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Yeah, hello. Can everyone hear you? They hate each other? OK, thank you. Um Sir, for delay in the start, you have some technical uh issues. Um So today's uh session is uh uh and, and wri wrist fractures. Uh But I think due to the uh the volume of the potential things to cover uh will mostly be limiting uh today's session to dister us, you know, be essentially wrist fractures. Uh and then to avoid uh this, you know, this session uh being unduly prolonged and we organize a different, you know, session to continue and uh extensively delve into and injuries. Uh I invite his uh speaker to share this career and get going the uh can you see my spin? Um Sure. Can you see my screen? Um uh it's done. I think it was coming on but um we can't see your screen. Uh I think it's just your dex of uh I think what it's, it's telling me to either share entire screen, share window. Uh But then it's not showing allowing me to put the, the window that I would like to share. That makes sense. So that option is not there, let me uh because II think what we would usually ask you to do she entire screen the the to of the entire screen and so ship the entire screen. Yeah. Yeah. Can you guys see anything right now? What I think? Yeah. The cream. Yes. Bo bo No. And then if I do that, yeah, that comes on. Can you see the screen now? Yes, I can. Ok, good. That's fine. I just wanted to check that. So, and then I'll just put uh my uh video on. Can you see my video as well? Yeah. OK. I good. OK. Are we good to go now? Good. So, uh morning Yvonne, my name is uh Stanley uh Mauna. I'm gonna be discussing uh uh this story with you guys. Firstly, I would like to thank me and uh Mr for inviting me once again to come and speak to you. I discussed with you guys regarding these injuries, uh which are, I think uh in our profession are very common and we tend to see on a daily basis. So it would be good for anyone uh with any interest in orthopedics just to get an idea of uh uh uh the principles behind trying to manage these uh patients. The objective of the course would be obviously to go through the introduction, a brief touch on anatomy and then uh discuss how patients typically present. We'll go through the imaging of uh these uh fractures, which is mainly gonna be xray based treatment and uh the complication that may might arise. So, as an introductory note, we know that in the UK UK, we see uh more than 1/6 of the fractures that we see are de the radius fractures. Uh So they are quite common and the incident has been increasing from uh two people in uh about 1000 rising to about 12 people now in 1000 in those who are uh over the age of 85. And I know uh typically, when these were usually described in the past by colleagues and, and colleagues, uh they were mostly seen in postmenopausal women. So there is a, a high uh uh I think uh uh incidents in females as compared to males as uh demonstrated. Uh There we do get a bimodal uh distribution. So in younger patients, it tends to be a high energy mechanism. Whereas uh in uh older patients, uh it's usually just uh a simple form or low energy mechanism uh on the anatomy. Uh So basically, uh the part we're, we're trying to describe if you can see my cursor is just about from the joint line to just about where the images show that that's the distal radius part. We, we're trying to look at which is uh the lower third of uh of the radius and uh some important and features uh maybe to be aware of uh the radio of dite which would be very important uh when looking at uh uh these injuries because at times it can inform stability or instability of the fracture. Uh It's also important to look at the distal radio ulnar joint, which is an important aspect as well, which helps you uh get a picture of uh how stable or a fracture is or how well you've reduced it as well. Uh looking uh from the dorsal side or which is the backside of uh of the fracture o of the, of the di of the distal radius. Uh I think an important aspect to look at is the uh dorsal tubercle of uh of, of the radius, which is the list of tubercle. It is important mainly because of uh just the way it is. And we know that the, the uh E PL or the extensor policies are long as tendon winds just around there as it goes to uh to insert in the thumb. So it's just things just to be to be aware of. I know we typically call these fractures, risk fractures. But what we tend to mean is fractures going around just about the distal aspect of the radius. Although we know that the, the wrist, uh specifically speaking, would be this radar uh uh joint. But then uh I think when you say wrist fractures uh from, from, from henceforth, we will be describing to fractures around the distal radius. Uh and then uh also just other important things to know the volar side means the front. I know you already know this and then the dorsal side means the back, which is what will be. Uh I think the, the, the are the terms that we tend to use as we describe these structures. Uh simple radiological anatomy. Um The X ray that we used to, we usually try and do our pa s so from the back, uh the x-ray being, being shot from the back to the front, which so shows you what you can see on the left side here uh of the SP and this is the lateral view as well. Uh And, and basically what you're trying to see looking at this uh important uh uh landmarks that uh can help you determine uh how the, how uh the dis alignment uh looks. And what I mean by that is uh there, there's uh there's about three aspects that we try to look at. So we try and measure what we call the uh radio height, which is uh a distance from the tip or the top of the radio styloid to the bottom of uh the, the radius just as as it uh joins uh the distal radio ulnar joint. That distance is usually about uh 11 millimeters a and then we have a radio inclination which is uh an angle from the tip of uh uh the radio sky uh to just about uh there. If you draw a uh uh uh a transverse line, which is uh that this angle that you're looking at should be about 23 degrees. And then when you look at it laterally, so if I should do move back, so what we've been described is the angles you can measure on the pa X ray, the radial inclination, the radial heights uh and then on the lateral view, you're trying to measure uh where the the radius is facing is it vol facing, which it usually is, which is a, a 10 degree angle. So if you draw a line from the top tip of uh the dorsal aspect, the back of uh sorry, the back of the wrist, if you draw a line from there to the top of the volar aspect of uh the uh the distal radius. Uh and then you, you make an angle through