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To the microphones working. Yeah, I can hear you. I think you can't. Okay. People can put we. Oh, yeah. Okay. That's great. Thank you. Um Yes, thanks for introduction, Caitlin. Um My name is Katie Hoban. I'm all the paid a registrar that's based in Dundee. Thank you for having me along this evening to present this topic of um upper limb cases in trauma and orthopedics. Um broadly speaking, upper limb is a huge area to cover uh the plan is that I'm just going to touch briefly on in the next hour or so on certain aspects just to give you a flavor for your exams and common conditions that come up. Um So next slide. Thanks Caitlin. Um So the format for this evening will be approximately a 45 50 minute converse presentation with a 15 minute questions at the end. Um I'm going to focus on four main cases depending on how we're doing for time. Um And if anyone has any questions, I'm, I'm happy to take them at the end. But the plan and of the evening is that we'll do a review of anatomy for the case and then some questions intertwined um into their case discussion that follows with the case. Um So the first upper limb topic that we're going to cover. Yeah, if we just get everyone's maybe logging on mental meter. Yeah. Going. Yeah, just so it's quick. Um So if everyone could scan this QR code or log into meant to meet you. If you've used this before, we've got some interactive questions throughout the presentation um that so we can get this sorted now, then Katie can just flow through presentation. I'll give you guys a minute and then we'll carry on. Yeah. Okay. So the code will stay at the top and we'll just just carry on from there. Okay. Cool. That's great. Thanks. Um Yes. So the first a pill um topic that we're going to discuss is um the shoulder. Um So if we move on to the next slide, um we should hopefully have some anatomy images on there. So the shoulder joint. So the glenohumeral joint, um it's an articulation between the scapula and the humerus. It's a ball and socket synovial type joint and it's one of the most mobile joints in the human body. So we know that the shoulder joint is formed between the head of the humerus and the green owed cavity of the scapula. And like most synovial joints, these articulating services are covered with highland cartilage. Um The head of the humerus itself is much larger than the glenoid fossa and this gives it a wide range of movement. However, what that does mean is that the cost of the and the downside of this is that it's uh can be unstable. So to reduce the disproportion surfaces, the glenoid fossa is deepened by the fibrocartilage rim and this is called the glenoid labrum um surrounding all this, you have the joint capsule. This is a fiber sheath which encloses all the structures of the joint and this extends from the anatomical neck um up to the or the rim of the glenoid fossa and the capsule itself is fairly lax. Um and this allows greater mobility. In particular abduction. You have the synovial membrane that lines the inner surface of the joint capsule and produces synovial fluid which as we know, reduces friction between the articular surfaces. There's various ligaments that surround the shoulder joint itself. Um and they play a really important role in stabilizing the joint. Um So you have the glenohumeral ligaments and there's three of those you have the superior, the middle and the inferior mg glenohumeral ligaments. And they extend from the humerus to the glenoid faucet and they help reinforce the joint capsule and they generally speak and stabilize the anterior aspect of the joint. Um You then have the coracohumeral ligament and that extends from the base of the coracoid process up to the greater tubercle of the humerus and that supports the superior part of the capsule. The other two ligaments that you have are the transverse humeral ligament and that's between the 22 bickell's of the humerus and it holds a long head of biceps tendon in that into tubercle into tubercular groove. And the other ligament is the karaoke, oh, karaoke, oh, acromial ligament. And that extends between the a chromium and the coracoid process of the scapula. And yeah, that's important to a recognition when you're doing arthroscopy. Um So if we move on to the next slide, this is a question which um hopefully should be able to answer on your little mental meter things. So we'll give them, give you a chance to do that and then we'll reveal the answers. Um Yeah. So if you didn't get a chance to log on and get your mental meter sorted, um There's a code just at the top there. So I'll give you guys a few seconds to uh vote and then we'll talk about the answer. What? Okay. So we've had seven responses so far. Um Anyone else wants to love on a wait a bit longer? Okay. Seems to have put it off. I'll let you talk about the answer and I'll just reveal it. Yeah, that's great. Thank you. So, um those of you that answered correctly um Seven of you. Yeah, terrors minor is not a rotator cuff muscle. Um The other four are um so this image nicely demonstrates the four rotator cuff. So it's four distinct muscles and the tendons and these provide strength and stability to the shoulder complex itself. So you have supraspinatus, which sits in the supraspinatus fossa. You have infraspinatus which sits in the infraspinatus fossa. You have subscapularis and you have tears minor. Uh these all arise from the scapula and they connect to the head of the humerus to give a cough around the glenohumeral joint. It's the subscapularis tendon that attaches to the lesser trochanter and the remaining uh and then the remaining ones attached to the greater tuberosity of the, of the humerus. Yeah, tuberosity, sorry, not trochanter. Um As a group, they're responsible for stabilizing the shoulder joint and they allowed fine movement of the head of the humerus within the glenoid fossa. Um And the, the they're kind of classified as the intrinsic muscles of the shoulder and there's extrinsic muscles um such as the deltoid, the trapeze, the trapezium petrels major and latissimus dorsi. And they also give some support and stability around the shoulder joint themselves, but their air considered to be extrinsic. Um So the next question is, what are the possible movements at the shoulder joint? Um So the on your mental meter, you should be able to have uh some free text box. So if you just want to kind of pop in some words that you, that you think in terms of movement, what the shoulder does and we'll see what people come up with. Yeah, that's all looking positive. Mhm Yep. Yeah. Excellent. All look very good. Kaylin, there's people coming up in the chat just saying that there's um events starting soon. I don't know whether people need admitted or something. Okay. I'll check that out. I'll see. Thank you. Yes. So these uh movements that you're describing. Yeah, they're all correct. So if we move on to the next slide once Caitlin's had chance to admit others. So there's like I said, the shoulder