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Oh, fantastic. Thank you so much for joining us, everyone. Welcome to uh to Med Education. Uh My name is Alex and I say it's great to all. Have you here this morning. So we've created the organization of Me Education with doctors in mind, er, but all health care professionals and students are welcome. So in today's session, we're joined by the wonderful doctor Jawad Navi who will chat with us about interpretation of musculoskeletal radiographs. Now he's gonna talk for around about 45 minutes. And in this time, please pop your questions into the chat and we should have some time at the end to make sure that we can answer at least a few of those just to give you a bit of background as well. I don't have any kind of medical knowledge myself. Um So I am depending on you the audience to ask those questions. I won't be able to produce any myself. Um At the end of the event, there's going to be a feedback form, emailed to you. Please take some time to complete that and once you have completed it, you will be able to access your attendance certificate. So I'm gonna hand over to the wonderful doctor now. Um And as I said, if you do have any of those questions, please make sure you pop them in the chat as we go through over to you. Thanks very much, um Alex for the introduction. Uh Can everyone, um, see the slides? Is that clear? And can you hear me? Ok. I assume that's, that's a, that's a, a thumbs up. So, um I'm Jawad, I work currently in Manchester as a mus musculoskeletal radiologist. And in this session, I just wanted to um cover the interpretation of upper limb radiographs predominantly. So the shoulder, elbow and wrist and focusing on um trauma, um looking at what search pattern you should follow when you're um interpreting x-rays in these body parts, common pathologies that you may see and cover some case examples just to illustrate some of those concepts in terms of the search pattern that we've talked about. So we'll, we'll make a start with the shoulder. So my general approach to musculoskeletal plane films is to follow an A B CS approach. But the, the C being cartilage and I'll just change that to joint there because joint makes more sense on an x-ray. So alignment, bone joint and soft tissues. So if we go through the shoulder to start with coming to the alignment to start with, so your standard shoulder series will have an A P view and usually another view, maybe a transcapular eye view, maybe an axial or an axial oblique view. But starting with the A P view, in terms of the alignment, you want to check that you've got a nice smooth scapulohumeral or glenohumeral arc. And this will be disrupted when there's potentially a shoulder dislocation or maybe a humeral neck fracture. You also want to look at the glenohumeral joint and to make sure that it's got this parallel morphology and that represents that it's being in joint and it's not dislocated, then coming onto the ac joint, the acromioclavicular joint. So you have your acromion here and your clavicle and you want to ensure that the inferior margins of the acromion and clavicle are reasonably well lined up. The superior border is always, there's always a bit of a step off, but it's the inferior borders that we use to check for AC J alignment. We'll also check the subacromial space which should measure around seven millimeters or more. If that's particularly narrow, it may indicate tearing of the tendons that go through this interval, particularly the supraspinatus tendon, which passes through this interval. And we also look at the coracoclavicular distance. So this is the coracoid bone, this is the clavicle. So we have the coracoclavicular ligaments that run in this space. And we should ensure that the space here is about 11 to 13 millimeters. If it's widened, it may indicate a rupture of the coracoclavicular ligaments coming on to the bone. So we would make sure to trace the bone cortices. So the humeral shaft, the scapula, the clavicle and the acromion again, making sure that there is no cortical defect that may indicate a fracture or in disruption of the fine trabecular pattern within the bone. A few areas that I would say are important to look at are the humeral neck because that's a a common site for fracture. The lesser tuberosity, the greater tuberosity, the glenoid, particularly the anterior inferior glenoid, which is can be a site for fractures in the context of shoulder dislocations. And then don't forget to actually look at the ribs as well because they're often included in the field of view in terms of the joint space coming on to the third section. We're looking for any obvious joint space narrowing that may indicate osteoarthritis, any osteophytes which would um be be represented by any bony exc excrescences on the inferior border particularly. Um and then also look at the ac joint for any osteoarthritic changes. So any undersurface osteophyte which may indent the supraspinatus tendon which passes underneath here and then the soft tissues you always want to look at the lungs, make sure that there's no pneumothorax in the context of a trauma, there's no rib fractures, there's no incidental lung cancer. And often sometimes we do see um calcium building up in the tendons around the um left shoulder or or the shoulder. Uh and that may be seen as globules of high density and that can be quite painful. And we would refer to that as calcific tendinopathy or calcific tendonitis, the additional views. So you may have an axial view and sometimes these are quite difficult to interpret and make sense of. One of the main things that I would recommend looking for when you do have an axial view to orientate yourself