Computer generated transcript

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

On the screen. So there are people who pass through Norwich. That's fantastic. I'm Adrian Hoofs. Uh, I'm a hand wrist, er, surgeon from the Norfolk Norwich Hospital. Um, and, um, I've got two talks for you today. Um, I've got a focus in particular on proximal to phalangeal joint and then I'm going to talk about perilunate injuries. I think I just happen to have my slides the other way round. If nobody minds, I'll just start off with. I think there's a logic to that. We had to shuffle the speeches. Yes. Last time as well. Yeah. So why don't you just crack on? There's quite a lot to get through. I certainly, my metacarpal fracture, um, talk is quite long because there's lots of different ones. So why don't we just crack on then folks right now? I hope this is going to work. I'm going to try and do a screen share. Um, please. How's that? That looks? I can certainly see it. Ok, great stuff. Look, I think. Yeah. Ok. So hopefully, um, everyone can sort of see that. Um, all right. So let's get started. Um, a patient presents with a painful hand after a rope's wrapped around it and pulled by a heavy branch. He's a trainee tree surgeon, true story, pain and stiffness in a little finger. Uh These are the X rays performed at the minor injuries unit and he's referred to the hand therapy team who come and find you to say, well, we really don't think this finger's moving terribly well and they're a bit concerned about it. Um People, uh anybody want to sort of just switch the microphone on and tell me what they think about the radiological assessment of that little finger based on these X rays. Anybody, anybody, the slides uh there msk. Oh sorry. Ok. I'm gonna have to go. I don't, I can't seem to minimize and see all you guys and keep it going. So I'm just gonna go back to the slide. Bear with me. Can you see it now? Cream or not? No. Uh Is it full or is it partial? Partial? Ok. I'll do this. How's that? Yeah. Now I can see it cream. Great green. You're a good man. Well done. You. Um What do you think cream about the assessment? Radiologically of a little finger with these x rays? Um I'm, I'm not happy with the uh basically these are uh ap and uh the radiographs of uh the right hand and I'm not sure about the congruence of the base of the fifth metacarpal, the bone and the bones around it. But I would want a lateral X ray to actually make sure if I'm correct or if I'm just, yeah, right on Kim. So please everybody do not accept an oblique. And I particularly like this set of x rays because when you look at them at the AP and the oblique, they look apparently, all right, they don't look, mas look like there's a massive problem and it just goes to show how this very pathetic two dimensional representation of a 3d structure can, can really mess you up because actually there's a lot going wrong and it's with the P IP joint. So that is the true lateral of the P IP joint. And I hate using the word true lateral, but we use it and we use it to remind the radiographers to not send the patient back until they've done a lateral X ray because it can be really hard. Um because you know, um patients in pain, multiple digit injuries, maybe something's open. It's very difficult to get imaging. But can everyone see that lateral X ray? Um So Kareem, since you're the man, you're fantastic, have a, have a lash. What do you think? So, this is an intraarticular fracture at the uh base of the uh middle PNX, the little finger. Yeah, the uh the fracture is displaced. He's a young three surgeon, as he said. So uh I wouldn't be happy with the Congress and the joint at the moment, especially at the, the end therapists are saying that uh it's not moving particularly well. So I think about uh possible surgical intervention. Yeah. Well, look fantastic. So um I'm just gonna modify some of the language you used. Um So this is a, a sublux joint, isn't it subluxation of the proximal tonal joint because of a fracture of the base of the middle phalanx. Uh And so what we need to do now is kind of work out how to classify these a little bit better. But everyone can sort of see that the remnant decent bit of joint, which is the dorsal part is not aligned. So that's that, that uh that subluxed. So just the message here, II show you what happened to this guy is that he actually because he kind of went by the therapist and presented late. He actually ended up with a hemi hamate. That is where a small piece of bone is taken from the hamate, articular surface and screwed on um to get a joint to be congruent, which is kind of classically done for these kind of missed later presenter injuries. So the first take home message about the proximal interphalangeal joint is you must have a good lateral X ray and please use the word true lateral if you wish to really press the point home. Um Is uh George George, are you on the line? Sorry, it's I'm gonna, I'm gonna get the people I know. Uh Yeah, I'm, I'm here, George. You're a good chap. Here's another one, another P IP joint injury. What do you think? Um So slightly more satisfied these look like true ap and lateral views of the very good. Um So there is um the suspicion on the ap the suspicion of overlap at the, at the um P I PJ and you can see that there's um volar um dislocation with, with shortening um of the P I PJ on the lateral well done. Is this the commonest dislocation you get at the P IP joint? Um I would have thought dorsal was more common from what I've seen. I'm not sure. Well, you're absolutely right, dorsal. It is. And do you know how much, I mean, when was the last time we saw a volar dislocation? Yeah, I II don't think I have no. Yeah, exactly. So about 90% of dislocations, 85 90% are dorsal. So everyone be very, very clear in their heads when they're looking at a dislocated P IP joint on your good quality lateral X ray to make sure that you are differentiating between a dorsal and a var dislocation vs are very rare. Dorsal are, are normally the ones you get because George, what is the difference in terms of outcome and therapy? Um So I'm not sure I would have thought if this is gonna be very unstable. Um Yeah. OK. Well, let's go the other way with a dorsal dislocation. What structure is ripped? In fact, sometimes you see a little fleck of bone on the palmar side, don't you? So, what, what the lar plate? Perfect Bolar or palmar plate on a, is ripped off on a dorsal dislocation. Do we, are we worried about palmar plates? Do they heal? Do you think? Um, I, yeah, I reckon there's, they'll just stick back down if it's the right. Do they over heal sometimes problem? Absolutely. All these dorsal dislocations, the big problem is the palmar plate aggressively scarring and giving you a fixed flexion deformity. So palmar plates we don't care about. Indeed, they're terrible things that give us fixed flexion deformities. Now, on a volar dislocation, what else might be, what, what, what might be ripped off as well? Um So probably the central slip is Star Man George, the central slip. So basically a volar dislocation equals a central slip rupture and is essential slip rupture toxic or not. What do you think? Um So chronically because of the pull of the rest of the extensor mechanism, um you might end up with um a sort of a deformity, a um a finger well done. So these lead to an aggressive bonia deformity which very rapidly becomes fixed as your palm plate remnants scar up. So it's a real nightmare. And th this is that same x-ray showing the photo dislocation reduced. Everyone can see there's a small flake of bone on the back. You may or may not see that, but all volar dislocations are a central slip rupture. Now, here you can clearly see there is that volar piece of bone off. Uh Can anyone see my cursor? I don't know George can see the cursor if I do that, I can't see the cursor but can see the fleck uh try this. Um So if I do that, how's that? Yeah, brilliant. So everyone can see that. And that is where the, the, the central slip has been avulsed. And what do you think of the distal joint on this X ray? It's already sort of quite hyper extended. So, can everyone see now that already this finger is going into a Bouton type deformity? Oops. Um Sorry. So everyone can always see we're, we're developing that, that, that bouton deformity and always look for the hyperextension of the distal and Toha joint. So how are we gonna manage these uh while I'll tell you it's very simple, they actually get managed in a Bouton Splint regime which any hand therapy team worth it salt will have. And all we need to do is keep that P IP joint straight, mobilize the distal interphalangeal joint to make sure those lateral bands are gliding away. And actually, after about four weeks, that thing is gonna stick itself back down. It's quite aggressive, the scar reaction that happens. So there's a massive difference between how we treat volar and dorsal dislocations, which is why it's important not to miss that var dislocation because they will decay into a nasty patonia quite quickly. Uh and, and that becomes very difficult to treat presenting chronically. So I'm gonna now continue to talk about the more common pattern of P IP fracture dislocation or fracture subluxation. And here and here it is, there's another version. So we can see here, approximate pharyngeal joint and how we classify this is we, we try and look towards how much of the articular surface er is er has been damaged. Now, everyone look very carefully, you can see this one, you can see the dorsal buttress and the articular surface is intact. So this is a DFD dorsal fracture dislocation and you can see that the the joint surface here is damaged or avulsed and hence the head is sliding through. And while you've got a significant piece of bone loss there, the head will always be sliding it out. I need you to differentiate the dorsal fracture dislocation from uh which is caused when a, when a sort of ball, you know, hits, you hits your finger or, or, or I we had a dog lead on the other one. So all sorts of injuries can cause it. But I need you to differentiate that from a pelon fracture. A pelon fracture is, is is bone either side of the head. You see pelon fractures of the ankle and the distal tibia and, and it's quite significant. The difference cos a pelon fracture of the head will be contained by various fragments of bone and actually, you can just let them heal and get them going. Whereas a dorsal fracture dislocation you have this horrible sort of edge loading here. Um And they don't do well, they turn up with a sort of painful sort of crepitus. So, is it stable or unstable? So, the first thing you do whenever you see a horrible x-ray, well, first of all, make sure it's a good quality X ray is to try and get them to move it. Cos actually, you're sometimes surprised by what a patient can or can't do so just get them to move it. And most of these, they won't be able to move much at all. Make sure you've got that good quality lateral X ray. And what we're gonna do is assess the percentage of involvement of the articular surface. So, on that good quality lateral X ray, you're looking to see how much of that bone has been evolved, crunched in, squashed, damaged. Uh There's clearly going to be a bit of inter and intra observer variability on this one. And after the fracture lines are running obliquely across, but you get a rough idea, 50% if you're up to half that is unstable. So let's just say you took the finger, put some local anesthetic ring block pulled on it, let go. It'll just pop straight back out again at about 30% which is kind of a rarer area you're tenuous, the head might be engaged, particularly if the middle phalanx, if is flexed. So the head will engage the good bit up to about 15 20%. It's pretty stable. You're just gonna get them going. So it's very, very important that you start to assess the articular surface loss and what happens. Uh Unless there's a lateral there, comma Alvear plate, there's a lovely congruent sort of joint surface here. Um And um you can see here this cresentic sign, you can sort of see it ving in. So it's called the V sign or cresentic sign. The head is trying to force its way out. Ok. Um And so that is bad for API P joint. And so that's your, that's your marker of this significant amount of articular surface loss, the crescentic sign. So when we look at this X ray, is it stable or unstable? Uh Georgia or star, is it stable or unstable? It looks like it's approaching 50% is probably unstable. And you can see the v perfect great answer. So I'm just gonna kind of just really ram that home. I'm gonna say that that's about the missing piece of articular surface, which looks about 50%. So you think hello, something's up there? But of course, that is hardly concentric, is it? I mean, that's really ving in. So you've got the V sign with 50% articular surface loss. It's chronic, it is unstable. You've gotta do something about it, they won't do well. And there's that V sign. So, um, the trouble with the P IP joint is that, and, and what we, we tend to do is we tend to splint P ip joints in extension cos that's the position of safe immobilization. Um, but for API P joint that's unstable, they're even more unstable in ST in extension than they are in flexion. And so if we look at this example, we've got a finger that's clearly not right. It's clearly a sublux version on dislocated. We call it a dorsal fracture dislocation, but we might have a little bit less of the articular surface involved. And that gives us the opportunity to flex the joint and that will improve joint congruence. So this is the same finger now with an extension block splint put on by the therapists. You can see it's a pretty, it's a difficult science. You can see sort of uh gaps, it's difficult to squash AAA, painful, um you know, swollen finger, but you can do it in case of ring block. Um if you need be, but often you can just get that finger to flex a little bit, send them around to therapy, get another X ray. And here you can see we've now got this wonderful congruent reduction. Um There's a flake of bone off here and this, we can just manage in a fl in an extension block splint. Um We sadly like all conservative treatments in orthopedics need to watch it like a hawk. They'll be back the next week and we can slowly ask the therapist to let the finger come into more extension and like elbows p ip joints go from instability to stiffness at about the magic week, 3 to 4 mark. So you gotta get them through to that. And by that point they'd have stabilized and that's the same finger now. Um, and you can still see, yeah, there's some little bit of damage here that's not gonna repair itself, but the vast majority of the joint is congruent and by not having to operate on this finger, uh, we've got AAA, it's good. We've got a good range of motion. So, uh, proximal interphalangeal joint, dorsal fracture dislocation treatments. Er, we're stable where we're at 0 to 15% of articular surface loss on the middle phalanx. We have relative stability at 15 to 30%. We're going to immobilize an extension block splint. You may not be sure exactly how much has gone, but you could always put a splint on and take another X ray and just see. And if they're still out, ok, gotta do something. If they're back, then we can manage them definitively with the splint. So, should we try and splint this one? Well, you look at this one and it's a very dodgy looking x-ray on the lateral. You can't really tell what's sort of going on. Can you, there's clearly some degree of articular surface damage, but you're not quite sure how much. Well, that's ok. Maybe it's 30%. Maybe we can flex them up a little bit. So let's just send them off for a Splint, have one made up and re X ray later that morning in clinic. And just having a slightly different view on the X ray here has been helpful, but you can sort of start to see some strange things happening. First of all, you can see a ruddy great big defect. Um, a and that's about 50% isn't it? And so you think, oh, gosh, well, that should be v signing. Well, it is, isn't it? And actually when you look that, that the, the data is there, these things are converging, aren't they? So that head is trying to still uh slip out of joint. So this is one, sadly that we think, well, probably we should do something about it, er, rather than sort of leave them a little bit subluxed in a lot of flexion and this is what it looks like. Now, this is a clinical photograph taken with a shotgun approach, which is the volar approach to these joints. It's a very aggressive approach. Uh, but it allows you to look at the articular surface of the middle phalanx and that's the same case that you just saw the picture of. So here you can sort of see this horrible depressed fracture with some comminution and you can also see how it kind of comes across obliquely, which a lot of them do. So here, this part of this head might still be articulating with a kind of a reasonable bit of articular surface. But this part of the condyle will have slipped out. And so you can start to see how that would have given you a rotational profile to the finger as well. And a not a not great P IP joint. So, these are the ones we're particularly interested in in the certainly greater than, you know, I'd say 50 greater than 40 probably greater than 40% articular surface that you're gonna have a chronically dislocated finger. And so why are we gonna do anything about it? Well, occasionally you'll see this. So this is a chap who's come in at three months after a effectively missed dorsal fracture, dislocation of API P joint. And you can sort of see how he's carved himself a new joint and he actually moves 20 to 80 degrees, which we might be quite pleased at after surgery for API P fracture dislocation. And he wasn't in a huge amount of pain. He just kind of tried to get his own finger going. So you might think to yourself. Well, why don't we just do that to them? We just like, try and mobilize them. Well, many of these people are really painful and, and sort of can't. And you would think that's a bit suboptimal. You would think I'd rather try and have the decent bit of articular cartilage here, articulating with the head rather than some kind of soothe thing going on. But it is of interest. Um, you can't predict these, you can't predict osteoarthritis how rapid it would be, meaning pain and stiffness. So generally we're gonna really try and diagnose these and reduce them. So here's a, another example. Um, we've got a finger that's been presented to us in extension for a dorsal fracture dislocation. Well, that's not great. But of course, all A&E thinks is, oh, we must, must put them all into extension. You can see a bit of a V sign on the back again, it depends on exactly how the X rays taken and we can sort of see a little bit of a, a little bit of bone loss sort of sort of there. But we've also got quite a, a big sort of chunky fragment. So this is somebody who's kind of unstable and what we can do for this is say, right? OK. I think that's a bit beyond 30. I'm not gonna bother with my extension block splint and we can reduce them and simply fire a wire across them. So picking up these injuries acutely reducing them and using a simple transfixion wire is an excellent tool because after the wire comes out, we can see that the head is kind of congruent and we can get them going. Now that wire can be transarticular, which is a problem and it does create a hole in the articular surface or an extension block wire that doesn't create so much of a hole, but it has to pass through the extensor mechanism. And if they start mobilizing their finger um up and down with your, with your wire in it, then you can create a fluffy tract. And some surgeons really don't like this because they've seen an infection in the P IP joint. Other surgeons haven't and like using extension block wires either way, pick up the injury, reduce it, hold it with a wire. For me, it would be a transarticular wire. We can have other situations where the the fragment of the bone is really quite large ct scanning can be helpful. Uh but to go to the operating room with a full Armamentarium is, is quite handy. We can see here an an extension block splint effectively was tried. Mm Meaning that the finger was just flexed except so you can sort of see the the splint material on the volar aspect. And you can see actually now that it was quite a large sort of defect, but equally, you're sort of looking at this thing and it's quite a big old fragment of bone. And in a rare example, then the fragments of bone can actually be reduced and fixed with a screw from a VR approach or if it's one big fragment, sometimes even from a dorsal