is one of the most mobile joints in the body and there's so many different movements that can be done. So you kind of mentioned the bulk of them already. So you can get forward flexion extension ab deduction. So that's initiated by supraspinatus initially and then deltoid takes over, you've got external rotation and internal rotation. Uh Somebody also on the slide mentioned, yeah, circumduction as well. So again, that relates to um yeah, the rotational aspect of things. Um So yeah, huge variety of movements um that can be done. So next slide, so I'm going to start looking at some radiographs. Um Now, so if you go back onto your mentee, um and if you can drop a pin on where you think the acromion process is, yeah. So that's um that's great, well done to the seven of you that have correctly identified that. So that's the acromion process there at the most. Uh Well, on the AP view there, it's the most lateral looking aspect just slightly lateral to their clavicle on the, on the AP view. So if we look at the, at the shoulder radiographs that you see, there's so many different types of views that can be taken at the shoulder. And these really depend, you know, on what essentially you're looking for. You know, in trauma patient's, you can usually only get one view because there to sort to be able to allow you to do another view. But if we just focus on the plane ap radiograph initially, so that's the image on the left hand side of the computer here um of the slide. So you've got the clavicle and that you can see that you've got the acromioclavicular distance there. Um That, that's the region between the clavicle and the chromium and it's usually less than eight millimeters. Um You've also got the coracoid process there, which is highlighted in blue. Um So that's the anterior aspect of the clavicle. You've got the humeral head which articulates with the glenoid fossa, which is depicted there in the yellow color. Um So you can kind of make out the ballpark landmarks of things there on that view. Obviously, you can kind of see ribs and things as well. Um So it's always important to look at all the bony architecture, but also, you know, have a look at the, the soft tissues as well because that's important because on an AP view, you know, you can see potentially if you've got the clavicle fracture that it might be coming through the skin. And obviously, if that is the case, it's then an open fracture, which changes your management. Uh you know, in comparison to what it would be if it was a closed clavicle fracture. So the image in the middle depicts an ap and lateral radiograph of the shoulder. Um And they're like the mainstream views that you would be that you would be wanting um the axial views of the shoulder here, they can be good um to see whether or not you've got patient's, if you're struggling to decide whether or not there have got a dislocation. So it's probably quite small print there. But you can see you in the bottom left axial view picture there. A gas production, you can see that you've got a dislocation there. Um As I said, that you do, you want two views, two orthogonal views really for um any radiographs in orthopedics. But in a trauma setting that can be quite difficult. So if the patient's are sore. So next slide. So we're gonna do a case next. Um So you have a 24 year old man that presents to the emergency department and he's been tackled during rugby and he's got a painful shoulder. Um, he's not able to move his left shoulder and he denies any pins, needles, weakness and numbness, uh sorry, denies any pins, needles and weakness. And, but he tells you that he's got a little bit of numbness over the lateral aspect of his upper arm. Uh, he didn't have any head injury or loss of consciousness. Uh, he's otherwise fit and well, it doesn't take any regular medications. Uh, his right hand dominant manual worker nonsmoker and doesn't drink alcohol to excess. So it's important when you see these patient's that you do get a full history from them, which is why I've been quite thorough there in the description. And then the next step, which you do obviously, for any part of your assessment of patience is you've taken a history, you then want to examine them. And the main orthopedic mantra for examination is look, feel, move. So any joint in the body, that's kind of what you need to be doing. Um So if we move on to the next slide, so in terms of looking, the types of things that you're looking for in the shoulder, uh is there any obvious deformity, um swelling redness, um particularly for this case, the type of thing we'll be looking for, is there any shoulder contours i deformity? What's the position of the scapula? And, and in other cases, obviously, you're looking to see if there's any muscle wasting or scars and things like that. So you kind of obviously looking for um depending on, you know, the patient that's coming in, but these are the types of things that you should be looking at in the shoulder. Importantly, you want to be looking at from the front, from the side and from the posterior aspect of the shoulder as well, because you can gain information from all different angles in terms of the field part of the assessment, you want to palpate along the the bony landmarks. So starting at the clavicle at the front, working your way around across to the academia acromioclavicular joint and and then obviously onto the acro me in and then round the back. You want to be palpating along the spine of the scapula and also the medial and lateral borders. You want to be checking if there's any muscle spasm. Um and just generally like, are they where they tender if you're not particularly for this case, because the trauma case, so you'll probably be too sore, but in elective setting, you'd be palpating at the front and the back to see if they've got any tenderness to suggest that they've got glenohumeral arthritis in terms of the movement. And you want to assess the range of movement, which we know there's lots of different movements at the shoulder, which we've already described. And you also want to check whether or not they've got any scapular winging and you can get them to do that by standing like against the wall and pressing their arms against the wall. But again, in a trauma setting that wouldn't be appropriate. So you really have to tailor your examination to, you know what you think is going on. Um in terms of the movements, you can check if they've got painful are because that might be suggestive of impingement. But that's again, in an elective setting, uh, special test. That's another thing that we do in orthopedics. So that the types of things that you can test for our, the integrity and the strength of the rotator cuff muscles. So, for example, you can do Hawkins Kennedy test. That's when you've got the shoulder at 90 degrees of flexion, the elbow flex to 90 degrees. And then after that, you want to internally to take, they are essentially. And if that is the case and you get positive pain response with