually stick sutures through um pull muscles together, make the whole capsule quite tight. Um So you do watch it, um, or watch some, watch it on youtube. Um, it's quite, it's quite an interesting procedure if you're interested in shoulders so well done guys. Those are my two ca, uh, cases that David's kindly, uh, written out and, uh, um, will hand over to David now and, um, all right. Yeah. Yeah. And you, uh, you crack on, uh, the only thing is because I'm sharing my screen. I won't be able to um see the chat. So OK. No worries. Yeah, I'll keep an eye on that. Is that right? Yeah, that's fine. Yeah, no worries. Let me just get up here powerpoint. So I'll read the scenario if you want to. Uh No, it's OK. Yeah. So um a 30 year old male presents to A&E with sudden onset pain, swelling and limited mobility in the midshaft region of the upper left arm. This was following a work related injury where a forklift drove over his arm. Um radiographs show a midshaft fracture. So, um the first question is it is an open fracture. What are your initial management options for an open fracture in A&E? So it's four marks. So give, if you can get four points in the initial management of a patient coming in with this presentation, just give her, give the chap some time to answer. Yep. Someone said remove your February. Yeah, that's good. Um And tetanus vaccination status. Yeah, that's good. Anything else? Um No, there's nothing else. So, that assess neurovascular stasis. Yeah, that's good as well. You have a look. Yep, I can look at the answers. So, um, so you, it's open fracture. So you're gonna be worried about any sort of infection. So you want to do, give BS fracture and IV antibiotics. So, a tetanus tetanus, uh, vaccination status. So, yeah, you also wanna give that prophylaxis as well. Um, and whilst a and if there's any, you know, severe um displacement, you want to just stabilize it briefly, you know, using a splint, a brace or uh traction, you wouldn't want to remove obvious debris in A&E because it's not a sterile environment. So, um you could, you know, you would rather use some sterile saline soap dressing on the wound. So you'd get some um some swabs or some of that um dressings and then put that in saline, cover the wound just to cover it. So nothing else gets in. Um you would want to do irrigation. Um I and D so incision and drainage uh within a steroid environment. So that would be in A&E um in, in theaters and you'd also want to take a picture of it as well. So um if, if there is any need for plastics to get involved, if the wound is very big, then you'd want, you don't want to be constantly removing that dressing. So taking a picture is important to show um other departments like vascular surgeons or plastics. Um What the, what the wound looks like it looks like without having to remove that um that dressing constantly. Yeah, that's great. Yeah. Uh Next question. So uh name the classification given for open fractures and describe each type. So, yeah, Castor Anderson. That's good. Yeah. Yeah. So, yeah, so that's good. Yeah. So you've got um uh well, you've got three types and then some subtypes in the type three. So your first type one is a puncture wound. So that's just a little bit of bone sticking out. The wound is usually less than one centimeter and there's minimal soft tissue damage and minimal contamination. So this isn't, you know, very complicated to treat. Uh A type two would be where the laceration is more than one centimeter but less than 10 centimeter. And there is a bit of moderate soft tissue damage and then moving on to type three is is when the laceration. So the puncture wound or the wound, sorry is uh bigger than 10 centimeters. And because of this, that would be extensive soft tissue damage. However, it's a type a because there is still adequate bone coverage. Um whereas in type three, it's um it's worse because there isn't this adequate bone coverage and you've got more bone being exposed um due to loss of any tissue. And in type C, this is when any fracture has any vascular injury and this is when you would get vascular surgeons involved. So any vascular damage you would uh classify that as type three C and um as well. You want to, yeah, check for neurovascular status as well. Um Yeah, great. Thank you. So, yeah, there's a diagram showing you the, the three types. Um So yeah, you can see in three A um you'll be able to, um would you start fixates it with pins and plates or if required a external fixation and then you'd be able to just um close that wound up as there's a, there's enough