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OK, we're live. Thank everybody for joining us. Uh This is uh Mister Irian Sky, uh consultant head surgeon at the North University Hospital who'll be taking us through uh a hand and carpus injuries today, Mister Sky is yours? Thanks very much indeed. Um Guys, welcome. Um I hope you get something out of this. I am very, very happy for you to just chip in at any stage questions as we go along. I will ask um you know, for uh for, for your guys opinions. Um please, again, anybody just chip in, er, you know, have a go have a lash that, that you, you know, have anything wrong from, from, from having a go. So can you hopefully see my full screen, Kareem? Are we ok again? Yes, absolutely fine. O ok. So um this is sort of part um Didac lecture, part kind of um clinical cases to try and prove a point. So, um we're gonna start with this. Um, a patient presents with a painful hand after a rope wrapped around it and it was pulled by heavy branch. He's just like a tree surgeon. I think it was like day three of joining the tree surgery outfit. So he presents to the emergency department with pain in his little finger and he, uh, has these, has these x-rays just these xrays taken. And so we're, we're sort of concerned with the little finger really, which doesn't really have a very good range of movement. And he's referred on to hand therapy because they think, well, that, that's all ok. Um, any comments from anybody just chip in, are they, can they speak Karim or is it on chat box? They can speak, they usually a little bit chat to start with. So go on, somebody have a lash, would you say look painful finger? These are two really good views of the finger or would you say probably need another view of the finger? Anybody want to have a, have a go later? Perfect, well done, sir. So this is actually the later of that x-ray you're looking at and it's quite alarming, isn't it? I think you'll all agree with that and just cast your eyes back at this. I mean, I've, I've, I've given you the copy of the, the sort of the ble co A P but it is extraordinary what can hide on an A P x-ray. I mean, they call it the sort of the gull sign if I go back. Um You know, you're supposed to on oo on the x-ray. See this sort of uh can you see my pointer Karim? Is that, is that there. No, I can't see, I can't see the cursor. You can't. Ok. So, um, it's the seagull sign. If you look on the, you can sort of see the base of the middle phalanx it supposed have but wings and you can sort of see on the little finger, it looks a bit more squashed. But you know what, it, it's pretty subtle, isn't it? So, so you need that true lateral x-ray. And it's really bad how the word true has appeared. I mean, the word lateral is lateral. I want a lateral x-ray, but true is simply saying to the radiographer, please keep trying and don't send them back until you've given me a lateral x-ray. And you got to bear in mind, it can be really difficult for the radiographers, particularly if there's wounds, um particularly if there's multiple fingers involved, then you know, to get a, a lateral is difficult. But you can all see that actually things are not good. Um So yeah, look, I don't know any of you guys guys are cos I can't, I can't see anything other other than, than, than the slides I'm showing on this format. So does anybody wanna have a quick go and just tell me what's wrong with this lateral x-ray? Uh There's a a fracture at the base of the uh middle phalanx of the Bolar surface. It's perfect. 50% of the joint surface and it's sub perfect. And which way would you say it's subluxed, right? So uh for everybody, perhaps the more sort of junior people into orthopedics, it can be a little bit confusing. Like is this a, a dorsal subluxation or a lar subluxation? So this is not a dislocation because some part of the kind of the joint is still touching another part of the joint. So I think we would use the word subluxation here rather than dislocation. And you, you've heard that it's the middle phalanx that's got the fracture line on it and it's gone dorsally. OK. So you always refer to the distal component relative to the proximal component. So this is a dorsal fracture, subluxation of the proximal interphalangeal joint. Now, the comment was absolutely 100% spot on because we've gone on to now estimate how much of the articular surface is lost. And this is really, really super important um because it's gonna give us a clue about how stable it is. So if we pull on this like under a local anesthetic ring block or something and try to do a reduction maneuver, what we need to know is will that finger be reduced? Will the head flip into the decent bit of articular surface or will it just slide out again? Now, in this particular case, he was a late presenter to me um and we managed to rescue the situation and if you look at the x-ray there on the screen, you can see there's a whole bunch of screws and something kind of vaguely going on underneath them. And this is an example of where I had to kind of replace if you like that, that broken piece of articular surface. And it turns out that some of the carpal bones, the hamate bone in particular has a shape exactly like, uh, the, the natural socket of the middle phalanx. So we've taken a bone graft, um, for those who, who've seen done shoulder surgery, think sort of almost like a latter J where you, you're gonna take a bone graft and improve the uh the, the width and depth of the glenoid here. I've improved the, the depth of the middle phalanx. So the message I've written here is if approximal and Phay joint is painful, a specific lateral view x-ray must be requested and you're gonna miss these things on oblique fractures. So, onto the next one, here's another finger injury, we've got an A P and a lateral. Anybody wanna have a go just pipe up, have a lash. What do you reckon? What's wrong with this one? It's an anterior dislocation of the interphalangeal joint? Very good, but it doesn't sound cool to say anterior in hand surgery is Kareem. So what would you sort of, you know, what can you change that to a little? Perfect. So, um, you'll even hear people saying palma at the moment. Most people really don't care if it's VR or palma now to be fair to Kareem anterior is, you know, fine but, but in hand surgery we just tend to use the term palma or vla dislocation. So well done. Kareem top marks. Um, it's a volar dislocation. So can everyone really jam this set of x-rays into their heads? Er, er, Tom, we got you on the call, haven't we? I think it was your voice, Tom. Um, I'm going to pick on you because you could, you know this. Um Tom, how many people tend to get these vla dislocations compared to how many people will get dorsal dislocations. Uh dorsal is much more common. Yep. So well done. So, dorsal, you're looking at 80 80 85%. So the majority of people you see in clinic have got dorsal dislocations or dorsal fracture dislocations. Like the one I showed this is a vla dislocation. So it's very different and, and you can sort of get a bit confused sometimes when you're a busy clinic. Um but it's really, really super important to know the difference. So what injury nearly always happens with a lar dislocation anybody? Central Smith? Perfect. So, is everyone cool that basically your central slip is an extensor is a piece of the extensor tendon. It sits onto the base of the middle phalanx and that almost certainly will be ruptured closed, rupture with a volar dislocation. So the this is why it's just so important to pick them on volar dislocations because first of all, you'll be able to reduce them under local anesthetic just by pulling hard as long as they're within a, within a couple of days sort of thing. So that's fine. You'll get them reduced, you'll stick a splint on because that seems to be a sensible thing to do. And that can be just an extension, could be a bit of lollipop. But what will happen is that the finger will start to decay into a, an abnormal position. And you can see that deformity here in the postreduction film. So here we are postreduction film. Everyone can hopefully see on the lateral, there's a flake of bone off the dorsum of the middle phalanx. But what is happening at the distal phalanx? Anybody is that potentially the action of the er extensors where it's been sort of pulled back and out of position? Oh, yes. Yes. Yes. Absolutely perfect. So, behold and marvel at this and, and this is already a what deformity? And it would get worse if you did nothing to it. If you just told the patient to mobilize, this would get worse. So what deformity would this decay into further? Um That's fine. Tell you wrong. Is that still a Boot Andie? Even though it's not in the incidence of like an arthritic picture, it is a button deformity. You're a, you're a rock star. You don't need arthritis to get a button. So a button can be formed purely simply through a central slip rupture. Now, the majority of patients you see will have inflammatory arthropathy, won't they? So, so often like that's the classic person to have a button or swan neck with somebody with like rheumatoid arthritis and the joint will look a bit knackered. But actually, the cause is nothing really to do with the arthritis. It's to do with attenuation of the central slip. So everybody think the central slip is one bit of the insertion of the extensor mechanism. The distal phalanx is the other bit of the insertion of the extensor mechanism. If you avulse off the base of the middle phalanx, then all the force of the extensors is pretty much focused on the distal phalanx. So you can see in this beautiful x-ray that the patients already hyperextending at the D IP. So they got a flex P IP hyperextended D IP. This is a button deformity and if we didn't manage this, it would decay it into a more extreme version of that. And then the proximal interphalangeal joint gets stiff and they, they get stuck and it's very, very difficult to rescue them once that happens. So it's really simple. If you see one of these, it's a vla dislocation, you always assume the central slips ruptured. In this case, you can actually see it can't you because you can see the bit of bone pulled off the back where the er central slip is. So guys, what are you gonna do for this case? You there you are in fracture clinic patient comes round says, oh, my finger is much better. Still a bit painful, slightly funny shape. But it's a, it's better. What, what are you gonna do for these guys? Er, you, well have a discussion about options but you'd list them to reattach that central, slip your anchor or? Ok. Um, now stay on, stay on, stay on the b up. Um, if you had a closed mallet, how would you deal with that? Yeah, not that you would do, um, uh, you put a special kind of splint on. So, well, guess what it's called a mallet? Splint? Yeah. Yeah, it's a slightly extension. It's a, it's a slight, a slight extension. Splint closed extensor tendon injuries will heal because the extensor mechanism does not retract very far. Ok. It's not like a flexor tendon that might go pinging off up your arm. The extensors are stuck on to you by all the sagittal fibers. So you could take this guy to theater and you could put an anchor in, but actually you don't have to, that's actually a bit extreme and, and the risk of that is you kind of create stiffness or you got, er, any other option? Could you do sort of like a reverse management then? And, um, yeah, you just do that. Alright, brilliant. So you just basically keep the finger in extension. Uh, it's called a B Splint regime and your very helpful he, the department know a lot about button. They know a lot about how nasty they are to deal with and any hand therapy department should have a regime where they basically stick an extension splint on. So you don't need to hyperextend. You can, it can just be neutral. You put an ex a splint on and they wear it all the time. Now, look, can you see that the distal into phalanx joint is kept free? Right? So you want them wiggling that D IP and that helps the lateral bands kind of excursion. So a volar plate equals a central slip rupture. Sometimes you'll see it with a flake of bone. Sometimes you won't. But if you see any volar plates, you just refer them all for a boot on your splint regime. Now, if you want to spend ages trying to assess if their central slips intact or not, feel free to do so, but it's a slightly dangerous slippery slope because personally they all just get sent for a boot regime. Splint which is four weeks in a splint. And, and as I said, if they get into a bouton, then the palm of plate contracts and they get a fixed flection deformity before you know it. So basically voter dislocation central stick of just send them off for a splint. This is a closed extensor tendon rupture just like a mallet finger. You put that in a splint. Alright. Ok. Any questions on that? Yeah. Could I just ask my name's Bethany. I'm an E DS T six. Um, what would you expect us to do an ed with this if they had this deformity after reduction, if we can't get a fracture clinic appointment for a few days, um, just Splint, splint them with a lollipop with their P IP ST straight or put a bit of zimmer on them just like that. Pretty simple. Yeah. Happy with that. So, I think from your point of view, you know, you see a lot of dislocated P IP joints. But the problem is is that the vast majority of them are dorsal and mostly stable. So they just need to be reduced and mobilized basically to avoid stiffness and all the dorsal are gonna be stable unless they've got a significant chunk of articular surface missy. And I'm just about to get stuck into that. So your problem is, is recognizing the vols in a busy, busy environment. And so, um I'll tell you a wonderful story. There was a guy who went to Rane and he had a Bola and he was reduced. He said, thanks very much. And they went Cheerio and they mobilized him just a bit at Bedford and his finger over the course of the next eight hours began to assume a quite a significant bouton deformity and as much as he tried, he couldn't straighten it actively. So he thought this is really wrong. So he got a bit of lollipop stick and he taped his own P IP joint straight onto the P IP onto the loop stick. Cos it seemed intuitive to him that it was a good idea to do that cos something strange was happening that he had no control over. So these new to go to hand therapy, they need to see a hand therapist. It's by whatever, you know, way gets them there. And with the volar dislocation bit of Zimmer splinting and just splint them straight. If you can cut the Zimmer splinting to leave the D IP free. That is brilliant. But basically the finger needs to be splinted straight. You're writing volar dislocation equal central slip. Please see urgently and, and your job's done any other questions? So, with that, Mr, um, when you're splinting it in A&E, so are we splinting it on the volar or dorsal surface? Are we sucking it into the splint or sort of propping it up on the volar surface? Uh, doesn't really matter. Um, I think you can basically, it would probably be more comfortably tolerated on the volar side. Um, when the therapists make their splint, they make it out of thermoplastic material and you'll see that