internal rotation, that can be professional, subacromial impingement. Um Other things that you can do will be the apprehension test that tests for um the whether or not a shoulder is stable or unstable and whether or not there are generally lax, but in a trauma setting, really the majority of things that you're going to be able to do in this case is your, your bony landmarks and your contours, um palpate, um an obvious deformity and then just see where it is exactly the sore. Um So next, next slide. So, um this is the X ray that you're presented with in the emergency department. So if you want to answer the question and we'll see what you, what you guys think. So we've got 10 people answering so far mixed response. It's always nice to have a bit of variety. It's 50 50. Okay. Yeah. So, um this one is an anterior dislocation. Um So yes, seven of you've got that one, right? Um So you can obviously see that it's dislocated, but that is a classic a radiograph for somebody that's gone anterior dislocation. The posterior dislocation tends to look like a light bulb and the radiograph doesn't quite look like that. We flick, flick on to the next slide. So, like I said, with any radiographs, you want to try and get two views if possible. But in the, in a trauma case like this, you usually will only get one next slide. So we've kind of briefly been over this here, but you can see that um this is just depicting the normal anatomy on an abnormal radiographs. We've got um the ap view here which you can see the glenoid process which is highlighted in red. The humeral head is sitting out of the ball and socket joint there in blue. Uh And obviously about the coracoid process and which should be in its normal position. So what do we do um with this? So, in the emergency department, um these shoulders should be reduced. Um So there's different methods by which that this can be done. But the baseline management initially is you've got need to make sure that you've given the patient IV analgesia, whether it be morphine ketamine depending on your emergency department. Colleagues, obviously, the require little bit of oxygen and sedation at the same time as well. So the most common method used is a closed reduction using the cocker method. So what that involves is the patient is in a supine position with the arm, a de doctored and the elbow flexed at 90 degrees the practitioner. So whether it be the emergency uh department doctors or our orthopedic doctor, they give external rotation to the shoulder until a resistance is felt. And then after that, the shoulder is a deducted and flexed in external rotation. And that should hopefully get it back in. Um And once you've done that, you put the patient in a policy sling and, and obviously, once they've come around from the sedation, you want to make sure that you've checked the neurovascular status. I said that he had this patient had numbness and in the lateral aspect of the upper arm. So that would be alluding to an axillary nerve neurapraxia. And then you would hopefully, if you've got it back in a reasonable time that should settle. Once he's been reduced, there are other methods by which um you can, you know, reduce the shoulder closed. There's the Hippocratic method. So that's when the patient's lying supine, you hold the affected limb by the forearm and the hand and then uh the teaching is you put your heel in the patient's Axler and then that acts as a fulcrum while you a D doc the, the uh and that helps initiate the reduction. And again, put it into a policy thing after the, the Stimson method. Um That's just another method that you can also use where you put a weight on the bottom of the patient's at wrist in the hope that you'll reduce it closed. As shown on the diagram there, patient's once they're in the sling, they're usually in that for a couple of weeks or so, give them analgesia. But the important thing is that you don't want the shoulder to stiffen up. So you want to refer them to physiotherapy and start gradual early mobilization next slide. So, instability, um common, you know, in younger patient's, they tend to be young sporty and most of them are traumatic. Most common is an anterior shoulder dislocation which we've seen the radiographs for and, and it's usually due to a traumatic type injury, posterior dislocation you can see on that radiograph there and the top of the humeral head there, it's more light bulb appearance in comparison to a normal ap radiograph. Um these are rare. They count for less than 5% of dislocations and they're more commonly seen in patients that have epileptic fits or electrocution. But still, even in that subgroup of patient's an anterior dislocation is more common than posterior. But the posterior dislocation is more commonly seen in those cohorts if that makes sense. So next slide. So those patients that present acutely usually traumatic, seen in the emergency department and they're sore and then they get point a sling slightly different flip of a coin are the chronic instability patient's, they're usually seen an elective shoulder clinic and it's usually when they're a bit more a traumatic in nature because the patient is lax and they can sub locks and they're generally speaking, not too painful and they don't require any support in a sling, but you need to, then go on to consider what you might need to do for them if they're dislocating all the time. So if we click on the next slide, so if you've got a recurrent dislocate, er, so slightly different from the case before, what investigations would you consider if you want to pop some things in the text box? Same and we'll see what you come up with. If anything, what type of investigations do you are aware of a shoulder instability? Yeah, great. So that these are the types of the answers? Wonderful, excellent grand. So if we move on to the next slide, Caleb, um so the you might consider additional radiographic appearance is um, so you can get, you know, you're, you should already have your A P but you might consider getting a garth you, which is an apical oblique that would help determine whether or not you've got, you know, any Hill Sachs Lesion's or a bony Bankcard lesion. But the mainstay for recurrent dislocate, er, is that you need to get the patient at MRI Arthrogram. So that's where you inject dye into the shoulder joint and capsule. And then you essentially take an MRI to ascertain the status of the soft tissues and you know, the, the the ligaments and the capsule on that on the MRI. So, um associated injuries with recurrent dislocate ear's, you can get a labour lesion. So that's a bank art lesion that's shown in the image at the top there of the slide that you can see that on the MRI there where you've got a high signal um on the on the scan, you can get a fracture of the humeral head. So that's called a Hill Sachs lesion. So you can remember that by Hill Sachs begins with an h humeral head fracture and you can get a fracture of the glenoid. So that's a bony bank card. So obviously, you've