approach just with a, a sort of a, a blind screw. So large fragments can be fixed, but it's rare. Of course, then we can have a more complex injury such as this. You can see, first of all that, you've lost a significant piece of articular surface. That's the good bit there. Uh, we've got a definite V sign. Yep, that's unstable. But that makes sense cos we've lost a big chunk of articular surface, but worse, we've got these terrible splits running up the middle phalanx. So this now starts to get complicated. Does the patient need to go to the theater and have it reduced? Yes. Can we, you know, with an art with a, with a, you know, extension block splint? Well, no, it, it's a huge defect. Can I put a simple transarticular wire across? Well, it's actually really quite difficult because that wire would probably end up running through one of these fracture lines. So that wouldn't work great. So we can go mad and we can go mad on fixation. Um, and that can produce a, a congruent joint, but it's very difficult. Uh a big skill set needed and it's gonna give stiffness. You can see here, he's probably trying to extend his finger for the uh X ray and you can see he's got what, 2030 degree flexion deformity. Also, it kind of looks a little bit rotated, doesn't it? Although it's not a true uh lateral of the uh of the joint so we can fixate when we start to get even more complex. So we've got awful sorts of splits on this older lady's finger here. We don't know what's going on. We've definitely got a fracture dislocation of the P IP. Um But what we can simply do is say, look, this won't do, it's clearly unstable. We're gonna take you to the theater, pull on it and see what happens and actually, we can simply apply a simple distraction frame if that all wants to sort of drop into place. But we've still got a little bit of displacement here but not, uh, not too bad. So, um, sorry about my door. Um, so an external fixator can be used and, and here's a slightly longer term sort of follow up of, of that. Um, so external fixators can be any shapes. This is, er, ones that are made from simple K wires that you might have 1.1 millimeter K wires. Um, you might have some form of, kind of, er, premanufactured external fixator. Er, everyone's got their own favorites but we just may run out of a, out of a couple of bent bits of wire. So that in a nutshell, if I can escape this, um, is the first bit of the presentation, does anybody have any questions on, um, uh, on that speak? I've got a quick question is far away. You're applying a frame like a get ins frame, then And what do you do with regards to the neurovascular bundles that are lateral? Yeah. So your neurovascular bundles are on, on volar side. So by, by applying a pure lateral frame, you're, you're actually no, you're dorsal to them. So it's never a problem. Er, you'll make a tiny little stab incision er at the mid axial point. Uh if I try and share this, um I'll just try. Uh can you, can you see that George? Yeah, right on the lateral. So, so your neurovascular structures are actually uh we'll draw them here. OK. They're slightly more palmar. So this is the significant wire you're trying. This one's supposed to be at the mid axial sort of point and this one doesn't really matter where it is probably just outside of the capsule. So you don't, you know, risk infection. This is actually called a reverse Giddens frame. When Giddens originally created his frame, he had the single wire here and the moving wire there. Of course, then you've got a moving point through your P IP joint capsule. So we so most people, so, so this is called a reverse it in, it's just flicked around. So the, so the static wire is here and you've created the hinges here and here. So movement takes place, you know, not through the bone and the capsule, potentially creating infection. Sure. Thank you. Just, just one quick thing there. Not, not a question at all. Um Adrian um just to draw the students attention to this unpredictable good result. You sometimes get with untreated patients. Um We do all see them, don't we? And they are always shocking. But the message to the, the younger surgeons is don't be fooled by them. They are as, as, as Adrian said, they are complete unpredictable. You get some people who are untreated with P IP fracture dislocations. You see them in a couple of months, you've never seen them before and they're doing profoundly well. And it shakes your, your understanding of the, of the, of the biomechanics and everything do not be fooled by them, as they say, they are rare and they are completely unpredictable. You don't know who's going to get them. So you don't, you don't want to perform that experiment, do you? No, you're absolutely right. Statin it's such a difficult situation because the treatment options for these can be quite difficult. But actually to simply pick up the fracture first as in to have uh between the orthopedic department and the emergency department to have a protocol where finger fractures are x-rayed. A lateral x-ray is performed. Instability is picked up and a referral made to an orthopedic surgeon as a good start. Yeah. Once you've realized you've got AAA 40% articular surface loss. Plus, you recognize the instability, you take them to the operator, you re reduce them and fire a simple wire across the joint. Pull it out 3 to 4 weeks later you've achieved and II use a magic number. I use 60 degrees to say that if you have an arc of 60 degrees after your treatment, whatever it is, that that's your sort of good standard. And then you push from beyond that. So that, that's, and I sort of picked that 60 degree number completely arbitrarily at my own brain. But that's what I kind of feel. And II suppose when you, when you start to look at the literature and the ranges of motion out of outcomes, once you're pushing past 60 degrees, 7080 that's fantastic. You know, so that's, so, is there a role for a primary fusion with these fractures? Yeah. Uh, it's really interesting, Kim. It's a great question and it comes up on the ao course, er, with the trusty faculty who I sort of ship in. I've got one case of a guy who was an it worker who came off his mountain bike who's absolutely smashed his little finger to pieces. You've got bits of articular surface everywhere and it was his little finger. He's a keyboard warrior. Um, and I just couldn't see any rhyme or I couldn't see any way of fixing it and I fused it primarily. It's the only one I've ever done and he's done fine. He's gone away. But, but some of the faculty members were quite critical of me for doing that and they said, well, because you might get a bit of a pseudarthrosis, you should sort of try and shovel it all back as best as you can and just sort of wiggle it and then do a secondary fusion. So, and II really couldn't see that at all, but that's usually what I did what I did. So I think the simple answer is yes, you can do a primary fusion. It's excessively rare because you can still have these quite sort of mushy pseudarthroses that may not hurt. It's not unreasonable to push for, you know, some form of fixation which might give you some degree of congruence. If you, if you feel the bits are just ridiculous, then, then I still think primary fusion is on the table. So yes, but rarely when you, you, you can't think of a way of, of doing anything else. I mean, people end up putting frames on distracting them frames, come off, the patients go through six months of misery and then you fuse them. So, so we, you want to try and avoid that the flip side of the argument being, you can't quite predict who'll be in misery and who won't be statin do have a strong feeling on that. Just microphone, microphone, sorry, quite aggressive um based on good hand therapy. Um I II, I'm always, but then you talk to the patient and you try and get a feel for how much agro they are likely to want to go through really? Um I think that's very important, especially with the elderly patients, um, with horse, horse riders who've got five other fingers who are also injured. You know, it's, it, it, there is a lot of it then is discussing with the patient what, what they're going to go through and what their expectations are. Yeah. Absolutely. Statin. So, Kaim, I think that's a bespoke discussion in a highly unusual situation when the thing you are staring at is so ridiculously exploded and displaced that you can't think of anything else you can particularly do. Um, bridge plating has been done for P IP joints much in the same way. You take a horrible wrist and you put a bridge plate across it. So you could put a little tiny plate, a little 1.5 millimeter plate just across the P IP, distracting it. It'll help shepherd some of the dorsal fragments in and then take the plate off and see if you get any movement. So that might be a way round it. But these are very bespoke uh patient led discussions for unusual injuries. Welcome to orthopedics. All right. Ok. Well, let's crack on. I think there's plenty to do fine. Fantastic. Ok. So my, my next remit was to talk about perilunate injuries. PL is, so let's just get my stuff back on. Ok. So um are we, are we OK for that? Everyone? Got a view? Yeah. Thank you. Um PL is, are what you'll see as the buzzword for these injuries. PL I stands for perilunate injury. A perilunate injury is a rare carpal pattern. It's missed in 25% of cases because little tiny carpal bones can be quite confusing when looked at on plain x rays. It causes posttraumatic arthritis and a chronic loss of wrist function. So it's a good idea to pick him up. It's associated with high energy injury, carpal extension. The deviation and supination of your carpals as it all strips apart. And the classic classification to use is the Mayfield classification, which is a proper orthopedic classification. 1 to 4. That's, that's enough for us. The thing that really helps you with perilunate injuries is the Lula's lines which, which most of you will, will, will know. And it's worth just saying, well, what the hell are goa's lines? You should have smoothly congruent lines uh on your radiocarpal, midcarpal joints on either side. So you're looking for very smooth concentric lines and you're not really gonna accept any sort of incongruity in that line. So Lula's lines will really help you interpret the a PX ray for a perilunate injury. So what on earth is a perilunar injury? So the when you fall onto an extended sort of wrist, you, the the you can uh just go on to, to develop APL I you kind of start from the radial side and you tear across to the ulnar side and you the first structure to kind of fail on the radial side will be the radioscaphocapitate ligament. You need to know a few volar extrinsic ligaments. You need to know radioscaphocapitate long and short radio lunates because they're the real power houses of risk stability. And you know that cos when you've got a volar barton's fracture, you know that bit of bone is off the bit of bones off the the volar aspect of the radius. Well, the whole carpus sublux is off so clearly the carpus is attached on to kind of that volar radial piece by some powerful things. So the radioscaphocapitate ligament fails um when the wrist is loaded in extension and all the deviation, it, it can either tear or it can avulse a radial styloid. So welcome to the first bit of PL I which is, it can either be a ligamentous injuries, a series of a series of bony injuries where the ligaments have pulled off chunks of bone or a bit of both. Ok. So we've got a mix of what we might see on the X ray. So once the rasca a capitate ligament has failed, the scaphoid is unprotected and becomes the next structure to be kind of got at in extension, the scaphoid will then fail by either fracturing or rupturing the scapholunate ligament. Another example where you might have a bony injury or a ligamentous injury, which effectively means that all scaphoid fractures are Mayfield type one there. You are. So you're not gonna forget that sca an isolated scaphoid fracture is a mayfield type one, the four grades of mayfield calcification pretty much refer to the four articular surfaces of the lunate. So a mayfield one will be scapholunate issue or compromise escape a mayfield two cap lunate, mayfield three, lunotriquetral and then finally reg lunate displacement. So back to our sequence. So at two and I'll just pop to this one. So the Mayfield classification here uh is, is, is sort of here. You can see 123 and, and four and, and again, a a nice complex schematic, sorry, but welcome to carpus kind of illustrating stuff, tearing and stuff, not going well. So a two would be a cap lunate injury. A three, the injury rips off the triquetrum. Um and a four is where fundamentally the the lunate is kind of um it finds itself dis dislocated from the radiocarpal joint and the capitate will tend to, to flop back in. So Mayfield 1 to 4 refers to the sequence of injury around scapholunate capitol, lunate, lunar triquetral and radiolunate AAA scaphoid fracture or scapholunate ligament injuries effectively in Mayfield one and the ones you'll tend to see are sort of threes and fours. So we can have this concept of a purely ligamentous perilunate injury. So lunate perilunate du du and that would be often known as a lesser arc. So just be aware of that a lesser arc injury is the soft tissue stripping around the lunate or we have the more common greater arch injury, all a greater arch is, is a displaced uh lunate, but with some bit of bone shoved on as well. Um And in our series, 60% of all pl is are transscaphoid perilunate injuries. So we see a clear scaphoid fracture and then we see a displacement of the lunate. So what, how are we gonna manage a perilunar injury? Well, the first thing is to diagnose the flipping thing and I've told you 25% are missed. Um, it's the trouble. The reason why is that they're often in the context of high energy injuries in poly, traumatized cases. Uh, not, not always, but, but certainly a decent chunk of them. So you've got distracting er, injuries. The second thing is that looking at the x rays, we're gonna look at a few coming up now is quite confusing and so you can look at an X ray showing some degree of subluxation of a carpal bone and not quite realize it. Once we've picked it up, we generally want to reduce it. Now, some of these have, are so ligamentously damaged that the wrists are effectively quite floppy and you can give them a pull and a tug and stick them in a back slab and actually reduce them in, in, in the emergency department failing that to reduce them in theaters. Of course, what's allied with that may be carpal tunnel syndrome? I think if somebody has carpal tunnel syndrome you'll, you'll document your, your, your findings, you would want to get an emergency reduction, but you don't necessarily need to acutely decompress the nerve. It depends on your feeling of, of how kind of painful and how miserable that nerve is. If the nerve is kind of partially injured, you could just reduce and then reassess if you're concerned, you'll reduce and form a carpal tunnel decompression. Definitive management ideally is gonna be in daylight hours because definitive management to stabilize the carpus does need somebody with the right skill set, an experienced surgeon. So if for example, it was four in the morning, three in the morning and you had APL I and the patient's got other bits to sort out and their median nerve is working. Ok. You might just tee them up first on the trauma list. If you knew a hand surgeon was around or a second on the on. If you knew there was somebody around. If you work in a hospital with no hand surgeon or no uh fast access, nobody on speed dial, then you might want to just take that patient to theater, reduce the risk, perform a carpal tunnel decompression. And you could then either see what the carpus is like and just leave it in a cast or even put some form of external fixator on it if you wished, which, which may be helpful, but it is not necessary. Normally, it would just be a, a cast treatment So we've got a few examples uh to, I've got a few examples to show you. So here are 4 ft motorbike at 100 miles an hour, lower limb trauma as well and a painful wrist. So this is our wrist. Um Right. Anybody have a lash, talk to me. It's good for the exam. I can try. Brilliant. Thank you. Who are you? Sorry, I can't. Uh It's Maria. Maria. Fantastic. Well done. You just have a lash I'll start is an ap and lateral e over to you. OK. And um I can see that is a trans uh perilunate dislocation, the lunate maintain its position in the uh radiolunate uh fossa. However, the rest of the carpus is dislocated dorsally and I can see a scaphoid waist fracture, Maria 100% 10 out of 10 gold star. So uh it's a, it's a sort of what Maria has done is given you a descriptive classification. She spotted that the scaphoid here looks very abnormal. The more you stare at carpal x-rays, the more you will understand them and get quite good at interpreting them. You can see here is the proximal pole of the scaphoid. Here is the distal half of the scaphoid. Here is the scho lunac junction which is intact and you can see here is the triquetra which seems to be overshadowing our Lula's lines are clearly disrupted. So for those more junior of you who are a bit concerned looking at that apply your lines and they're all over the shop, aren't they? The radiocarpal one is, is, is, but the midcarpal one is, is all over the shop and there's nothing clear around it to complete. Yeah. Sorry to complete what I said, being a fracture involved, that means is, um, uh, is, um, a greater arch injury. And, um, I wanted to also point, what did I wanted to point? Uh, sorry, I forgot on another point. Ah Is the Mayflower type three type Mayfield, Mayfield Mayfield lot of Mayflower. Yeah, very good. Mayfield. Wonderful. Honestly, that's a perfect answer. So everyone can see that the lunate is here and the lunate is still in its it's trying, the capitate is trying to force it out but it hasn't yet done that. So this is a Mayfield three. A Mayfield four is where the lunate is out. Very good. So that is pulled into shape in the emergency department. And an X ray within the back slab is here, Maria, keep going. What do you think? So, I think the reduction is very good. And as an initial management that we'll do, next step is to uh refer to this to a hand surgeon for definitive fixation. And I would think in terms of definitive fixation, the skway will need fixing first and then um most likely the the carpus um will need to be stabilized via K wires and then the dorsal ligaments might be injured as well. And might need um ligamentous repair from a dorsal approach. Yeah, well done. So for, again, for the more junior ones, look at the Lula's lines. So you can see the apart from the fracture of the scaphoid, you can see the line of the radiocarpal, the line of the scapholunate tr and the line of the hamate capitate is it, it has been restored. The lateral X ray shows the capitate is back on the source of the lunate and the lunate is on the sourcer of the radius. So we can draw a line straight down from the middle, uh finger, middle metacarpal through the capitate through the lunate through the radius. So this is something we would generally want to stabilize and, and with uh a and the scape fractures that we will fix are those associated with uh a carpal instability such as APL I. So I think that is an indication for scape foot fracture fixation rather than any sort of conservative management. The problem with conservative management is that these are, these are unstable and might start to drift within cast. So we would all really tend to fix these. Where is er fantastic. She's gone for the, for the scaphoid and we can easily put a screw across that because uh we've got two nice chunks of bone. So that would seem like a sensible thing to do. Um Maria, what would you rather have, would you rather have a greater arch injury? Trans perilunate or would you rather have a lesser arc injury? Bone is healing better than the soft tissue. So, I would have a greater arc injury. It's mad, isn't it? I mean, you'd rather, yeah, I agree with you. So this is what we've done. So we can see it's a dorsal approach because your screw heads, dorsal, that's quite easy. That's going to allow you to visualize the dorsal ligaments. The screw is quite powerful of fixing the scaphoid. It might be a, might be a touch long. We'll have to keep an eye on that. Um And we've got a little cross wire technique to hold the TriC in place, um which may or may not be mandated. We've got a little anchor lurking around here, which may be to do with the in insertion of some of the dorsal ligament as complex if it's been ripped away from the