there that should be uh 10 degrees, meaning that the, the, the radius is not always facing straight, it is slightly tilted by 10 degrees facing to the front or facing vol. And those important uh I think the, the way to remember it for myself, II usually say 11 times two, so 11 millimeters, 11 degrees times 2, 22 degrees, 22 degrees of uh radio inclination. It just makes sense. And I've, I've always used that. So I think for, for people who uh don't want to uh to, to be working a lot, you can use that uh to, to help you remember these uh these angles and uh and measurements. Uh So patients usually present, uh uh mainly we see all elderly patients in, in our, in our population, well, who had a simple fall. So they've either tripped and fallen on their outre hand. Uh And then, uh they come in uh with the typical what we call the dinner for called structure, which means uh the hand seems more to the back and the, the rest of the arm seems likely to, to the front. So almost like a picture like that. But then you also tend to, it does uh occur as part of a high mechanism of injury, which is also very important uh to anyone working A&E and orthopedics, uh because you should treat the patient as a whole. So make sure that uh we've gone through those uh ATL S uh ABC S to make sure that uh we've ruled out any life-threatening injuries uh, before we do anything else, uh for the patient, because it's well and good to fix the fracture, but it, uh it is not uh helpful to the patient if you've missed a, a lifethreatening uh injury. Uh For those who have just come in with an isolated fracture, they usually uh complain of a swollen, painful and uh usually often uh deformed uh wrist that you can see clinically. Uh like I said, you have to rule out any other injuries. Uh I think another important aspect is to rule out any associated neurovascular compromise, particularly in the median and the ulnar and the radio nerves. And uh you can do this quite uh uh simply by uh checking for the sensation and the, and the movement. So the way II tend to do it is looking at uh uh the first web, the dose of first web space, just delete uh the, the radio uh nerve and then uh the, the, the tip of uh the index finger and then the, the, the er for, for the median nerve, sorry. And then the uh the oh sorry, the radio tip of uh the index finger depicts uh the median nerve and then uh the ulnar tip of uh the little finger just depicts uh the ulnar nerve and then simple movements such as uh OK sign. Uh you're bending the uh I PJ in the, the from the thumb and uh D I PJ from uh the index finger which uh is supplied by the median nerve. If you ask the patient to open or make a paper, uh you are measuring uh the, the nerve as well and they just simply a asking the patient to extend their wrist or, or, or, or their hands helps you measure the uh and assess uh the radar nerve. And uh also very important uh I think to uh identify and document any associated uh soft tissue injuries. So uh if there is an open wound, uh you really need to uh address it, identify it documented together with the neurovascular status of the patient because that will determine how this patient is managed. Uh Ultimately, so when you are assessing and treating these patients, you want to uh consider their age and their level of activity. So the way you treat a patient who is uh 99 years old with the steroid structure, who is basically uh maybe in a care home being looked after, not very mobile would be very different to uh a business executive in London who's uh in a minute that is in a higher, high uh high functioning uh job. And you want to know uh if the patient is right-handed or left-handed and particularly what they do. Uh This becomes a very important aspect if these patients who do uh a lot with their hands. So either sports uh sports people uh or, or, or or manual laborers, they, they would really be keen to try and get a AAA highly functional uh wrist as uh as soon as possible. You also want to look at the nature of injuries as discussed before, whether it's a single bone or polytrauma. If it's a polytrauma patient, then uh you prioritize life-threatening injuries first and then progress down towards uh less uh life threating injuries. And it's also important to have an open and uh honest discussion with patients regarding their expectations, uh fractures that you might think need surgical intervention. Some patients might they have very, very strong feelings to say, you know what uh doc II would rather you just leave this uh as it is because uh I just do not want to have surgery and some patients might have very strong feelings towards uh having uh their, their fractures surgically fixed fractures that you feel shouldn't be uh fixed surgically. So that discussion and, and relationship with your patient from the start is very, very important. You also want to look at the images and look at the displacement of the fracture, more severely displaced fractures will obviously warrant uh a bit more uh treatment as than just a simple conservative pull and uh and immobilized uh whereas just simple undisplaced fractures might just need AAA wrist splint. So I think it's just things to consider as you're seeing the patient, as you're looking at the X ray from the start just to try and categorize what you think these patients uh might uh might fall into. And uh the mainstay of investigation from our side uh is mainly X rays. And you should always remember the rule of twos. You should remember that all these patients when they come, they require two views of x-rays. So it's not good just doing an ap because just a simple A uh a pa X ray might not show you the full extent of the fracture. You want to make sure that there are two joints that have been x-rayed. So the joint below and the joint above. Uh you want to make sure that you get two clinical opinions. Uh either from a colleague or a senior colleague. You want to make sure that uh these patients are usually x-rayed in two occasions. Uh Usually we tend to do, do that quite uh quite routinely in, in, in, in our unit. So we echo the patient when we, they come in and they initially present, then you can always x ray the patient after you usually put a, a back slab as well. Uh But then if you still have uh concerns, particularly in Children, you can always uh uh x-ray both limbs. Although I think uh we get a lot of from the radiographers and the radiologist in terms of uh X ray exposure for, for kids and uh for patients who require uh surgical intervention or patients that are not completely clear about uh the full extent of the fracture. You can always do act scan and that helps with the surgical