got the labrum that surrounds the, the glenoid. You can get a bony component attached to that called a bony bank card. And in older patient's, you might see a rotator cuff tear. Um and that's shown at the bottom of, of that diagram there where you can see you've got the rotator cuff muscle like torn off on the MRI. So next slide, the treatment aim for all of them. It is non operative management initially. So they need to be referred to physio and you need to make sure that they're having rotator cuff and core strengthening and scapula stabilising exercises given to them. I'm sure it goes without saying, but the younger the patient, the higher the risk of recurrent dislocation. Um if they, you know, they see an upper limb um orthopedic specialist and decide that they need to go on for operative management. The options for instability treatment are arthroscopic or open stabilisation and then essentially repair of the bank of the bony bank card or the bank art lesion itself. And those patient's obviously it's a bit of a longer post operative recovery in terms of your non operative side of things. They're in a sling for six weeks. They're not allowed to drive for 8 to 10 weeks and they're not allowed to lift heavy things for 12 weeks and return to sport. Well, it depends obviously on the patient but broadly speaking, 12 weeks for non contact sport in six months for contact sport and the images, there are just arthroscopic images which you could see a patient that did have a bony bank ever had a bank art lesion. So next case, um so that's kind of shoulder anatomy covered in things. And with the case, we're going to now move onto elbow anatomy. So elbow synovial joint found in the upper limb between the arm and forearm, you've got articulation between the humerus and then also the radius and the ulna. So it's a synovial joint and it's also what we call a compound joint. Um And again, we're lined by highline cartilage similar to the shoulder. And you also have the synovial fluid which allows them lubrication and movement of the elbow itself enclosed by a fibrous capsule. And then, um as we know, the elbow itself is a hinge joint and it allows movement only in one plane. So it's a uni axle. So you get flexion and extension essentially. Um there's a collection of ligaments in the elbow and they contribute to the stability of the joint. So you've got the humerus ulnar and the Humira, radial joints. And they each have a ligament that connect the two bones called the ulnar collateral and the radial collateral ligaments. So, the ulnar collateral and that extends from the medial epicondyle of the humerus and it runs to the coracoid process of the ulnar. It's triangular in shape and you have the anterior posterior and the inferior band with your radial collateral ligament that has a low attachment to the lateral epicondyle of the humerus. And the distal fibers blend with the annular ligament which wraps around the head of the radius. Um The annual ligament that helps reinforce the joint by holding the radius and the ulna together at the proximal articulation. Obviously, you've got your bony anatomy here which we briefly touched upon already. So you've got your humerus, you've got the radial head, the radial neck, the electron um and the capital um and the trochlear, um they're kind of the main points to illustrate. And I think we've got a question next Dewey Caitlin is that right tip now. Mhm Okay. So if you'd like to drop a pin on where you think the electron in is and then we'll discuss. Yeah. So yeah, there's um yeah, four people have correctly identified where the electron on is. So if we move on to the next slide there, so this is just um an illustration of the radiographs that you are looking for are looking at in the elbow, you got the A P and the lateral view. Um So the image on the far right illustrates same all the different bony landmarks. So as I've said, you've got the humerus at the top, you then got the electron um fossa which is on the distal humerus itself. And that is, it allows the insert for the electron on process, which is what you've identified already on the lateral view of the elbow. Obviously, you've got the ulnar and the radius and then the radial head and the radial neck, which Caitlin's nicely illustrating, I think with the mouse there. So the capital um you get there um is also part of their distal humerus on the radial side. And then you've got the chalk layer on the on the side. Um Important landmarks on the distal humerus are the medial and the lateral epicondyles, the medial epicondyle because you've got the ulnar nerve that sits in nicely behind this. So, next slide. So talking about nerves and we're now going to look at what does the on the nerve supply um in terms of its motor and sensory components. So it's a question for you all. Um You want to answer on the mentee software if you don't know, just take a guess. Great. So we're getting a bit of variety. Yep. So, um yeah, most of you are right there. So in the anterior forearm, the muscular branch of the ulnar nerve supplies flexor carpi, ulnaris, uh and then also flexor digitorum profundus, which is the medial half. Um So yeah, that's kind of what the bulk of you have said there with your answers, which is good. The remaining muscles in the anterior forearm are innovated by the median nerve. Um So that's kind of uh and then in terms of the ulnar nerve distribution in it's motor supply in the hand, it supplies all muscles in the hand except the loaf muscles. Um So it supplies the ulnar lumbrical, the hypothenar muscles, the deep head of flex a policy brevis, a Doctor Pollicis and the forearm flexes, which we've already mentioned. Um in terms of the sensory supply, um it's the ulnar sided of the, so your median nerve supplies the 3.5 digits on the volar surface and the ulnar supplies supplies the remaining 1.5 um digits in the volar surface of the hand. The radial side is innovated. Um The radial nerve innovates the web spaces on the extensor surface, but we'll revisit those a little bit later. So next slide. So the next case is um a 65 year old man that presents with 5 to 6 months history of pins and needles in his little finger. You, you sense that on examination, his little finger does look a little bit thinner in comparison to the contralateral side. Um He denies weakness as such but finds that his general hand is use is quite clumsy. Um He's not got any neck pain. Uh He's diet controlled diabetic hypertension for which he takes Ramipril. Um He is right hand dominant and as it works as a as well as a retired electrician doesn't smoke or doesn't drink. So what do we do next? So, same as all the orthopedic mantra, we want to examine the patient. So this is a classic example of what somebody with an ulnar nerve neuropathy looks like. So you can see that they've got atrophy um in the hyper thena and the interosseous gutters in the image on the left hand side there. Um They're, they've also got clawing of the ring and the small finger because