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I can't see any questions on the chat, so I'll assume there are no questions at the moment. Uh, so I'll introduce our next speaker, Mr Rich Palmer, who's an upper limb consultant here in Liverpool. There are many things to say about Mr Palmer, I think one, that kind of, uh, stuck with me is the fact that he volunteered for a year as a consultant in Malawi. Sounds very interesting. Well, might find out more about that later. Okay. Thank you. Thank you very much. So who was out until three o'clock in the morning last night, then everyone. Nobody Sort of feeling a bit dodgy. Yeah, right. Um, what I'm gonna do is try and make this quite exam focus. I can't really go through the entirety shoulder trauma in 15 minutes. So hopefully I'll just, um, sign post you to information. It's quite a lot of slides. And Adrian has says that he will, um, make sure the slides get to you. So you've got the links and the information on it, So try and concentrate what we're doing. As opposed to scribbling bits down, if that's okay. Okay. So in terms of your curriculum, that's what it says. Okay, It's fairly, uh, short compared to the other side. But that's essentially what you need to know. So the exam, what it will do is it will probe your understanding. Okay, so the rope learn facts that won't they'll get through that fairly quickly. But they'll get to a point where they start testing your higher order thinking, okay. And how you're applying your knowledge so they will discuss controversial areas. And they will discuss gray areas because that's where they're going to test your knowledge. Okay, so expect to be under pressure in your exams. So in terms of the shoulder itself, you've got three joints to articulations. You know, most people concentrate on the glenohumeral joint in the A C joint. Don't forget the SC joint. Don't forget your little articulations as well and all your soft tissues, okay. And the reason it's got all those, it's It's an amazing joint. Okay, It does a huge amount of movement, okay, But that's at the expense of stability. And it also then leads to lots of problems when that goes slightly wrong, and then trying to decipher what those problems are are a little bit of a clinical conundrum safe. What you need to get to is to the point where, in terms of trauma and surgery, to a certain extent, is you need to know, What's your rate of union? What's your time to union failure, conservative management, surgical indications, complications and then function that can actually consent process essentially, but that you are meant to be a day one consultant in your example. So you need to be able to talk through these. Okay, It's day one general consultant or shoulder and elbow consultant. So let's just hit on some of the stuff that you don't tend to learn. Okay, So in terms of your scapula anatomy, that the biggest bone of the shoulder that most of us ignore. Okay, there's loads of muscles attached to it. Okay. And you've got some important nerves around the area, So in terms of trauma, you've got scapula. Fractures tend to be high energy, okay? And they tend to be in particular regions when it's high energy. What else has been injured? Okay. Have they got a pneumothorax? Have they got a hemothorax, etcetera? So if you're presented with the scapula fracture, just go, OK? What else is injured. What? What else am I looking for? That's more life threatening. Okay, Mhm. The other thing not to forget is that in terms of the shoulder, it is floating essentially and only attached to your actual skeleton by this particular structure. Okay, so anything that breaks that ring, okay, Like a polo mental break into places you need to be aggressive and you need to get right. What do I need to do? So if you look see a glenoid net fracture? A lateral clavicle fracture. Don't think. Oh, this is nothing. It will be fine. They're relatively undisplaced. Okay, Think this ring is broken. This shoulder is actually floating. What do I need to do? Okay. The important bits So that some of these references are quite good overviews the scapula fractures. Essentially, there's not a lot of evidence. Okay, What you need to know is basic principles. The intra articular segment is important. Okay, so you need to be more aggressive at that point in time. Your ring is important. So looking for that floating shoulder and then the rest of it, you've got the sleeve of muscles around the scapula. Okay, so the sleeve and muscles tend to keep the blood supply going and tend to mean that they heal quite well. Conservative management. Okay, Okay. If you know, coffee calls, clavicles are controversial. Okay? There's lots and lots and lots of research. Meta analyses, papers saying one thing or another. So I'm just going to go over the saline points of clavicles, okay? And try and just give you a take home message. So the majority of the mid mid shaft clavicle, so as you can see in the top, right from Robinson's paper from Edinburgh? Um, very few remedial. And about a third of them a lateral. Okay, then you in terms of your lateral clavicle, you need to think about the stability of that particular area. Okay, So have the ligaments gone. Is it? Lateral to ligaments is immediate. A ligament? Is it completely few bar, But essentially, that's what you're trying to figure out in terms of your treatment options. Take home message is okay. The majority he'll with conservative management. Okay, but nonunion rates are high. Okay, What we do know is that if you go to have surgery, lowers the nonunion risk. But you've also got your risk of neurovascular damage. And that's something you need to discuss with your patient. Okay, If they unite conservatively, the functional schools are similar to if you operate on them. Okay, If you have a malunion, you will have poorer results from surgery trying to sort that malunion out or that nonunion out. Okay, so it is all really quite controversial. So that's the discussion that you need to have with your patient's go. Actually, you know, you've got a 70% chance of you healing. You should be fine, etcetera. But if we operate on you, then I could do X Y and said, But if you end up with a malunion, which is only a small percentage, you will have a worse result overall. Okay, Um and that's what you need to take away from that. Shortening is always mentioned after the Candida trial. Try and avoid that. You'll talk about clinical shortening, radiological shortening function, etcetera. Try and avoid that if you can. Unless you really know about it. Okay, because it's not the be all and end or it's a relative indication. Okay, everybody knows a Rockwood classification hopefully, and the classic question is, has anybody seen a type six. Anybody know? Okay. Still waiting for somebody to see, They say, Okay, there's a brilliant review of surgical treatments of lateral clavicle. Um, done by risking from London. Um, take home message grade one grade to do really well. Non operatively just need to do Physio grade three. Controversial. The personal opinion is if, uh, symptomatic. At three months, I will go and operate most of them. Settled down by three month. Uh uh, by three months. Four and 6. 