planning in terms of uh what approaches you're going to use and how you're going to fix the fraction. And also looking at uh intraarticular involvement uh of extension of the fractures to see which fragments are being affected. And, and how, how best uh you will need to to immobilize uh and what systems you're going to use and principles. If you uh then give an X ray for of a patient with a distal radius fracture. Uh there is no need to be afraid. You have to try and uh uh describe it in a systematic way. Looking initially at the most important thing. Are you looking at the right x-ray? So the adequacy of the X ray, you want to look at the bone, look at the cartilage and to look at the soft tissues as well. Uh So the ABC S uh rule of looking at uh uh bone uh uh bone x rays uh is always important and handy to try and use so simple things. Uh If you're looking at the adequacy, you want to see, is it the right patient you're looking at? I know it sounds pretty simple, but uh there's been times when you know, you probably also know where people have looked at the xray, wrong x-ray come up with a marvelous diagnosis. Uh But unfortunately for the wrong patient, uh you also want to look at the age of the patient, the hospital number and the date is very important because some patients might have previous x-rays, a similar fracture, uh or or a different limb. So it's always good just to make sure that you're looking at the right side, look at the views, look at the dating of the imaging as well, look at the the location. So you want to describe the bone that is involved. You want to look at the position, is it happening in the distal aspect of the radius or approximately. Uh You want to describe if this uh fracture is complete or incomplete. You want to use terms such as is it a simple fracture or is it a complex fracture? Uh There's some important aspects that you're seeing from the fracture uh is the radio length now uh shorter. Uh How is the apposition of the fragments? Is uh one fragment completely uh offended or is it, is there any rotational deformity that you can see? So all those uh simple aspects of uh the displacement are are important to, to describe and you have to move on and describe any cartilage involvement, particularly important in kids who uh if uh whose uh growth plate are still, this is the point that are still growing because that determines again how you want to approach and and fix that and treat these fractures, soft tissue involvement. We've talked about you want to look at obvious swelling emphysema and at times, you might see uh a bit of uh bone poking through the skin. Uh So you can also describe that I can conclusively give you an idea if a patient has an open fracture. But oftentimes open fractures are just uh a clinical diagnosis that you have to note in the, in the and document. So uh as an example, so going through the a so in this patient, we know that there are no obvious, there is no obvious uh it's not a, it's not an adequate image because we can't see the patient's name. We can't see the date of birth. There is no obvious uh time when this was done, but there is indeed the the side. So, you know, it's the, it's the right side. Uh And as we look at the bone, it is a distal radius fracture. Uh And then we describe this fracture, it is what it is displaced uh dorsally. And the way we describe this is we always want to talk about where the distal aspect of the fracture is in relation to the proximal aspect of the fracture. So looking at this lateral x-ray, we know that the distal part is this one as compared to that one. And this bit here is at the back as compared to this one which is at the front. And how I know that this is the back as compared to the front is I always look at the thumb, this is the thumb there and this is the first CMC joint wherever this is this is the front where this is not, it's the back, which is that. So this is a dorsally displaced transverse fraction of the distal uh radius with the what appears to be some commun communication around there. The fracture is dorsally angulated as you can see from there that this carp is meant to be facing to the front, but it seems to be slightly flat or just about facing the back. Uh and you can also then uh discuss that is it, it is not completely uh displaced. Uh But what we can see as well is that there is a, a line which looks vertical and it is quite, it's quite translucent as well extending to the joint line uh as you can see, but there is no obvious step on the joint and uh there is no obvious uh uh gap that you can see as well. So this is just particularly describing uh the the the distal radius. And you can see also commenting on the soft tissue that there is a bit of uh swelling in that uh in the, in, in the soft tissues as well. So this also informs that could this could this could be an acute fracture at this point in time. I know there's a small ulnar thyroid fracture. We'll ignore it for now. But once you describe this fracture, if you describe it in a systematic way such that the person on the end of the phone knows what you're talking about, and then you can discuss a plan in terms of how to treat it. Uh just some simple fractures that uh we will come across in that have been eponymously uh described in the past, we know the cordis fracture is a low energy displaced dorsally uh dorsal dispace, extra articular fracture. So it's a fracture which is not involving the joint and it's extra articular even common in elderly females again, dorsal, dorsally displaced first thumb. So this is the front, this is the back and we know the distal radius is at the back. So it's a distal radius fracture which is dorsally uh displaced. And you can almost see that typical da fork appearance. If you look at the, the soft tissue all the way through there, if you look at the soft tissue uh definition, you can almost see, oh sorry that uh that do that appearance of uh of the fraction. Uh the S Smith fracture is opposite of that. It is a low energy full displays extra articular fracture of the distal radius. So again, distal radius, we look at the thumb, this is the front, this is the back and we see that the as in relation to the proximal aspect of the distal radius is slightly in front. So it is dorsal. It is vally uh displaced. So simple uh low energy extraarticular fracture which is full uh displaced is called a a Smiths fraction. So this is just uh a clever way of uh describing. So if you tell your consultant, just see a 52 year old male patient who's coming after a history of a fall and for a Smith fracture and I think we should manage this da da da, you know, you, you look a bit uh much