that's where uh you see an on the nerve uh where you've got somebody's gotten all the nerve lesion, that's got the classic position of hand altered sensation in the region distributed of the ulnar nerve. So they the volar surface in the uh 1.5 digits that we've mentioned. They also, when you test the patient's abducted digital mini me So you get them with their little finger to press against your finger and you find that that's a week because that's one of the muscles that is supplied by the ulnar nerve. And they're also week in terms of the grasping and the pinch grip, you get what we call Wartenberg sign. And that's where you get an abducted small finger, second edition on the nerve neuropathy. Next slide, other tests that you want to do when you're examining the patient to check for an all nerve neuropathy Tinel's test. Although commonly done for the median nerve, it can be done. The same principle applies from on the nerve. So essentially, you know the course of the ulnar nerve. So it runs around the medial epicondyle, you can tap it along at any level, working from distal too proximal to see whether or not you get any on the nerve symptoms and you tap the nerve directly. Again, Fallon's tests usually commonly associated with median nerve tests, but you can do it with the ulnar nerve as well. But it's a modified version which is where you flex the patient's elbow to try and precipitate the ulnar nerve symptoms. Freeman's test. That's an example, using a clinical photograph there. That is where you want to get the patient to grip some paper. And you see if the patient's not got on the nerve function, what happens is that they end up having to recruit um flex a policies longest and that we know that that is supplied by the anterior interosseous nerve, which is um a branch of the median nerve next slide. So we're die in terms of investigations, things that you can consider our nerve conduction studies or electromyographs. And usually the GP would refer this patient into orthopedics and with uh signs with the history and signs and symptoms consistent with a cubital tunnel syndrome. So that is where you get compression of the ulnar nerve at the level of the elbow. If a mild, moderate cases, you want to essentially splint the elbow, tell them to try physiotherapy. And obviously, we can try analgesic agents as well if you have nerve conduction test, which suggest that they've got severe um on the nerve neuropathy at this level. Um It's not uncommon that we would do an all the nerve decompression. So that's obviously surgical management. So if we click to the next slide, um, what you would be looking for here or what you would do is that is the medial epicondyle that demonstrated on that clinical photograph graph there. You want to make an incision and, and release it around the elbow. And essentially that can be done from the level of the intermuscular septum right down to the, between the two heads of f see you. Um So it's a day surgery, it can be done either local anesthetic, regional or general anesthetic depending on the center that you work at. And as I say you're releasing it from the intermuscular septum through the arcade of struggles down to the two heads of f see you um Usually the, if you put stitches in, they would come out of the 10 days, you can also close it to the skin as well. It just depends on surgeon preference. Um These are successful in 18 90% of cases. So next question for you um should be able to get this one which of the following is not supplied by the ulnar nerve. So we have um split so far. So the right uh the which of the following is not supplies, it's the lateral lumbar Kroll's that are not supplied by the on the nerve. So the loaf muscles are supplied by the median nerve and the l of loaf, it stands for the lateral to lumbrical. Um The other muscles supplied by the median nerve in the hands are the opponents policies, abductor policies, Brevis and flexor pollicis, Brevis, the rest are supplied by the ulnar nerve. So if we go to the next slide, so that encompasses a case at the elbow, we'll move on to another shoulder case. Um So we have a 53 year old lady that presents to your G P with a traumatic six week history of increasing painful, stiff right shoulder, the pain that she gets complains that she does get it at nighttime, but also when she's just resting as well, she denies any neurological or vascular deficit, she's having to take coq Codimal, which does help. But the pain she describes is pretty much eight out of 10. Um, she's an insulin dependent diabetic and she doesn't smoke or used to and she doesn't drink to excess and is a right hand dominant admin worker. So, from that history alone and what we'll move on to the next slide. Uh What do you think the most likely diagnosis is from those five things that I have listed? We've got a question just asking how old the patient was again? Is it 46? Was she uh yeah, she was 40 40 or 50 something I can get put on the slide. Yeah. Some people are also putting answers into the chat just in case uh not able to use renting me to. Oh yeah. Yeah. Okay. Yeah. So the most likely diagnosis is a frozen shoulder again, it's one of these things came, is a buzzword thing, more to be honest. So she's got night pain rest pain and he's an insulin dependent diabetic. So diabetes has an affiliation with patient's getting frozen shoulder. So if we click on to the next slide, so again, your examination is the same as always, look, feel and move. I've already honed in on the first case, the types of things that you should be looking for. So the salient points for a frozen shoulder are that you get global restriction in your range of movement and, and more most importantly, your external rotation is decreased to less than 50% of what is normal. Um, radiographs are normal. Um In these cases usually, and there are three main differentials really of reduced external rotation on your examination findings. Um The, I don't think I've got a question for this Caitlin. I um no, I didn't. That's fine. Um So the three, there's three things that it can be if you've got reduced external rotation, it's either a locked posterior dislocation, it's either a frozen shoulder or it's glenohumeral arthritis. They tend to be the three things that reduce your external rotation. But in this case, because of the history that I've given you, the most likely diagnosis is a frozen shoulder. So if we go to the next case, the next slide, sorry. So the mainstream management for frozen shoulder and what the pathophysiology behind it is where you get contractor and thickening of the coracohumeral ligament and, and also the rotator interval and the axillary fold. So you get a decrease in the joint volume itself. It's not necessarily adhesions that cause the reduced movement. There's three different phases, there's the frozen, there's the freezing, sorry, there's the frozen and then there's a thawing. The process itself can take, you know, 18 months to two years before it's fully resolved. Um The