10 to need surgery if you ever see a six. Okay, But what's controversial is how do you do it? Okay. Do you do with the hook plate? Do you do with the surgery leg? Do you do with an anatomical repair? What's the pros and cons of each of them? So you can get into a lovely discussion about how you're going to treat so they'll run you through the Rockwood things and then they'll get on to treatment, okay. And then you need to discuss things like, Well, you can put a hook plate in, but that's the second operation. You can get acromial disruption from that etcetera, etcetera, especially during covid. Um, there was a few hook plates that were left in for a bit longer. Okay, but then you need to balance that up against your lack of a pea. Translation stability with certain synthetic, um, reconstructions, Um, and whether you do it acutely or whether you do it chronically. Okay, SC joint disruptions. Rare resented teeth. Okay, three things you need to take away from this. Okay, If it goes forward, that's all right. There's no neurovascular structures there. They can pop back in, okay? But they tend to pop back out. There may end up with chronic instability, which you have to do something with if it goes backwards. That's when your neuro vascular structures are at risk. Okay, surgical emergency. Make sure you're talking about neurovascular structures. Make sure you're talking about cardio thoracic back up and talking about taking them to theater to reduce it. And the way classically, too, is the talc clip putting your arm into abduction and extension and then pulling it forwards. Okay, The other one to remember is an an adolescent child adolescent child. That's the wrong word, isn't it? Adolescent, whether if isis is still open, okay, you can get a Pfizer feel fracture where your SC joint is in joint. But you're Fyssas is off so it can look like an s e dislocation. Okay, so just be aware of that proximal humerus. Okay, Tend to the penny in the shoulder and elbow clinic. So it's it's going to be asked at some point during your exam somewhere. Okay. You need to know the anatomy of the proximal humerus. Okay. Need to know the blood supply to the head, because that's your surgical management is based upon that. Okay. You need to know the approaches to the proximal humerus. Okay, The ultimate question is gonna be Which ones are you going to treat conservatively? Which ones are you going to fix? Which ones are you going to replace? And I'm sure if you ask 50 different shoulder consultants, you'll get 50 different answers. Okay? So have a basis of what your decision making process is okay. And as long as that sound, you'll be okay. Mhm. So nears classification talks about anatomical parts of disruption of greater than 45 degrees or a centimeter. It's not a guide to to treatment. Okay, but everybody talks about 23 and four part fractures Okay, um, talked about head splits. And then if you get a head split, your avian risk is higher. Does anybody know what this classification is? Yeah. Hertel. So what he tried to do is take each of the little segments and see which ones have the Hy vee hy a vien risk. Okay, so 9, 10, 11 and 12 are the ones that had a high via a V n risk. He also talked about having an eight millimeter calcar segment. Okay, that increases the blood supply to the head and decreases your avian risk. Okay, but it's quite colorful. And it's quite easy to remember if you can just remember those high avian risk. You can talk about that, and your exam is supposed to remembering all of it. Author bullets has a really, really good, um, overview of how to do approximately human. Right? Okay, it's really well written out. The sorts of things I'll ask you is is cases like this for a little bit gray? Okay, so it's not a classic or going to replace up. It's not a classic or go in and fix that because they're 40 something. It's going to be like a 62 year old with, you know, combination. The Tuberosity Zaroff. What you're gonna do, you're gonna fix them. You're not going to fix them. You're going to replace them. What's the issue with replacing them? You know, and that's what you're going to get. And hopefully there'll be a discussion about that later. Yeah, Humiral shafts. There's lots of equipoise about human chef fractures. Okay, so, um, just remember, not all conservative treatment is the same. Okay, so a collar and cuff, it's not the same as a beagle brace, which is the one on the left compared to an OT custom stroke. Same ent type brace which molds you fracture and sees you every single week and molds it into place. Okay, so it's not supervised. Neglected? It is true conservative management for the ones that heal. Well, with that, you're the thing that they will ask you about. It's a radial nerve. Okay, because there's lots of evidence and research on what to do with the radial nerve and when, Okay, when to explore it, when not to explore it, whether you can wait and see, or whether you have to rush in and do it okay. And, um, j a nudist did a paper in, I think, 2005. But there's been a few more meta analysis in the last couple of years looking at what you should do with the radial nerve injury, post surgery, post manipulation and when you should investigate. Okay. Another controversial subject that you should all sort of know about your trauma survivors. So here we go. This is going into your seven and eight territory for your exam market. Okay, If you can say that, is trials going on for the midshaft humerus? Okay. The hush trial proffer to most people will have known about proffer One prophet to is looking at ARTHROPLASTY versus Conservative Management 3 to 4 part fractures because there weren't that many 3 to 4 part fractures and profit one and then at the present moment in time, died Act is about to start up, which is looking at lateral clavicles, which is run from the York Trials Unit and led by Lester Proffer. One now has to I think they reported it to three and five year results. Okay. Again, there's no difference between any of them, but you just need to know that they've reported three times. Okay, I'm not going to go into nerves. I'm not a brachial plexus expert. Okay, so, um Tom, Quick, um, and, uh, see why? From writing to not to break your plexus experts, They've got loads of stuff on webinars and things like that. I'll leave it to the experts about not confusing you with the brachial plexus. Okay, that's me over and done with Any questions? Yeah. Stunned silence.