they have a tendency to put the splint on the palmer side and then the bits of tape like a velcro whatever go across the top, but they'll make a sort of more of a troch if you like slight, slightly free on the dorsum. I think if you think about it, the dorsal skin's quite thin and also the site of the rupture is dorsally so it's a bit more tender to press on. So, if you're gonna press probably on the palmer side, er, it is the, is the better way to do it. It, I mean, at the end of the day, certainly in no Norwich, you've got a great hand therapy department that you, as you're just splinting them straight and you're getting them off to the hand therapist. You can do that via the virtual finger fracture thing or you can just do it via a white list. Is that ok? That's great. Thank you. Does it. So that's your Bolas and I bring that up because it is rare and welcome to hands. So hands has got all these stupid little things that are rare that you just have to have a bit of an awareness about and voter dislocation, central slip injuries is one of them. You might not see one for a year and then bang one is gonna come along, right. So another case now, um cricket ball finger injury onto the tip and this is actually a decent set of x-rays, isn't it? It's, it's a fantastic set of x-rays, wonderful clarity. So, um repetition is always good. Um Anybody wanna just tell me what is the diagnosis of this index finger injury? Looks like it's me again. Absolutely. Repetition. Repetition is really good. The exam has a significant speaking component. So the more you can speak orthopedics the better. And that's, I would encourage anybody listening on, you know, on, on the, on the thing today. Just have a bit of a go, er, er, er, just to try to start to enunciate cos actually it's quite hard stringing the right kind of terms together to sound cool and the more you do so the more you'll see your examiners just sit back and look relaxed. So go on off, you go. This is a so er index finger, middle phx er base vla fracture with Sulu. Yeah. Which way less than 50% in this dorsal? Yeah, it's a bit less than 50%. How accurate do you think we are recording like the amount of percentage involvement of that surface? Probably not very. Yeah, we're a bit rubbish. Actually. I mean, you'd say it's significant, it might be just under 50. But, but you know, beyond that, I wouldn't be able to tell you myself, I'd say it doesn't look very good and I'm, I'm a bit worried about it, but I couldn't tell you exactly what it is because there is a dorsal fracture dislocation. Actually, I suppose. Really, I should say dorsal fracture subluxation exactly when the head stops being in contact with that remnant bit of articular surface is a, a mute subject, I suppose. But you could say DFD here, DFDFS dorsal fracture subluxation, dorsal fracture dislocation when the head is no longer in contact with the articular surface. It's right, right on the edge on this one, either term would be acceptable here. So here you've got a cricket ball ball flying at speed or maybe a funny fall where you hit, hit the end and you kinda kind of see how the middle phalanx bounces off dorsally and this is the classic sort of in finger injury really. So, what we need to work out is, is this stable or unstable? If I stick a ring block in and give the finger a bit of a yank, will it stay reduced or will it pop out? The first thing you're gonna do whenever you see an x-ray and here's another x-ray and it all looks a bit frightening. It's a bit weird. Middle phalanx is definitely broken. No, two ways about that. But you can't tell a lot more. The first thing is simply to say to the patient like without like doing anything massive, just just give me a wiggle. What can you do somebody with an x-ray? Like this is not gonna move it very much. You're gonna ask them to get, you're gonna get a, an x-ray and you're gonna ask for a lateral x-ray and unfortunately, you're probably gonna stick the word true lateral, which is, please don't send them back until you've given me a lateral x-ray. And then, and as we've just spoken about the most challenging bit is to talk about what's the percentage involvement of the articular surface? Because this is quite important and it works like this. If you have about 50% loss, it's unstable, you could pull on the finger, the head would reduce into the remnant bit of middle phalanx. Let go pops out. If you have around 30% it's tenuous, meaning that in certain positions it might be reduced. But in an extension, it would be unstable if it's 15% or less. And, and those of you doing the, the fracture, we'll see this quite a lot with the PP dislocations who've been reduced, there's often a little tiny flake of bone. Well, that's fine, that's stable. And actually, you're worried about stiffness and you want to get that joint working. So it is all a bit difficult. And so what is it that guides you? Well, it's this. So a on the top, we've got a proximal phalangeal head stuck into a middle phalanx. And you can imagine that palma or volar plate um sitting there big thick structure bones just so in b what you've got in C is a crescentic sign. So you're looking to see whether the articular surfaces are congruent or not and the pip joint will tolerate incongruent very, very badly, meaning it'll be stiff and painful and then everything just scars up. So you're looking for the crescentic or I mean, these sign people will call it and sometimes it can be quite obvious. But you do have to kind of, yeah, make sure you look at it. All right. Here's another one. So here's a finger, you can see it's got a bit of splint material over the top. You can see it's a little bit flexed, isn't it? And you can see there's an articular surface at the top bit and then it all goes mushy on the volar bit. So maybe this is about a 50% defect. We can't be 100% certain, but it's about that. But this is the obvious V sign. I mean, clearly those articular surfaces are not congruent. This is bad. You need to do something about it. It's unstable. So we know that dorsal fracture dislocations slash dorsal fracture, subluxations are most unstable in extension. If we can bend the finger, then we can sometimes engage the head. The tenuous ones tend to be the little bit more of, of the, of the rarer ones. But here's an example of one where you can kind of just see the heads out, but there is a there is a half decent chunk of articular surface. So if we flex the joint flexion will improve congruence. So if we saw something like this, we could just stick some zimmer on it and re x-ray and you can see it here, we've stuck the zimmer on, we've put a bit of bend on the finger. You can see the zimmer is pretty much, you know, getting towards 90. Uh, the finger won't quite so closely follow that, but the head is now engaged. And this is an example where you can reduce the finger. Sometimes even just like get him to bend a bit or give it a shove for. Get some local in. Put the splint on, get an x-ray looks reduced. Thanks very much. They can then keep flexing but not extending. And you and you brought them to therapy, they make them a nice splint and you can bring them back weekly and gradually bring the splint out and they'll actually do. Ok. And here and here you can see the finger is, you know, got a lot more extension on it now. But as a uh towards the end of follow up, but the head has remained congruent even though the kind of the broken bits a bit knackered. But the bottom line is that there was enough joint surface there to bring the finger safely through over the next few weeks after, after the injury. So we know that stable injuries of dorsal fracture dislocations are 1st 0 to 15% articular surface. Basically, early mobilization just get them going protected. Bedford nothing massive. Er, just don't do football again for a few weeks. Relative stability is that weird? 15 to 30%. And these are always a bit difficult, but basically you're just gonna get their to bend their finger, take an x-ray, has their head reduced. Uh You would get them bending but you'd be doing an extension block you would need, it's a bit laborious. You need to check them weekly, but by the time you get past about week three they'll be going. Ok. So here's another one, another case. What do we think about this one than anybody? I'm not certain. But do, is there a double shadow over the head of the dis, sorry? The proximal? Yeah. Um, I like the word not certain because I'm not certain about this as well. It's really weird, isn't it? Yeah. And your heart of hearts, Kareem. Do you think that what, what do you kind of guess is going on and around the pip if you had to kind of take a wild guess? So I know the volar plate is, is a, I know there's a little bit of uh dorsal subluxation. Uh but I'm not happy with the, with the imaging cause I can't delineate whether there's a fracture in the uh head of the pharynx as well. Uh uh Or if it's just the uh the volar plate. Yeah. Well, Ver Pla's definitely gone but it just looks weird, doesn't it? And so, and kind of what would you do if this popped up on your white list? I'm looking for the leak images and these are the, so they sent you an A P in a lateral this later. Um I could potentially, I mean, get a CT scan and see where. Yeah, I mean, our CT department's not exactly on fire at the moment, you could just get a, some, some repeat films. And actually here we can allude to the fact that it's gone dorsally. It's most likely, as you say, palmar plate's gone because you can see that funny, like little drip of bone on the palmar side and it's probably scrunched the articular surface somehow. So here what we did with this one was to say, well, crikey, the joint is not good. It's there's something wrong but the image is weird. So you know what? It may actually be that it's not a great lateral x-ray. And I put it to you that if you look at the proximal phalanx, can you see that the two heads of the proximal phalanx are not overshadowing each other? So it's slightly oblique, isn't it? Yeah. Yeah. So, so this is actually an oblique x-ray of the proximal phalanx yet a true lateral x-ray of the middle and distal phalanx. So what's happened at the P IP joint if I put it that way? Uh there's a rotational injury as well, well done. So it's a rotated injury. So this is gonna make the x-rays really difficult. But assuming this is kind of still a dorsi fracture dislocation, we can bung it in some flexion and get some more x-rays, which is what we did. So what do you see now? Go on Karem, you're on fire. What do you see now? I see a large intraarticular fracture at the uh pip involving more than 50% of the joint surface. And this constitute an unstable injury. After a discussion with the patient offered them surgical management. Uh if they're a good candidate for it, maybe using some dorsal blocking wires. Perfect. Just to brilliant, we're going to get on to that in just a sec. So can everyone see that the repeat x-ray? It's the same finger just a bit bent suddenly looks suddenly looks a lot clearer. So why was it that this x-ray was so rubbish where you seemingly had quite a nice clear distal into phalangeal joint? Well, because they have given you a true lateral of the distal interphalangeal joint. But actually, the distal and middle phalanges are twisted as a rotational element to this injury, which means effectively, they've given you this kind of weird oblique o view of the P IP and they've just got the x-ray better by luck of, of this one because you can see in this one, they've given you a decent latter of the P IP joint and look at the distal interphalangeal joint. You can see it's twisted. So the middle phalanx is twisting itself on the proximal phalanx. So you're never gonna have like a true lateral of one of both bones together. You can have a lateral of, of the proximal phalanx twisted one of the middle or a lateral of the middle twisted, one of the proximal and that's why that was a difficult x-ray. So th this one has actually been quite helpful. Really. Now, is it V signing? Well, it is a bit, actually, you can see that and you sort of know it's unstable because you can see it's probably about a 50% to. So, you know, it's headed for some form of surgery because it's unstable, the flexion box, uh sorry, an extension box, but it's not gonna cut the mustard and I give you this lovely gory photo. Now, believe it or not, one way of dealing with this is to open it all up and I'm gonna get on to that a bit later on. But feast your eyes on that. That is called a shotgun approach to the finger. You can see the flexor tendons have been flipped around to the side of the hook and you are staring at the proximal phalangeal head on the left which looks fine and uninjured and you are staring at the base of the middle phalanx on the right and you can see there's a rod big fracture line and you can see there's a bit that's definitely depressed and a bit, that's a bit mushed up. Why then were we getting this strange x-ray appearance? Can anybody figure that out based on this intraoperative film? So why was it rotating? Uh because more of the base is involved on the lateral side than on the medial side? Yeah, because the fracture line is not nice for us. It's not running perfectly across. In this particular case, can you see the fracture line on one side is about 50% and on the other side, maybe down to 20%. So, what that meant was, is the one of the knuckle joints, one of the condyles was falling out of joint on one side and the condyle on the other was intact. In other words, it, the middle phalanx was rotating because of the oblique, the ubiquity of the fracture. So this is why when we look on those lateral x-rays, it's sometimes quite hard to determine how much the articular surface has gone because the fracture line can run at funny angles. Is everyone kind of vaguely clear on that if not shout out. So you can, it's just, it just makes life a little bit more difficult. But here, basically, if you had to go back to here, the, the, the lateral x-ray, you can see it being away, the head is just trying to fall into the hole and this is not a great situation which we need to do something about. So it's these are the ones that we're mostly interested in to go tootling off to the operating room, unstable about 40% articular surface. That's a little tongue in cheek because there's gonna be big inter observer variability. But what you're looking for is the V sign. Basically, you're looking that, yeah. OK. That, that head is not sitting comfortably on the remnant bit and we need to do something. Now, you might ask yourself what happens if you don't do anything. Well, you get patients who uh don't turn up and try and get on with their own finger joint injuries and this is what a dorsal fracture dislocation looks like uh at about three months down the line. And um, you can see there's a bit of deformity on the A P you can see on the lateral, the head is sitting in this sort of mush of bits of fragment. And then you can just about make out the normal articular surface. And these sort of patients will often desperately try and think to themselves. I don't have an injury that's of any significance. I must just get my finger moving and this guy sort of carved