dorsum. And so these can do quite nicely and this is at four months. So a transscaphoid perilunar dislocation, you can see scaphoid healing. Uh and actually a carpus looks quite nice with no degenerative changes. Of course, there's bound to be a little bit of stiffness but they can actually be, be er, injuries that do. Ok. So uh next example, er, anybody, Maria, thank you so much. Thank you. Um Kareem. I think you should anoint somebody a anybody wanna have a go. What do they think? Ok, dear. Do you wanna have a go? Anyone be brave. Sorry, did you say? Yeah, we all do. What's wrong with her? You're online you're on, tell me about these two X rays have a look. Ok. Um So I'm just having a look like clearly on the lateral. The lunate, doesn't, it looks like a kind of perilunate? Just the, it's not, this is not easy, is it? You can see the kind of, yeah, you can see that crescent moon shape, the kind of sauer cup and apple aren't stacked up the way you want it to be. That's absolutely fantastic. That's really good and then disruption to a on, on the ap Yeah. So, so the lunate has kind of been levered out interesting. The capitate hasn't quite got, got itself back down onto the fossa. So it's a kind of a, it's still a kind of a three. Is this a greater arch injury or a lesser arch injury? I'll remind you of the, the definitions, a lesser arc is a pure ligamentous injury around the lunate. A greater arc injury is with some form of bony, you know, fracture as as well as potentially soft tissue. What do you think? I'm just looking. So I'm struggling to enlarge the X rays, but I'd say lesser from what I can, I can't see an obvious bony injury from here, but I think if I could, you're spot on, there's no obvious injury. Yeah. So classic care is for, yeah, you're absolutely right. This, this is a lesser arc injury. So classic bits to look for would be radial styloid avulsion cos the radioscaphocapitate ligament comes off here. That radial styloid looks great. We've just had a transscaphoid perilunate, which is the commonest. Well, the scaphoid looks great. There's no massive disruption here. There's clearly something funny going on around here. Well, that's the capitate head here and, and there's the, the lunate and we've got TRM, which is actually here still. And it's kind of, er, tr probably, er, actually that styloid is there and there's TRM er, and so TRT is about to be ripped off. So this is a sort of a two slash three on the Mayfield classification. This is a dorsal approach and of course, with a lesser arc injury, by definition, you, you've got a scapholunate ligament injury as part of your problem. A dorsal approach will allow you to reduce the bones if you haven't been able to reduce them close. To be honest with you, I often end up reducing them open. I can put a little mcdonald in and wiggle it around and that kind of helps uh skid the bone up and you can see here a clamp has gone between the scaphoid and the lunate and this is actually the scapholunate ligament joysticks gonna be placed into the foot and the lunate to try and bring them together as well. That's another way of doing it and then you're gonna have to hold them together with some transfixion kws. So this is what a classic array of K wires would look like for, for, for that case, that trans er, for the, er, the lesser arch injury. So you're going to, first of all try and reduce the scaphoid onto the lunate and you'll need a wire at least one holding that the scaphoid will want to rotate away. And so a derotation wire is the scaphocapitate wire and then you'll want to stabilize the other side of the lunate, which is the lunate triquetral wire. So that might be a standard pattern of wires used th er after a dorsal approach for a lesser arc injury. So another one, a 24 year old falls down the stairs with a very painful, er, where am I with a very painful wrist? Ok. We need somebody senior on. Well, actually anybody can say wanna have a go at this one go. Marius, thanks Kaine. Have a go. She does like I'm um I'm just in a loud area and I'm not that senior anyway, so I'll leave it to someone senior. Go, just talk to me about his x-rays, talk to me about glu lines are glu lines normal or abnormal. Um, so the greater arc looks normal to me, the lesser arc looks abnormal to me. Now, hang on, hang on, hang on. So let's just a bit. Thank you for that. But let's just think again, a lesser arch injury is a pure injury around the luna, sorry, just microphone off wherever the noise is coming from. Well, it's mine. That's why I said I shouldn't go cos I'm, oh, I see. I I'm sorry about that. I'm doing great. But two seconds, I two seconds, a lesser arch injury is a displaced lunate with a pure ligamentous injury. A greater arch injury is a displaced sort of lunate or around the lunate displacement with bony bits. Ok. So I asked you about Gul's lines. So let's do Gallo's lines. So we can follow the scaphoid round to the lunate. So that Galua line looks OK. But somebody tell me about this Gul's line. Is that normal or abnormal? The two midcarpal lines abnormal, well done. So, um what do you think is going on here is the lunate in its fossa and is the capitate in the lunate and then what might be happening around here? Any, any sort of any guesses? So the lunate is not in its fossa. It is, it is the lunate is here and here the lunate is a fossil. But what we do is we sort of lose it here a little bit, don't we? The middle parts blurred? Ok. So, um that thank you. Well done. Micro off. Thank you much. Is it ready for that? That's OK. It's good to hear from you. Well done. Um So anyway, the more senior guys wanna uh guys and girl that wanna have a little go at this one looking at it is Maria again, Maria, good to hear from you. So, looking on the API could say that probably that is a fragment that belongs to the, to the Capitate. But then looking on the latter, it looks like there might be a chip of the lunate as well from the side. So yeah, but it, so for everybody else, you can clearly see a bit of lunate and then we sort of lose it here. And then as saying, she's looking at the capitate, she's following the capitate, then loses it and there's clearly something sort of strange happening in this area. Very good Maria, sorry, keep going. So looks like there is a fracture of the capitate with a fracture of the lunate. So I can just presume then um obviously the the ligaments in between the two rows are also damaged. Yeah. And so anyway, how would you investigate this further? So we need the more investigation probably in the first instance, a CT scan will give us a better understanding of the architecture of the fracture. Absolutely. And I think for all these carpal injuries, we're going to have a very low um you know, we we're gonna grab a a CT scan, basically, they're very, very difficult to, to understand on, on these simple two D er x-rays. Um And so we're gonna get some, some CT ing and so you can see in this particular example, it's that funny lump actually turns out to be the head of the capitate and the head of the capitate has dislocated itself uh out of the, out of the lunate. Um And it's come to rest in this funny position and, and also having kind of fractured that as well. Um We're generally gonna have a go at that dorsal approach to the carpus is always gonna be easier even though the fragments kind of on the side. Um And we can sort of have a go at trying to put those fragments back and holding with some KWS. Um And that's that you can start to see that there's probably was some mischief a foot here, maybe at the sca forate. And this is part of the carpus opening up, uh fracturing the head of the capitate, so a greater arch injury and then the carpus flopping back. So this is our next problem with these perilunate injuries. Sometimes we're gonna see subluxation or dislocation of the lunate fine. But that's fairly obvious. Our problem is when the carpus separates and we have instantly a kind of a mayfield three, but then everything flops back, which can happen. So you can have a lesser arc injury, but the carpus on a plain film looks fairly normal. Now, the wrist will be swollen as anything that the, the the the the um the patient would have been still in a high energy accident, they'll be complaining of wrist pain. And so you may see slight widening particularly of the field in an interval. So these are risks to be treated with caution and you do want to scan those as well. So just be aware, a wrist can be uh sort of um er, er, er dislocated or subluxed for that split second and then it can actually flop back together again and the capitate head can shear off and then as the wrist comes back together again, the capitate head can spin around and that's called Scaper Capitate syndrome. It can be associated often with a scaphoid fracture. Um The scaphoid separates and then the bits come back together again. And so that's our X ray at three months. So another high energy injury, Kareem, this is for you because you're very special. I hope you don't mind. And you know what Kareem, I'm gonna do the work for you and I want you to tell me how good I've been. I see a greater arc injury, I see a fracture of the radial styloid. I see that the radiocarpal joint on my Gluta lines is not bad. But when I look at my mid carpal, it it's not right. My, my lines are not concentric. I've definitely got some little steps here and there. I look at the lateral. I see the lunate is here and the capitate sure is in the lunate. So that's a Mayfield three, but it's great because I'm gonna have a little bit of ligament attached to this bone. So I'm gonna go to the operating room, I'm gonna do a dorsal approach. I'm gonna reduce everything and I'm gonna fix that radial styloid back on. And this is what I've done and I'm very proud of myself. What do you think m doofy or a star? I know. Am I just a moment? Look on the lateral. Oh As far as the answer, I'm about as far as the order of the Brown Tongue Award. It's very good. You're very kind to me, Kaim. But I'm actually II say that for a bit of a fail there because I'm not very good. Am I? Oh, the uh the the reduction has not been achieved? Yeah. So everybody can they all look at this? OK. So here is the lunate. Here is the capitate, the capitate should be on the lunate. So here the patient has been taken to the operating room where the carpus was not actually reduced. So really you gotta spend a lot of time looking at your lateral x rays, making sure that you know the carpus is reduced, making sure that the capitate is in the lunate and the lunate is in its fossa there. So Kareem, what do we need to do to this? Well, I'd say we, we possibly need to revise the the the whole thing. We definitely need to reopen and reduce it and then uh stabilize the uh the carpus again. Absolutely. So here you are. So you can see the screws been changed for slightly different screws. This is one of the old, old style headless compression screws. Actually. Um You can see there's a scaper lunate wire. A capito, I say a scaper Capitate wire is a derotation wire. We can see a lunotriquetral wire just, just about just has gone in. We can see a couple of anchors they might be involved um with um it's possible scapholunate repair or dorsal capsular repair. Ok. Well done. Sorry, I set you up for fail there. Kareem, forgive me. Right. And there's our long term outcome. Are we happy with that? Well, yep, let's look at Lula's a, there's Gul's midcarpal line and it definitely does seem to be looking a lot happier. Radiocarpal is always quite good. Styloid is healed. We've got ourselves a capitate, got ourselves a lunate, got ourselves a radial fossa. So pretty good. Uh 24 year old man falls on to wrist is a smoker. Um These are the X rays, there's pain and the anatomical snuffbox George. Are you happy with that or unhappy with that? Um So looking at the ap and lateral, I can't, I'm not completely convinced about any obvious fracture, but given the history, I would be concerned about a sapho fracture. Very good. Um Lula's lines look um sort of, so there's our first, there's our second. They, they don't look bad, do they? And on the lateral, we've got this double bump. So what is this line? And what is this line? Oh, sorry, I can't quite see these lines. Um, I don't know if anyone else can. Uh sorry, II uh can you see my pointer at all? Oh, yeah, I can. Yeah, just now that's catching up. So the X ray is not great. It's, you know, we see, but we've got a line here and a line here and I would urge all of you when you're looking at your lateral x rays to look for the double bump. So what must that line be if your eyes shoot across? So that's going to be a very good. So the second one here must be what it going for it. So I would encourage you every time you look at a lateral X ray, I want your eyes going to the most proximal rounded line that's gonna be lunate and then to the scaphoid and then to a capitate that's probably inside the lunate. Very good. Anyway, painting on the ant snuff box, those are the x-rays you've been given satisfied, unsatisfied, Georgian and unsatisfied. I'd be concerned about escap fracture in particular. So, and re X ray um as a as a minimum in, in 7 to 14 days if still tender and then further imaging, if uh if that's not still convincing on an X ray. Yeah. Um we can actually do that's a sort of a, that's a sort of 19 eighties textbook answer. So, you, you've got flares on. Um, so I need something slightly better than that. Now, first of all, these are the two views that you've been given. Are you satisfied with that? That because you're sus suspecting a scaphoid fracture? Ok. So no, there's at least a full view for you. Do you know how much percentage increase in your diagnostic accuracy that takes you up to, I'm not sure far from 100 I suspect uh, it, you're still far from 100. It's gonna take you up to about 70 80%. So two views are inadequate. You must have four views and actually four views. You would have probably spotted a sapho fracture. If it was, you would you want to be immobilized for two weeks and re x-rayed at that point or would you want another modality of treatment if you wanted to work out whether you had a wrist sprain or a skp fracture? I'd probably opt for a quick MRI. You would do exactly that. I would wander around the corner with a bottle of red wine and give it to MRI and say, please scan me now because it's a huge difference for us, isn't it? If we're gonna go into a cast for two weeks, be off work or have a spray and we can still do stuff? It's just nice to know. So you can re x-ray in two weeks, Joe Dias wrote a paper on this. It's a slightly older paper now. And do you know how many fractures were picked up via the modality of the re X ray? At two weeks? There's a sort of percentage of ones that turned out to be fractured to be fractured. Let me guess about half still if they virtually none, what happens is that you see them at two weeks and if the ones that are still sore, your X rays often don't help you, but you would be referring them for a scan. But what the two week period did is that some of the wrists get, feel, just feel better because they're just wrist sprains and you, you're a bit more confident about them and they didn't have tenderness in the anatomic snuffbox. So II think, and the trouble is it keeps creeping back into the textbooks and we've got lots of papers now looking at early MRI scanning, it definitely does save cash. Um, because it gets people going earlier. So basically for scaphoid fractures, it's a low index of suspicion. Everyone's got one until proven otherwise th er, thorough examination, er, anatomic snuffbox pain. Um, for views. Ok. For skate forward views, uh, immobilization, an early MRI scan I would suspect is probably the way forward if, if we have that ability, if, if we've got, you know, the ability to get hold of the MRI scans, the MRI scans are short sequence, meaning you only asking them about scaphoids, they can do it in about 20 minutes. So it's much, much faster. But I think that's the thing to have. This is when he repented at one year with his scaphoid non union, which was uh painful and he can undergo bone graft, er, fixation. You can see bone graft has been placed in there and there he is at six months with his bone graft. Sort of few, you know, u uu uniting. So he's got a union there. So, aca non union and that is me well done. And that's a mayfield one. remember, you know, er, er, er, er, in terms of actually, er, a, a scape and fracture by definition is a mayfield one. OK. Any other questions? Can anybody any problems out of those two things? Well done. Thanks for chipping in those people who did? No, no questions. Oh, there you go. Ok. Um Well, thank you very much. Um What do people wanna do? Do you want to have a five minute break now? Uh stretch your legs or should we crack on with two? There's two more lectures to go. Any anybody want to shout out an an opinion, Mr Cows. I've just got a question. Go. Azim. Ah The one was there a dis ra ulnar joint dislocation as well? Uh No, n no, I, none of those cases had a druze dislocation. Dru dislocations are very rare. Um The trouble with Droge is that when you look on an X ray, a lot of bruges look quite open, which is actually can be a normal sort of finding. Er, but none of those cases had a dister on joint dislocation. I've seen very few. Um, the last one I can think of was a man who caught his wrist in a press. Er, so a very high energy injury, er, the ulnar head was forced out, it was obvious because he's locked, he has no pro no supination, er, and the head is out of the sigmoid fossa. So, er er a distal radioulnar joint, um dislocation is normally very overt no pronation, supination, high energy injury, your problems come when you've got subtle dru subluxation. Now that can be associated with distant radial fracture. Um First x-ray quality always make sure that you've got a good lateral view of the wrist. That means you need to see the pisiform just for shadowing over kind of the scaphoid to make sure you've got that good lateral view before you make any decisions. Th then you'd probably need scanning as well. Um If you've been reading your, for those of you who are super keen hand and resurgence, you get the journal of hand surgery, European, er, Greig Giddins has been talking about this. There are a small subset group of er disor radial fractures, which tends to be in a lady who you see a gradual dorsal subluxation of the ulnar head. I think maybe they, they hold themselves in pronation. There's a little bit of stripping of intraosseous er membrane. And that can be a big problem. You can manipulate them back and just keep a careful eye on it. So, Droge dislocation acutely is very rare, obvious locked. Take them to theater reduce, you can bun mans in or volt T FCC. If you like Jewish subluxation mostly isn't, most are just projectional and actually not really a problem. Occasionally you'll get somebody who seems to develop this very strange change between the radius and the ulnar, get them into supination early. Er and then actually, you'll often be fine. Finally, finally, finally, distal radial fractures. Whenever you fix them, you should give the Jews a wiggle. The vast majority of Jews, if you have fixed the dis radial fracture properly will be fine. There'll be a few that will feel a bit wiggly, they'll probably be fine. There will be a few like you're talking now, one or two and 100 which may be very wiggly if you're worried, stick them in neutral in a sugar to cast for four weeks and they'll probably stabilize. So the Droge actually is, is kind of um although a bit of a mysterious joint, uh quite a forgiving joint, as long as you've got the bones pointing the right way, most druze instability will arise from malunion of radio snar fixation and gli RCI fixation. Ok. Sorry. Thank you. The case with the capitate and the lunate fracture would be classified as a great rock Mayfield two or does it not really fit the classification? Um So it's an interesting one. George classifications do let us down. But you're right if you think about it, it, it is a two, by definition, a scaphoid fracture is a 12 is where the interface between the capitate and the lunate is affected either ligamentous or bony. In this case, bony, the head of the capitate was sheared off was the lunar triquetral joint affected. Probably not, was the regulate joint affected? Probably not. So, yes, I would classify that as a mayfield too. And then I've, what I've also said is that sometimes the displacement persists, sometimes everything kind of flops back together. And so that's just where you have to be a little bit cautious. Basically, any of these wrists will be swollen and