um soft tissue, there's enough coverage. However, with three B and three C, you can see a big chunk of soft tissues being removed. So you would want to get plastics involved in this and maybe require like a skin graft as well, possibly. Yeah. So um next question. So which nerve is commonly affected in this type of fracture and what associated symptoms would be present? So, any ideas? Yep, someone said the radio nerve with wrist drop? Yeah, that's good. Um And then does anyone know what uh area sensation loss would be present? Nope. So, yeah, we can move on. Yeah. Yeah. So yeah, as someone's correctly said, radial nerve, so we're thinking midshaft fracture of your humerus. So that's the radial groove and then you've got um loss of sensation in your dorsal surface of your radial. So that's your um your lateral 3, 3.5 fingers on the dorsal surface. Also the posterior arm and forearm will have lost sensation and you have a lot of wrist extension which would cause that characteristic wrist drop. Great. And the orthopedic surgeon performs a an or if so open reduction, 10 fixation 24 hours after surgery, the patient reports excruciating pain, which is worse on passive movement. What has happened? And what is the treatment option? Yup. Yup. People who had compartment syndrome? Yeah, that's great. And then what, how would you treat this? Ok. Fasciotomy. Yeah, that's good. Yeah. So um a classic presentation usually after um um yeah, usually after a fracture you've got um increased pressure within your, your, your, your compartment and that causes compartment syndrome. Um And then does anyone know what other symptoms might be uh might be present week? So you also wanna think about um kind of connecting this to vascular surgery. So you wanna be thinking about your six, your six ps or is it five ps. So you want to be thinking about pulselessness, paresthesia, paralysis. Yeah. Progressing to limb ischemia. Yeah, exactly. So that's when you, yeah, really want to um send get them into theater and get a fost foy. Yeah, great. And that's end of the three cases. Um Yeah, great. Um So yeah, if anyone has any questions or anything that they would like, you know, like us to go over, please put in the chat. Um So yeah, can start with the first SBA. So um a 21 year old male is stabbed in the axilla. A surgical expiration is performed and a bleeding artery is identified and repaired. So, when does the axillary artery normally become the er brachial artery? So you've got four options at the inferior border of the subscapularis, at the level of the fourth rib, at the level of the intertrabecular groove of the humerus or at the border of the lower, the lower border of the teres major. Nice. So you in D That's great. Yeah, most of people put D So yeah. So, and does anyone know where it become where the auxiliary artery becomes a subclavian subclavian artery by any chance put in a child? So, yeah, at the first rib, if I'm not mistaken, the first rib, that's when the subclavian artery becomes the axillary artery. Nice. Um Next, next question is a 25 year old patient presents to the emergency department after sustaining a forearm injury. On examination, there is a fracture of the ulnar shaft and dislocation of the radial head. What is the correct term for the combination of injuries? So, we've got your Galiazzo fracture, your Monte fracture. Barton fracture and Smith fracture. So, yeah. B that's good. Yeah. So um oh not B A Yeah. Um Yeah, it's a because um that's so Dizi Fracture. Um I know I'm wrong. It is meant to be, it's meant it's meant to be I highlighted the wrong one. It is meant to be Montegue fracture. Yeah. My bad. So, it is meant to be. Yeah. Yeah. My bad. Yeah, it's meant to be there. So yeah, whereas a giai fracture is your um um oh no, it's not. That's the wrong wrong diagram um of radio head. Yeah. It is actually meant to be a um that's that diagram is wrong. So yeah, with a giai fracture. It's your ulnar shot. So that's your um proximal ulnar and then your radial head dislocates. Whereas in the Montag fracture it's your proximal. Um Oh no. Oh no, I am wrong. It is b it is b Yeah, I am wrong. So, yeah. A is actually your distal, yeah, distal radius and then your radio ulnar joint dislocates. So it's actually b and then a bar of fracture. Does anyone know what barter fracture is? So, a Barton fracture is um a fracture which is um similar to AQ. Yeah. So, yeah, Monte. Yeah. Yeah, it's a proximal radius. Um So yeah, your bar fracture is, is an intraarticular fracture and it's similar, but instead it doesn't go all