himself out a new joint and he managed to get about 60 degrees, which is extraordinary. And uh you just, it's suboptimal, we can do better than that. And he was quite lucky that he got that much movement. Most people would just grind to a halt. So they are, if you didn't do anything, that's what you end up with and it's doesn't look particularly nice, but sometimes patients can get a bit of movement out of it. So uh here's one. So we can see that there is something funny happening here on the lateral. We can see that again, the middle phalanx has gone dorsally and the head is beginning to ride out. It's got a I shall, I shall name it the Karim sign. It's the Kareem sign is positive. We've got that little lip on the Bolar side where the palm of play has clearly pulled off and something funny is happening, the articular surface. But have they got a crescentic sign for sure, but equally what is the most stable position? Is it in extension? Well, no, it's not, not these ones, they're actually much more stable in flection. However, that's what we're gonna do to it. We're gonna say, well, look, I reckon that at least 50 percent's gone on that one. I'm gonna toodle off to the operating room. I'm gonna play with it and maybe if I'm wrong, we can just end up with an extension block splint. But if we can reduce the bone, if we can fire a wire across it to transfix it, we're doing fine. Now, cream mentioned an extension block wire. That's perfect. This is a trans fiction wire. This is good. Extension block wire just goes through the top, uh, slides along the middle phalanx pierces into the phalangeal head and stops the middle phalanx riding up. Either option is great. Um I don't tend to use many blocking wires because if the patients wiggle their finger, you can end up with a slo tract going straight into the joint. So I kind of go for the transfixion, but lots of consultants do dorsal blocking wires and it works well in their hands. So either techniques great and this is what the finger looks like after the K wi has come out. So you can see it's a bit fatter. Um But you can see the head is congruent and you've lost that dorsal dislocation or subluxation. I should say of the middle phalanx. You can see the bits of bone on the Bolar side but they're all gum together. So this is an example of the extension block wire. This example of the transarticular wire which can be put in that way or, or slightly more from the side doesn't really matter as long as you cross the joint and keep it reduced. The extension block wire probably has the benefit that you don't run the risk of, of running across the fracture site. But the flip side being, you know, it's going through the top and it's uh very close to the uh the, the articulate the, the, the joint and in theoretic you can introduce infection. So we got another one and I'm gonna pummel you with dorsal fracture dislocations. I would call that one a dislocation and the head's got any contact remnant articular surface cream sign positive, but it's mega positive, isn't it? There's a big chunk. So once we've determined that that's unstable, once we've determined that we need to go to the operating room, that's fine. And then we have all the tools in the toolbox, once that finger is numb and, and relaxed to pull on it, kind of assess the articular surface. And in this case, um by the way, there you are, sorry, I forgot there a somebody we tried to, to flex it up and it's still the signing away and you can see just how big that piece is, but in this case, it's a piece and that's quite unusual. Sorry about the slightly blurry x-ray. The piece means it can actually be fixed. Um So, um so very rarely, we can actually fix those bits and you know, that might be nice. In this particular case, you might say, well, why didn't you just do one of them kwire jobs? Well, can you see that the whole piece is kind of flipped around? So if you open that up and stuck it back, probably going to have a slightly better result maybe. Um But nonetheless, after the operating room, it's unstable, you need to reduce it, you need to hold it reduced. And if you have the ability to stick some little screws in, that's, that's tip top. Um It gets worse. What happens when the fracture line starts to propagate? Um So here we can see a dorsal fracture dislocation um over 50% because that lar piece is just kind of crunched up. And this represents a really difficult challenge now. And you've got a number of strategies for dealing with this. Is it unstable or stable? Clearly, it's unstable. Do I need to go to the operating room? Yes, because there's no point putting an extension block splint on this if I go to the operating room and I can just get it to vaguely start to reduce with a, with an extension blocker transfixion. Well, that'd be great, but my problem is with those splits that I might start to run into problems away from the joint so we can start to go mad on these. And there are as a triumph of orthopedic ness. How much metal work can you get into a small area? And that's just gonna give stiffness, but it does give a, a more reduced joint. So you might want to back away from that. And here's another example. So you can see here we, we're getting a bit worse, aren't we? Those that dors rash dislocation is just more complex, more comminuted. And so is that stable? Unstable? Well, Jim Mon Georgia looks bad, doesn't it's probably gonna be unstable. So I'm going to go to the operating room, I'm just gonna pull on it. But these where the frames come out. So external fixation can be very helpful for the more complex fractures. As long as when we pull on them, they reduce. And you can just see on the right there through the mesh mash of metal work that the head is congruently reduced into the socket. These frames can easily be like made just with bits of bent kwire. So it's a nice little skill set to have. Um But you can see, see that once we get to complexity, then actually, as long as that fracture will reduce with simple in line traction, we can put a frame on. So what's beginning to come across you all now is you've got an unstable fracture dislocation. It's gonna be dorsal probably by a mile. You're gonna say that's unstable. I'm I gonna try an extension block splint, nah massive chunk ing or you can try just to see what happens. But off we go to the operating room, what am I gonna do? I'm gonna give it a pull. See what happens. I, if I fire a wire across it, keep it reduced. That's great. If I've got splits running everywhere that I can't even do that, I'm just gonna, I'm gonna put a frame on. And so that's your kind of treatment algorithm for these really difficult injuries. The frame can allow a little bit of movement. But to be honest, even if they don't move, it's only on for 3 to 4 weeks. Finger fractures heal really, really quickly. That's it a bit later on. You can just sort of see it's still holding its own bit of displacement on the Bolar side. F DS probably pulling that bit a little bit. But nonetheless, you've still got a head that's congruently reduced there. So that's a pretty good for a nasty little thing there? Ok. So I'll come out of it there, actually. Right. How are you doing, Kare? Sorry to ask you it, it's Matt. Um, I was just wondering with that last one with a frame. Do you ever look to combine, you know, if you have a large avulsion fracture there, could you ever combine it with a little small headless screw to put it back on as well as your frame holding the joint congruent or was it just? Yeah, I er, anything's possible. I've never yet neededed a frame as a neutralization device with the screw. Also, in terms of the screws, we don't at this moment in time have headless screws that are small enough. The screws, I'm showing you in those fixations are one millimeter, 1.5 millimeter. So I'm not aware of decent 1.5 millimeter sort of screws. So, um bottom line is, if you've got a fragment, you can fix eight. Generally, the joint will be stable enough to be managed with a splint as a neutralization device. What you do see with frames is that somebody might put a frame on and then use a wire just to, just to elevate the joint surface a bit. So you might see a frame and a kind of a couple of dodgy K wires. Um But it's rare to see a frame and a screw. Normally, it's kind of either you can fix it well enough to mobilize them or it's so com that you got a frame on and the frame is definitive. Does that make sense? Yes, it does. Thank you. Yeah. So it's rare to have that mixed technique. I imagine anything's possible, but I don't have headless compression screws small. They'd be 11.5. And if I'm gonna get those out, I would want the fixation to be robust. If it's robust, they can mobilize early. I suppose. It's like, it's like the worst thing, isn't it? You had to open that joint right up to stick, screws across it and then you have to stick a frame across it as well. It's like, ah, you, you, you've had to open the soft tissues and you, you're not allowing them to move early. So I'd probably keep the soft tissue envelope and just go for the frame. Does anybody have any questions about proxim? Phalangeal joints? I've showed you uh dorsal fracture dislocation, fracture, subluxations. I've showed you a VLA just to emphasize that it always think central slip injury and you get a button deformity from that. I've showed you a number of different techniques of, of, of, well, you're determining they're unstable, 40 50% articular surface loss, they're unstable, chronically, you know, you need to support the joint that could be with a Kr whether extension block transfixion fixation occasionally depends on your skill set who's available, what's going on or, or an external fixator. Ok. Um With the Bolar fracture dislocations is there, is there that same, um, sort of grading on like the degree of, um, yeah, it's mad involvement. It just never needs an operation. They're just mad. You virtually never ever, ever see that, that, like when they vote to dis lo the head comes popping out and if you think about it, the extensor mechanism is just so weak, it just tears apart and lets the head come through. So the head either comes through and there's no bony injury or the head comes through, pulling away at the central slip and that just rips off a little piece of bone. So it is, I, I don't think I've ever really seen a Bolar fracture dislocation where you've got a, like a massive chunk of bone out. If you did, then you will be the same thing. But it's super rare. Yeah. Ok. Thanks. Is there any role for primary fusion? These injuries? Mrs? Yeah, that's a great question. So, um, funny enough, there was a slide, I, I just took out of the, er, of, of the presentation where I did, I've done one and there was a guy who came off his mountain bike and absolutely blitzed the joint and I just couldn't see like any way of making this joint better. And I, and I basically performed a primary fusion with a dorsal plate and he was, er, although he came off his mountain bike, he just worked in it. His finger was fused in a slightly more extended posture to allow keyboarding. He's happy with it. It went away. Obviously, it's a bit of a pain in the ass because the little finger is a bit sticky outy uh when you fuse it, but it was pain free, he could mobilize straight away. And I showed the x-ray on one of the A O courses I teach and it was very interesting because instinctively people were like, what are you doing? Um, you know, just even if it's really rubbish, just try and do some form of frame or something because sometimes, you know, they'll have something now. I just couldn't even see it for this guy. And I was kind of happy with my treatment. So I'm gonna say very, very rarely. Yes. But you're always generally looking at some form of fixation or frame and then do a staged fusion. Like if it all doesn't go well because there's always a small chance they'll get like 10, 20 degrees of pain free movement out of even rather rubbish joint. And you might say, well, actually that's better than a fusion. I can always fuse you later exam answer then, um, you might say nothing's impossible but I always, always attempt, er, to reduce, er, even with a transcription frame and mobilize and have salvage of a fusion at a later stage. I think that would probably be your exam answer. Sorry, Mr Xw. Er, why choose the fusion over, um, sort of an art option. Like a Swanston. Yeah. Er, quite simply. And I've done Swansons for, for, for a very rare couple of cases because in these cases they tend to have splits running all the way down the middle phalanx. So you've got no tube of bone to stick an arthroplasty into, um, arthroplasty also does pretty badly in post traumatic cases. But basically it's, it's, it's, I would fuse that when I couldn't even contemplate an arthroplasty cos the middle phalanx is blown apart. Thank you. Yeah. But, so arthroplasty is out there guys theoretically, I think we've really got into small print now. Um, and, you know, and you're never gonna do anything wrong by putting a simple, er, er, er, I mean, these cases where you're thinking, oh my God. Well, you're just gonna put a frame on, aren't you just gonna try to line it all up and you're never gonna do anything wrong that way. And then if it all really still looks horrible, then you could start to think about other things. Um, ok, so we're gonna flip subject now. Um, and we're gonna focus on another really difficult area that you just don't tend to hear a lot about. Um, but when it happens it happens and it's associated with a high-energy trauma. So I'm just gonna flip back to my full screen. So a dude comes off his motorbike. Um, he's got some lower limb trauma and he's got a painful wrist and feast your eyes on this one A P in a lateral. Anybody wanna have a lash at what vaguely might be going wrong with this poor bloke's wrist. Um I'll have a shot. Um I think this is very much a true A P and lateral. But so I think you've got radial head vla dis uh subluxation. I think it probably represents a Droge injury. So I definitely want to get an x-ray of the elbow to make sure there's nothing else going on, especially with that high mechanism of injury. Ok. Um First of all, you mentioned the word radial head, where exactly is the radial head the other side? Sorry. So are you talking about the ulnar head? Yes, I am. Yeah. So you don't like the look of the ulnar head on the radius. That's what's drawn your eye has anything else drawn your eye on the lateral? If you want to flick your eyes a little bit more distal. It's the lu Yeah, tell me more Leon A mm dislocation. Well, actually the lunate is kind of in the right place. It's trying to come out voter. Can you see there's almost that crescentic V sign. What can you tell me about the next bone along the line from the luna super peri luna? Yeah. So can you see that there is something very, very ODDD going on in this car first? Can you see that the capitate should be sitting into the Lunate. The capitate is on top of the Lunate trying to knock it out of joint. I can, I hope I, I really wish my pointer would work and I don't know how to make it kind of work on this, um, pen in the very bottom corner and drawer. Is it working? So, hang on. Is it, is it working now? Anything? I