miserable and you'll be looking at a wrist that really looks bad. But the, the x rays can look, ok, have a, have a, have a, have a, an awareness and get an MRI scan if it's purely ligamentous or CT, for example, in this case, right? I probably should shut up now. Thank you very much for the off and leave you guys to it. Thank you very much, doctor. Thank you. It's a pleasure. It's a pleasure. OK. All right then. So we will crack on um, what you had. There were two really good lectures in the sense. First of all that they were, were very good. But, um, also that they covered, um, they were exactly the sort of thing you will be asked in the exam. Now, both those topics, uh, perilunate and lunate dislocation and the P IP joint fracture are beautiful exam topics. And it was good that, that, that we had sort of case studies there which were very much like the vi will be, starts with a picture and then you talk through it. Um, and, and they're difficult in the hand because you probably won't have done that many of them. You may not, you certainly wouldn't have operated on any of those yourself. Um, you know, unsupervised, um, you know, perilunate or, or, or P IP joint injuries. Um, you may have been in with a surgeon doing them, but they are not things that, you know, well, but you're expected to know them quite well because they are serious. The implications are serious and you need to recognize them. So they are beautiful exam questions last week we um, um, Miss big talking about uh wrist fractures and that's a different type of question. You've all done those, you will have all seen 100s of those. You will have all operated on those. And those are, are, are questions where you will be expected to know absolutely everything. Uh technically, um, and to have done plenty of them. Uh, and then there are others which are slightly different. So what we're going to do today is, is something along those lines. Let me start by sharing the screen. Uh I present now. Yeah, show your screen and Oh yeah, that one too. Uh Which one are we doing? Uh I can't see. OK, so I'm going to do my best now to shuffle things around apo apologies for this. This is a little uh a, a piece of kit. The technology isn't quite, doesn't quite work on my screen. Oh gosh. OK. So what we're gonna talk about now is something different. Um Can you, can you see the um the slide, somebody just, just shout out that they can see the slide and they can see my cursor just running along the title. Yeah. Yes, we can. Perfect. Thanks. OK. So we're going to talk about something different. Now, um we're going to talk about biomechanics of the carpus. Now, you will, will not have a question about biomechanics of the carpus in the exam. Um But you've already had two lectures which which rely on an understanding of the biomechanics of the proximal role. So that's the, the SK five fracture and the perilunar dislocation. So, what we're going to do now is go a bit off off in the sense that you wouldn't be asked, asked about this, but let's explain it to you. And then we can uh what you learn from this lecture law doesn't come up directly, should, should help you in the exam. OK. So, um and again, please, please shout out. I mean, we are not, it's not going to be quite like um we just had where we would do a form of question because as I say, um you don't get formal questions about biomechanics, but it's helpful if you can just shout out uh an answer to my, to my simple questions. So we're gonna start, I mean, I don't know how much of you, how many of you are in the throes of the exam and how many of you have started reading uh around the text. But you start thinking about the, you know, biomechanics of the carpus. How does the car work? Uh You look at the carpus, there is the, there are the carpal bones, you start by learning the names of them, which is a feat in itself as a junior doctor. Um And then at this stage, you, you haven't learned much more, but you start to realize these bones in the wrist, all allow the wrist to move. Um but they are not all the same um clearly that's obvious. And the question is, can I give you today some kind of scheme or, or, or uh theory which allows you to understand something about how they move um without having to understand every single ligament and that's what we are going to try and do. And, and if you again, if you read through greens, you will see a diagram or you will see three diagrams like this, which um which will confuse and confound you. And, you know, these are A and B are both the volar ligaments. So that's looking volarly and these are the dorsal ligaments and, and you start to say to yourself, well, what do I do here? Um, you know, I II, I've got to understand this in some way but I see numbers here going up to, I think it's 27 or is it, or 2021? Um, do I learn them all? Um, do I, uh, uh, and it, it, it, you know, you think, well, I don't ever hear any of my hand surgery consultants talking about this ligament 13, which I can look up here. Um, so what, how do I understand how they, how they work together? They're all, the bones are not all the same, they are different shapes and they're held together in a different way. How do we, how do we move forward with this? So that's what we're going to do today and you can sort of see something already that I would draw your attention to. There's a AV shape here, a Chevron here, there's something like a little V shape here pointing upwards and then on the dorsum there's something like a V shape pointing sideways and let's have a look in a bit more detail at that. So these are dissections from, um, from greens. Um, and I just want something to shout out. This isn't anything like an exam question, but it's helpful if we, if we can interact. Um What do you notice this is the volar ligaments or the palmar is neighbored here. These are the dorsal ligaments. Somebody um shout out something that strikes them about the volar ligaments and the, and the dorsal ligaments. What's the difference in those pictures? Anybody, the midcarpal area seems relatively sort of bare dorsally. Absolutely. So, there's something obvious here. It almost looks like you've dissected too much here. First of all, vally, there's a lot of ligaments and dorsally, there's not a lot. So it's very rare. It's very bare. Sorry. OK. And what, why do you think that is? I don't know who I think it was George, but I'm not sure. Uh what, what do you think that signifies somebody else? W why are there so many thicker ligaments vly than there are dorsally? Well, it's basically that your, you know, your, your hand is a, is a flexing tool and the strength of the hand and the forearm is all in flexion. Um We were monkeys before we were humans and we used everything is to do with grabbing onto trees and things like that. So the volar part of the wrist, the ligaments are much thicker, the flexor tendons are thicker, everything is thinner on the dorsal. Ok. Now, um, uh and if we, if we have a look at this, what we can start to see here is this Chevron, there's a V shaped chevron here, right, just above it. So 16 and five, that's one of them. And there's the l is the lunate behind there. And there's another chevron which is two and three forming a V shape. Ok. And what we can say is that basically, um, the strength of the, of the wrist, the wrist is designed to um be stronger in, in flexion like that. Um What does, does anyone want to call it? Does anyone know what this dotted line represents? It's a sort of space between the two chevrons between the two vs. Um And particularly given the last lecture. Uh Does anyone know the name of that particular area? No. OK. So sorry. Yeah. Oh, it is indeed. OK. So again, I, II don't know what level you're all at. So I don't want to, you know, sort of expect you to know things you don't know. This is the space, the potential space of OK. It's the gap between the two chevrons here. So there's a set of ligaments there, another set of ligaments there and there's a, there's a space there or potential space. Um And the reason for it is it's like joints in the PSE of armor. When your wrist is flexed, those two chevrons come together and there's no space, it's, there's nothing there and then the uh everything is very strong. Um And when you extend it, those two chevrons come apart and this opens up and there's a bare area if you like called a space of Poirier um between and what, what is the, does anyone know? And I want to tease George again, anyone else know what is the significance of that? Particularly in terms of perilunate and lunate dislocations? That is an area of weakness. That is the area where the lunate usually dislocates off. Yeah. In um in lunate dislocation. Absolutely. So this is the joints of the pseudo arm. The L if, if you saw and II II can't go back obviously to Dr S's lecture. He, he showed us one of the perilunate dislocations where you could see the head of the capitate, you know, trying to push the lunate off its position. But how on earth can the lunate be pushed off the radius when there's all these ligaments in front? Well, it happens when it's when the, the lunate is hyper extended and the, when the wrist is hyperextended, the lunate can flip through and it can actually go through that hole or through that space, tear a hole and end up in the region that's in front of that, which is the carpal tunnel. So that's some ligaments there, EVR and Chevron. OK. Now, then tell me something else about this. George said this area is fairly bare of ligaments, but there are some ligaments there. How would you say the ligaments are arranged, the ones that you can see here? How would you describe them? And somebody can anyone else can shout out Maria or anyone? Um You know how, so that is that Kareem shouting? Yes. It, it looks like an inverted chevra. It looks, well, it looks like an inverted and which, which bones are linked together. Uh The scaphoid is linked to the, basically to the, to the proximal carpal row. Yes, exactly. So, I mean, what it says here is that the three of them, it looks like an inverted and that, that is not really the, the, the, the ligaments on the outside. That's the uh ligaments between the bones, but the three bones there which is s scaphoid l lunate and TQ triquetral are all linked together fairly strong strongly by these ligaments, but not linked from this proximal row to the distal row or to the radius. Forget about the pisiform, which we can't see really, it's somewhere around there. Isoform is a, is a sesamoid bone. Um And that doesn't really take that much part in biomechanics. Yeah. So what we've got is, and here is an even better picture, right? So these three bones are joined together quite strongly, but they are not strongly linked to this block and to this block. And this is what we call the um intercalated segment theory. And this is a simple way to understand the biomechanics of the risk and to understand really quite a lot of the injuries that any injury which affects this role. Um It, it you know, it, it, it, it, it what happens to it and the outcomes um are dependent on um the biomechanics here. So a scaphoid fracture unit ligament injury, this lesser arch injury, which actually would go through something like that would go through the ligament there and the ligament there and even the greater arch ligament injury, which would go through the bone there, possibly the bone there and so on, this will cause disruption to this, this row. Uh and, and fairly severe consequences. So let's go through it. The, the integrated segment. Uh uh uh theory, if you like says that there is a block of bones here, a distal segment which is the blue bones and you can work out what they are. All the metacarpals and the distal row, there's another block of bones which are linked together quite strongly, the radius and the ulnar and then in between are the three bones of the proximal row. And the pisiform is not included here, the scaphoid, the lunate and the triquetral now. And the idea is, and you could see that on the dissection that there are no uh muscles that directly attach to these three bones. Um There are ligaments between them. There are ligaments that hold them in position to stop them from coming completely loose, but there is no direct muscle attachment. So all the muscles go from the green block to the blue block. OK. And so when you move your hand, your muscles move or the extrinsic muscles of the hand move the move, pull from the, they're attached to the green, they pull the blue and they bend the hand. So the question is, what is the red bit? Four? And the red bit is if you like in order to get more flexion, get more movement, because what you've done is you've taken, what would have been a blue block attached to a green block, one hinge and you've made if you like two hinges, so a hinge between green and red and then a hinge between red and blue. Ok. But it's more than that. What also happens is that this, this intercalated segment, even though it has no muscles on it attached to it, what the theory is, the idea is that as your muscles move the blue block, the red block, the intercalated segment takes up a position by being pushed into position by the blue and green blocks and, and it takes up a position which supports the hand. So it's a little bit like, I mean, I use this analogy too often. I know it's a little bit like a ball bearing. Ok. It's nature's best attempt to evolve a ball bearing ie something strong which will support the hand in whatever position it's in. But you haven't bothered to actually move it into position. The, the, the evolution allows the forces that are applied to the red block to move it into position. Um So that, that, that, that makes a lot of sense. That explains why it's so complex. It explains why you've got so many bones, not just a few bones, because it gives you so much more flexion by having two hinges and it supports the hand in whatever position by those bones in some clever way, sliding into position, passively passively. They're not, they're not being pulled by muscles that are actively firing. They are passively pushed into position by, by the other bones. Ok. So, but it's not, not as, not as simple as that, if it was so simple, then this would be just one bone, wouldn't it, it would just be one big banana shaped bone consisting of the scaphoid, the lunate and the triquetra. And it would just move into position. It's more complicated than that I'm afraid. And what you've got is three ligaments uh sorry, two ligaments between three bones. And the idea is that these ligaments control rotations between these three bones such that as you push as the wrist goes into different positions, not only do the three bones of the proximal row, move relative to the, to the red and green block, but they actually move relative to each other. And that allows them to take up the, to support the rest of the carpus. And in particular, and it sort of makes sense. Let's go back to here. It sort of makes sense if you put your hand up like that, like, like the diagram, all the bones, there's no space is there all the bones sort of, they fill up all the space. Now, how on earth do you get your hand to radially deviate? If all those red bones are where they are? There's just nowhere for the thumb to go. There's nowhere for the thumb to go down to. OK. But what happens is they slide, they slide along a little bit, but there is movement within the, the, the intercalated segment and in particular, the scaphoid flexes, OK? It flexes out of the way of the thumb as the thumb comes down. And then when you move the thumb back or you go into ulnar deviation, the scaffold comes back into that position. It's shown there. Now, it's not doing that in a conscious way. It's not doing that by muscles pulling on the scaphoid. It's been pushed by the trapezium down into that position. So it's been pushed into flexion, nothing pulling it right? And then when it is released, it is pulled back and it's pulled back or uh sprung back by this ligament here, the sca ate ligament. OK. So what we're saying is there's a sort of the, the lunate, particularly in the scaphoid, they're attached together by a sort of rotating spring. So when, when you, when you flex the wrist or when you go into radio deviation, the scaphoid flexes, and then when you come out of that and go into the deviation or back into neutral, the Skard is drawn back into position by a spring that's attached to the lunate. So they perform a double act and also the lunate and the triquetral do. But in, in less of a profound way now that is the key, well, the 22 key facts, the the fact it's an integrated segment and the fact there is a very important unit ligament holding the two and acting as a torque converter. So what does it look like when it looks like this? It is quite a good diagram from greens here, here is the three of them in a row. In this diagram, you have now removed the scold and you can see the scapholunate ligament in detail. It's all it's U shaped. OK. They you can't quite see it's U shape. It's got a AAA palmar or volar component which is relatively weak. It's got a AAA proximal component of the bottom of the U which is like a membrane. Very weak indeed. And it's got quite a strong dorsal component. So that's the diagram there. So in the U in the ligament that links the scaphoid to the LX, very important clinically, the dorsal component is strong and conversely um in the uh lunar triquetral ligament, which is much less important clinically, it is kind of the other way around and the palmar uh uh component is stronger. So what's gonna happen and sorry, this is all didactic. But um it, it, it is not something you can work out for yourself. So this is now a a AAA picture looking down uh is it, I can not remember whether it is towards the hand or away from the hand, but this is looking down on the proximal row. Um This is volar looking downwards and then dorsal upwards. And so it says here is a the strong part of the scap for unit ligament. It controls this kind of movement of the scaphoid flexion and conversely, but much less in uh important clinically. Um uh There is the ligament here which is, which is Bolar, which controls the rotation the other way of the triquetral now. So um we shall try this dare I try this, shall we try this? Right? I just want to show you Kirk Watson's test because this demonstrates it nicely and it teaches you the test. Um I can't see what you're doing. So you could be, you know, just having a cup of tea but have a try of this. I hope you can see me. So what you want to do is the Kirk Watson test. Um find get, get you. I presume you're on your own. But if you're with a, a friend, you can do it on a friend. But if you, if you put your hand up on, on the table as if you have arm wrestling like the black hand there, you put your finger on the radial styloid and then it around volarly to where the woman's thumb is there. And you will feel almost at the level of the styloid. You will feel a hard bony lump, which is a bit like a marble, right? That is the distal pole of the scaphoid. OK. So make sure you've got that. This is the critical thing. So find the radial styler slide round at about 90 degrees. The first big hard lump you come across is the, is the uh distal pole of the sc. Now, then if your hand is in neutral, bring your hand into radial deviation and tell me what you feel with your thumb. OK. So take it back again if you weren't sure and bring it back into radial deviation. OK. And you should feel there's a lump there. You tell me what happens to the lump as you go into uh radial deviation. Could somebody shout out? So I hope you found this. What's happening to that lump? You can feel the lump just about when it's in neutral, bring the hand into radial deviation. What do you feel more prominent? Yes, absolutely. So it's more prominent. Yeah, very obviously, you know, on yourself, but certainly on someone else. Now, then what does that represent? Somebody? Shout out what's actually happening? What are you feeling happened there? The scaphoid flexing. Yeah, that's all it is. So you're feeling the scaphoid flexing now, try and stop it. Flexing right. So, bring your hand into radial deviation and press as hard as you can tolerate and see if you can stop it. Flexing. And what you'll find unless you have a scapholunate ligament injury is, you can't stop it. Flexing. Ok. It is extremely strong, right? And this is really important, right? And it's not the test, but it is very important. First of all, the scale five flexes when you do that. And that's quite a pronounced movement. Yeah, you can feel it under your thumb. It's, it's not moving a tiny bit, it's moving a lot as seen on this picture. Secondly, it's incredibly powerful, right? You cannot stop it in a, in a normal uh scold in a normal wrist, you can't prevent it flexing and it's not being pulled by muscles. It's been pushed there by the uh the movement of the trapezium and pushing into flexion. OK. So be aware that the forces here, the forces that are constrained by the SCFA unit ligament um are extremely strong. So this is why when you repair these things, you see these, the ligament, it's very tiny, but it's extremely powerful and it's often very difficult to repair. And often you need to put ak wire across it to stabilize it. Because if you don't, and the patient starts doing this, they're just gonna cause the scaphoid and lunate to flex against each other and tear it apart. OK. So the other thing is as you say, once you've got the, the, um, your hand in the radio deviation, if you let it go back into, well, now that prominence disappears, that is the scaphoid extending again. You are not extending it by pushing it back. It's not extending itself, so, so to speak, it is the scapholunate ligament. So it's the movement, it's the torque between the scaphoid and the lunate, which is allowing the scaphoid to go back. That's really important because it's got to go back. OK. Now, the, the test itself is, is a, is an interesting test. You certainly have to do it. And you could easily be asked in the exam to perform a uh a Kirk Watson test on someone. What you do is, is, is, is what we see there. This is my go. Can you see, can anyone see the drawing there? Is it visible or is it too, too fine? Can you see it? Yes. Oh Good. OK. So this is my drawing. So basically, what you do is you bring it, let's have a look. That's right. So II can't see myself. So basically, as you bring it into radial deviation, if there's a problem with the proximal row, and if the scapholunate ligament is ruptured, then when you press against the scaphoid, uh you will actually prevent it from uh you, you, that lump won't come forward what you'll do. You'll push it, you'll push it so hard that it dorsally sublux. OK. Because it's not being held there by the scid ligament. So you will possibly feel a clunk, right? And then when you leave it go, you'll feel a clunk as it comes back in and it's subluxing dorsally against the dorsal rim. Now, you've just done this Kurt Watson test on yourself. I assume you've all got normal risks and you weren't able to cause that subluxation. You weren't able to cause a clunk. You weren't able to cause pain in a patient where they've got a scapholunate ligament injury. You may well be able to sublux the, the scaphoid. When you, when you bring it into radial deviation with a clunk maybe or when it comes back, you'll get a clunk either way it will be painful, right? Which it normally isn't when you've got a healthy. OK. So there you go. Now, then. So let's just uh run through this because this is important. So place your thumb, discal disal pole and then keep, start with the patient's hand in deviation. 