the way through your um your radial bone, your radius. And then a Smith fracture is what we've talked about before. Um where you fall out, fall on an outstretched hand. Yeah. Yeah. So with, with these, with these fractures um with wrist fractures especially at third year level um just be, be a, just know er Smith's collies like in and out, in and out with the, with the Galia and montague fractures have a, have an awareness of them. Um More than, more than anything. Yeah, great. Um Question three, a 35 year old patient sustained a fracture of the surgical neck of the humerus, which blood vessel is most commonly at risk for injury and this type of fracture. So, you've got a brachial artery, subclavian artery, ulnar artery or your axillary artery. Yeah, we've got d Yeah, that's right. Yeah. So your axillary artery. Yeah. So, um that we talk. Yeah, that's good. So, it's quite similar to um your auxiliary nerve in a, in a dislocation of your humerus. So you can see here that's in the axilla, axillary artery. Nice. Um, a 32 year old female presents to the clinic with complaints of pain, swelling and limited range of motion in her right shoulder. On examination, there is tenderness over the acromion, clavicular joint and painful abduction. External rotation of the arm is noted. What is the most likely diagnosis? So, you've got rotator cuff tendonitis, frozen shoulder oa of the glenohumeral joints or tennis elbow. So, any ideas? Yep. So, yeah. Yep. So that's right. Yeah, it's b so it's adhesive capsulitis, capsulitis. So, um why is it? So, um on. So it won't be rotator cuff tendonitis because that presents more with tenderness. They, they would put um complain of tenderness around sort of the rotator cuff insertion point. So that would be the er greater tuberosity of the humerus and pain as well would be more, uh, they would complain of pain when lifting their arms over their heads. So, reaching for things on the shelves, things like that. Um, for frozen shoulder, the highlight on the painful abduction and external rotation is important. So that's commonly seen with people with, uh, adhesive capsulitis. Um, it's not, not likely to be osteoarthritis because, um, that would be complaints of, mm, um, uh, capitis. It would most likely be worse after some sort of movement. Um, so worse off to exercise or after a long day, uh, at the end of the day, that would be kind of pain then and then it's not too because, um, tennis elbow is affects your lateral, upper, upper condyle of your, of your humerus. So, um, there'll be pain around your elbow in that lateral aspect. Yeah. I, and then, uh, finally a 62 year old female presents with pain and stiffness in her right hand, especially in the mornings. Um, along with noticeable swelling and tenderness in the base of her fingers. On examination, you note the presence of herb's nodes. What is the most likely diagnosis? So, it, is it a carpal tunnel syndrome? B osteoarthritis, uh, C rheumatoid arthritis or D gout. So, yeah, we got people saying b yeah, that's good. Yeah. So it's osteoarthritis. So, um, does anyone know what joints herb knows, affects which joints specifically? Uh, not, no, not quite the MCP. No. Is it P I PJ. Uh, yeah, I think it's the distal, yeah, distal, we had distal to go into your joint. Yeah. So your P IP is your, uh, Buchard node. So, um, so it's not carpal tunnel syndrome because that, you know, affects your, um, the nerve, your median nerve. So you'd get tingling numbness in your, in the palms of your hands. Um, it's not rheumatoid arthritis because despite the fact that, uh, the patient complains that the pain is worse in the morning. Um, osteoarthritis, even though characteristically, I'm a expert, people say it's, you know, worse at the end of the day after exercise, osteoarthritis can still be worse in the morning. However, it usually goes away after, you know, 30 minutes to an hour. Um, and, um, osteoarthritis as well commonly affects the distal phal joints. Whereas rheumatoid arthritis most commonly affects the metacarpal pharyngeal joints and the proximal inhal joints. Um, as well ra um, is a symmetrical, usually symmetrical presentation. So, um, in this, in this case, the, uh, the patient complains of stiffness and pain in the right hand only. Um, whereas rheumatoid, you kind of see him in both hands symmetrically. And, um, you'd also notice more systemic issues as well in rheumatoid arthritis such as scleritis or uh interstitial lung disease. And then it's not really be gout because gout commonly affects the big toe, the ankle, the knee, the