can't see the cursor, but I think the pen tool might work with anos if you uh if you use that. Yeah. OK. So what I'm gonna start to do if I start to do this, can you see my red ink? Yes, perfect. I am gonna draw for you the lunate bone. OK. And it's really difficult because you've just got to keep looking at x-rays. So there is the lunate right here is the lunate fossa, the lunate fossa is always the most uh sort of proximal bit. So the lunate is, is that OK guys? Can you see me? OK. So the lunate, sorry. Is that right? Kareen? We got? Yeah, that's absolutely fine. I can see very clearly. Thank you. Perfect. So now what I'm gonna do guys watch really carefully is I'm gonna draw around the capitate. OK. So here is the capitate and I'm gonna go all the way up to the base of the middle metacarpal, quite impressed with my drawing. It's not too bad. And then I'm gonna go through the base of the middle of the, of the uh the middle metacarpal. OK. So this is a peril lunate dislocation because the lune, the decapitate is trying to force the lunate out of the way, but it's not quite succeeded. OK. So this is a peri lunate dislocation. Now, well done. The other guy who it was who, who, who, who, who was brave enough to fire up first, but we got a chat. So this of course, is the ulnar head. Alright. And it sort of looks ok on the A P. So that's, that's a good start. We've got some joint surface there. But what you were worried about quite reasonably is this bit here, the ulnar head is here and yet the radius is here and there's a sort of bit of funny radius here. Unfortunately, this may well be a normal finding and the reason it may be normal is it's very unlikely. The radiographer is giving you a good quality lateral x-ray and you can determine a lateral x-ray by looking at the scaphoid, which will be kind of coming along like that. And the pisiform superimposed on it here. And that's what gives us a true that decent later. So unless you have this, you cannot comment on the orientation of the ulnar head and the radius. So I accept that you might be right, but you can't tell from this x-ray because you, you you haven't got a clue where the sk foot is, let alone the pisiform superimposed over it. But what you have got is a sodding, great big mid carpal dislocation. The capitate is out of the lunate for sake of doubt, the capitate should be here. Alright. Well, I'm loving the pen. Thanks for the, it should be like that. So you should have a line that runs right through middle metacarpal capitate, lunate and radius. Now somebody said per dislocation, which is exactly what it is and a periodic dislocation is part of a greater arc injury. A greater arc injury basically just means a fracture across the carpus. Ok, like that. And the classification of these is descriptive. Does anyone wanna have a go at telling me what this one is? It's a greater arc injury but does any of the more senior guys wanna tell us what it is? Well, um so I don't know the classification system but there's a scaphoid fracture as well well done. So I think most people would just start on the uh on the sort of the, the, the, the radial side because just cause. So can everyone see that there is a fracture here through the scaphoid? We've got one bit of scaphoid here and another bit of scaphoid here? Ok. So this is trans scaphoid. What's next? So the fracture line has run through the scaphoid and now it's popped out to the mid carpal joint. So where does it go? Now, the lateral x-ray should help you the ca lunate joint. Perfect. It goes it just goes through the joint, doesn't it? Because like the joints dislocated. So it's trans runs across the lunate. So it brings you uh and if you think about it, that is the lunate here, isn't it? So we've now gone. Oh God, sorry. Previous there we are trans. Uh So it is peri lunate if you like scaphoid and now through the walt just descriptive. Really? So the, the, but so can you see it comes out through here because this is the triquetrum and this is the, the lunate? Ok. So it's, so it's a scaphoid um midcarpal lunotriquetral Pernal dislocation if you like. And this is a, there's a Mayfield classification and this would be a Mayfield 34 is when the Lunes spat out. And uh so you can start to see that there's a lot of data on an A P and natural view of a carpus. You've just got to stare at it till you're blue in the face and you'll hear of Galus Arcs and Glu there's arcs are clearly messed up here. There's no kind of an arch, you come along here and then hit some bone, you come along with mid carpal joint and it's all over the place. So, so here we are and it's just er, let's look at the reduction. So this guy has had a pull in A&E and can everyone now see that here is the capitate, here is the lunate. Here is the radius to answer that. We had a, we had a worry that the Droge was dislocated fine. But let's have a little look at this one. We can now see if scaphoid is here and we can now see if pisiform is here. So we're getting back to what a normal x-ray should look like. And can you see that this isn't a problem? Now, the ulnar head is perfectly aligned with the radius. So that was purely down to radiographic error. You can all see the scaphoid fracture, the lunotriquetral joints reduced and Gala's arcs do do do are all pretty nice, really? Aren't they? They're all, they're all cool now. So make sure you look up Gala's arcs and, and see if you can look at some x-rays. Ok. Everyone. Ok, with that so far or do you want me to go back and go over it again? Ok. So this is the treatment that we would propose for somebody like this. So the acute scaphoid fracture can now be dealt with with the screw fixation. Now, if you have a scaphoid fracture, is your scho lunate ligament likely to be ruptured or is it likely to be intact? What do you reckon? 50 50 answer intact? Yeah, exactly. So, and I actually believe it or not, I'd rather have a scaphoid. Well, I wouldn't rather have either of them, but if I had to have one, I'd have a scaphoid fracture because actually an acute fracture fixated, would probably heal. And if my scaf lunate ligament's intact, that's really nice. And you can see here, there's a couple of wires, one wire here is stabilizing it. Sort of the, like the kind of lunar triquetra joint and another one crossing the triquetrum to the capitate. So sort of crossing the mid carpal joint. There's a, there's little lots of different wires you could use. Um, there's a, there's a sort of a bit of a uh an anchor here. This is a little bit misleading. It, it may be um an anchor that's actually to do with, you know, tri ligament or it might actually be an anchor that was used for a, for a bit of sort of capsule just to get it back on. But a, a trans with perate dislocation, this represents about 60% of all the carpal dislocations you get traumatically case. It's your commonest one basically. First of all, don't miss it. So when you get a funky set of x-rays, stare at them till you're blue in the face and do not send the patient home. Um OK. The capitate should sit in the lunate, the lunate should sit in the radius. You can see here that somebody's just given it a pull. So it's been quite floppy. It's just flopped back into place. So they've actually just had a cast put on and that's brilliant treatment because then we can spend our time, take them to the operating room with somebody with the right skill set and do the fixation, uh wires have been pulled out and you can see it all kind of behaves itself basically. Um So you can see here there's the scaphoid roughly and there's pisiform. So, you know, this is a good x-ray. So you know that there's the, on the head, there's the radial head. So, you know, the dru is OK. So, so, um that's a, a really good thing to sort of think about when you do see those really horrible looking x-rays. I'm just gonna go back up to that when you, when you have the apparent ulnar kind of out the back there is just to sort of take a breath and say, hang on a minute. I just need to assess the quality of the lateral x-ray. And here it's impossible to say. So you wouldn't want to jump to that. I, I hope that's ok right now they're all on fire. Here's another motorcyclist off a motorbike. What does everyone reckon normal or abnormal? And if abnormal, what's wrong, uh it looks abnormal. Uh the arcs are, are not uh congruent and uh I suspect that that the lunate is vally dislocated and uh looks more uh flexed, perfect. So everyone just, it's really difficult, isn't it? But where is the lunate? It doesn't actually seem to be sitting in the fossa because we, we haven't got real clarity here. But what we have is this thing that looks like a lunate sticking out the side. OK. And there it is. All right. So can everyone see there is the fossa. So the lunate is now out of the fossa. Where's the middle metacarpal? There's the middle metacarpal, where's the capitate? It's probably this thing here. Ok. So you can clearly see that lunate ain't where it should be. So that's great work. But it's there on the x-ray, but you had to look for it. Now, these people will not have normal wrists, they'll have very painful wrists or wrists that are, you know, not very nice. They'll be swelling up quite quickly. If you get them really super early, it might not be that swollen. But if you get them plus a few hours, they'll be really quite swollen. So be aware that young man complaining of pain in the wrist will give it a wiggle. It's not gonna be very nice at all and then really spend some time on the x-ray. So can somebody tell me that, uh, maybe some of the more senior guys or, or anybody? I know what, how, what, what's the descriptive classification of this and, and the other classification? If, if you know it good line. If I said that New Mister Annoy. Ok, Kareem, I'm gonna stick with you. First of all. Do you think the scaphoid is about right on the radius? Not trick question. Yes or no. Yes. Yeah, I agree. The scaphoid is about right So it's not a trans scaphoid, is it, so that when you look at the scho lune interval, does that look all right, or abnormal? Is it clear the schiro luna or not quite right? No, it looks like there's overlap. Yeah, exactly. So, so we have our first line, you know that the med carpal choice is not good. So we know that there is something bad going on here. Where do you think the line of force then comes out? Ok. Uh Through the, um, the uh capitate and the hamate. So you think it's sort of heading off into the wide blue yonder here? Yeah, but you just told me there was overlap there. So that looked bad. Well, what about the overlap here? How does that look? There's overlap. This is, this is pisiform here. Yeah. And then this is, this is triquetrum, isn't it here? And it's overshadowing here. So, actually a line of force comes out here and it'll disappear. It styloid, it looks intact and the styloid looks, uh sorry, the ulnar stool looks intact and the radio styloid looks intact. Ok. So anybody now know what this is, how would you define it that Mayfield for? Yes, well done. It's a Mayfield four, by the way, guys, Mayfield only has four good orthopedic classification. There's only four and four is when the lunate spat out. So you can see the lunate spat out and really has no contact with the, uh um er lune fossa. So it's, it's a lunate dislocation. So it's a Mayfield four. But on the descriptive classification, I've used the term greater arc before. Is this a greater arc injury? Yes, bad luck. 50 50. Have you ever heard the term? Lesser a, have you heard that term? Yeah. Hold on. This is a lesser arc injury. So a lesser arc injury is a pure lunate like dislocation effectively. And this is exactly what this is basically the lune has been spat out and everything else around it is ok. So the lunate spat out. So this is a lesser arc. So this is the definition of a lesser a soft tissue injury with the leon sprat out and a greater arc is everything else. For example, there are, I mean there are many now different sort of things. You can have a trans styloid, trans trans capitate trans Tril fracture. That would be a great a arc injury, for example. So you can class for in which way you like treatment is just the same stuff it back and here's a dorsal approach. We've got a nice big er er you can see here by the way that um kwire joysticks can be used because the force er on this is can be quite huge. So joysticks will be used to squeeze the scaphoid back onto the lunate. There's the sca sca lunate ligament here and you can see that the scaphoid and the lunate are being squished together. And then you've got some K wires, the, er, the joysticks have been removed and you've got some K wires coming across. Ok. So that's for example, a spray of, of K wires that you might want to use for, for a peril lunate dislocation, sorry, lunate dislocation. Mayfield. Before you can see the lure joints held, sca lu joints held and you might wanna put some sutures in the scaphoid desperately wants to flex. So this wire here is used as a kind of a derotation wire because the scaphoid could flex around one of your K wires. So the scaphoid capitate wire is used to stop the scaphoid flexing. All right now, I've been uh Yeah. Um OK. Tom. Are you there, Tom? You're a rock star, painful, fall down the stairs, painful wrist movement, a isolated injury, closed wrist swollen. What have we got? Um If you can think out loud, that would be even better. It's really difficult. Just give it a lash. What have you got? So, the Lune on the A P, the lunate doesn't look quite right. Which bit of the luna? What about? So this bit of the lunate? No, that looks fine. Fine. So we're good here, aren't we? We've got the lunate seemingly on in its fossa, but you're talking about sort of a bit here, aren't you? Yeah. So that doesn't look right. I agree. Um Sk Froid, how does that look? It's a bit of a funny profile. Yeah, this is called the Signa Sign. When you start to see that equally, you have got a scaphoid. That's vaguely all right. You've got a lunate that's here, vaguely. Right. And you actually do have some lines of it here and here's your triquetra. Ok. And I've got a hamate here, so now we can start thinking about the capitate. So I'm gonna come round the capitate, come around the capitate and, but it's also sort of in there, isn't it? That's right. So, do you know what this is? So that's a great arc injury, is it? Well, no, I mean, it's a cap fracture. It's a cap fracture. It's a head of a capitate fracture all done. So, yeah, I, I think you probably have, you can, um, you can have these injuries, you don't have to use sort of greater, lesser arc for these because actually everything else is, is pristine. These can be associated with scaphoid fractures and it's called sca a Capitate syndrome. So the wrist flips out of joint flips back in again and as it flips back in again, then I suppose a mid carpal dislocation, then then the piece of capitate is knocked off and then it, it doesn't kind of settle back into its place. So these can be really difficult. But basically, you've got a blurring of the mid carpal line. You know, you, this midcarpal bit is, is difficult to understand. This is difficult to understand so Kla's arcs gone a bit and so these need CTS um, treatment