is look for the coracoid process because that tells you what's anterior. So we can just about see the coracoid process here. So that we know this side of the I image is going to be anterior and this side is going to be posterior. So if we're looking for a dislocation and the humeral head is lying somewhere down here, then there will be an anterior dislocation. So I'd say the coracoid process is an an excellent landmark. If you went to work out where you are on that axial view on the scapula wi view, we're essentially again looking to see where the humeral head is positioned. And the landmarks here are similar to the previous x-ray. So the coracoid process which we can see just here demarcates the anterior side and there we can see the spine of the scapula coming into the acromion, which is this bone here. And then we can see the blade of the scapula going down. So what we tend to say is that the humeral head should lie in the middle of this y formed by the scapular spine. The coracoid process. And the scapula blade again, if the humeral head had moved in this direction, it would be anterior dislocation and then in the opposite direction, a posterior dislocation coming on to some different pathologies. Now, this this slide has a lot of information about it, but it's just talking about what the salient features are when it comes to describing humeral neck fractures. The one of the most widely known classification systems is the near classification and it divides the humerus into four anatomical parts. So the anatomic head, the lesser tuberosity, the greater tuberosity and the humeral shaft, you may have multiple fracture lines, but they're only considered separate parts if each of those components, I is displaced if one of the components is displaced more than a centimeter angled more than 45 degrees. So the reason why that's relevant is because most one part fractures can be treated nonsurgically, whereas two or three or four part fractures may require surgical repair, but the classification has its limitations. And quite often you will see non surgical management being used in minimally dis space as well as 2 to 3 or four part fractures, especially in the elderly. Um in younger patients, you know, they may, you know, be considered for more surgical options um to restore the normal biomechanics in terms of ac joint injuries, we've kind of touched upon the acromioclavicular alignment and the coracoclavicular distance, which are very important for grading the type of a CJ injury. So in grade one injuries, we just get a sprain of the ac ligament, which we can just about see here with the red mark on the ac ligament in higher grades of injury such as grade three injury, we're getting rupture of those coracoclavicular ligaments. So the radiograph can be quite helpful at grading different types of injury. In the more severe grades of injury. You can get injury to the uh trapezius muscle which lies above um the clavicle as seen on this Sagittal Mr sequence. And you can get the clavicle becoming entrapped within the trapezius muscle. So the reason why the classification system is helpful, it somewhat guides treatment. So grades one to do injury may be treated conservatively. Whereas higher grades such as 4 to 54 to 6 may be surgical and in the middle grade three where you have rupture of the ac and the croc clavicular ligaments um is controversial. It may require surgery. It may not scapular fractures tend to be high, high velocity um injuries. So always look for any associated pneumothorax, rib clavicle or spinal fractures. If the imaging is there, usually scapular fractures are treated conservatively because the surrounding musculature acts as a splint to the scapula. However, if there's significant displacement, rotation angulation, if there's intraarticular extension to the glenoid or an associated clavicle fracture, then surgical management may be considered. These are a few ways to assess the displacement and angulation of scapular fractures. So in the coronal plane, we can look at the gleno polar angle in the sagittal plane, we can look at angulation of the scapula blade with respect to the um uh vertical. Uh We can also look at translation and displacement in both the Cron plane and the sagittal plane um called the lateral border offset and translation in the sagittal plane about a centimeter is considered significant. So coming on to some examples now, so if we look at the uh first radiograph we've got on the left hand side of the screen, if we follow through with our normal kind of search pattern, the glenohumeral alignment looks satisfactory. But when we come to the ac joint, we can see that the inferior margin of the acromion and the inferior margin of the clavicle have a step off the coracoclavicular distance, however, looks normal. So this will probably be a grade two ac joint injury with rupture of the ac ligaments that connect these two bones but intact coracoclavicular ligament coming onto the second radiograph or the second set of radiographs. On the right hand side, we can see that there's marked offset at the inferior border, the acromion and the clavicle and the coo clavicular distance is significantly widened. So here we're coming on to higher grade. So potentially a grade three injury of the ac joint. Um If we use the axon oblique view, we can actually see that the clavicle which we see here has moved posteriorly with respect to the acromion. So it should be articulated with the acromion. We can see it's moved posteriorly because the coracoid process points anteriorly. So this would actually be a grade four injury given that there is posterior displacement of the clavicle and this therefore becomes, you