knee. Um, and you'd also get quite a sudden onset as well as uh fever and night sweats also and gout. So yeah, that's everything. And if you guys want the um answer to the slides as well and or just give us, you know, any feedback. So this is our first session. Um uh Yeah, I didn't realize it would be, it would run that quick. So I think for the next session, I'll probably add a few more, a few more cases and a few more questions as well. Um But yeah, if you guys could fill this out, yeah, greatly appreciate it. And if you guys have any questions as well, put in the chat and we could uh answer them is the QR code not working. OK. Should I go? Uh If, if you are, I was not working, uh David, you can perhaps um copy and paste the link. Yeah, perhaps be able to do that. Um Yeah, thanks everyone. Um It's our first session um of doing teaching series like this. Um You've like honestly been really good. Uh David, thanks for the slides. Um And, and I'll be honest, um, uh, the slides are very, they replicate how er exam questions are. So I appreciate there might, there may be one or two discrepancies in answers and things like that compared to my scheme, but obviously we don't get them. So, um my advice is even for SBA s um do what David does try to. Yeah, I know on pass me and things like that. So easy to just be like, it's that answer, try to actually um use your clinical er, reasoning to be like, why it isn't the right answer is that it is wrong. Uh Rather than getting into that, that scapegoat of just going through things like past and just trying to do all the questions you can, it's, it's actually trying to understand the content cos that's where Sa Qs can kind of catch people out. So, um, next session is, er, two weeks today on the 26th and it's on hip fractures, probably one of the most important orthopedic fractures that come up in medical school exams. So, so stay tuned for that. We'll put the link out, uh and we'll put a post out on Instagram. So follow us on uh your sock. Um if anyone wants to reach out, do a session, um and obviously we're running this every two sessions, but if anyone wants to do something on to something totally different, um for sure, we're a blank canvas. Um, just reach out uh DM us and we'll, we'll figure something out. Um And yeah, so this, this teaching service will run up till May and that hopefully is, um, before you guys have your exams and we'll hopefully do like a bit of an ay station as well. Um Perhaps that might be a useful thing to add in David for the next week session. Just add in a bit of a um, yeah, definitely. Yeah. But yeah, for upper limb, I think from, for my, for my uh knowledge and understanding, make sure, you know, your um dislocations of the shoulders. Uh make sure, you know your um nerve anatomy um and uh sensation and dermatomes. Uh make sure, you know, um make sure you know your wrist fracture types and the risks of scaphoid fractures, um uh complications and like the nodes. Um because that links with rheumatology. And so the med school exams are all about linking things together. So um it's all good to uh it's always good to do that as well. Um Is there a link? Is the link in the chart? Now? Do Yeah, I put a link in the chart. Yeah. So just let me know if it's not working and I can try to sort it out. Um But yeah, and if you just put in, fill out the link, then I can, we can send you the, the slides of dances and stuff. Yeah. Thank you everyone again. Yeah. Lovely. I'll stop sharing. Yeah, I think for the next session I'll probably probably add a few more S AQ cases as well. Um Yeah, yeah. Why? There's, there's plenty of time. Um And obviously this is the first day it's a bit of a trial run as well. So um yeah. Wicked um lovely stuff. Um Cheers for taking time out of your Tuesday evening. Um and again, uh yeah, so what will happen with this recording is if there's anything you've missed, um, it all gets recorded and it gets put onto the, um our page or medals or whatever you used to sign on. Uh If you just click on our, our page link, um, there will be all the recordings that we've done before and now, um, so if you wanna listen to something that you might have missed or feel like I can't make it, I'll listen to the recording then. Fair enough. Um, so it's all up there as well. Wicked. All right. Awesome. Yeah. Thank you, everyone again. Bye bye. Ok. I, I'll, uh, I'll end the call here, David and I'll, uh, I'll, I'll, I'll touch base with you during the week. Yeah. Yeah. Perfect. Yeah. Great. Awesome. Thank you. Thanks everyone. Good bye. Thank you.