more clever and uh they'll, I think uh they'll think highly of, of you as well. A button fracture. Now is a intraarticular fracture. And there's an element of dislocation at times of uh of that. So this fracture, as you can see on this lateral x ray, if you, if you come all the way through the posterior uh cortex of the radius to the top, and you can see just about the oops there, the step and it just comes to the front there. So this is the fracture that has been uh fractured, it fractured through the joint and it's displaced volarly as well. So I know most people when they talk about a a Barton fracture, we always think about the volar Barton fracture, but it can also be a, there can also be a a dorsal Barton fracture as well. So again, the way you describe it, if you describe it that way Barton fracture already in your mind, you're thinking about there is something that I need to do about this fracture in terms of fixing it because you have to follow the principles of trying to fix these fractures, all articular fractures. You want an absolute reduction with uh complete uh with, with uh with primary uh bone healing. Uh So you want to fix this surgically. So once you say Barton fracture, you want to think about a surgical fixation. And once you say that to your consultant, they already know what you're thinking about next in terms of how to treat these fractures. So it's just a, it's a good way of describing these fractures. Uh And then showing that uh you, you have a knowledge of uh of how to address them uh going forward, what are the goals of treatment? So, our main goals of treating these fractures, uh I think it, it goes with our reason, we always want to restore the anatomy. But uh after you've done that, you want to make sure that this patient is a, a functional hand and wrist. You know, so you also want to promote bone healing. You allow any wrist and elbow exercise. So whatever treatment you're giving, you want to allow them to start moving their wrist and elbow and you want to avoid complications. Uh I think when it comes to the hand and the wrist, they saw quite easily. Uh And unfortunately, with the hand swelling means stiffness, stiffness means pain and pain means loss of function. So the sooner you get the moving, the better based on the treatment, uh you plan you would, you would have given them them from the start. So again, it's no use to have a good functional a, a good anatomically reduced fracture if the hand is not working. Because ultimately, in the end, we want to restore these patients back to their baseline, to go back to their work, to go back to caring for themselves as well. Uh Then I know we discussed uh the radial height initially, the inclination and uh and uh and the body tilt and uh there are some acceptable radiographic uh criteria that you can look at. So if uh the radio height you want to at least try and fix it and make sure that there's uh less than five millimeters of uh shortening after you sorted it out. And uh radio inclination at least less than five degrees as well when you fixed it as well. Although you want uh uh it to be anatomical as possible. The volatility, you want it to be less than about uh five millimeters in dorsal angulation and within 20 degrees of uh control later uh of the other side of the hand, which is a a part where you feel it might be important when you're, when you're operating in theater to maybe screen the other hand, if you, if, if the hand of the patient doesn't look uh completely normal, but you feel like uh you've completely reduced it. So that can always help to look at the other side as well. Remember, uh we want whenever we're treating fractures to allow for absolute complete reduction. Uh So you should at least have at the very most have two millimeters of step off, but you want it, you want there to be no step off altogether. So you want the the arterial surface to be completely converse. So treatment options, I think in orthopedics, it's pretty uh it's pretty uh straightforward whenever you treat patients you there, there's always an option of not doing anything or doing minimal. So, non surgical or, or surgical and by and large conservative treatment is mainly close reduction plus or minus casting or just casting or just simple splinting as well, depending on the nature of the fracture. So, it's, it's an undisplaced, uh, simple fracture patients coming in, moving their hand, you can just give them a wrist splint and they can go home and they'll be fine. But if it's the displaced fracture, and if it's the dose of a displaced fracture that you think you can fix, uh conservatively, then you should consider trying to reduce it. So the main indications for treating patients, uh conservatively, usually these patients are patients who are elderly, these are patients uh with maybe multiple comorbidities or the fracture itself is minimal space and you feel you've got a good chance of putting it back in place, extra articular fractures uh that are totally displaced, uh can also be treated uh uh conservatively as well. I know there is no hard and fast room and with the experience, you will find that there, there are some fractures with intraarticular uh uh extensions that might end up uh being treated conservatively based on the patient based on uh expectation and based on uh the fracture itself. If it comes back nicely after a reduction, then you might, well, you could try and run, run with it and see how, how far it goes. Uh If you then consider to try and fix uh to this patient conservatively with uh a close reduction. Uh you want to do it uh with the patient as comfortable as possible. And there are different options in terms of uh based on uh settings, based on experience. Uh and, and, and based on different hospital trusts, I know some people just use simple analgesia for that uh which can stretch all the way from just paracetamol ibuprofen. Some people then use uh uh morphine IV to try and calm the patient and control their pain whilst uh they, they reduce uh in some centers, they advocate use of uh a hemo tumor block. So basically, what you're trying to do is usually use uh lignocaine, some use a combination of lignocaine and uh uh marcaine orca which is a bit longer acting and you want to go where the fracture is about 10 mills usually go with uh just palpate. Obviously, you, you want to do as an aseptic uh procedure, clean the area have a feel of where the fracture is and where the step is and you just want to inject just about between the two fractures there and the, the local honest thing and that usually tends to dry and the uh helps with the pain. But uh I think uh in the UK uh the, the, the