55, firm pressure. OK? Um Because you're gonna have to sublux this, be careful. It's a, it's a provocative test, it will be painful. Um And then bring it into radial deviation. As you say, what we've seen today is negative, the foot reflects painlessly and even firm pressure. Your firm firmness, pressure really can't prevent it if it's positive esca flexes, but there's pain, firm pressure can cause it to sublux to, OK? No, it, the question is, then we're sort of see seeing what will happen. Now, what will happen if you have a disruption between the rom, the bones of the proximal carpal ro and we'll start off with ek iun ligament uh injury because that's the most clinically um uh important. So what will happen when you uh do that? What, what will uh what, what do you think will happen now that we've done that test? So you, you disrupt, say you've torn the scale forum ligament. What will happen over a period of time to the uh bones in the proximal carpal row? Anybody venture a guess. This isn't an exam question. This is a guess given what we've just discussed. So if the ligament in between the scaphoid and lunate is ruptured, the lunate is gonna do what the triqueter does and that is extension. Yeah. So the lunate will extend because now it's not attached to the scaphoid, which was trying to flex and what will happen to the scaphoid. So the scid will do what he does usually, which is flexion. Absolutely. It will flex and it will sort of get stuck there because it isn't going to be pulled back whenever you uh go back into all the deviation. So what happens is they, they decouple and if you look the men on they, what they do that and they get stuck like that instead of going back and forth, back and forth, they sort of one the L will go into extension, the fight will be going to will go into flexion and they will get over a period of time. They'll get stuck there. And what we call that is a dizzy. So you may well, oops, you may well have heard of the term dizzy which is dorsal intercalated segment, instability, dorsal because it's the, well, I always think it's dorsal cos the lunate points, dorsal, that's not right. It's dorsal cos they, it's usually the result of a rupture of the dorsal part of the sc for l ligament. Ok. So many of you will have heard of dizzy. This is what it is, you know, and that's a dizzy. So somebody tell me what, what is wrong with that picture. Now, that picture is very similar to some of the ones that we might have been shown in the previous lecture. Indeed, it could be, you know, a picture that you could get after reducing a perilunate dislocation. Now, that's not normal, is it? Yeah. And what's wrong with it? The angle in between the scaphoid and lunate is not normal is not normal. Absolutely. Let's stop the, you know, and we're going slow. This is, as I say, this is not many of you may already know this, but some of you don't. And it's quite difficult to sort of put this all together from the textbooks because it's uh we, you know, you, you have people present disease, the trauma meeting, you know, we discuss it. But what, what is it? Yeah. So what Maria has just said is there's the l now that on its own doesn't look particularly normal that's dorsally angulated. Yeah, it should be pointing vertically upwards. Um And it's pointing dorsally. Now, why would it be in a dorsal position like that when the wrist is in neutral? There's the s now the SCA four doesn't look too bad. But if you look at the angle between them, then it's substantially more than it should be. And there's the capitate. OK. So the capitate is still uh in the head of the if you like, it's not dislocated. Um but the the angle between the scaphoid and the lunate is abnormally large. They, they've done this and now you know why? So the scaphoid is flexed and has stayed more flexed than it should. The lunate has extended and remained more extended than it should. Ok? Not because they've been pulled there by muscles, they've been pushed there by the action of the other components. OK? And this is uh my rather rather terrible notes from when I was doing Fr CS. This is what a dizzy is. Now, remember, dizzy is not a pathology, right? It is not, it is not a scapholunate ligament injury. It's a radiological uh definition because a number of things can cause a dizzy. Yeah. OK. So this is a dizzy. There's my, my rubbish pictures. So we have the lunate. And if you look who is my uh the lunate, you measure the axis of the lunar by taking the two horns of the fat moon, you draw a perpendicular to it and that's called the lunate axis. OK. Scaphoid axis, you just look along the long axis of the scaphoid, which is a little bit difficult to find and you measure that angle there and that's the scapholunate angle. And what we are saying here in a dizzy, although the figures are, are slightly, can be quoted very, you know, sort of differently. Um I would say greater than 60 degrees, we could call it a dizzy. Some people would be more uh more lenient than that. Um But also what's noticeable is that the lunate is, is extended, which it normally shouldn't be greater than 15 degrees. So that is a dizzy. If you see a dizzy, you are suspicious because something has gone wrong back to our biomechanics. Something has gone wrong with the linkages between those bones. It doesn't have to be sc ate ligament. It could be any linkage between those bones can cause this obviously because you've now got these forces unopposed. OK. And that's what it looks like. Ct Yeah, there is this um where you can't see all of it because you can only see a slice, but there's the lunate. Why is it in that position? Um It's simply pushed there by the other segments and that's not good. Ok. Uh What do we say? Dizzy? Yes. And I suppose a surprise there. So when you have a dizzy, what you might see on the AP is that, yeah, you might see it, you don't necessarily need to, but you might see it and that would tell us that we've got a scapholunate ligament. Um, injury, complete disruption. Yeah, it's completely disrupted if only they were all as easy as that. Um and that is visible there, but you may well have a sca luid injury which is not as obvious as that, but it may still give rise to your dizzy, which is why you need to look for the dizzy because that tells you that they're decoupled at least to some extent, ok? And we call that as you know, the Terry Thomas sign and if you're younger, you call it Madonna sign. Ok? So dizzy is um a ra radiological definition, not pathological. Um And we're saying that the scale luid angle greater than 60 the lunar capitate angle greater than 30. Some people will say 15 and on the ap view, you may or may not get ful unit intimal widening. So get used to looking at for dizzy and understanding what it is. Ok? Now, then conversely for completeness, we could um you know, you can tell me now what's gonna happen if we have a disruption to the lunar triquetral ligament. Um This is much less clinically relevant. I can't remember no one has ever been referred to me, the disruption of the lunar triquetral ligament or there must be some of them out there clearly. If you have a, a perilunate mayfield three and four, you'll have disruption to this ligament. Um but it's not something which clinically manifests in the same way as the, the, the scun ligament. It does what you gonna get, what you're gonna get a kind of mirror image of this and it's called a Visy, a volar intercalated segment instability. Again, you could sort of guess what it's gonna show. I won't, I won't bore you by asking you to predict, but it's gonna be the opposite thing really. Now, what you've done is slightly different, the lunate and the scaphoid are still stuck together. So they're gonna go one way and this time the trl will go the other way. OK? Because you've ruptured the other one. So the two fleck and one, the trr goes into extension. The trouble is you can't see the triquetral very easily. So what you do is you don't ignore the triquetral and you look at the angle once again between the scaphoid and the lunar and this time the angle is reduced. Yeah, they go, they're moving too close together. Whereas in the, in the dizzy they were moving too far apart. And so we have this, we have the sorry, the scaphoid axis is here, the lunar axis between the two horns is here. And we're saying that it's less than 30 degrees. OK. So that's a visit. You can have a visit that's much less uh as I say, clinically um important. Um but, but you can have it, OK? And these are things they could ask you in the exam dizzy, certainly dizzy, possibly. Um And you can be asked to comment on that and they, they are a profound thing because they, you know, if, if, if you've got a dizzy, you should be suspicious of some kind of problem with that proximal carpal role. OK. Now, then the question is, what are the causes of dizzy? Well, you should be able to tell me now because it's really um well, we'll come to that what the ID or SID is. Um it's a disruption in the linkages of the proximal carpal row, right? So anything, if you remember what that proximal carpal row consisted of any of the things that break that row up can cause a dizzy. So, starting from one end, scaphoid fracture, nice scaphoid waist fracture. What's gonna happen? Well, the scaphoid, the distal, the scaphoid is going to continue to flex. OK. It's not attached to any muscles, it's just been pushed there. OK? And it can't get back because it's not, it's not being pulled back by anything else, the rest. So the lunate and the other half of the scaphoid are going to go into extension scapholunate ligament injury. Well, that we've just done King Box disease. If you have, this is clinically doesn't happen very much because the kind of the last thing to disintegrate are the ligaments king box disease is avascular necrosis of the lunate. So as the lunate sort of disintegrates, eventually it'll decouple the two, the, the triquetra from the scape foot or the remnants of the lunate from the tri and of course lunate and perilunate dislocation, which include either if it's greater ar arch injury, sca foot fracture or um if it's lesser arch for unit ligament injury. So this is what you will see. So you, you can reduce these, you will reduce these fractures, maybe as, as doctor Mr Ki said overnight, um you get a good reduction but they probably still have a dizzy, almost certainly because you've torn the ligaments. Yeah. And now we know why. So you can't leave the ligaments there, ok? Now, then let us digress and digress again. Let's just go through um just some uh again, you know, sorry to, to take you away from exam questions. There's no way they'll ask you this in the exam, but there are lots of terms regarding carpal instability. Um They are confusing um when I was reading for my Fr CSI spent a long time, you know, going through this and working out what they meant they are used with, with gay abandon, you know, and, and they can, they confuse you because, you know, they, they're not really defined carefully. All the time. And so people use them a little bit wild for you. So this is my uh my theory, my, my little diagram for you to understand definitions of carpal instability. So you draw a picture of the carpus in whatever way you want, you draw the lunate. OK. And the lunate is the center of this theoretical diagram. And then you can say, oh called L draw a rectangle sideways, that's supposed to represent the proximal carpal row, right. This is very important. If you disrupt the proximal carpal row, you get all the problems we've just talked about. And the disruption of the proximal carpal row is called carpal instability, dissociative. OK. OK. Because you have dissociated that proximal carpal row and the results are usually pretty dreadful. There is also, you know, conversing, I could ask you to guess what this would be. There is also another type of instability where you have instability between the rows. Now, you already have a sort of instability between the rows because they're not connected directly because of the intercalated segment. But you can have a, you know, more tearing of the, of the, of the ligaments. And so that the, the distal and proximal and intercalated segment do not relate to each other properly. And this is called sint which is carpal instability, nondissociative. So those two terms are used quite a lot. Um That's all they mean one is within the row. One is between the rose and then you go from there. And basically, you can say, well, if we've got one type of instability, which is within the rose and one which is between the rose, the next one will be a combination of both, which will be called carpal instability complex, which will be both within the rose and between the rose. So it'll be something like that. In other words, it's the kind of instability you'll get when you have a perilunate dislocation because you will have some dislocation, you'll either have a scapholunate injury or a s scaphoid fracture. And then you will dissociate, you will have problems between the lunate and the capitate, which is sinned and then you'll go back down within the room. So if they may well say, or, you know, per unit injury, per dislocation is an example of C IC. Well, if they say that now you can understand what they mean. And then finally, for completion, everyone always comes up with other, you know, other, other things, there is a thing called complex, sorry carpal instability adaptive. And the idea of this one is that it's uh you get a disc, sorry, a fracture of the disc, the radius, it distorts the architecture. So it may be a big dorsal angulation of the radius. And then all these bones which work by forces being transmitted across them, all of them are disrupted because the angles of pull of different tendons are all wrong. Things don't flex when they should, things don't extend. Yeah. And you can see how that could be. So, within the row between the rows both and this other one which catches on. So one of the causes on them again, you know, this now this was all, you know, I suppose I say they are not likely to ask you these things, but they can come up in conversation. Now, you understand. So what are the causes of C ID disruption of the proximal role? So sca fold fracture Price's disease, which is uh avascular necrosis of the sca very rare scapholunate ligament injury, which we've seen now a number of times king box disease, avascular necrosis of the lunate and uh lunar triquetral ligament injury. So anything is obvious? OK. What could cause a problem within the rose? Well, capitate fracture, distal radius fracture, the complex one which is both is the arch injuries, which is the perilunate dislocation or lunar dislocation. And then adaptive, we said distal radius. OK. So that is, I mean, put your cameras up to the screen or if you're recording this or whatever that, that helped me a lot. These are not terms that are used massively often, but they are very difficult to understand if you don't do the reading that II wasted many days trying to work all this out. So that was the way I kind of put it together and that's the point of this. OK? Um What happens? And this is really what we get to. Now. Now you can see how you can have problems fairly acutely with um injuries to the proximal carpal row. Um but the real problem is the chronic injuries. Um and that's in a sense why we for the perilunate dislocations, you reduce them, but then you have to repair them well, when they're reduced, they look ok, you know, apart from the dizzy, they look ok, but the ligaments are not holding things together. So things will go badly wrong. Um And if you have a scapholunate injury or a scaphoid fracture, that doesn't unite. Well, that's, that's a problem in itself. But the real problem is the disruption of the proximal carpal roll and the altering the biomechanics. But that doesn't show up acutely. So if you don't, if you don't repair this, if you don't treat the, the dissociation of the proximal carpal road, the wrist will collapse. Ok? And it does it like this, which is sort of, sort of obvious. So you get this space between the, let's call it the, the sca and the lunate, the, the um scaphoid will flex as we've said, which you felt and you've seen in a dizzy, the lunate and the triqueter which we in this draw and say they both attach to each other, they will extend and they will continue to extend. Um Both and then the capitate will be pulled. It looks like it's gonna fall down the gap it's not gonna fall. Obviously, it's been pulled by all the muscles in your forearm and it's gonna, oops, it's gonna come down, uh, uh, it's gonna fall down the gap. Yeah. Excuse me? Just, um, now you'd think, as you say, you'd think that the real problem here was this, the capitate falling down the gap, it just looks like, almost like a cartoon. But actually the main problem, well, everything is a problem But the first problem that you notice is the flexion of the scaphoid, which causes the flex part of the scaphoid to rub against the radial styloid. And you get beating of the styloid. Ok. So you get what we call a slack risk. Keifer lunate, advanced collapse if you have a sfer lunate injury like we've got there. Um And it looks something like this. Now we will stop in a sense here. This is a whole topic. This is a whole topic of elective chronic orthopedics that if you have one of these injuries that is missed, you have to deal with the consequences and the consequences come from exactly what we're discussing in this lecture, which is the disruption of the row and then all the bones rub in the wrong places because they are not moving properly. And you can't, you can't quite see it on this one, but you can see that there's a loss