for this K wis and yeah, you know what, just open it up. There's your CT scan. Ok. So that's ac t of that injury. Sorry, I jumped. So you can actually that it was all right. And you can see this really rather horrible sort of gap here where the pieces flipped out and this here is the articular head of the capitate, which should be here. Um, so you can actually see it's a capitate injury so subtle reduce it, hold it with headless screws if you can, if it's a bit too comin to, you know what, just pop those in. Now. Suddenly you see a Cala's ac Yeah. So on this, is that a lip of the lunate off as well or this bit here, I think actually that it's a, it could well be, um, I can't recall on this particular case. Um, the loon a does look a bit nasty just there, doesn't it? But um, nothing needed to be done to the lunate. And if you go to the next, you can see the luna's just like the lunate and it all looks vaguely all right. And that piece you were looking at was somewhere around here. So there might be a little lip of lunate, but you wouldn't chase that. Um, to get to that, you'd have to sort of do some massive approach to the Bolar side of the wrist and move all the flexor tendons out of the way and just be a bit of a disaster. Whereas most of our wrist work is done dorsally, isn't it? Just because it's much easier to, to access the carpet. Um And there we are, that's all sort of healing up basically. And there we are. And actually the head of the capa has actually healed itself back on, obviously, that could have problems, but that's done. All right, well done everybody. Um So I'm going to flip back to me. Um Sorry, I know you are CRE I went over my 20 minutes by a good 49. Um Has anybody got any questions on carpal um injuries um or um pip joint injuries. Um Hi, there was um I think on your, the one where you had the fracture going through the kind of the, the mid body of the lunate. Um and then you put the screw in to kind of reduce it when you had the capitate dislocation. Um Why, why do you not, why, why does the lunate not get avascular necrosis? Is it because it's through the middle, middle of the body rather than the distal or just in that last case of the ate fracture? You the very first one I think. Ok. Um because I didn't, I didn't show a lunate fracture then. Um So s sorry, the sk I mean, yeah, so it's actually quite dogmatic to say that all scaphoid get avascular necrosis because you know what they don't, it's just something that's crept into the textbooks. True, avascular necrosis of scaphoid is Press's disease where they like the proximal pole fragments. And it's incredibly rare to see that. And so actually, a SCAD has problems with vascularity from healing, but it doesn't have problems with vascularity in terms of collapsing and falling into a million pieces. So it's, it's become a little bit dogmatic in the textbooks. You're always gonna mention a AAA difficult blood supply because that's why it doesn't heal, but it doesn't die and fragment like a keen box does. Um So for most Garos, they will unite if they're kept still. So think about stability as well as vascularity. So being kept still might just be simply being put into a cast and most G wo will heal. Of course, a screw fixation gives you even better stability and a screw can be used to help correct displacement because we know displacement leads to nonunion. So um think to yourself, first of all, diagnosis of scaphoid fractures can be difficult because the x-rays are sometimes you are not in the plane of the fracture, so you can easily miss them. So you have a high index of suspicion and everyone gets an MRI scan that they get four views with an x-ray first, you might pick it up, but then everyone gets an MRI scan if you're not sure. OK, then if it's, you're gonna judge the displacement of the scaphoid fracture. It's probably gonna be a middle third. If it's not displaced or minimally displaced, you're just gonna put it in a cast and they're gonna heal. If it's displaced you're probably, then gonna wanna put a screw across it. They'll heal. The, the problems are the skate roids that are moved early. They can go to a nonunion or occasionally ones that are casted and go to a nonunion because of poor blood supply. But it's not fall into pieces. It's not a keen box. It's not true. Avascular necrosis of the bone. So it creeps into the textbooks. Nobody takes it out. But it's actually about instability, movement and poor blood supply to give you a nonunion but not true avascular necrosis. Does that make sense? Yeah, that's great. Thanks very much pro any go pretty well. No, there are no questions in the chat. I think there's a, a lot that uh to take on board this uh this talk sky because a lot of this stuff is uh uh not very, you know, delved into generally at this level. So this is yes, sorry to interrupt you. That's why I went for it and I went for it for the reason that you don't, you are, these guys are in A&E and they're in the emergency department and you can see in a poly traumatized case or whatever carpal dislocation and you need to have an awareness of the assessment of that and just have a little bit of an idea of what's out there. And also that's why I went for the finger as well because I think the pip joint is poorly understood. So, um, I think for you guys, it's just having an understanding what's there. And I accept certainly I've sort of gone off into stuff you don't need to know for the exam, but it's about recognition and instability. And I think, I think hopefully if you've got an idea of that, then that's why I kind of pick those two because I think people don't teach them. So have you got some nice simple distal radius for a screen? Uh Emer is our radio, hopefully, uh you know, something that uh people will be a little bit more in tune with. But thank you very much for the, for the talk. This is extremely helpful, I think for everybody at every level. Good evening guys. So sorry, I, I was caught up with some cases um and couldn't come earlier. Now, how do I share the screen? So at the bottom of the screen, you should see um uh share entire screen. OK. Let's share this Glauco. Good. Sure. OK. So can I just ask guys what level are you first? OK. But what level do we have in the, in the room? Cream? A variety of levels? We have uh people from F two all the way to ST six and I see. So guys, this is um this is a very, very basic um this radius lecture which was designed to be for an S level. Uh Can you, can you see my, my screen? Can't see it? OK. Let me just make it bigger view 15 minutes. Uh How do I make it like? OK, let's see. Is that OK? So guys, if you are still there and if you are still uh OK, to go ahead, we are gonna do a very, very basic um approach to the distal radius, the one that you know, as an so you are gonna deal with and you, you want to learn something about it at the basic level. If you are registrar, uh especially if you are S DC, there is nothing for you to learn out of this lecture. So probably it's not the necessary worth your time. But I'm going to go for the guys who actually need basic knowledge for that. Why do we want to present this? Because it, it's, it's a very common injury. Is it is you are going to find it everywhere. You are going to find it in ed in fracture clinics in, you know, trauma in major trauma, whatever it is is 17.5% of all the fractures. So it's a lot now anybody knows why it is more frequent in females. So now I want all the junior levels to pop in because this is a very, very basic questions and very, very basic knowledge. So it is nothing extraordinary, is nothing difficult, is just, you know, common sense, is it due to osteoporosis and aging and uh you know, excellent, good. So osteoporosis is the main, is the main factor why the female, you know, will have more fracture. Actually, quite a lot more is double or even triple. So there is a bi modal distribution. We know that fragility fractures in elderly, you know, mild falls, falls from standing height. And then you have, you know, very high injury, sporting injury, trophic collision fall from height from from young adults with good bones. Now, obviously, you can see it depends how you put the hand down. When you fall, you can have dorsally displaced fracture, you can have roar displaced fracture with the mechanism. You can have an idea about the severity of the fracture and how are we going to deal with it? Now, it's very interesting actually, because out of all this, the ra structure, 50% are in particular, you wouldn't think that so many is it. I didn't think that so many will be intraarticular. I thought, you know, we deal with lots of extra articular cholesti fractures in elderly, but actually half of them go into the joint. Why is um why we are concerning the fractures going in the joint? Anybody basic stuff, simple things don't over think it. So any articular fractures lead to traumatic arthritis of the joint. Excellent good post traumatic arthritis. Yeah. Ok. We know that the most common mechanism is this fall on the outstretched hand. And it's very interesting and very important to understand that sometimes this can be associated with very severe injuries of the wrist. Yeah. So you have the distal radioulnar joint which is there and can be damaged. You have lots of ligaments that are very important in keeping the stability of the wrist that can be damaged. And this can be far more than just a distal radius fracture. So a bit of anatomy is very important to understand how the bones are sitting there. So you have the radius there, you have the ulna there. You have the styloid of the radius and the ulna and then you have the bones in order. Yeah. And you have the scaphoid and the lunate articulated with the radius and you have um you know, the 222 carpal rows there. And then again, it's very interesting to check the 3D um um anatomy of the distal radius because as you can see is a pretty interesting shape and there are multiple fossas um on the distal aspect of it. Yeah. So you can see the sigmoid notch that is where the ulnar articulates with the um with the distal radius. Yeah, you there is where you have the distal radioulnar joint. OK. And then you can see that you have the scaphoid fossa here. You have the um lunate fossa there. And then if you look here, you can see that the ulnar styloid yeah has the TFCC attachment, which is again, very important. So then you will understand why when there is a base of the ulnar styloid fracture, why we're a bit concerned about the TFCC and more damage there is than just, you know, um an ulnar styloid fracture. Then again, you can see the list of tubercle on the dorsum aspect And you know that there is an EPL going around this list of tubercle. Very important when, when uh you do, you know approaches to the wrist and you know uh when you do aspirations or anything else. So then again, you can see the other view from the other side, you can see now how the the surface of the radius is tilted towards volar side. Yeah. So you can see is not uh in horizontal plane is tilted. Yeah. And then there are just a couple of ligaments here. So there are intrinsic ligaments and there are extrinsic ligaments. The intrinsic ligaments connect carpal bones in between each other. And then you have the X ligaments which basically connect the, the ra with the carpal bones. Yeah. And you have dorsal ligaments and you have volar ligaments. Now, on the volar side, they are the strongest one. So now we will understand why if you have AAA volar displaced fracture. Yeah. So all these stable ligaments there are attached to this part of the radius which is now displaced. So that why you need to fix most of the v uh, volar displaced fractures. Ok. So, in terms of history, it's very important to ascertain the mechanism of injury because you will treat differently. A 22 years old involved with the motor vehicle collision or fall from height and you are going to treat a 99 years old falling from the chair. Yeah. Um, symptoms. Yeah, the symptoms are just basic pain, swelling, deformity in most of the cases. What you see when the ed call you to see this, the ra fracture. And then during physical examination, it's very, very important to see. Is it open? Is it closed? Ok. And then to, to assess the neurovascular um um status of the hand. Now we know that all of us are just writing, they are neurovascularly intact. Can somebody tell me what exactly do they mean when they say neurovascular intact? And what exactly do they do to assess that? Anybody? Just, you know, simple stuff? You do it every day d it's nothing complicated. It's just basic stuff. So I split it into um blood and Noves. So you want to check for the radial pulse and you want to also feel for the ulnar pulse. Should you be able to feel that you can also check the per feel distally? Um But bear in mind if they're cold, if they've been sort of in a polytrauma situation and they've been out for a while and then you then split your neurovascular, your neurological assessment into two again. So that sensation and motor sensation, um looking pain. Ok. Choose one nerve. Choose one nerve and tell me about that nerve. Very simple. What you do we need exactly. I choose the easy one. Then radial extension. Excellent, good. Where is the sensation? Bad? Ok. Do you have a point? No sensation of the radial nerve is only the superficial radial branch, which is the back of the thumb. Otherwise radial nerve is exclusively motor. So when you check the sensation is the first web space, is it the rest of the dorsum of the hand is just, you know, lots of branches from everywhere. But basically, if you check the first web space here, OK, then most likely that's gonna be only the radial nerve and then wrist extension. OK. How do you assess wrist extension? If the the patient is, you know, with a deformed wrist and can't move the wrist and then is in a cast uh extension of the mc pjs? Yes, good. But bear in mind that lumbrical function may um muddy the waters. Excellent, good, very happy that you understand that. So then what you are going to try to do when you put a cast on to make sure you can still assess the radial nerve even after the cast. Well, if they're in a cast, you want their fingers for you. When you, so you'd still be able to check the. So make sure when you put a cast, you don't cross the metacarpophalangeal joint is what I'm saying. OK. So you can then assess because um obviously, if you just extend the interphalangeal joints, you're not assessing the radial nerve. OK. Somebody else tell me about ulnar nerve, what just things, easy things you do need it. Which side of the, of the hand is the winner, nerve, winner victory. You're going to say something earlier. So, come on and uh join in. There is nothing complicated about that. Just nothing complicated. Where do you think the ulnar nerve is going? You have ulnar fingers and you have radial fingers. Where is it going urinary or radially? Um So I guess the the textbook is that it covers the little finger and the ulnar aspect of the ring finger. Um in terms of sensation and in terms of um motor, you'll think about your um palmar and do um palmar dorsal interosseous. And so you're looking at your kind of abduction um of your fingers to kind of