Mainstay Management forum is non operative management. So gentle movements, analgesia, physio, steroid injections and you can also try um the fluoroscopic distention as well. So that's an example of a radio graph on the previous slide there. So that's where you've got, you inject dye into the capsule. And you can see that, you know, you've got a distension there and then you essentially want to burst the capsule in order to distend it and allow the movement to be increased. Next slide, patient's that refractory to non operative management can undergo an operative procedures. They can have a manipulation under anesthetic that involves a serial series of range of movements, including abduction, a deduction and then a combination of external and internal rotation. Um They can also have an arthroscopic capsular release. And so these are just an arthroscopic pictures here shown on this slide that show that they've got, you know, inflammation and sign of itis um um in the as part of the pathology there. And you can also see that they've got a thickened glenohumeral ligament, but it's mainly the coracohumeral ligament that's affected that you in frozen shoulder. Um patient's, you need two polys sling afterwards, pain control. And then it's really important that you get them going with the physios as soon as possible. So, radiographs and for these different pathologies. So the radiographs that you see in patient's with glenohumeral arthritis, that is an example of an ap shoulder X ray there. On the slide, you can see that you've got subchondral sclerosis, joint space narrowing and you have cystic formation and then you've also got osteo fights and then the four cardinal symptoms of osteoarthritis, a traumatic rotator cuff tear that's depicted in the radiograph underneath. You can see that they, we already know from our anatomy session earlier case one that they rotator cuff tendons, three of them attach onto the greater tuberosity. And that's, um, if they get a rotator cuff tear, sometimes it can pull the greater tuberosity off. And that's what's illustrated on that radiograph with the yellow arrow frozen shoulder we've seen already, they have a normal X ray dislocation we've seen in the previous case, that's either an anterior or posterior dislocation. Most commonly, you sometimes can get a different type of dislocation, um an inferior type dislocation, but that's very rare and septic arthritis. You would expect them in the early phases to have a normal shoulder X ray. Um You wouldn't see any bony changes as such in terms of Osteomyelitis in the acute phase. Next slide. So the final case that we're going to look at is um some hand, um common conditions that we see in the hand. But firstly, we'll cover the anatomy of the hand like we have done with the other cases. So, um the obviously you've got your bony anatomy and then you've also got your tendons, um your, your flexes and your extensive is. So you've got the radius and the ulnar, they articulate with the carpal bones, the carpal bones that you can see illustrated here. You've got the skate void. And what? There's no point me naming them actually because you can probably already see them. But it's important when you're looking at the anatomy at hand. Are you looking at it from a, a P point of view or you're looking at from a P A radiograph point of view? So remember to learn the, the eight different carpal bones in the hand, the carpal bones, you then uh these articulate with their metacarpals and then you have your phalanges. Yeah, either have the proximal, the middle or the distal phalanges as well. You've got your flex a compartment, flex a compartment of the hand with the tendons, obviously. So you've got flexi digitorum, profundus, flexor, digitorum, superficialis on the volar side and then on the extensive side, you've got your extensor tendons. Next slide, we've visited this already in terms of the, when we looked at in another case, but we've mentioned the median nerve, these supply the loaf muscles of the hands, the lateral lumbar calls opponents policies, abductor policies, crevices and flexor pollicis, crevices. The ulna nerve supplies the intrinsic muscles of the hand. Uh so the hypothenar muscles, the medial lumbar calls adductor policies and the palmer and dorsal interossei of the hand, the radial nerve supplies the the posterior forearm. And so they are responsible for, you know, your wrist extension and your finger extension as well. So the next slide. So these are the types of things that you want to be looking out for in patient's. And when you're clinically looking like at the hand, obviously, you're kind of doing your general inspection. So you're looking at the, you know, the age, the the age of the patient, the general physical condition of the patient, like the gender. Um that's all kind of generic things that you need to be doing. But honing in on the hand, examination, the types of things I would suggest that you do are that you start distantly and, and move approximately or vice versa. So for example, you want to be looking at the elbows, looking at for whether or not they've got any nodules, have they got any psoriasis? And then you want to be looking at the patient's palms. So you're looking for any asymmetry, you're looking for any muscle wasting in either the thena or the hypothenar eminence. You're looking at the, the interosseous I have they got any guttering between the metacarpal phalangeal joints. You want to be looking at their patients' and nails, have they got any swan neck deformity which is hyper extension at the P I P joint, um and flexion at the D I P joint. So this if we go round and you can see on these clinical pictures that I'm showing you and the top left one here, you've got um what looks to be a flexion deformity um at the both the metacarpal phalangeal joint and also the uh the approximal Fallon deal joint, the distal one seems to be spared there on the little finger and you can also see it, it looks a bit Claude you, you could think it might be clawed. But then if you look a little bit closer, you think, or there might be a band there and, you know, at the base of the metacarpal and they're well over the metacarpal joint. Um on the image underneath, you can see that you've got wasting of the Thenar eminence. Um So you can think, you know, there's something going on potentially with, uh you know, is it, is there a nerve pathology um or is there, you know, bony underlying pathology such as a patient, you know, got muscle wasting. Um And then you've also got the picture to the right of that. You can see that they've got what looked to be um sorry, attic plaques and on the picture above, you could um can hopefully, you can convince yourself that yes, Caitlin's pointing out there, you've got a little bit of squaring of the thumb, but also you've got some wasting of the thenar muscle um uh there as well. Next slide. So in terms of your feel, part of the assessment, um general things that you need to be doing, feeling that your