of, of space there between the scaphoid and the, the, the distal radius. Um the rate of styloid. You can see that the capitate is rubbing against the l, it's not obvious why they're doing that until you understand what's happening to them. In three dimensions. They've all rotated into the wrong position. They, they're now and not congruent and they're rubbing. Now, that's a massive problem. All come from that tiny ligament. Yeah. And the longer you leave it the worse it gets, the gap gets wider and look at this, the whole s scid is basically sort of been fused. It's, it's, it's flexed, come to the point where it's so flexed. It's now not able to extend at all. Uh The cartilage has rubbed away and you've got this complete, uh, uh radiocaps arthritis because it's, it's like it's in the wrong position. The lunate is sort of spared a little bit, but it's still, this wrist is not normal or you could have snack, which is scaphoid non union, advanced collapse almost the same this time. Instead of having a problem here, you've got a problem here. This is scaphoid fracture, but the results are almost the same, this part of the scaphoid flexes and it doesn't extend again because it's not attached to anything to extend it. It's not got any muscles attached to it so it can't extend itself. Um And so this flexes and it rubs against that and these all extend and they rub against there. So you get something like this and it looks almost the same, the slack and the snack look almost the same. Even though one is a ligamentous injury, one is a bony injury because they, um, because they, um, the, the, the biomechanical problem is the same and it can, well, where, where, where is the rest of the ski here? Ok. So that's the, um, uh, sort of technical lecture. Um, I hope that's useful, let's say you won't, shouldn't be asked about it in the exam in by mechanical terms. But if you can remember the um this sort of thing, you can understand it, then you can, you can talk very knowledgeably about ace the problems of sapho fractures, the problems of perilunate uh injury as, as we just heard Slack and snack, which are topics in themselves. We can't cover here because they're not strictly trauma, they're in elective chronic conditions. Um all sorts of things and dizzy, busy sin sid all these terms come from this and it all comes from a understanding of the proximal role. OK. Let us, what time is it? Now? It's now four o'clock. OK. We're doing pretty well. Um Let me stop there then. So, um any questions on that? That's a bit didactic. There's, you know, we're not asking you exam questions there, any, any comments or questions that uh people want to say about that one? No. Okie dokey right then. So shall we uh do you want to take a break? Now? We've been at it for nearly two hours. Do people need a quick rest break or shall we uh continue? I've got a lot of fractures to show you. Continue. Ok. Let us continue. Give me two seconds to close this. Um I'll say whatever changes I made. Ok. Bear with me. Ok. No good. Yeah, I OK. Mhm. Ok. Ok. Ok. Ok. OK. Can I just just shout out again just in case you got a problem that I can't uh detect? Can you still see, you can see my uh uh uh uh sheet which says metacarpal fractures. You happy with that? Somebody shout out. Oh, now I'm getting more concerned. Can somebody just say they can see it and see that I'm running my cursor along the bottom? I can see. Thank you very much guys. Sorry to be a pain. But it's so easy for these things to not set themselves up correctly. OK. So metacarpal fractures uh these now this is, it's interesting, isn't it? We've got a whole lecture today on proximate pharyngeal joint fractures and a whole lecture on all the other metacarpal fractures. Now, there's a reason for that and that is that the, the P IP fractures are complex difficult. They're beautiful exam questions. There's no easy management. Um And metacarpal fractures are, are a huge section. It's a bit of a long lecture. This um some of them are very important. Some of them are less important. Um But we have, we have reasonable algorithms for treating most of them. So I, you know, it, it is, I would not be surprised if any of you were asked about API P fracture in your finals. I'd be a bit surprised by a metacarpal fracture to be honest because there's, there's not a lot to talk about um uh for various reasons. OK. Let us go. So here's the, the hand we're going to talk about metacarpal fractures. So we're going to talk about the thumb metacarpal and all the others. Now, then we will start with the thumb because the thumb has got some named fractures, which means they're common, which means they're important. OK? And the fractures aren't really of the metacarpal in the thumb there at either end. So they are the fractures at the base of the metacarpal. And again, II, II could ask you to shout out but it, it will just slow things down. So there is, there is a set of very famous name fractures here. The, the, the Bennett and the Rolando. Those are very common, very important and the the consequences of mismanaging them would be, would be fairly catastrophic. So that's, we'll start with that. There's a ligament as injury here, the ulnar collateral ligament, which has also got a name, you know, skiers, thumb, gamekeeper's thumb. It's very common. It's easily missed, shall we? Not easily? But that's not true. It's easily misdiagnosed, it can be missed, it can be mistreated and the consequences of that are very serious. So those, we'll do those first, you can also dislocate your, your thumb, CMC joint. All right. Um It's not that common. So we'll, we'll go through that fairly quickly. So that's the thumb and the thumb and then you could, you can fracture the metacarpal, the front. Uh But you know, that's, that's almost not, not worth mentioning really. OK. Other than the, the, the, the, the basal thumb branches. so we'll do a lot about that. Those are important. They can ask you that they expect you to get it right. And then we move on to the other metacarpals. Now, other than the reverse benefits of the fracture dislocation around here, the rest of them are, are, are an interesting bunch because there are 100s of them. You can have head neck shaft and base fractures. Um But what we'll find and I'll, I'll say it now, but I'll stress it again. There, there are numerous ways of treating these. OK? There is sort of one way, there is one algorithm. If you like for the Bennett fracture, there are, you can do all sorts of things for these provided you get it to heal in a good position. Um And don't make the hands stiff. OK? So let, we'll, we'll come through that. So we will go do, do all of those uh in five, in not five minutes because we'll show you all the examples of how to do it. Um but you can choose different ways. Which is odd. Whereas you can't do that in many other things in, in orthopedics. Yeah. So there's no strict algorithms here that kind of are here. OK. So some metacarpal injuries, the first one, the Bennetts and the Rolando fractures, um then on the collateral ligament fracture of the MCP joint rather than the CMC joint. And then the first CMC dislocation, which we'll go through, you know, because we've got time and not all, you know, it's not all about the exam that's, I've graded out because it's not, it's, it's rare. It's interesting, I guess, but it's rare. OK. So let's talk about the venous fracture. So there's a bene fracture. Um um Let us just skip through uh uh asking you to comment because it just takes so long. So there, there is a fracture and the critical thing about this is that there is, there is one fragment uh And the rest of the metacarpal is the other fragment. So that jagged bit matches up with that jagged bit. The point about this fracture is it's important, not because it's a fracture. It's important because it's a fracture dislocation or it's a fracture subluxation. And what's happened here is that this part here, the little triangle bit is in the right place. It's the rest of the thumb that's in the wrong place again, I'm sure most of you know that. Why is that? Well, it's because the uh just like in other parts of the body. But it's, it's very, particularly so in the, in the, in the hand, um you've, you've fractured the bone and now the pull of the muscles on this bone and on the nearby structures is unbalanced and it's leading to a grossly unstable fracture. The main uh deforming force is this one abductor pois longus muscle. Yeah. And it's pulling on the bit of the metacarpal that isn't fractured. But there's also the um abductor pollicis in there which is flexing it and there's also a rotation as well. And this but but the little fragment which looks so innocent has actually been held by numerous ligaments in the right position. And this, I mean, we should take some time to, to think about this. This is um this is APL this is Doctor Paul Longus, which is the main deforming force. And this picture is, you know, if you want to remember something philosophical about the hand today, this is the picture to remember. Um remember evolutionarily, well, there's, there's two, there's two functions in the hand in humans. There's the uh the fine movement function which is um to do with intrinsic muscles, usually um powered by the ulnar nerve. And it's kind of recently evolved. It's not common in other creatures. And then there's the the older function which is hanging on to trees and hanging on to trees function relies on this mechanism which is uh a massively powerful muscle in the forearm attaching via a very strong tendon uh to one of the little tiny bones, right? So the little tiny bone looks tiny. The fracture looks even tinier, but look what's all attached to it here. Obviously, because we all have to hang, be able to hang from a tree by our fingers. Babies have to hang onto their mother's fur. So we have massive strength there going through these tiny little bones. It also explains a lot of the pathology. The elective pathology, look at the, the forces in these tendons are massive. Um But they have to stay in position and you know, how do we keep those tendons from slapping around and bowstringing? Well, they have to be held in position by these rigid fibrous tunnels. Yeah, tendon sheaths. Um, and therefore powerful tendons pulling through tiny tunnels in funny positions, repetitively are going to get swollen. This is all the tendonitis which you're gonna see in the hand, which is a huge part of hand. Uh uh surgery. Nothing to do with fractures today. But that, that picture tells you the whole story, right? Once the Benes fractured. So it's intraarticular by definition. Otherwise, if you think about it, if it wasn't intraarticular like that, it wouldn't actually dislocate, you've got to have half the, the, the, the APL has got to be still attached to the rest of the thumb with a little bit, freeing it up. Um It's a fracture subluxation. That's the most important thing. It's not just a fracture. So, it is like a dislocation. You cannot leave it um caused by axial loading and partial flexion. Um, the um ligaments there, we don't need to know them in detail. Hold the little piece in pace and it all sublux approximately and dorsally. What's the prognosis with this fracture? Right. Ie if you'd missed it or didn't treat it or treated it in a, in a conservative way and didn't, didn't, didn't reduce it. What's the, what's the prognosis? Well, the prognosis is absolutely dreadful. You, you're simply not allowed to do this and you would certainly fail your exam if you suggested doing this, um, in anything but the most bizarre circumstances. So this is because that joint there that is disrupted now has enormous forces going across it when you, when you pinch something with your thumb, thumb and fore fingers or pinch grip or chuck grip, um, or key grip or chuck grip, um, the force at the joint is about 1214 times the force that you're applying with your fingers and you can apply 6 kg force with your finger. So it's significant, you know, 60 kg at the joint. Yeah. So if that joint is damaged, the forces across it are enormous, whereas most of the other forces in the hand are less big. Um, which is, I guess why as doctor Mr Kowski said, um, you can get people who do very well with bizarre fractures with big articular steps because not all the joints in the hand have huge forces across them. This is the exception. This one does. And so you simply can't say, oh, let's see how this one goes. Let's see how well the person does. They, they'll always too badly. Um, and also you're gonna have a joint, which is now, which is famously a saddle joint by a bi complicated saddle joint. Um And now by putting these enormous forces across it in an unbalanced way, the whole joint is going to become unstable that will cause it to um uh get secondary arthritis very, very quickly, very quickly. Um And so we know we, we must do something about it. So treatment option, uh surgical, non surgical, rare, that's an understatement. I mean, you really, very rare. You'd have to have a very, very, you know, life threatening reason not to deal with this. Um, treatment surgical is, is surprisingly, uh uh uh good, surprisingly easy for various reasons. So you can either um reduce it either or closed with K wires, um, or you can open it up and fix it, um, anatomically. Ok. So how are we going to reduce this? Well, um, obviously, in the sense, we are going to oppose the forces that are causing the deformation, causing the, the dislocation. We are not reducing a fracture so much as reducing a, a dislocation here. So we will, we will do this and this is a given us beautiful pictures once again. So we're gonna use our thumb to, well, we're gonna use our hand to pull, first of all to oppose APL L. And then we're gonna, when we get into the right position, we're just gonna push that um that metacarpal into position. But the pulling is the most important thing. Um So, and this is another, you know, I guess a philosophical thing for the hand where, you know, the hand, a lot of the problems in the hand, a lot of the fractures um are unstable because of these big muscles in the forearm. But the lovely thing about it is that you as a, as a, a reasonably healthy human being can overcome those forces by just pulling it back into position. So you, you don't need traction tables. What you do need is a good assistant who understands this so that one of you can hold it like that while the other one puts the K Ys in. OK. So that's what we do. We er work against the deforming forces. Um And here we are, again, I can't see this. Um what it's saying here. Uh again, ao is saying you have to um pull the um metacarpal uh away from the hand at the head, push it in there. Don't just hyper extend the thumb that doesn't help. And if, if you can't, I can't really see it on this one, but it does cause a cause it to come out of position and then you can plaster it. This is again, I'm sorry why these ones are so fine when the others are not, have not come up, have come up quite well. So you can see there's a plaster there. So you know, there, there's no reason really if you can get this back into position. Um and you can hold it there that you can't treat this in a plaster. Yeah, without surgical fixation. So, even though it's very unstable, you can overcome that and you can treat it conservatively in a, in a cast and it, it just needs to be AAA um A Collie's cast. I OK. Now the issue comes when you can't keep it. Um, it's not, it's, it's too unstable and you're trying to put the plaster on, you can't control it er, with plasterer. And then in which case you do the next most obvious thing you just put AK wire in. Um And so what you need to do, remember the fracture is not what's important, it's the dislocation. So it is perfectly reasonable. In fact, I would almost always just put one KK wire from the metacarpal shaft into the trapezium. It's the easiest one to do. It does go across the joint. You don't wanna do it 20 times or do it with a huge blunt K wire, but that will solve the problem. OK. And remember the, the fragment here has been held uh nicely by the, the ligament. So you, it's actually quite easy to reduce this big chunk to the little chunk because the little chunk has been held by the best assistant in the world and is pushed into position and then you've just got to hold it there. Sometimes it's more unstable. Some people will prefer to put Ky S elsewhere. It doesn't matter. And what's important is the K Ys do not need to cross that fracture. That's not the important thing. This should be stable once you've, once you've eliminated the deforming force, but there's a lot of anatomy there. So you don't just do it percutaneously. You should and can they come out? Sorry, they, they, they're visible, not on my computer. They're probably visible better to you. There's a lot of, er, er, stuff just under the skin there. So you need to make an incision, get the nerves out of the way, et cetera before you go in. Ok. And there's a lovely picture from greens. Tell you what to do. Single person. You're performing the reduction which uh, and you're putting the Ky from the metacarpal into the trapezium. Uh, and you'll get a good reduction. Uh and you should get reasonable anatomical fixation if you can't. And if you, um, you know, if you want more, you know, you can, you can choose then to, you can look at the, the contour of the articular surface and the question is, have you by doing this? Got a sufficiently good reduction. If you haven't, there is nothing stopping you. Uh, instead of putting the Ky across, you can start fixing it more, uh, more accurately, you could open it up, have a look at it, check the joint and put a screw or a cut K wire across. Um, and that's perfectly acceptable. That's a little bit maybe long. That might cause a problem. Ok. And then you've got, well, I'm not sure you have. Then you've got hopefully a better anatomical surface. So there's nothing wrong with that. It's just there. It's not normally necessary. Um, and it's seldom necessary to do this. OK? Uh, POSTOP uh, thumb, uh, and remove the K Ys at 4 to 6 weeks, 4 to 6 weeks, not a fracture. We're not treating the fracture. We're treating the dislocation. Yeah. So keep it in for a bit longer than just to know a fracture in the hand. Ok? Now, then the Rolando fracture. So the Rolando fracture is, is the evil twin of the Bennett fracture. So it's got a name. So it's common and important. Um, and the difference is it is comminuted. So it's the comminuted intraarticular fracture, basically, blah, blah, blah. Um, and this doesn't make it more, er, quite, it doesn't make it more dangerous, it just makes it more difficult to induce. Um, and so here's a Rolando fracture. Um, and you've got, uh, two chunks there, maybe a little bit of combination there and the, er, the metacarpal shaft there and there you go. Now, these interestingly, of course. So, um, they let, they're not of, they're often not a subluxation because the, the, the pull of the APL is there. Um, and it's not on the metacarpal so it hasn't slid out there. It sort of, uh, hasn't pulled it all the way out. Um, the problem is, and let's go back. The problem is again, this isn't a brilliant example because those two pieces are still in a good position. So they may still be held together. There may be only a partial fracture. You may well be able to fix those two together to give good articular surfaces, reconstruction without even getting to the shaft. So it may be only getting towards a Rolando fracture. But normally, if that, if those two pieces are separate, then it suddenly becomes extremely difficult to hold onto the thumb and reduce the shaft and two pieces of two small pieces because this 1 may play ball, but there's another piece in between and that piece isn't attached to anything very much at all. So it's like trying to, you know, maneuver one piece onto the other, using it with a, with a, with a ball bearing in the way it's extremely difficult. So Bennett is often very easy. These are often very difficult. Um So you, you should try it because um they may be only partially fractured. Um But it's usually unsuccessful and you should certainly be prepared to do uh or if, ok. Um So there it is, again, you can just see that fracture there. Um And what they say is it, then you get into um all the different uh geometries of the fracture which are very various. Um And you're now down to your surgical technique um uh as to how to fix this, um It's quite, quite different from the, the, the Bennett fracture. And they tend to be this, either you've seen two already like that or more often a bit Y shaped or comminuted or more comminuted. So these are all, all the complex