at test the the ulnar nerve supply or crossing of the fingers. Excellent, excellent. Sometimes the the cast is too tight, they cannot spread the fingers. But what you can do is put them to scissor, the finger. Yeah, which is gonna check a deduction while the other maneuver is gonna take a deduction. OK. What's left median? Anybody speaking medium? Come on somebody anybody. OK. So for the now, yeah. Um as a sensation on the palm of surface of the thumb and 1st and 2nd finger. OK. And then um ask the person to do kind of like the OK sign. Perfect. What branch of the median nerve review assess with the OK sign? Oh I can't really remember the A I Yeah, anterior entero which goes into the deep compartment of the forearm. OK. Very good. Very good. So OK. Sign and sensation in the thumb, index and middle finger, half of the ring finger as well. Um And then you're done. Now, can somebody tell how do they assess in, in kids all this? What do you ask the kids to do? Um So I go finger guns so that's radial nerve. Um Everything's OK. A OK. And now cross your fingers, you show me everything's all right. I'll see. Excellent, good. Did they listen to you? So I like to play police with them. The police has a star on his chest. Yes. Yes. Is it OK? To play? The police is OK. Now the policeman has a gun bank. They all the time for, for this. So yeah, you, you need to be a bit creative with the kids because they are not gonna just do what you tell them to do unless you engage them in some sort of um um stories or easy, easy movements to do good. Now, I want to share with you guys, especially that with the, the S shows which started the job in orthopedics and they are overwhelmed about, you know, needed to present the cases in the morning, what they've seen and whatever. And as all of us started at some point, we, we start telling half an hour stories about what happened and stuff. There is, I have learned very early in my sho job, this system of presenting um, every single trauma patient in, in these six rows. Ok? Now at Miss, OK, age stage for age and near the age I put hand dominance. If, if we are talking about the upper limb, OK. It's very important. It's a very important thing. It doesn't matter what injury you have. If you have 99 years old or if you are, you know, three years old or 20 years old might be uh treated differently. Time of injury is very important. I will say like that, don't say yesterday when you document the things electronically or in the notes, yesterday doesn't mean anything. If you read those notes after two week, two weeks, you put a date, OK? Time of injury. Put down the date or last Monday. OK? You open the system. Yeah, you look at the computer last Monday. When was last Monday? Then you need to look was the date today? When was last Monday? Put a date down. It's just easy. OK? Then it's very easy to know. Is this fracture two days old or two weeks old mechanism of injury, important as well because you from there, you can understand what is gonna be the severity of the injury or the associated uh fractures or injury associated that specific mechanism. So I again, I will say keep it short, don't put their stories like this. Patient went to the shopping center and in the shopping center, somebody left the bucket of water and the water spilled and the patient went there and then lost the balance on, you know, doesn't matter, fall on outstretched hand, inversion, injury of the ankle, uh fell from chair or from standing. He simple, simple, but take the essence of that. And then under the eye, you put injuries, there is one injury or there can be 10 injuries, doesn't matter, put them in order and for every single one write it down, is it close? Is it open? And then neurovascular status when you write it like that, then it is very easy to spot what exactly is wrong. And then neurovascular status just put there neurovascularly intact. And then later on in the notes, you can detail this or put median nerve symptoms, social, social under the s social and past medical history, ok? Every single person who's gonna be 90 years old is gonna have osteoporosis. Put they the, the relevant past medical history, the one that gonna um tell you about the fitness for surgery or about things that you know, might stop you for, for from operating or um might have implication on the anesthetics or, you know, important stuff, heart problems, you know, lung problems, diabetes. If the patient is on steroids, um you don't need to put all the list of medication, but you need to put if the patient is on the on anticoagulants and, and, and the steroids usually and then treatment what was done, you can say NP and yeah, and then rule number two, consent one and marking for, for example, I promise you if you have this structure in mind and if you try to use it on everyday practice is very, very easy. In the morning, you sound sleek, you need 30 45 seconds max to present the patient. And once you have this structure in in any system, you are using electronic or on paper or whatever you basically is, is is very nice helpful page. Everything you need to know about that patient is there. And then if you have it electronically, it's just enough copy paste, discharge, letter, copy paste, referral to cardiology, copy paste, whatever, put the the the thing at the end. So this is going to save you lots of time and it is going to structure very nicely your, your presentation. OK? Then obviously this the ra fracture, what you're going to do first, you're going to x-ray. So those are the parameters you need to look for. So you, you will have in most of the cases, you'll have an A P and the lateral on the A P, you need to look at two things mainly. Yeah, radial height is one and radial inclination is the second, radial height. You know, they are giving you normal values. Depends what books you are reading is gonna be 11 or it's gonna be 13 or it's gonna be 10. Doesn't matter is around 11. But what do you need to know? Generally speaking, in most of the people, your radius should be a bit higher than the ulna. Ok. If the radius is shorter than the ulna, that's bad. There is radial shortening. What do you need to do by different methods? Nak or if bring the, bring the height back, why do you need to bring the height back? What's gonna happen if you don't bring the height back and you leave the radius being shorter than the ulna? Um So both the radius and the ulna make up the joint. So you're gonna get stiffness again. I think that's one anything else. Why are we, are we most concerned about? I think because that's where the luna articulates, that's very, very good. Um to note as well, but basically, if the ulnar remains longer, yeah, then it's gonna impinge of the car on the carpal bones and you are gonna have impingement and pain on the ulnar side of the wrist and sometimes that can go so badly that actually the patient needs later on shortening of the ulna to reduce the impingement symptoms. Ok. So that's the one radial inclination around 22. So you can remember this like 11 22 11 or 11, 11 22. Um again, important to restore that. And then on the lateral, you look on the tilt if you can see there. And as I showed you in previous image, if you look at the 3d radius is not horizontal slopes towards the palmar side, OK? And slopes around 11 degrees towards the palmar side. And then with fractures most, most of the time you have shortening and this volar tilt becomes neutral in the best case scenario or becomes dorsal tilt. OK? And then you're gonna have the joint surface looking the other way looking dorsally instead of volley. So those are the parameters we need to check for and then you need to correct by different methods. And obviously, you're gonna look at the articular surface. But if you have a step off, which is, you know, more than two millimeter, then you need to correct that as well to ensure that the wrist is functioning properly and the biomechanics are maintained. So you, you, you touched on this before overall, you need to look at the alignment of the wrist in the Sagittal and the coronal plane. It was very well explained to you. What Ulla lines are is on the picture, on the on the right. So there are three lines. Yeah, going proximally and distally, you know, along the the first row and then approximately along around the second um row. Now you need to have these lines parallel as soon as those lines are not parallel. Something is happening in that carpus and usually is very severe injuries like lunate, dislocation, peril dislocation things that uh require emergency treatment. And then if you look on the lateral x-rays, it's very difficult initially to understand which bone is what. But basically try to think about like that. You have the radius and then you have the lunate which looks like a peanut. Yeah, in the second picture and then you have the capitate sitting on it. So basically you need to make sure that these three, these three bones are on the same ax axis. Yeah. So they are aligned. The the the lunate sits on the distal radius. They, they describe this as an egg cup and then the egg sits, sits in it. So uh is and what you you have in the first picture is, is basically the s safeway which is pretty difficult to understand on the lateral x-ray when you start looking at them. So when do you do CTS? Well, you do CTS when you have very complex fractures, which are going intraarticular, very community, you need to plan surgery for that. Yeah, you, you need to have a better understanding about how we're going to fix it. And then you can even go crazy and request MRI if you suspect that might be um significant soft tissue injury, which as I said, can be TFCC or scapul lunate ligament or you know, rheumato ru ligament, which is now complicating the story far more than just having a distal rady fracture. You need to address those as well. So there are loads of classification guys, I mean, you know, loads um they are more and more complicated, very wordy, nobody can remember them and I'm not sure if you guys were into a trauma meeting so far where they were trying to explain this structure using any of this classification. But what you probably hear on the daily basis, you you hear about colleagues or about the displaced dorsally distal radius fracture. You hear about Smith and Barton's type of fractures which are volar displaced. You hear about radial styloid. You hear about leon fossa or bit punch, I'm sure all of you heard this during the trauma meetings or in Ed or whatever. So this is actually very important to understand because some of them are worse than the other. So now let's do an exercise. Somebody shout first image. What is, what type is that? OK? Looking again, look at the dia colleague. Good. This is the most common one. Is it osteoporotic fragility fracture. Little ladies falling off outstretched hand bang and then there is lots of comminution dorsally. OK. What are you going to do with this type of fracture in the scenario. I've just given it to you. What, what, why would you do in Ed? So I would start with every patient by assessing the neovascular status and documenting a history, making sure they are comfortable and have appropriate analgesia. I would attempt to reduce this under either a hematoma block or, or appropriation as per my department protocol. Perfect. Can somebody explain how they're going to reduce this structure or how did they do it? So what is the maneuver? Because most of you will need to do this on a regular basis every on call, at least one. Um So the past I seen it's important to give, give yourself plenty of time for traction just to let the muscles relax. Um And then you kind of want to hyper hyper um so that you can kind of get that fracture fragment over the distal aspect. Um And then you're gonna then bring it back into alignment good. Do you guys understand the concept of making it worse first? And do you, why do you sometimes you need to accentuate the deformity initially? What, what's gonna happen if um instead of doing what he just said, he's gonna do, he's just gonna go there, put the thumbs over the dorsally displace fragment and try to put it back. Is it gonna go? He's gonna be very lucky if he goes, but you, he needs to impact the fragments first. OK. So that's the reason that sometimes you put you, you, you make it, you put traction, you make it worse first. And after that, after you that impacted the fragment and then it's easier to manipulate it back in place. OK. So let's say you are gonna achieve a great reduction there. Um You are happy with the parameters. Um And this is, as I said, an elderly lady. Um, what are you gonna do as a long term management with this? Usually these can be managed conservatively where they excellent, good. And how are you going to manage conservatively? What are you going to do after you initially put it in, you know, in a good position, put a cast x-rays, neurovascular status. All is good. Let the patient go home. And next is what uh back to fracture clinic in two weeks to check the clinical evidence of union should be decreased pain at this point. Ok. Well, yeah, I would rather bring them back in a week and check the x-ray again just to make sure, uh because they tend to slip back where they started off. And if you bring them at two weeks now, at two weeks, you start to have some sticky calls forming. And if you need to re manipulate, it's better to do it after a week where you don't need to break any callus or any, you know, soft callus that forms there. So probably bring it back in one week in fracture clinic, check the x-ray again. If you are still happy, I would bring them again at two weeks. If I'm happy at two weeks, I would change the back slab with the proper cast, better fitted and then bring them back in three or four weeks, cut the cast off and then start rehabbing the wrist. Because inevitably, after such a long time in a cast, they're gonna be very stiff and then they will need to work very hard um themselves or sometimes with physiotherapy to regain a functional level of movement, you need to warn them that sometimes they will never return to the preinjury range of movement. OK. But they should return to a functional level of movement. OK. Let's say you have the second picture. What type of uh fracture is that? Anybody look again here, Smith job. Somebody said Smith very good. So the difference in between uh Smith and Barton is the fact that one doesn't have intraarticular involvement is usually extraarticular and the other one has. So this is the Smith fracture. So what, what is bad about this fracture? Are you concerned more about the first fracture or the this fracture? The second one, Smith, who's the lady who responded? What's her name? Victor? Hi. So if you have these two fractures in D, which one are you more concerned about the ones that have intraarticular involvement? The Smith um fracture. Mhm But this one is displaced Bolar. Yeah. Oh, well, yeah. So water is bad. Dorsal is right? OK. But volar is, is, is um you, you need to do something more in terms of intervention if it is volar displaced. OK. So what are you gonna do for this one in needed then? So um who asses the patient's special um of neurovascularly intact? Yeah, then give adequate analgesia and then