both guidelines advocate for a, a regional block. And in our center, we use uh what we call AAA PS block. So basically, we put a, a cuff in the upper arm with uh with two. so it's, it's, it's a double cuff uh in the upper arm. Uh And then you put a cannula there and we use prilocaine when you put the cuff in the cuff is to limit blood flow uh past uh past the past the cuff. So that once you put in your, your, your anesthetic, uh Aldo canine, the, it stays within, uh, the lower arm so that, uh, it altogether and you can do it quite comfortably. The patient will not usually complain and they'll be fine. They'll be awake discussing with you and you'll be taking them through the procedure as well in terms of, uh, which helps them have a better understanding of what is happening and then, and what they need to do as well. Uh, afterwards, uh, then some centers, uh, advocate for sedation and in some select patients, particularly pediatric patients, you might end up having to, uh, to do, uh, general, uh, give them a general anesthesia to try and, uh, uh, keep them calm and, uh, and, and pain free. So I know you, I, I'm speaking from people from different, uh, countries and, uh, and different, uh, uh, uh, trusts. So you, you probably will know what, uh, you guys do at your, at your own trust. II don't think there's a right or wrong way but, uh, of doing it as long as it gives you the, the best results. But I know the British uh uh guidelines, the post guidelines advocate for a regional block. No. So how do we reduce uh a fracture? So the main fractures we're trying to reduce uh are the dos uh displaced fractures. Uh So in a patient who is uh adequately anesthetized, either simple anesthesia, hematoma block BS block, which is number one for us, you want to apply or you should not trust him. So usually at least you need three people. You need one pulling the the hand, the other person pulling the around uh the forearm to the elbow and you need someone who is going to apply a cast or, or a back club, whatever your trust do with the acute fractures. So give it about 1 to 2 minutes. Usually I go for two minutes uh with uh uh so sustained longitudinal traction. So you, you want to avoid any jerky movement. So you don't, you just apply simple traction for a bit of time to allow the muscles to re relax. And once the muscles are relaxed, all you want to do is have a feel where the fracture is with your hand over exaggerate the deformity. If it's a dorsal angulated uh dorsal disc space structure over exaggerate, which is putting the wrist out to the back. But maybe you're pulling the fracture side to the back and with your thumb, just about where the fracture is. You want to apply pressure, pressure, pressure and then vly angulate the fracture to try and hit it back in place. Once you've done that, uh you can only deviate, hold it in position. Uh And then a colleague of yours, uh who's applying the plaster can then apply the, the plaster. And you want the plaster to be molded as demonstrated in this diagram vally, uh just about where the fracture site is, you want three point uh uh uh mo so at the fracture site there above and, and, and distally as well, which ho holds the, the wrist, the fracture snugly in place. And once you've done that, you really want to watch this like a hawk to make sure that the fracture doesn't displace any further. So, in our trust, the guidelines are you want to see it, you want to see the patient again in a week's time, repeat, the radiograph, assess the fracture, assess the neurovascular status again to see if the patient is OK. Uh And then see them again in two weeks, time, assess the fracture, assess the patient and to see if the prostate is OK as well if you're OK there. Uh Usually you can then see them again at uh at uh at four, at 44 weeks time, at which point, uh you should be aiming to remove the plaster altogether and give them a lighter rest for about 1 to 2 weeks. So that, that's how we would uh usually treat it and uh it seems to work so far, touch wood. Uh So there are some drawbacks with the plaster. Uh I think the anyone that you might notice with most patients that there, there might be a tightness of the cast doesn't tend to get to the full extent of uh having a compartment syndrome, but it's just something to be aware of that. You can cause a compartment syndrome by applying a very, very tight cast. Also, uh there's what we call if you over fex the wrist as well, when you apply the plaster, you can cause a lot of pressure in the carpal tunnel and you can, that can result in acute carpal tunnel syndrome. And that could also be just as a result of the fracture and immediate sweating after the fracture. So it seems that that you have to be aware of. Uh we know that the fracture came out unite. Hence why we want to see if the fracture is displacing in the early weeks and nonunion, which is less common in these stories thankfully, but you can tend to see them in uh elderly patients as well. Uh I've placed the ep or rupture uh there as a complication. If you remember the uh the list is to that I mentioned there. So at times after the fracture has been treated conservatively, everything's fine patients going home, they're back to work, no problems, everything else is going on. Everything else is is going well, they might all of a sudden wake up one day and feel, oh I can't really lift my thumb up. And because when we treat fractures, they heal by secondary fracture healing, which means you start by, they start healing by with colors first, which then remodels uh and then smoothen with time the times even when these fractions heal. Uh because if it's gone through the lisus tubercle just about where the fracture or where the ap tendon uh winds around, going to the thumb, the surface there is no longer smooth. So it becomes an attrition injury over time as you're moving your thumb, it's it's rubbing on uh on that new colors or, or, or on that new and even surface and uh slowly, slowly the tendon is being uh I think uh torn until it eventually ruptures. So these are less uh uh common acutely but more com but, but then if they do present, they can present uh uh maybe after years, at times after a month, I've seen one who presented, I think after two years uh after having been treated conservatively uh surgical treatment. So I think uh there's a few options of treating these fractures uh surgically. Uh I know in some centers, people treat these fractures uh using percutaneous uh pinning with the K wires. Uh Some surgeons advocate for uh open reduction and internal fixation using uh uh volar locking plate. I know in the past, people used to use dorsal locking