ones. Um and you usually end up fixing them with a plate. Yeah, you have to open it up to get reduction and then once you've opened it up, you have to fix the articular surface together and then you have to fix the articular surface to the shaft. Ok? A good way to do it is this, this is in theory, so you open it up, you concentrate on the bit that is the most important um which is uh reduction and fixation of the articular surface. Um And so you end up with something like that, you've opened it up, you've got something on that and then you've made it in not quite to a Bennett fracture, but you've made it into extra articular um metacarpal fracture. And hopefully, if you've got that reduced fairly well. You can get this into position and, and you're away. The problem here is if you, if you get that slightly wrong and those two pieces are slightly malreduced, then the third piece, the shaft piece will fit together and you get, you could get a bit frustrated. But remember this is the important bit if you've got a good articular surface, actually, it's not so important how you fix these together. Yeah. So surprisingly different from is the one that looks very similar to it. The Bennett's fracture. OK. And you, you end up, I, in my experience, you end up with something like this, you'll end up with a plate, you'll end up with locking screws here. Um I usually try have I find that I have one locking or one screw, uh not through the plate because I will start this operation. You know, most of the time by reducing these and putting a screw, nothing to do with the plate to, to form the articular surface. I will then plate the reconstructed articular surface to the shaft. It doesn't have to be perfect, but the articular surface does. So the first screw is a screw. It's not a lag screw, but it's like a lags screw across there. And sometimes this will be an L shaped plate just to avoid that, but it'll look something like that. But, and again, we are going off off piece a little bit here. Um the nice. Well, the thing about the Rolando fracture can get more and more uh devastatingly bad and annoying to, to um to treat. And I guess you could be asked this in the exam. Uh So you could have something like that as the comminuted uh very comminuted Rolando fraction. Now, what do you do there? Well, all your um all your ideas are out of um are not going to work there because there are those two, there isn't that articular surface to reconstruct. So again, II am sure I can ask people here and you shout out ideas, but you may end up doing external fixation if you've got lots of tiny powdered pieces of joint surface. Um That's all you're gonna be able to do. There's no point in trying to screw those together and this is good because this is a principle in the hand. You'll see this not time and time again, but it, it, it's always there as one of our next steps in our trauma ladder, which is, if the surface is too, too comminuted, then an external fixator in the hand can be done. Uh And you don't just don't leave it on for too long. What happens if you've got that? You've tried your reduction and uh you've got a piece missing. Well, fortunately nearby is lister's tubercle in the dorsum of the wrist, um which is full of lovely chunky, chunky bony goodness. You can make an incision nearby little incision there over Lister's tubercle, get the tendons out of the way, uh, open up a little trap door on the bone and take out a lot of bone graft. So there's a nice little technique as well. So I'm going through these because probably, you know, you wouldn't be expected to, to have seen this, but it's of general interest and, and I guess they could, you know, if you're doing well in the, and you've, you've, you know, knocked, you've batted the, the Bennetts and the Rolando fracture away. Then the next thing would be, what else could you do? What would happen if, what would happen if it's comminuted, what would happen if, and, and you could say then even if you haven't seen this and in my reading, I've seen, you know, the external fixators may be used. You made bone graft from nearby source such as Lister. So those could be getting you your seven and eight marks and there you go. There you've bone grafted. So it would look something like this. Here's the thumb, thumb is that way. Um And we have got the external fixator on and here we see somewhere buried in here, a load of pieces. There is one piece. Uh You've got a Ky there holding them. Uh Maybe you have put a bit of bone graft in. So it is small potatoes, but you really want get that small, small fracture, but you really want to get that articular surface uh reconstructed. And obviously, you must reduce any dislocation and the patient could end up like that. And look, he's, he's definitely had a bone graft there, there's the donor site there. And that, you know, you don't, I don't know if you do. I mean, they, they're very useful in the hand external fixator is surprisingly useful uh whether it be the kind of Giddings frame or, or, or things like this um for, for severely combined fractures, they, they work very well. OK. And, and eee ever more so, you know, there are other ways you can apply traction. There are other ways you can put fixators. So this is a nice summary of the different fractures. Um So this is the Bennett. Um your fragment is held the rest of the fungus dislocated. This is the Rolando. It's not quite as bad as you can see. The whole thumb doesn't dislocate cos this bit usually just gets pulled off. Um but very difficult to um uh repair a comminuted one which is also a Rolando, which should have an R as well. And then there is an extra articular version which we, we don't normally name um where of course nothing is dislocated. In which case, you can treat this in a, in a much simpler way. In a cast, you might, you might, if it's very flexed, you might plate it, but it's an easy job. But to plate that to that these are, these are the different. So that's your summary. Yeah, Bennett's Rolando um A a and Rolando goes on into the, into the distance and then other things. OK. So uh on the collateral uh ligament, how are we doing for time? Um Let's have a look. So this is um this is very common. So this is something you should know and I'll, we'll go through it and we'll go through the operation if, if you're ok about it. Um You know, you may as well know and everything you're, you're register some of you will be hand surgeons, but you may as well see the whole operation, the acute injury to the ulnar collateral ligament at the MCP joint is called skiers thumb. Uh The chronic one, gamekeepers, skiers thumb is, is, is exactly as it, it's described and you do very rare, uh, regularly get skiers coming in with skiers thumb. Um You know, it's, it's where you've, you've had an injury and you, you were holding something um, like the steering wheel or like a skiing pole. Uh And as, as you've gone forward, there's been a force like that abduction of the thumb and the bonus of aorta, there has been a rupture of the ligament there chronic is gamekeeper's thumb, um which was originally meant to be gamekeepers would catch rabbits and they supposedly broke the necks of the rabbits in a certain way. And over the years of annihilating rabbits, they uh they developed a gradual uh stretching of this. We, we, we normally see it really as a, as a, as a, as a delayed presentation of an acute injury, I would say, ok, so hyper extension or abduction injury, um what's the diagnosis? Well, as long as people notice it, then they'll come and point to that part of their body and say it hurts, then it hurts when I grip things. So it's not difficult to diagnose and the history will give it to you because as you say, you're falling with your thumb in getting caught if you like um and what you do is you, but you can do, we, we'll talk about the imaging but basically you want to um examine it, you stress the joint uh in neutral and at 30 degrees you compare it with the other side, often it's very painful. So you put a ring block on. So if in the acute phase, if you're concerned about it, which you often are, you get the patient, you give them a ring block, you sit them in the side room and then later on you do this, this examination. If you get a firm end point, you're very relieved. If you don't, you're very worried because it's uh either completely torn and not sticking down or, or whatever. OK? And this is what you um are looking at. There's the thumb, uh there's the ligaments there. The, the uh the collateral ligaments are, are uh against the joint. But there is this um adductive pollicis uh upper neurosis. So, the abductor pollicis is this big the flat muscle here in the thenar eminence. And if you think about it, in order to, to adduct the thumb uh into the plane of the hand, the, the tendon from this has to come along to this side of the, to the dorsal side of the, of the thumb. And it comes through as a thin aponeurosis, which is very important and it's completely in the way it completely obscures that joint. Um Even though it's not shown doing it there, so it's wider than that. So you have to remove that in order to get it. So that's the anatomy. Um There are two components to it. So there's the aponeurosis. So every picture of this surgically always has the aponeurosis there because it's the most obvious feature that you see when you think you're going to see a joint. Um And then you can see underneath it, the collateral ligament and the accessory collateral ligament. OK. And one is to prevent uh uh to, to control uh uh your thumb when it's in flexion, when, when it's an extension. So you need to repair both of them and they look quite distinct and they, they are in that position in that sort of 40 35 30 degree position and you need to repair them like that. So again, because time is pressing, we'll crack on. Um So this is what they look like. You can have a bony avulsion. Those are the nice ones. Um So this is the history will tell you and when you look at the X ray, you'll know what to expect because they'll have told you why I caught my thumb. When I was doing something, you'll see this. Um If it's in a good position, then it will heal nicely and can usually be treated conservatively. I don't think you would see this in your, in the, in a, in a fracture clinic, but clearly there's a problem there. Um And that would be, to be honest, when you, when you do examine them and it is fully ruptured, you can get close to that sort of uh amount of uh of, of movement, they're really very, very um loose. Um And sometimes you see nothing. Oops, sorry and sometimes you see nothing, um which are the most difficult ones, which is then when you, you would need to examine them. So here we have obviously the tendon is intact, but it is an avulsion fracture. Uh And here we maybe the tendon has ruptured um somewhere along its course. Uh Oops sir. Um and then there's the associated injury which is very important. This is the Stena lesion. Um Here we are looking dos from the dorsum. Here is the aponeurosis again, on the side, it's drawn every time because it's so important and the problem here is you have this, here's the diagrams of the events during the course of the injury. Uh The patient's uh thumb is getting more and more. Uh which one is it more and more abducted away, sorry, more extended away um as it does. So, so in, in A, in B what's happening in B and the aponeurosis, the, the ligament, the ulnar collateral ligament is tearing at this point. So it's torn at this point, but the movement continues until the whole aponeurosis goes uh distal to the, the, to the ligament and the ligament is caught by the edge of the uh of the aponeurosis. And then as the thumb returns into neutral, the, the, the ruptured tendon is flipped back and now you've got a problem because it can't heal in that position. Otherwise, it heals often very well. If it's, if, if it just ruptures and falls back, it can heal very well because I guess because it's always coming to land in a good position here, it can't, it really can't heal. So this is the Stena lesion and this almost always means you're gonna have to operate because it can't heal. So it will always go on to being, being unstable. Ok? Uh Let's look. So, non surgical and surgical. Um I'll know you can um you often ask for a ultrasound scan. It would have been nice to have uh Mr Cows here. Um My, my findings have been that the ultrasound scan is, is quite odd because you always get a uh the, the, the, the ultrasonographer will always give you a distinct answer. Stenner or no Stenar lesion. But that answer seems to be no relation to whether there is a Stenner or not. Um And I've opened up people with positive ultrasound scans saying there's definitely a Stenar lesion and there isn't. And I've done the opposite. I've said people where they, they've said there's definitely no Stenner and I've seen a massive Stenner as soon as I've opened it up and this is not in one hospital, this is in various hospitals. So it, it, it, it must be a difficult thing to scan for. So we always scan, but I'll be very cautious with what the scan says. It doesn't, it doesn't, doesn't help, it can be very misleading, more misleading than almost anything else. And I don't know why because these, these are good, good radiologists, but they don't seem to be able to tell the difference. Um So it's clinical, really, the decision whether to operate is clinical. If it's, if it's unstable, um then then you're very inclined to operate. If there's a firm endpoint, then you're very inclined not to operate. OK. How do you operate? Let's spend a bit of time doing this. So I'm not sure they would ask you this in the exam, but it's a lovely operation to, to watch and be involved in. So, uh you do an S shape incision. Um Anyway, let's go through it. So this is my uh again for your amusement, these are my notes from uh when I was the registrar. Um Again, I don't know how junior or senior you are. Um You should certainly be making notes, copious notes. Um And particularly by the time you get to the fellowship, you need to record all the operations you see because you may see them only once. Um And you don't have to draw, I like drawing. I'm good at drawing. So II draw everything but you, you make your notes in your own way. But you, you should be now um getting together your, your, your set of notes that will take you through your whole career and why not draw things because it's all about what you see when you're operating. So um this is how to do it. Um You do this incision, the s is very important. It's very important to get exposure to the incision. Here is very precise because the aponeurosis is in the way the joint isn't quite where you think it is. There are lots of nerves. This is the first thing you see. You see lots of nerves that's really under underselling the nerves. These are my notes, they're not meant for anyone else. But um so they make sense to me, they may not to you. There can be five or six very noticeable branches of the superficial nerve. There you need to get them out of the way. Then you see the aponeurosis, it really is quite like that. Um, uh I always put a dental pick underneath next to the tendons, you then put two stay sutures there. Uh Then you can cut the upper neurosis close to the tendons. But obviously, even a cuff to repair those stitches are extremely useful because this thing can retract almost out of sight. You can always recover it, but it's, it's, it looks a bit more elegant if you don't have to fish for it. And when you put it back, you can hold the two sutures slightly apart and that spreads out the aponeurosis to repair it. And then sorry, this is, that's, that's the whole hand surgery stuff and then you repair it and the repair is quite easy. It looks like it does on that picture. You've got a, a kind of true, true, true and not true segment and you just suture it up or more likely, it's evolved from the bone at the distal point you put in an anchor. OK? And it looks like this and this is, I don't like this incision. Uh I think it's gonna, well, let's, let's have a look. So here's a Stena lesion. So what the reason we've got this photograph is here's the Stena lesion. So this is, there's the aponeurosis, this thin uh film here with the star on it and here you can see the, the, the ulnar collateral has flicked and it's pointing straight towards you. So it doesn't look like a torn thing. It's covered with a sort of pseudotendon, uh, or pseudo ligament, which is trying to repair it, but that can't stick down. So you'd have to, you'd have to that up, uh, and stick it down. Um, but on this one there, there's the aponeurosis, the joint is under the aponeurosis. So it's, it's not really the center of the incision, the center of the incision is here. And his incentive of his incision should have been where that red dot is. Yeah. So he needs more space. Oops needs more space. Ok. And how do you repair it? Well, you can repair it either as a direct repair or all these anchors, little kind of barbed harpoon or screw ones or these lovely ones called a a juggernaut, which will just crunch up and, and catch inside the hole. If you can see it there, there is a nice uh anchor repair there and then you can just about see it there and it's in the right place because the ligament is at an angle there. Ok. And rehab for a long time. Um, chronic uh and the collateral injury is, is, is I say it's not from, from, you know, decapitated in rabbits. It really seems to be delayed or missed presentation of the acute injury, um particularly if you fail to recognize a Stenner because then it's gonna heal but not, you're gonna have instability. Um And the ligament becomes attenuated, um, by six weeks, probably before that you can't repair it. It's shriveled up. You can't do it. Ok. Um You c you know, so you, you can go in and you can attempt to repair if you think you, you, you should certainly consider that, but often you will need to um do a reconstruction. Um, and you would need to use a free tendon graft. So either pus Longus or scr and this is the, the sort of thing you do. And again, just for your kind of information, uh uh only for hand surgeons. But um you know, you may as well, your, your senior people, you may as well know everything. Um And so there is where the ligament was and you pass your tendon graft through two holes at 90 degrees to each other and suture them together like that. Um Oops, there's my notes again for two seconds worth. Um This is an a four sheet. Um So I always put my layout, I put my instruments. Um I leave lots of space for future notes um around my sp that's me RG my colleague and all the people named and the I get used to doing this. If you're a hand surgeon or foot and ankle, lay out your theater plan, everything like this. Oh, yeah, I hope you can see this. Well, we'll skip through it. So um I can't see it, but perhaps you can. So there's my incision again and then I go through in detail how I'm going to make the holes and so on. Uh And there was the result. So there's one of the holes end on and then the other hole is, is transversely through there and we, we fixed it with an endo button which is just a piece of, of a plate and it was reasonably good result. Ok. First CMC dislocation, we'll go through quickly now because time is running out. Um, it's a biconcave saddle joint. Um, it's rare to dislocate. Ok. You're normally gonna get, um, um, a be fracture but you can dislocate it. People will miss it because it's rare. Um, well, sometimes you'll miss it, sometimes you won't hear an obvious dislocation. Um, you know, normally you would expect that fragment to have come off and stayed there and it would be a Bennetts. So we'd be happy. This is much more difficult. Uh, and I think it was missed. Um, you can reduce it and see if someone has reduced one of these fracture. Uh, one of these dislocations put it in and K wire, it almost the same as the Bennetts cos in a sense, it's almost the same. Um, how, however you've now got to reconstruct the ligaments. This is much more difficult, particularly if it's chronic. Uh, and you end up with something like this, which is, uh, we can, we can go through this in a second. So you're gonna use, um, your F cr tendon, which is this thing here, this thing here, this thing here you're gonna splitt it, uh, and flick the, the, the, the uh end back on itself through a tunnel in the metacarpal and wrap it around again. Um And depending on what they, depending on what they want, you can do more and more. Ok, let's leave this, sorry to rush through this. But I'm aware we're running out of time and I'm sure this isn't stuff that you all need to know. Uh So OK. Yeah, so what can