know, more likely to require surgical management. So that's two different types of uh a CJ injury we've seen there. Further example, we've got here. So looking at the gleno glenohumeral alignment, it's, you know, obviously not in alignment, the glenohumeral or scapulohumeral arc is disrupted. Um The humeral head is appearing to lie in a subcoracoid location. So there's the coracoid process. So this is an anterior dislocation. Looking at the other view, we can again see that it's a bit difficult to make out the coracoid process. But with an eye of faith, it's potentially in just just in this region here. And we can see that the humeral head is therefore moved anteriorly. And again, the axial view confirms an anterior dislocation of the glenohumeral joint. If we look carefully at the A P view, again, we can see that there's an additional bone fragment just sitting here in this gap and this is likely to have risen from the anterior border of the glenoid. And this is called a banco lesion or a Banco fracture. And it's displaced uh displaced fracture from the an inferior glenoid as the humoral head moves across it shaves off a bit of bone with it from the glenoid. So that's an anterior subcoracoid dislocation of the shoulder. So here we have another set of radiographs. And what we can see here is we're getting a light bulb appearance of the proximal humerus, which indicates that the humerus is in internal rotation. But we also see that there's widening at the glenohumeral joint. So there's not a normal kind of parallel appearance that we usually tend to see with overlap at the glenohumeral joint looking at the axial oblique view. Um the coracoid process is not easy to make out, but it's just about seen here on fast. What we can see is though that the humeral head, if I just annotate it, the articular surface of the humeral head, which is seen up here is no longer congruent with the glenoid, which is seen here. So this is a posterior humeral head dislocation X example. So we can see that there is an impression of a light bulb sign but not as obvious as seen in the last case. But again, we do have widening of that kind of humeral joint and the joint surfaces no longer appear parallel as they normally do. If we look at the axial oblique view, again, we can see the coracoid process just overlapping here. It's not the best axial view. It's probably you're not high up enough. But again, we can see that there is some loss of congruence of the articular surface of the humeral head with the glenoid. What we can also see is that there are several lines on the medial aspect of the humeral head. So we can see one line here, another line here and a third line here. So we've got three individual cortical lines here. One of them is probably normal. One of them is probably the normal lesser tuberosity, but one of them is abnormal and indicates basically a reverse hill sacs lesion which is an impaction fracture of the anterior humeral head as it dislocates posteriorly. And the name given to this appearance is the trough sign. So this is the trough sign and a posterior dislocation x case, if we look at the glenohumeral alignment, it looks reasonably well preserved. The ac joint alignment is well preserved but tracing the bones, we can actually see there's a cortical defect um on the lateral aspect of the humeral head at the site of the greater tuberosity. So this is an undisplaced greater tuberosity fracture at the site of the supraspinatus insertion. It's undisplaced, it can be a very difficult fracture to spot. Um So it's a it's a very good review area to have when you're reviewing plain films with the shoulder. Next example, we can see here is there's an obvious anatomical fracture of the humeral neck of the um proximal humerus. We can see that there's subluxation from of the humeral head downwards in relation to the glenoid and we do have some fat density within the um joint space as well as fluid density. So here there's a lipo hemarthrosis secondary to the fracture which is causing inferior subluxation of the humeral head. And this, this could be just left alone to gradually reabsorb and it doesn't specifically re require being put back in. Next example, here we can see is the alignment at the glenohumeral joint is satisfactory. The ac joint alignment is satisfactory but we do have a fracture at the inferior margin um of the glenoid near the scapular neck. And if we look carefully, we can actually see um a lung edge. So there is an additional pneum pneumothorax in this segment and there are also very subtle rib fractures, just one here and another one just there. So when you do see a sar fracture, always look very carefully for pneumothoraces and rib fractures. Just a final example of the shoulder, just always m make sure that you follow your review areas. And in this case, the glenohumeral joint looks OK, maybe there's a bit of inferior osteophyte formation. So maybe some early degenerative change, the ac joint alignment looks satisfactory. But following our review areas, we can see that there's a spiculated mass in the right lung which would be in keeping with a primary lung cancer. So always make sure to look at your review areas, one of which is the lung. So coming onto the elbow, um again, we follow that similar approach of alignment, bone joint and soft tissues. So looking at the lateral view of the shoulder, the elbow to start with, we tend to look at a few a couple of lines. So one of which is the radio capella line. So this is the radius and the capitellum is this circular density that we can see just here which articulates with the radius and the radius. And the capitellum should be an alignment on all views, not just the