plates, but those have uh slowly, slowly fallen out of favor because I think they were associated with a, a high risk of uh of uh ep or rupture or tendon injuries as well. Because if, if you, if you, if you have a look, I think uh the, the dorsal aspect of your, of your wrist is more subcutaneous. Uh And so, uh the, the pace would rub off uh and cause more problems as compared to the dorsal, the, the volar p that we use now. And in patients with uh open injuries or patients with quite uh I would say in the simplest term, smashed, uh wrist fractures, uh and external fixation would be important. It just gives you some bit. If it's in, in a smashed frac fracture, you want to uh give some ligament or taxes just to stretch out the ligament and just to allow the fracture to heal in a, in a, in a reasonable position. It's one of those fractures that you think are very difficult uh to reconstruct uh but also in uh open uh fractures. So, indications for surgical treatment of injuries. Uh If in case, maybe you've seen a patient, you've treated conservatively, but 1 to 2 weeks down the line, it slipped back out of place and you feel like, OK, this is not gonna do very well, then, then you can then rethink uh discuss with the patient again and then offer them a surgical intervention. Uh If there's uh any particular uh combination step gap and, and you feel that this will uh lead to uh radiocarpal uh arthrosis and arthritis down the line, then, then it's something to consider for uh surgical intervention. And there are factors that are significantly displaced uh if they're extra articular or even if they are comminate as well, because unfortunately, it's difficult to hold and uh restore radio height uh in fracture that have significant combination because uh there is no buttress. Uh more uh that, that, that's usually been lost as well. Uh If there's a loss of molar support. So those fractures that I've described the Barton fractures and uh and the smooth fracture that are vol displaced, they tend to uh usually just uh require uh surgical intervention. Again, this is not an exhaustive list. It just gives you an idea of the one that we tend to uh treat surgically, things will be different from hospital to hospital, from uh uh country to country. So, based on uh I think availability of resources, surgical expertise and uh and uh and just uh treatment protocols in different uh hospitals. So how do you do percutaneous pinning? Again, these patients would need general anesthetic usually or original uh block. So, if they have been adequately anesthetized, uh the aim really would be again to go through that whole process of reducing the fracture nicely once you've reduced the fracture and you feel it's in a good place. You want to do this with uh uh uh a fluoro fluoroscopy uh in theater in a very sterile environment. And then you put uh K wires, there's different techniques of doing it. So there's usually gonna be a AFA Kr coming from the radial styloid, uh all the wave holding the, the, the distal fragment and trying to hold it to um the, the proximal fragment as well. And there's, there's usually also another uh wire that comes from the back, particularly in dorsally displaced uh fractures, which acts uh in two ways. Obviously, it's holding the fracture in place. But also you can use it as a frac as a as a wire to reduce the fracture in what is described as a Kanji method. So you can either is basically providing you uh external or extension, blocking, extension blocking of uh of uh of uh of the fracture. How you perform uh the Kanji method uh sorry. So how you perform the Kanji method of trying to reduce these fractures at times is you can go where the fracture is. So if it's, if the fracture is at the back, you just go with the, your, your initial uh Kor can come through the back where the fracture is, you've reduced the fracture and you then ho hold it onto the other cortex that will stop this fragment from pushing at the back because there's something supporting at the back. So that's that's one way of doing it. You can also use the Kanji method if the distal fragment, which is this one is regularly uh translated. Uh you can take a wire uh put it through this uh the fracture fragment on the, on, on the radio side, uh try and reduce and AAA and hold uh the outer side of the distal radio, sorry to try and hold it in place. But these techniques, I think that you will then learn uh as you go forward in your training and uh as you do uh more and more and see more, more, more, more and more of these projects after you've done pinning, uh the aim would be to then uh put these patients in a plaster uh and they can usually stay in a plaster for up to uh six weeks. The aim is to remove these uh K wires at, at, at uh 4 to 6 weeks. And this depends on uh the surgeon as or preference treatment uh plan and their protocols, but usually 4 to 6 weeks is a, is a, is a good ballpark uh number as to when you, you want to remove uh these wires uh a bit earlier in uh younger patients because they tend to heal quite uh quickly as well. Uh And then again, you'd also want to see the patient in clinic clinic again, maybe usually at two weeks to have a look at the wound to do another X ray to see if the fracture is displacing uh and uh in the next six weeks uh uh from the time of the operation. Uh And then if you're going to do an open reduction and internal fixation, I know previously, excuse me, people have described the Hendry's approach. But uh what we tend to do now is we do the F CR approach, which is uh the FK Regis uh tendon. Uh Sorry, excuse me, you, you try to make, make an incision just above that. So I think as you can see uh on this uh uh diagram of uh of the patient making a fist, there is uh on the left side, you can see the palmaris Longus. But if you, if you make another fist quite strong enough, you can see that the F cr is just slightly radio to the Palmaris Longus and you want to make your incision just about there. Obviously, the patient is, this is happening in theater. The patient is anesthetized uh and uh adequately. Uh uh I think uh relax as well. You want to do this with an upper tourniquet to avoid any uh blood flow. But again, that's different surgeons prefer different things. Some surgeons don't use a tourniquet, but I prefer using a tourniquet because it gives you good access and you can see uh the surgical field uh much clearly as you made a uh uh a longitudinal incision just about there uh clearly uh uh dissect the soft tissues quite uh simply until you get to the point where you're seeing uh more of what of this, this you're seeing the brachial radialis, which uh and then uh you're