pulse is feeling the temperature of both hands, then you can feel over the patient's palmer fascia to see whether or not you've got any thickening, which would be indicative of jupiter runs disease. We've mentioned already the THENA and the hype athena eminences have palpate those to see whether or not they're tender or whether or not they're just wasted. And you also want to do by manual palpation of all the joints in the hand as well. So if we look at this picture here, sorry, go back there, Caitlin the, yeah, the clinical photograph on the left, you can see that you've got what looks to be a Jew patrons cord um in the patient's left um ring finger and that extends from the palm up to probably the level of the uh the proximal interphalangeal joints suggestive of jupiter. Ron's. Then obviously the other ones there you've got by manual palpations of the joints in the hand. And then you've also got feeling the pulse there at the top, right. So the next step is obviously movements at the hand. So the types of things that you need to be doing um uh check wrist flexion and extension. So that's kind of done like this and like that, you're checking the patient's radial and ulnar deviation. You want to check patients' finger flexion and extension, thumb, flexion and extension and then thumb A B and A deduction and then also thumb opposition, you're checking. Um If you want to check specifically the tendons, this clinical picture illustrates here how to check for flexor digitorum profundus and flexor digitorum superficialis. So you need to make sure that you isolate the other fingers when you're doing this. So that is superficialis. If you're testing the ring finger there, you need to isolate the other three fingers to make sure that you don't get unnecessary recruitment of the other flexes when you're testing it and, and then same for flex, it'd show and profundus, you need to, to make sure that you're just testing that by isolating the movement at the proximal interphalangeal joint because F F D P attaches a more distal than FDS. Uh So special tests, obviously, you need to be checking the sensation of the nerves. So you want to check the ulnar, the median and the radial nerves. So I alluded to earlier, this picture demonstrates it nicely. The green area is the area that's illustrated supplied sorry by the ulnar nerve. The, the yellow area is the sensory area that supplied by the median nerve. And the pink area on the dorsum of the hand is they're both what's supplied by the radial nerve and you need to make sure that you've uh documented clearly in your notes, all those they're different functions. So common conditions which we see in the hand. Um So I should have said actually on the special test there, we've mentioned them already, but you can do Tinel's and Phalen's test as well. You can also do Freeman's test to check the integrity of the on the nerve. So you don't forget those if you suspect pathology beyond there. In terms of the common conditions that we see in an elective setting of the hand, the three that I'm going to briefly mention our carpal tunnel syndrome, juba trans and trigger finger. So carpal tunnel syndrome, um that is a very common conditions um is usually seen in patient's that are female. It can also be seen during patient's that are pregnancy, but that their, their symptoms tend to resolve once they've had the child, other associated conditions, hypothyroidism, diabetes, obesity and rheumatoid. That image there illustrates nicely the carpal tunnel. So contained within the carpal tunnel itself, you've got your nine flex attendance. So four FDP for F D S and one F P L and you've also got your nerve as well. So it's the median nerve, these are contained by the transverse carpal ligament and that is essentially what you want to release during a carpal tunnel decompression if you're offering surgery next slide. So the types of um things that um uh seen with the symptoms of these patient's early on, you see pins and needles, patient's complain of pain and clumsiness and the pins and needles are obviously in the distribution of the median nerve, which we've previously said. So the 3.5 digits late symptoms include weakness and numbness in terms of the day to day activities. Um Functional type of problems, people, people wake up from the nighttime, they have trouble driving symptoms can be worse when they're using the phone or when they're reading, essentially when they're aggravating and reflexing the wrist as such. And the clinical photograph there illustrates nicely wasting of the thenar remnants. Um You know, which is um is that the area that supplied by the median nerve next slide. So the question for you, um which of the following is not a sign of carpal tunnel syndrome. So we've only got one person answering maybe a few, few more if you can answer. Okay. So, yep, most people have put Durkin's test. So that's um that is a sign of, of carpal tunnel. Um It's at the apprehension test, which is a test that's done in the shoulder to check for shoulder instability. So Durkin's test is essentially where you want to press over the median nerve at the level of the carpal tunnel and see whether or not that precipitates um the median of uh symptoms. Um So the answer there is positive apprehension test because I is for the shoulder. So management for mild cases, um you splint them physiotherapy and you can give a steroid injection for those cases that are severe and you can do a decompression uh that's essentially uh done under local anesthetic. It's a day case and the incision and you can see is illustrated there on the clinical photograph, but you want to go through skin a little bit of fat and then you want to release the transverse carpal ligament to make sure that the nerve is nice and free. We can do nerve conduction tests um as well. And if you're a bit unsure or of the diagnosis, but that's not mandatory and it depends on the surgeon. Jupiter runs contractor. So, um that man there is Jupiter on, he first identified um you know, these uh this pathology, um that's essentially where you get thickening of the palm of fascia, you get cords and you can see there that's a classic cord. Um, in the patient's hand there, which you can see on the volar surface and it's really common. It's a disease of the Vikings thickening of the palmer fascia and it can be mild or it can be very severe. One thing that you get patient to do in the clinic is do what we call Houston's tabletop test. So, can they get their fingers straight on, on the table or do they have like a bend? And is it a bend that's related to a cord? And can that cord be released? So, and then in the clinic setting, you want to measure the degree of deformity using a goniometer. And if it's um at the level where you think that it's needs something doing, obviously, we can offer surgery or if it's mild enough, you can offer them just splinting and tell them to do exercises. But this is something that we see. You do see quite a lot of. So it's be important to