we say about the metacarpal fractures in the thumb? Uh And these injuries is there significant injuries? Um you know, the problems we've said to do with the thumb, the forces through the thumb. Uh and they can lead to disability and arthritis, low threshold of surgery to the point where you really with a benefit, you really have to almost always going to operate. Um You need to reduce them, you need to have a good articular surface. Um For the ulnar collateral, you need to rule out this stenar lesion which is going to prevent healing. CMC dislocation. Uh It's rare but you know, if you have a AAA person where you think this has happened, you need to need to refer to a hand surgeon straight away because it's so difficult to repair. Ok. Now we're going to sort of change tack completely. Now, the rest of the metacarpals are, are are different. Whereas with the thumb, you really, you have to get it right. And there are these accepted ways of doing it. Even if there are numerous reconstructions for the tendons, you really do have to reconstruct the tendons, you can't leave it. Um The finger metacarpals are, are kind of at the other end of the spectrum. And this often um confuses people um registrars because you want, you want um clear instructions, you want an algorithm and this is one of the few parts of the body where you can really do a large number of different approaches and different techniques and they are all acceptable um which is difficult in the in, in the real world because people, it's difficult to learn these techniques unless you've done a lot of them. And in the exam, you know, they, they, they, they are going to struggle to ask you this stuff because you can give almost any answer and it will be, will be right. So these metacarpal fractures in the hand, they're the most common fractures of the upper limb uh mainly between 11 and 45 year old, uh mainly men just because of manual labor. Um And they are, we can classify them. You can have fractures of the head and there's a fracture of the head, you can fracture the neck. Now the neck is there, neck fractures are very different. These are usually from punching. Um And then you can have shaft fractures. This is the middle of the shaft. The thing with neck and shaft fractures is there is a point at which your neck fracture becomes a shaft fracture, um which is a little bit vague. Um They are, they are quite similar um shaft fracture, as we said, and there's two of them there and then the base fractures, which this isn't a brilliant picture. But what you've got there is a fracture on the base. Now, this is very similar in the little finger, very similar to the Bennett's fracture. This is a mobile joint here. The uh the little finger, carpal, metacarpal joint is also very low uh uh mobile because of the way your hand grips and it's also very important. So that one which we call the reverse Bennetts. So there you go, there's the clear reverse benefit fracture is very important and should be treated with some care other than that, other than this sort of special exception. They, they, they it's quite flexible how you treat them, right? So head fractures and we can go into incredible detail with all the different types of fractures. So, avulsions and stuff like that. Um You don't need to know that. Um but just to say, you could, you know, as you become a hand surgeon, I guess you, you, you find more and more um right. So a lot of these can be treated non surgically, if there's less than one millimeter articular step off, if the fracture is not in the main articular surface of the head, which it often isn't. Um you can leave them and often with comminuted fractures, you wouldn't think so, but you can leave them because what happens here is they are all, all the the pieces are in a reasonable position. This is not a weight bearing joint. Um They will heal in a roughly spherical kind of orientation and the results from that will be probably as good as if you go in and try and fix these highly combined things with tiny, tiny screws. So it's surprising sometimes you can see things which look awful, which the hand surgeon will say. Well, we'll actually leave that. I think it'll do fine and the intervention surgical opening up will just end up with a load of little fragments on the floor kind of thing. So that, that's always difficult for, for a just but so, so you have these kind of weird fractures where you don't need to fix them unlike the Bennetts. So, um how do you treat them well? You just have to protect them in the sense that you have to make sure they don't displace further without making the rest of the hand stiff. So that's what we're doing here. If one of these heads is fractured, but the part the the fractures have not uh are in a good position, then usually something like this. A Bedford splint would be enough. Um And, and usually three weeks would be enough to get the, the fracture sticky and then you can start to mobilize stiffness is your enemy. Um And here's the really for the metacarpal fractures. This is the slide of slides. This is all the surgical treatments you can do. And the point is if you read here, you can K wire, you can use screws or headless screws. You can use plates, particularly condylar plates. You can use, you can do arthroplasty and you can even on rare occasions, do arthrodesis. So this is kind of everything, right? And that's, that's the point. You can do a lot of things. What you are trying to do is fix the parts together uh well enough so that you can mobilize the hand quickly. Ok? And how you do it is almost irrelevant. You can do it with K wi s, you can do it with screws or plates. And that's true for all these fractures from now on. So that's, that's unusual in an orthopedic. So for example, you can use plates, here's a plate, this isn't a head fracture, but you start to use these plates from a handset. These are um very flexible plates, they are locking in blue or nonlocking. Um You come, they come in various sizes, you will have seen them um in, I guess in theaters. Um and you have various different sizes of screws so you can use whatever fits clearly as you go down towards the Phalanxes, you tend to use smaller screws, but there is no hard and fast rules. And what you do is when you, when you, when you're looking at the piece of bone, you, you often pick up a screw and put it next to the bone and see if it will fit there without, you know, without breaking out. Um, and the plates are often extremely long and that's not because you're going to ever use a plate as long as that, that's very unlikely. But because the plates are so small, they can be bent and cut and you should all, you're gonna cut those plates to the length you want and often you'll just cut and just use two holes. But the plates because they can be cut so easily by the cutting, cutting and plate benders, they're always made long. So don't, don't be fooled by that. This is, this is not, you never, whenever, almost never use one as long as that. Um, you cut it to the right leg. Ok. So here's a head fracture. It is perfectly reasonable to do this. This is a screw. Now, if you look at that, you can say, oh, that doesn't look perfectly reduced. Um That's not the point you were there. You can see the head, you can reduce it adequately from indirect vision. You put the screw on you then wiggle the bone to make sure that screw is firm enough to allow, you know, to immediate uh uh immobilization. And then you check whether that head is in a reasonable position and you make sure there's no rotational deformity on the table. So the x-rays can often look a little bit disappointing uh even shockingly. So, but that's not what we're seeing. We might be seeing, we might have a very good reduction here, very strong. The dorsal surface may be well reduced. There may be a little bit of a gap on the, on the, the volar surface. But if clinically, the finger is not rotated, that would do very well. And you would not wish to make that x-ray look better and cause fractures of the little fragments, um head fractures. So there's one now that's, that's a nasty one. You are going to fix that because you can, you can see that there's a huge step there that's gonna, that's not even if it, we will always heal, but it's not going to heal in a good position. Not, they're not going to have good movement. And in this case, they've used a plate, a condyle, a plate, the articular surface is still there. They've done the same thing. They've opened it up and they've plated it. The, the lagc wouldn't have been enough perhaps in this case. Now, what you've got to do when you do that and they should have cut off an extra hole, they should have cut off a hole in that plate. Um In this case, you must fix this firmly enough for them to mobilize. You've done a reasonable dissection there. Um And you've got to uh by doing that dissection and now everything is going to have a chance of sticking down. You must allow this patient to mobilize straight away. So that's the price of these lovely plates and fixing things accurately and anatomically, the price is dissection and the price is potential stiffness. You can't, you can't go in and then not fix it strongly enough to mobilize it or you can't go in. And as we will see you later, you can't go in and fix one uh Frax one fracture, sorry, one metacarpal uh anatomically with a plate and use AK wire and another one because then you're, you're torn, you can't immobilize and you can't immobilize. So that's, that's the only thing you're not allowed to do. Uh And then you put them in the position of safety. Um Three weeks is usually enough, almost always. Uh And then you've got to get them moving because you've, you've really stiffened them up. These tendons in the over the metacarpals can, can, can, can um can stick down completely stiffness is your enemy. So this is, this is the logic, fix them well enough to mobilize them because stiffness is the enemy neck fractures slightly different because there is a particular um mechanism for this, which is the the boxer fracture of the little finger. Um and it's a punch injury almost always. It can be a fall. People do fall on their hand like that. Um So don't assume everyone's been fighting. Um and it's a, it's a very, very common injury. Um, beware of fight bite, which is the, what we see there, which is the, the uh the metacarpal head um striking a tooth of the, of the assailant or the victim. And, and, and the the the tooth cutting into the skin and cutting into the joint. Uh the the fight bite is usually on the middle finger because his longest box is often on the little finger. So you do not tend to get them together, but it is certainly possible. Um And then this is sorry, this is mislabeled angulation is the issue here. Um uh There is a vast difference in the angulation that can be tolerated with different fingers. This is I tried to label it. I couldn't change it. This is shaft and this is neck. So as you go from the shaft to the neck, you can tolerate far, far more angulation in, in most of the bones, but in the index and middle finger, not much at all. There's not, they're not very flexible, the fingers don't recover well. So you're looking at 10 to 15 degrees for a fracture there. If not, you have to sort it out. Um The ring finger is pretty tolerant. Um in a shaft fracture, you can tolerate up to 30 degrees of flexion, bit more uh a bit, you know, you can tolerate a bit more on the neck and the little finger is extremely tolerant. So 40 degrees of the angulation in a shaft fracture and 70 degrees, almost 90 degrees, 70 degrees at the neck fracture. Ok. So you can really, you can have a neck fracture which is very, very flexed. Um It will heal, they will always heal. Um And the thumb, the the index finger, the little finger will recover. It'll start with a, with an extensor leg. So it'll droop like that for a few weeks and then gradually that will come back. So you can treat conservatively. How do you do it well, how do you assess it? The neck fracture? Basically, you have to look for rotational deformity in particular, you know, other things are important like excessive shortening, but rotational is the killer. So here's a, a ring finger with an obvious scissoring. Um So look for major scissoring, minor scissoring you can tolerate. But uh the only way to assess that really is is clinically. Uh and you can see it like that. How do you reduce it? Well, always worth attempting a reduction even though it doesn't often uh stay in position, you use what we call the J maneuverer. And so you can't, when you, when you try to put your finger on the metacarpal and extend them often there's so much the hand is quite swollen, you can't actually get at them. The metacarpal head is well into the palm. So you bend the finger and you use the proximal phalanx as a, as a, as a handle if you like and you flex it like that, extend it like that and hopefully that, that gives you better control. Uh So same, very, very similar um uh uh methods, neck fractures and oops. And so here's a neck fracture uh of the little finger called Boxers fracture. That's quite common. You probably would fix that. It looks as if it might be rotated. Um All sorts of options. Again, I'm zooming through this in a sense because um you can, obviously, you can read it up yourself, but you can anything which will, will, will, will stabilize that fracture is permissible. Um Ky is used in numerous different ways. So, retrograde, crossed into medullary as a sort of sort of like an intramedullary nail and pinning to the next metacarpal and this sort of bouquet technique. So sort of have a look at those. So here's one where you would want to fix these are really offended. They flex more than 7040 degrees. There may be well be rotation deformity, it seems reasonable to flex the fix these and there's two of them and you could do something like this. So two small Ks, one gone into medullary. But other than that, they've got a reasonable position and clinically is the important thing on the table. You would have checked that they are, um, and not rotated and in good position. That's perfectly acceptable. Obviously, you can't mobilize that patient very easily. So that's you've gone down the uh minimal dissection but uh immobilization technique. Um or you can, here's another one you can do intramedullary. So you've got a combination here where you've gone from the shaft of this metacarpal into the carpus. And you had a neck fracture here. I think, let's have a look. You had a neck, so you had a sort of base fracture here and you had a neck fracture here which you quite commonly get and you've got intramedullary here, which is just enough perhaps to hold this head in a better position. Although it looks uh as if it's not in a terribly good position there. Ok. Neck fractures again. So a neck fracture and a shaft fracture is that a neck fracture is getting towards a shaft fracture? Yeah, that's definitely a shaft fracture. But in this case, both have been uh uh fixed with an intramedullary K wire. Yeah, depending on the size of the, of the canal. So again, you've got, you haven't got full control here. You have, you may have rotational instability. So your going for a, a, a AAA patient's gonna be kept in a plaster for a little while. Um Just to let that get sticky. So you can't mobilize straight away. So what you mustn't do if there was a fracture next door is put a plate on it because then you have compromised the mobilization of this one. But that can work well. Absolutely, no problem with that. Fully acceptable. Same here. You've got a fracture, I think of the neck here and you've pinned it to the next metacarpal. Absolutely acceptable. Very nice technique. Again, not one where you can mobilize straight away. So you have to use it sparingly. Here's the bouquet technique almost the same as the, well, it is an inter technique. The idea is that with more or more than one wire, you get better rotational stability, which is technically quite difficult. Um And it, it does have a problem because often these are people who punched something and of course, you, you're gonna leave these in sometimes um you cut them short and leave them in and, and then they go and punch again and then they've bent them. Uh And so that can be a problem, but that's acceptable plate fixation also acceptable. But again, this time, now you've, you've done a big dissection here, you have to mobilize them straight away. So this has to be fixed well enough to allow mobilization and it goes on. OK. And this is the, we, we can sort of uh talk in some detail about this, but the answer is uh pretty much the same. So what we can say is similar to neck fracture. Um You can have K wires in various positions. You can have plates, you can more and more. We do um sorry, intermedullary screws, we do L screws. So we will just show you more pictures of this. This is now a shaft fracture. You can use K wires, shaft. Oh, that's the final picture. Uh The same thing again, your incision is um usually between the metacarpals because often you're going to do this on a metacarpal or when you've got two metacarpals. So you want access to both from a single incision be where the nerves be careful with everything. Um But the nerves are particularly vulnerable. The tendons you think would be vulnerable. They usually you can be pulled out of the way very easily and you get to the bones, OK? Shall fractures more. Again, you can use combinations provided they uh follow this er mantra of uh mobilization. So you can put a plate and L screws. Nothing wrong with that because both of those, but both of those must be strong enough to allow mobilization. It's no good having really tenuous screws. And you're gonna say, well, I'm not sure about those screws. I need to put it in plaster for two weeks because that's going to really compromise your mobilization here where you've done a very extensive dissection. OK? And the same again, look lag screws a plate, another plate perfectly. Except look at the, look at the geometry of the fractures and here's circular wire as well. All of those are possible, but on this one, you absolutely have to mobilize them straight away. This is one you probably shouldn't do. Um which has got the bouquet technique which is not usually strong enough to mobilize straight away. Um And other things, headless screws can be used as well. They used to say this is always in the books, loss of segmental bone loss. Uh We don't see much of this. This is from industrial injuries from machinery. Honestly, in this country, we, I've never seen that anywhere except in a hand unit. And even in a hand unit, it's very rare because of the interlocks on machines. So not something you'd have to deal with and you'd use bone grafts. Uh And I think on base fractures, there's more um intraarticular and extraarticular. Let's have a look. And we will say again. So this case, it's a bit like the venous fracture. So you're talking about reducing it um and treating associated injuries. Uh And so we go, ok. Um I think we will stop there because we're running out of time. Let me have a look and we can see, I think that's probably all we need to do. Ok? Um I don't want to carry on with this because it is, you can read up about it and it's all. Um I II will confuse you by showing you uh any more pictures because what we can say is all of these things that I've shown you in the last few minutes are acceptable, um, provided you can mobilize a as appropriate. Um, it's been a long day. Um, have we got any questions? No. Ok. Thank you very much. Is that, is that correct? Yeah. So this is, um, I think we, you know, have a read of that, but don't, don't, you could spend hours doing that and I'm aware that my lecture continues to say the same thing again and again, and that's the point, you know, you can do any of these things. They are all acceptable. Um So if there is no other questions, anybody else got any questions about either of the two lectures, which we did. So the, the, the proximal carpal row and the um all the, all the fractures under the sun. Um If there's no other questions, then I will, I'll bid you farewell. Uh Thank you very much. I'm, I'm not here next week, next week you're doing, the plastic surgeons are here to talk about tendon injuries, um, which is uh uh half of hand surgery, all of the soft tissue stuff. So I hope you enjoy that. And then II will see you. I think in about three weeks time when we, we actually meet in person, um hopefully see some patients. So if there's nothing else, I will, I'm fully aware that we've run over a little bit. Um I will say goodbye. And thank you very much for your patience. Ok, Doctor Phillips. Thank you. Ok, Cheerio, that.