seeing also the palmaris longus and you're seeing the PQ is much more deeper as well. So you want to dissect all the soft tissue until you get to the PQ uh and use retractors along the way. And the, the PQ is the last muscle that sits on the distal radius. So, uh I think if we, if we go back to the first diagram, uh our, our V anatomy that as a demonstration of uh where the P you would be. So the PQ would be more or less sitting just about there and quad, right. So more, more like a square. So it's just about sitting just about there and you really want to peel it off uh the radius uh and then reflect it uh towards the outer side. And once you've done that, it allows you to see the distal radius. Uh And that's when you get to see the fracture. And then depending again on your skills, you then reduce the fracture. After you've reduced, you can either hold it first with AK wire and then you want to fix it with a plate and this is more or less how it's meant to look. So this side here where the mouse is, is the hand and this side here is towards the, the elbow and this here is a flo plate and the kind of plate and screws up we would use. And you can see this is where the fracture would be. And your plate is just basically sitting bang on, onto the, onto uh the radio B and uh ultimately, that's what, that's what you want to do. And this is how it would look uh on x-ray. Uh This is probably a, a few weeks down the line. I think all these images were taken uh from the internet. So I've uh got no claim to how uh this, how nicely or barely, they look, they look very nice actually, to be honest. Uh And then again, what we were saying initially, you can see that volar angulation has been restored. You can almost see that, that, that radio height looks fine as well and that radio inclination looks just about fine and your screws are all inside in a very good position. You can see that, that D I UJ, the Ana is sitting just about next to uh the, the radius there and there is no obvious screws that are trying to penetrate into the joint. There's no obvious screws that you can see that that are trying to penetrate into the joint. So that's holding the fraction nicely in place. And how you rehabilitate. This patient depends again on your center. But the good thing about uh after you die or if and you put a plate and screws in there. Uh You can try and mobilize the patient as soon as possible. So, ideally, you'd aim to review them in two weeks. You want to see the wounds at two weeks to see how they're healing. And at that point, uh, if you put a back slab or a wall slave just for comfort, usually you can take it off and just give them a simple wrist splint. You can encourage them to start doing simple wrist movements and see them again in six weeks for a final uh review of an of an X ray, you aim to avoid uh loading for the first three months. Uh because uh I think uh as you are aware, the fracture is the plate itself uh is not strong enough to, to take the load uh of the, the different things that people might live, particularly depending on the different uh occupation, not altogether, but by six weeks, you are you, you, you should be able to uh to, to pick up a cup of tea or a glass of water. Uh Again, it's surgery. So it does come with some drawbacks. There are risks including uh regarding infection. Uh There, there are some documented uh uh risks of uh epa rupture, particularly with the dorsal uh place, but you can still get it with the uh with the place, but however, very, very rare. Uh I've, I think seen just one case where you pa patient that had a uh I think chronic uh FP O rupture which again, uh uh creates the debate of after you've uh exposed the, the perimeter quadris, do you repair it or do you leave it as it is? There's varying, I think uh school of, school of schools of thought, some people say you have to repair the PQ because then it uh avoid the plate uh uh rubbing on the, the tendons, rubbing on the plate directly. Uh When uh when uh when the patient is now moving their thumb. But I think uh from experience to be honest, it's, it's not very easy to uh repair uh the PQ because it's usually quite torn. Uh It's probably maybe at times even more retracted and smaller and it's, it's difficult to really put it back together in place. But most, most people tend to agree that just covering the plate altogether. Uh After after the operation there is uh maybe not doing a full PQ repair, but just allowing uh you know, some of the muscle to cover the plate might be very helpful going forward. You know, there's a median and outer nerve in the vicinity uh in the radial artery as well. They all need to be protected using the tractors. Uh There is a small risk of malunion. Uh And, and this goes down to principles of uh whether you've not fixed it, you've not reduced it very well from the start or in, in patients with very, very well or very osteoporotic. And the schools are not just holding it very nicely small. There is also a risk of uh screw penetration. So ideally, you want to be certain that your, your, your screws are in the right place. Uh You want to do different views, you know, you want to do uh uh a complete uh lateral x ray uh of your, of your wrist. Then you also want to what shows you the joint line better at about a 1020 degree. Uh If you lift the wrist by 10 to 20 degree, as you're doing your II image in theater, it gives you a better shot of uh of the joint itself to see if the screws are, are penetrating. The joint stiffness is something that we have to worry about. And uh some of the patients end up having uh to see the, the the hand therapist who will help guide them with movement and uh massage. Uh and uh and dealing with stiffness uh of, of uh of their hands that are safe side of complications are always there. So again, you want to avoid doing this operation in patients with uh multiple comorbidities uh who are elderly frail and uh with uh very low uh I think expectations in terms of what they're gonna do with their risk. So it's again discussing with the patient making sure that they are aware of the risks and uh and then making a decision thereafter. Thank you. Uh Any questions? Thanks Stan. Um uh welcome uh questions and clarifications. Uh Please feel free to raise your hands and unmute and ask your questions or if you prefer, you can drop the message in the chat box. Uh And I'll ask the speaker. Thank you. Yeah, I know. I think we've got from what you told me. Uh Sure that we do have a different, I think pool of uh I think uh audience in terms of uh different levels of uh experience. So I can, I encourage you to ask any questions. I think uh we, we are all