put on a volar slap. Yes, excellent, good. So you understood that now you need to put a volar slab, not a, not a back slab. Ok? So you have a fracture which is displaced door dorsally, you put a back slab, you have a fracture which is displaced volar. You put a volar slab. Ok? We've seen patients coming from with, you know, vol displaced fracture in the back slab on the back. What's going to happen? If you put the back slab on the back, it would um put more pressure on the brake line and further fracture. So it would not mean same reduction. Yeah. Yeah. So basically you, you are making it worse, you push it even more vally if anything will you try to reduce this fracture or you just put the past on? Oh, I'm not sure I'll try this. Um OK. Somebody else will you guys try to reduce it? Yeah, I think I have a pop. I think you've got a risk of median nerve injury here and Yes. Yes. Yes. Um Both displaced fracture. That's, that's the key to remember. Yeah, they fall where in the carpal tunnel over the carpal, the the medial nerve is there. It's carpal tunnel there. You know all those bits that go that, that go um Palmer potentially can put pressure on the, on the median nerve. So I think they are unstable. Most likely you cannot align them perfectly. Most likely they are not gonna stay where you put them. But for now until you decide what you are gonna do about them, then you can put them in a, in a safer position. Ok. So, yeah, I would have a go and I would align that better. I would put a, a volar slab on and then what are we gonna do next then? So I think these are sort of inherently unstable. Um So I think this is more like the need to need fixation. So I certainly wouldn't be waiting a week or two. I'd probably be getting them into the next available fraction clinic that the consenting for RF. Yes, exactly. That. Now, let's say you, you brought that back in a decent position and you got, um, 75 years old lady is left handed. Um The functional level is poor. She has dementia and she lives in a nursing home for will that change your management? Well, yeah, I think it probably would. I think, you know, it's what her level of, we would say her level of function is poor. So giving her an operation to not particularly restore her function is not in her interests. So I would definitely in that case, really, really focus on getting a decent reduction in the first instance if I can. Um but I would be less keen on of rushing her for operation. Excellent. So do you understand guys? It's not all about the fracture is about the person who has the fracture first because the same injury you can treat it differently. Depends upon the packaging. OK? So this is what I wanted to to, to, to give across. So yeah, it is unstable is bad. But if you put it in a decent position and the level function is poor and the patient is demented and she's not gonna be cooper of any sort of management. And is it worth exposing that patient with the risk for the risk of surgery? No, if that is an aa for patient who has, I don't know, end stage cardiac and renal disease and stuff, is it worth putting her to a an operation? Um Probably not now. 3rd, 3rd 1 who who can have a go for the third one? Come on, just jump in. I can't even see you guys. I just can't see my slides. So I don't know you, I looked through the names, I recognize two or three. OK. So don't worry there is nothing wrong. You can say best name with you. Uh Would you like to join in? Sorry, I'm seeing if we can get some uh we can volunteer some people. He, he's gonna join in. He's my OK. So that's a roly displaced Bartons fracture. Uh that has a intraarticular extension. Um That's, that's basically it. OK. In between these four image, which one is the worst in yours all? And this is the worst of them long. Why? Um Naturally because of the roar displacement and all the complications that we discussed before and also the intraarticular aspect of it. Um So I'm expecting more for I need to reduce it um to get back pretty much all four aspects that we needed. So restore the intraarticular surface and then get the the on the a view, the radial inclination and the height basically restored and on the lateral, I would uh I would need the t to get it. So in a, in a fracture like this, most likely all the parameters we discussed will be will be off, will be off, will be off and needs restoring, which is very, very good. Now, how can you restore it? So let's say you, you, you reduce it, you know, just enough not to have compression on the median, not be put in a cast. What next? Um what are you gonna tell the patient? I would definitely um now, now, now we have to keep in mind the at miss. So definitely the patient factors whether they can be operated on or not to start with and then discussing the operation in itself um, we would need a, to be plated, so, plate and screws. Yeah. Um, that's, but one of the things I'd like to do, first of all on these types of fractures would be to order a CT. Excellent. Why? Because I need to know the extension of the, uh, fracture. Um, it could be quite comminuted and, um, basically, like we can see, we can see on the CT there's, there could be quite a lot of, uh, things in order to plan your surgery. Exactly. You need to. So I need to know, yeah. How distal are they, uh, is the fracture extending? Can I get, uh, solid screws in underneath the water shed line? Can I, um, I need to know if it's extending to the lunate also or not? And uh, basically do my surgical planning. Excellent, good. Do you guys understand why? What he's talking about? Yes. So it's not. So we know that we're gonna plate it. But next thing, um, is how are we gonna plate it? What plate we need to use? Um, do we have enough distal bone to put screws through? Is it salvageable? Um, has, does it has a lot of bone loss? Does it need bone graft? Um, if it's not salvageable and you look like something like that? Where is this one is not too bad actually, but it's, you have something which is very distal is lot of comminution, intraarticular. There is nothing, no space to put screws there, then you maybe the plate is not a good option. Uh If the plate is not a good option and this is not reconstruct, what, what do you have in instead of surgical that somebody else first? So what, what else do you have? So you can't K wire? Yeah, is not on hold it. Intraarticular is commuted. Uh You can't plate it because you don't have enough bone rim. There is no, you know, bone loss intraarticular in pieces. WW What can you still do? So you can spam this? Excellent, good. Can you explain to the people what is spending? No, not really. Um So we talk about it at the 12 meeting and it seems to, it seems it's almost like an arthrodesis of crossing the joint. But my understanding is then quite poor. Is that, that, that sounds like it's going to call basically a wrist fusion. This is that right? Or no, it, it's much better than that. So the way to spain it is either you do an infi or you do an X fix. And before we have these in fixes which are dorsal um wrist um spanning plates. Um We, we used to put X fixes on, yeah, we put an X fix on the wrist the same way you put an X fix on whatever else, ankle or knee or whatever. Yeah. So you put some pins in the radius, you put some pins in the metacarpal bones you put some, you, you bring it back to length. Yeah, and then you, you join these, these pins with bars and keep the keep the fracture, you know, align until it heals. Now, there are smart devices nowadays which basically completely, I think almost completely replace the X fix. Um Apart with for a couple of indications, I want to tell you about um where you, you can put a plate on the dorsal aspect of the wrist. In the same way you put the plate when you fuse the wrist. But the difference in between fusing the wrist and putting this plate on is you do not prepare the joint surface for, for fusion. You don't go there, scratch, articular cartilage, put bone graft and then fuse it forever. You, you put this, this plate just to span it, OK? And then you keep it back to length, you let it heal and when the fracture is healed in approximately three months time, you remove the plate, they are going to be stiff for sure. But then you are gonna rehab them. And in most of the cases, they will come back to a functional range of movement. I just took some plates off recently that I have put actually and um they are doing very well. So to be honest, I've done a bit of family way to break some this the scar tissue that has formed over the plate. But actually, by the time I removed the plate and I, you know, manipulated the, the wrist had a pretty good range of movement. So it's much better than the X fix because there is no, no risk for uh k for um pinsight infections. And you know, that frame is very difficult to wear and it's very difficult to, you know, do anything with that frame on while the plate stays inside the bone. It's protected from infection. You can still use your fingers in the same way you have a wrist fusion for three months and then you get rid of it. And um you have um in most of the time you have a, you know, functional range of movement. Now that being said, what is the last one, last image? All this radio styloid fracture? Yeah. So this is just radio styloid fracture. Yeah, it's the same like this one here. Yeah, you have it in the picture. Yeah. Um you know, in this situation is, is not displaced. Yeah, he is in a very good position. Do you need to do anything surgical about that? For the what would you do with that? In Ed? Uh For this one, I think it very much does depend on patient factors um for someone who's young and fit this, this could potentially heal by secondary intention. So because it's intraarticular, so this would very much would, you know, if they're a bit older, I wouldn't I manage this conservatively. But if they're younger with high function. It would definitely be one that I would look to fix. So, what, what, how, how would you fix it? KW crossing KW um, is an option. There's also internal fixation but I'm pretty sure I see this is quite a kwire injury. Yeah, I so nice. Is it that, that, that style just begs you for a Kwire? Yeah. So it's, uh, you don't need to necessarily play this. Um, but now this one is completely in displaced, you can even run with it and see it in a, in um in a a weak in fracture. You can see if this place is or not. If this place is definitely go and fix it, it doesn't displace at all, might as well heal nicely. Um If you look at the the radial inclination is is maintained. Yeah. So there is no no drop in radial inclination. So you can go either way with this one depends um what um what's gonna happen. So as as we, we discussed guys, now we we already went through this when I talk about the management. Always remember patient is first. Fracture is second. OK? So when you talk about the patient factors, this is the things you need to take into the consideration, age, hand dominance occupation, hobbies, you know, functional level. Past medical history, drug history, I had a patient in fracture clinic um with a this rays fracture. And when I looked at the x-ray before seeing the patient. I was like, and she was, I don't know, 70 something, 70 something. And I was like, well, you know what, I can run with this one, no operative. It's just on the edge with all the parameters, you know, and then I saw the patient and she's 70 something. Ok. And, you know, are you retired? Yes. What do you enjoy doing? Actually, I play piano three times per week and I was like, you are doing what plays piano three times per week. And actually she was doing that, um, as a part time job or something. And you know, and then I was like, oh, right then, ok, so this is not our typical 70 something years old, you know, dysfunction, little lady doing some gardening from time to time. So then you need to address the patient first and then think about your management, what you are trying to give to the patient back and obviously past medical history, drug history or those are important. Um, when you consider surgery, you don't want an operation, you know, for sure that he is going to turn into an infection or, you know, is not going to heal because the patient smokes for 40 years now, 40 cigarettes per day. So, you know, you need to have that ATS done very clearly in your head. So then you can then think about what we are gonna do obviously very important if it's an open injury or closed injury if it's displaced and displaced or. So we discussed that intra articular, extra articular. So all those factors are, are very important. Now, anybody, let's see, you have a, a wrist fracture in Ed and is open. How is this gonna change your management? Let's say you have picture number three, that is open injury. Will that change your management in any way? Um So I think, I think as per kind of the both guidelines that needs an early washout and then depending on contamination. Um So in order to kind of prevent the joint becoming infected, um we'd want to kind of consider her for a washout and if it's, if you're opening it up anyway, um you may then consider wanting to definitively fix it at the same time. What are the things you are gonna check straight away when you put your foot in or even before on the phone? Um So neurovascular status if it's open. Um Is there still good pulses because there's obviously been high energy trauma that's caused um bone attacks at the skin. Um That's the vascular state is very good. But what in terms of, of treatment, what do you expect that they will have straight away? So IV antibiotics and co your tetanus prophylaxis. Excellent. So you make sure you don't miss this stuff, which are basic stuff and usually ed are very good in giving those straight away. Uh But you need to check all the time. So, antibiotics in des prophylaxis. And then are you gonna watch it in Ed? Are you gonna wash it in theater? We would watch that in Ed unless I, sorry in theater, unless I thought that there was going to be, um, a significant delay in them getting to theater. Um, but I would take pictures as well before kind of putting a damp gauze over the wound and wrapping up. Excellent. Excellent, good. Don't wash it in if not needed. What you can do in d remove gross contaminants is, you know, is this open fracture? This is gonna go to theater either way, especially if it's associated with an injury like I I showed you before, which is, you know, pretty severe injury. Ok. Why do you think they say don't push it need the, I mean, if there are minor injuries in wrists, you know, um that you think they're not going deep and they are not reaching the fracture, then yeah, go ahead wash them any d close them. And that's that, especially if you think that patient might not need surgical treatment or might not be fit for surgical treatment. But why do you think they say, you know, um it's a little bit of a waste of time really? Because you're not going to be able to get, get a satisfactory wash out. And also, you know, it's a soft tissue injury with a broken bone in the middle. So you're not actually you know, unless they're a very um stoic patient, they're not going to allow you to sort of debride tissue enough to get decent closure. Potentially