be able to pick it up for your oscal exams. Uh, the other thing that we can see is a trigger finger. So that's where you got, essentially, you've got thickening of the A one pulley and the patient's finger gets locked in that, in that position like that because you've got the thickening of that pulley. What ends up happening is that you can either inject them with a steroid or you can surgically release that pulley and, and then that obviously allows them to be able to move the finger without it locking in that position. So that's just really brief touch on the, you know, three common things that we see in elective upper limb setting. The last bit of this, we'll look at some brief interpretation of some trauma cases. So this is a uh this is a pa view and an oblique view and an ap view of uh scaphoid fracture. So you can see there maybe Caitlin will be able to point out that you have a proximal pole scaphoid fracture on the far right image radiograph there. It's important that these are detected clinically because there is a risk of avascular necrosis with these types of fractures. So, yeah, the types of things that you want to be looking at when you're examining patient's with a possible, you know, skateboard injury is that have they fallen onto an outstretched hand and impacted the skateboard? And are they tender? And the buzz word for is anatomical snuffbox is where they've got tenderness. Um, and if they do you get the radiographs and if it's got an obvious fracture or you can, if it's undisplaced, you can manage them in a splint, um, or a cast. But if it's displaced, they might need an operation or probably will need an operation. In fact, and if it's, if there's any do Byatt about whether or not they've got a break, they need an MRI scan um as soon as possible. Next case. So they one of the next questions for you, where is the fracture? So if you're able to drop the little pin and that would be great, you can feel free to drop it on either the AP or the lateral. Okay. So what? Yeah, three people answering. Good job. Nice. So yeah, well done to those of you that have identified that. So yeah, it's a break in the distal radius um uh fracture for those of you that have put the market a little bit more distal. Um I agree with you. There is pathology there, there is arthritis in within the carpal bones of the hand. Uh there's no obvious break. However, there though the salient thing about this A P and the lateral is that there is a acute break of the distal radius um forever the distal radius bone here that is dorsally angulated and there is also a loss of radial height and radial inclination. Um I would yeah, be you're not wrong in saying that there is pathology at that distal part in the carpal bones because as I said that there is a chronic pathology there. But the acute break here is in the distal radius. Um Next slide. Yeah. So with it, when with distal radius fractures, like I've already described it as it's dorsally angulated. Um it there is a loss of radial height and loss of radial inclination. Um The common thing that people tend to do now or in the past have done is name them with synonymous names such as colleagues fractures, Smith's fractures. And I would avoid doing that in your exams now because there's certainly a move away from that in modern orthopedic teaching. Um So it's better to describe it either, you know, as an intra or extra articular fracture that is displaced on displaced and uh and describe it in terms of, you know, dorsal or volar angulations and the most common is dorsal angulations. Um Sorry. The most, um the most important thing to say is that if it's dorsally angulated, um these are uh different in the sense that if you've got a volar early displaced risk fracture, the buzz word for a Bolelli displaced fracture is that it's inherently unstable. So the volar one's almost always need an operation if the patient is fit enough, whereas the dorsal ones, you tend to be able to manipulate them. And if you can get them into a good position without an operation, they're more likely to stay stable. Whereas the volar ones are inherently unstable next slide. So that's been an hour or so. Um, of, uh, four different cases with appropriate anatomy questions and cases. I hope that you found it useful. Um And uh, yeah, sorry if we've overran, I'm happy to take any questions. Um, and you, if you want to email me, I'd be happy to take them that way as well. Yep. We had a question earlier during the carpal tunnel. Um, teaching. I don't know if you want me to read out or if you want to look on the chat there. Um, yeah, it was what percent of carpal tunnel syndrome? Czar associated with amyloid deposits in the carpal tunnel. And in which parts would you look for? Amyloidosis? Oh, wow. Ok. Uh, amyloidosis. Very rare in my clinical career to date in orthopedics. I've never seen a patient that's coming with carpal tunnel, amyloidosis. Um, I have seen it but it's in medicine, not in orthopedics. Um, I think that's very niche. Um, I wouldn't be able to give you the, that the percentage of hand, I mean, it's kind of really case reports stuff. So I think that's, that's pretty niche. Um, I'd have to do some research on that myself. Um, yeah, I don't have anyone else a chance if you want to ask questions, um, to put them in chat. Um, are you happy? I can put your email in the chat as well. Uh Find your problem. I would say when it comes to the amyloidosis, obviously, you would be wanting to ascertain from your history taking. Um You know, does the patient have any, you know, other suggestion that they might have something systemic going on? Um I think an isolated carpal tunnel is unlikely to be amyloidosis. You'd be wanting to get that from your systemic inquiry and your history taking. Great. Um Yep. So I was just about to say so this event has been recorded. Um And we'll be posting it on the bumps the UK page, so it'll be available for you to watch back. Um I think it was really good refresher of just upper limb cases to consider an X rays is to look at, but definitely for myself, I need to go back into my anatomy and just refresh that. So I think this would be a good guideline for just going over cases and things. Um So thanks very much Katie for your time. You know, you're more than welcome. Thank you everybody for coming along and listening. I hope it's been informative. Uh feel free to send me any feedback when you think how I can improve going forward. Yep. Um And we've got a feedback form as well available and after you complete that you'll get your certificates. Um So if you could do that, that would be great. Um We're running a few more of these events, we've got our next one's next Tuesday and that's on bone tumor's with Mr David Skip. See, so that should be a good session as well. Um So yeah, if you get any feedback, this is a fluid thing and we can improve as we go. Um Yeah, thank you very much for coming everyone. Um Have a good evening. Um I think we'll end it there. Thank you. Ok, thank you. Mhm.