learning and there is no right or wrong way. It, we can try and find and make an uh an answer together and work together. So feel free to ask the, I think we'll just wait um one or two minutes um to see if any question comes up. Uh Otherwise we can conclude the session. Thanks, Dan. OK. Yes. Um I think you, you must have done uh the third job of uh going through all the uh basic uh bits and pieces. Um I can't see any question in the chart box and I don't think um nobody has, um you know, raise your hands or, or me to ask any questions. I think they, they are gone. Yeah. II thought someone would ask me that. Uh So which fs do you treat with the Ky and which fractures do you treat with? Um Or if, because it's a, it's a, it's a big debate that, that that's going on. Uh And you will find that different centers treat these fucking differently for those we have time there, there's uh there's what's called a, a draft to trial that was done in the UK, I think around 2015, which looked at uh treatment of uh disease, uh disor fractures uh with uh K wires and uh with uh open reduction, internal fixation with the E and working plate. Uh uh interestingly, they found that there was no difference in outcome. Uh And in that uh patients uh did well either way and we know that K wires are way much more cheaper uh than getting a, a fuller working plate. But I think from experience, unfortunately, uh this doesn't completely tally as well because you know that those fractures that are quite communed, uh extra tar fractures, they then tend to reduce in height with time. Uh Whether that then ultimately ma makes the outcome poorer. I don't know. Uh And II think there's a draft 22 trial that is ongoing at the moment which might address some of those questions. So it, it's something maybe to, to think about just, just going if you, you can go through and just, I think it's D ra double ft uh draft trial, something just to read about just if you, if you have any interest in uh this story structures just to, to make you aware of uh of, of why people make these decisions of uh of treating these patients uh differently. Because I II, I'm bringing you some that treat these uh with just Ky and then they, they seem to be happy with the way things are going. Thanks, Miss Masina. Um There's a question in the chat box. Uh it says based on properties in UK, how long does uh an hearted fracture? Uh where you have placed the box lab? Will you ask the patient to come back for a full cast? Uh I presume this is asking about um a fracture that you are managing conservatively. Um You've probably, you, you've put him at any reasonable position in Box lab. When do you want to get him back in to convert to a full cast? Uh That, that's a very good question. Uh I think that that depends. So usually you want to do it within a week so you can bring them back within a week and uh and put them in a full cast. Uh I think in our center, we start all of them, we tend to see them. Uh So the first time, first time we see them, we don't reduce them. We see them after 48 hours uh to within a week and we do the manipulation under beer block and then we just put them into, into a cast altogether from the start. But II, I've worked in different centers where they put them in a back club and they then complete it in, in a week's time. So I think uh that's a very good question because people do things differently. You don't want to leave it up to two weeks because the backlog also doesn't look very nice at two weeks and uh is, is also very loose at two weeks as well. All right, thanks. Uh Mister Rosina. Uh I think there are no more questions. Um I think it's been a fantastic session. Thanks for coming again uh to, you know, educate us on this lovely s quite essential topic. Um There's a follow up question, there's a follow up question for you quick one that uh I think do is, is asking in your trust. What did you do in the 1st 48 hours? I think it's a follow up to and oh yeah, it's all. So it's a simple back. So the first time they come in and that's, that's the advantage of, of working in a, in a, I want to say first world count because they do have a lot of resources as compared to where I started working at home. We, you know, people buy their own clusters here. You can put them in a single back club, you can put them in a uh you can uh you can put them in what, what are called finger traps. Uh initially for about 30 minutes. So you, if you think about a drip stent and then you, there's, there's two finger tongs that hold uh the fingers up and then you put two saline, uh maybe 1222 L of uh Saline on the arm to try and uh just reduce the fracture for a bit. And then you just put them in a back slab for uh for two days. Uh And depending on availability of uh this, uh uh I think BS, we call it a BS block service where they are brought back again to have their facts uh manipulated. So they would come in uh after two days to, to about a week uh latest to have that uh reduced. So the first time just either just put them in a single back slab or put them in a finger traps uh to try and reduce the fracture just a bit if it's overly displaced and then uh put them in a back slab and then they'll come back in uh two days. Yeah, thanks doc. Um I think the other to heart, you know, just like you're quite right here. I lighted that the practice differs across hospitals across uh for um and uh sometimes some of these structures are not too terribly displaced and uh A&E puts them in, in a box lab after uh manipulation under hematoma block, some of them are not too swollen. And uh you find people actually put them in a full plaster and buy a valve, the plaster. Uh you know, we hope that in case you get too swollen, you can comfortably take the, you know, take that off. So, uh you know, it, it's just about doing what is safe. Uh and uh you know, adapting the management plan to the peculiarity of how the patient present a fracture pattern and liver displacement, et cetera. Yeah. And, and, and particularly resources as well because yeah, if you don't really have the resources to do a block, then maybe it's not the right thing to do. If you have anesthetist lying around everywhere and they are happy to, to anesthetize or sedate patients, then maybe that's the right thing to do as well. I think it's just tailoring whatever. However you treat these patients, uh working with them, giving them the choices, discussing the options that are there and allowing them to make a, a decision. All right. Thanks a lot of time. Uh Thank you everyone for attending. Uh I think until the next, next time when we bring you in another session. Thank you everyone. Thank you guys.