excellent. And you are then running into the risk of leaving behind foreign bodies, which you couldn't assess properly because you just had some local anesthetic and the patient didn't tolerate it and you left some frame bodies inside and then comes back with pus, an infection in the joint, infection in the bones and stuff. Actually, I I've seen, I've seen a case like that where a patient had a fall in the garden and came with a very, very small, very small um wound behind the lateral malleolus. Um with an associated fracture. Yeah, was even taken to theater. Yeah. Um It was a very small wound actually around one centimeter wound or something. Um you know, was uh I don't even know if it was lateral malleolus. I think it was only medial malleolus, the wound on the lateral side because they didn't, they didn't play the lateral side. So they put some screws on the medial side and just clean, clean the wound on the on the lateral side. And then you know, they had the washout and the bride in theater, wherever the patient went home, came in fracture clinic, the medial malleolus is healing but the patient is still in pain is still in pain. Something is wrong. The patient comes back, the ankle is swollen, the lateral side is very swollen. Um And then she starts, um, having high inflammatory markers and stuff and start discharging pus. And then you take the patient back to theater and we, we find a piece of wood which went in, in the first instance when she had the initial trauma because she fell in the garden. So a AAA piece of food went in and traveled up far enough that they couldn't find it when they've done the debridement initially and was not seen on the x-ray, which was pretty, it, it was like, you know, big, big deal was presented in all the morbidity meetings and you know, a lot of generated lot of interest in that case. So that is to show like what level of debridement you need to do sometimes to make sure you don't miss anything, especially that there are some stuff that are not obvious on x-ray. So even with the best precautions you take, you still can miss things, but at least don't, you don't need to miss, you know, things that you can um avoid, OK. If you are going to treat non operative, we need to put a cast. As I said before, make sure that the cast is put properly, leave the metacarpophalangeal joints out. You can see here this is the appropriate placement of the cast. And nowadays we don't put the wrists in these extreme positions where before we used to put in, you know, flexion and ulnar radiation and the patient will develop what, after a couple of weeks in that position of the wrist, what do you think the patient is gonna have, will they develop any kind of median nerve compression? Yeah. Yeah. So they're gonna start having numbness in their fingers and shooting pain and stuff. So it's, it's very uncomfortable to have a cast like that. Even that might hold your reduction reduction. Ok. So, ok. So what can you treat in a cast? Basically, most of the core is fractures if they're minimally displaced, if they are displaced, but you successfully reduce them and manage to hold that in place. Or as I said, it doesn't matter how the wrist looks like if the patient is, is is very frail and fit doesn't want surgery or is very low demand. Ok. First, do not harm. OK. So this is another way of fixing them. Usually you go for this type of fixation, extra articular fractures, you put them back in place, you feel that it is unstable and then you just pop to QR in to to maintain the usually um if there is too much comminution don't do that. It is not gonna hold, they're coming back in a week or two weeks and that all these beautiful image you've done in in in theater falls apart after two weeks if there is comminution, bone loss and stuff. So extra articular you know, clean fractures, put them back in pop to care, make sure you, you, you come to, to cortex out otherwise they're gonna be wobbly and not gonna hold. Um And in some of the cases, that's enough. Obviously, it was draft that say that basically you can deal with this type of fracture in a more easier, cheapest way like using KRS instead of plating. And um yeah, you can use that reference if you want to justify doing this. Um This is the plating most of the time we put plates and most of the time we put plates on the volar side, doesn't matter if the the fracture is displaced dors dorsally or volar li. And what do you think would put um fractures on the volar side for the fracture that is placed there dorsally? OK. Does allow you to identify um important structures like vessels and nerve, make sure you're not gonna put a screw coming out the back into one of them. Mm If anything, um the, the Henry's approach is much, much more dangerous because basically, you have a very narrow interval where you stay with the radial artery um on one side and the median nerve on the other side and a couple of branches and stuff. So it's much more dangerous approach this one than going um dorsally. But the problem with the dorsal plates is that there are lots of the extensor uh compartments and tendons. And um historically, these plates put on the dorsal aspect cause lots of attrition and irritation over the tendons because the tendon cannot glide properly. It was this bump of metal there and they start rupturing because they are rubbing against the plates in flection extension. So then it um there are ways to put these water plates it and be able to catch and reduce um the dorsal displacement and hold it in place. And sometimes you can use the plate as a reduction device if you, if you can see that plate on the lateral side. Yeah. So let's say you have a fracture which is displaced uh dorsally. Yeah. It goes dorsally and then you, you try to reduce it and keep it in place. And then if you put the, the the distal screws first. Yeah. OK. And fix the plate on that bone. Yeah. And leave the shaft free. Then you can use the the plate like a lever to reduce the fracture even more and then fix it on the shaft. Do you understand guys what I mean? Yeah, I've heard you call it joystick as well. Yeah. Yeah. Or you can use a Kai from behind, elevate the joint surface and that poet in as well. There are multiple ways to deal with that. But the the thing is that people have learned to deal with the dorsal displacement and comminution by using volar plates because of the complications associated with the door plates. Nowadays, there are low profile plates, you know that they are specially designed to avoid the bony prominence. It's much easier to use and sometimes in isolated cases where there is so much comminution on dorsal so that you cannot basically properly address with the volar plates. Sometimes that they are used as well. We discuss the dorsal spanning plate and just for the interest, the ones that are interest. I'm just going to show you how it looks like. Oh, maybe not so far. Just a second. So that, that's what I was telling you about the, the infi uh th this one. Yeah, that one. Thank you. Just the set then. Not that one, not that one, not that one, not that one. OK. So this one, yeah. Can you see that huge horrible plate which is on the dorsal side? Now, in this situation, you can see a roar plate as well because if you look closely to the fracture side, you will understand why. But um sometimes that huge horrible plate on the dorsal aspect of the wrist is enough just to maintain the line to keep, to keep all the pieces together. All right. And um let it heal and when it's healed, you take it off and see what residual function you have on the other side, if you have like a horrible fracture like this one and there is lots of bone loss and lots of comminution and you know, not enough bone to fix it properly. And you have those fragments which are actually going um volar. Yeah. And they are gonna, they're gonna drop and put pressure on the median nerve. Then you can actually use both of the plates to address the, the volar fragments. And in the meantime, you can imagine that that plate is not going to hold you the whole fracture, but you, you need the infi as well to hold it together. But you use the volar plate just to reconstruct what is reconstruct on the volar side? OK. So this is how it looks like. Now you put that obviously in this place, in particular community fracture, orally displaced and whatever. And this is the last frontier. You put an X fix on. We now put X fixes on only if you have horrible open fracture, crush injuries, soft tissue is compromised. Um and you basically cannot close um a plate under the skin, you know, is so bad might need plastic intervention might need multiple surgeries for debridement and stuff. So basically, the soft tissue will not allow you to, to close it properly. So in that situation, you put this um e on. So again, this is one fracture we've done today actually. So again, what do you have here? You have a dors vally displaced. Yeah, this the radial fracture you can see it's a lot of comminution, it's lots of um radial height, um inclination, whatever the thing is that fragment is volar is not safe to stay there. You put a put a simple plate like this job sort. It look at the inclination, look at the height. Um, everything is basically more or less restored with one single plate. Sometimes is just enough to put the proximal screws. You don't even need to screw the, the, the distal bit. If there is no comminution is just one big, big chunk of bone because basically what that plate does buttresses all. Yeah, then you have the worst stuff you have horrible fractures you have. This is what I'm telling about. If you look at the MRI the CT scan in the middle, can you guys see in the middle that there is a huge gap there and almost no bone? And can you see how thin that layer of bone is? So if you think about you need to put a plate where the distal, the distal screws are gonna sit in that brim of bone, which is basically nonexistent in half of the joint surface. So now this is a problem is it you look at the x-ray is bad, you do some CTS, it even worse. Now, what are you going to do with this one? Ok. I'm going to give you two scenarios, one, you have a 22 sport injury and second, you have a 77 fragility fracture. What are you gonna do in first scenario? And what are you gonna do in second scenario or what are you gonna try to do? At least uh save the joint versus primary fusion or who say the joint to the young man? Fuse the old low function. OK. So, so fuse the joint for the young man? No, no, no. The other way around. Yes. Yeah. OK. So what are you gonna do for the young, 22 years old apart from? Yeah, I don't really know. As you said, you've got such a shell of just radius now, I don't really know. Yeah. Where, where the heck we're going to put the screws, man. Oh It's so bad, is it? And if you go through the image is, is even worse. So I just caught that piece. Um that slice for you guys just to say that sometimes the bone can be in existent basically, then you can try the impossible and hope is going to hold. So what we have done here and this is probably one of the worst things I've done in my life so far. And it's what I've done today. So you can say that you, you can see very clearly that you lost the inclination, you lost the height, you lost the tilt and there is bone loss and there is everything, you know, just bad. I cannot now draw you exactly what I found when I went inside actually. And how much I needed to use all the skills available under the sun. I have accumulated all along this training to try to put the puzzle together somehow. Um At some point looking like a hedgehog of K wires and things, but you are sort of obliged to try to save it if you can. And my bail off of that was if I can't achieve anything that's remotely, looks like a joint, I'm gonna just open dorsally and put the spanning plate on the dorsal side and there's that. But as you said, if you have an elderly patient, then it is a different story, you might go straight away from the dorsal spanning plate without even trying to, to save the joint at all. Just go distally uh dorsally straight away, spend it out, three months come out and then try to rehab it. I mean, if you look here over the radio style, look at the level of comminution that was there. So what we have achieved, we, we have put it in no position. We supported all of that with screws under the surface. Um we managed to restore some of the height and then now the radius is not shorter than the ulna. Um Is it perfect? No, it's far away from perfect. I was actually unhappy with that at the end of the case, but might work and if might work in a 22 years old is worth trying. It doesn't work. You're gonna go on and you know, do something at, at the end. Uh Now this is what we're planning to do next week just to, to have an idea how bad it can go. So this one is dorsally displaced. It's not big deal. Yeah, if you look at the first glance, yeah. And then you look on the A P and you say, yeah, you know, all that surface is down and most likely, you know, there's lots of comminution and probably goes interarticular. And um yeah, then you do the CT and look what you find again. Shell, no joint surface, multiple fracture lines going everywhere and on top of that, what's that Skway track? Ok. Now, what are we gonna do with this one? Again? 30 years old, fit and healthy Maria, sorry to get rid of uh the time warning because metal is going to be kicking us off uh any minute now. Ok. This is the last one. So just in time. Nice. Ok. So what I'm trying to tell you guys whatever you going to see in d most of the time it's gonna be just straightforward, this fracture kid in a cast, elderly, whatever, but that can go as bad as this. The last cases I've show you which are pretty extreme in terms of options available to try to save them. And again is all about the patient, young, fit, active patient, try everything humanly possible to save it. But again, if you have an elderly fragility fracture, then then you might rethink how much damage do you want to do more? Ok. So did you guys learn anything from today or it was far too basic, especially after the first lecture guys. I, I felt embarrassed to teach this to you today. I think it was really good. Thank you. So, it, it's just our level. This is advertised from, uh, with funds with me now all the way up to sort of uh people applying to registrar training. So it really is a good mix. Thank you. Ok. Have a good night guys and uh thank you very much for spending this time listening to me. Thank you and hopefully that is something you could learn now. Thank you very much. Thank you very much, Mister Ano for the uh nice talk. Thank you very much, Maria. I think it all ties in together nicely. Now, you know about uh we learned about wrist fractures, carpus injuries and dislocations, uh which we uh usually see, but we don't learn much about and how to deal with the, you know, finger fractures both in the emergency department, acute setting and uh later on management and follow up. Uh Yeah, this is a very good session today. Thank you very much and uh we have a soon. Thanks very much, Karem. Thanks for asking me. Cheers. Thank you very much. Bye bye. Good night. Thank you. Good night. It's not.