lateral view but also the A P view. There should be good radio capitellar alignment. The next thing we tend to look at is the anterior humeral line. And whether that intersects roughly the middle third of the capitellum, which is true. In this case, if it intersects the anterior third of the capitellum, that then that may indicate a supracondylar fracture of the humerus. In terms of the bones, we would trace the bony contour um around the humerus, the Ronon, the radius and look for any fractures, any loss of the trabecular pattern to indicate occult fracture. And we'd look carefully at a few areas. One of which is the coronoid process, which is this part of the Ronon hidden here or the ulnar. I should say the coronoid process is very important to look at because it can get fractured in the setting of elbow dislocations. And the second area I would say look at definitely is the radius and the radial head because fractures can be very subtle here. It can just be slight indentations of the cortex. So especially in the context of the elbow joint, effusion, always look very carefully at the radial head. In terms of the joint and the soft tissues, the fat pads are a really helpful indicator as to whether there's gonna be any significant elbow injury. So normally in the absence of any pathology, you should be able to see the anterior fat pad, which we can see just here, it's hugging the anterior cortex of the distal humerus. And it's got this fat density. You can see here very similar to the subcutaneous fat density. The posterior fat pad is hidden um within this recess, the electron on recess of the distal humerus. So the fat pad, posto fat pad lies somewhere here and it only displaces out when there's a elbow joint effusion. So normally you don't actually see the posterior pa pad. But if you do see it, then that's a helpful indicator that there is a joint effusion. But the anterior fat pad, you do see it becomes pathological and it's raised up and it's irregular. And we may call that the sale sign. In terms of other findings around the joint, you may want to look for any osteoarthritis in joint space narrowing. Any loose bodies, loose bodies may tend to collect in the radial or coronoid recess here or in the electron on recess here. Coming on to the A P view. So back to the alignment again. So radio cap alignment should hold true on all views. So here we can see the radio radius and the cap are are in alignment. And the ulnar and the trochlea, which is this segment of the distal humerus should also be in alignment which they are. In terms of the bone, we would trace the cortices round very carefully looking for any cortical irregularity or fracture. The radial head is also very important to look at for any subtle signs of fracture. The coronoid, which we can just see here in profile is also important to look at and again, similar to the lateral view. We're looking for any joint space narrowing in terms of the joint, any osteophyte formation, which may indicate degenerative change, any loose bodies. Sometimes we do see tendon calcification and this can occur similar to what we see in the shoulder um at tendon attachment. So on the medial side, which is this is the medial epicondyle. So the medial side, we've got this flexor pronator mass which inserts here with the common flexor origin. And on the radial side, we have the common extensor origin somewhere around here. And perhaps there's a bit of calcification in this case, probably asymptomatic. But we would also want to, you know, evaluate these sites for any calcification build up which may be symptomatic. The pediatric elbow is is worth discussing because um it's important to know the order of their um appearance and roughly would they appear at intervals of 2 to 3 years. So, but the actual, I mean, some people use 13579, 11, but something that's probably more accurate is 157, 10, 10 and 11. So by that, I mean, so at one year, we would have the cap ossification center which we can see here uh five years, we should have the radial ossification center which we see here. At seven years, we should see the internal epicondyle which we see here and so on. Moving on to some pathologies. So, radial head fractures are one of the most common fractures that we see in the adult population around the elbow. And the classification that is widely used is the Mason Johnson classification and the key descriptors are, is, is the fracture displaced, is it comminuted? And is there any associated dislocation? So, if it's undisplaced, it's likely to be treated conservatively if it's displaced. Um and there's loss of cortical contact, then that suggests instability and that may require surgery. And if it's comminuted, it generally does require surgery depending on patient fitness and orthopedic surgeon preference and a grade four, whether the associated dislocation may also require a ligamentous fixation as well. Radial neck neck fractures, we tend to see more often in the pediatric age group. Um And the classification tends to comment mainly on the degree of angulation at the fracture site with increasing degrees of angulation. It's more likely that the patient may require surgical treatment, distal humeral fractures. Um We tend to um uh describe them with respect to the columns at the elbow. So you have a lateral column and you have am medial column and we would tend to describe which columns are involved. Is the fracture extending to the articular surface, is the articular involvement, partial or complete. So is the fracture completely separating off the whole of the articular surface or just part of it? So, in the B images here, we can see these are partial articular fractures. Whereas the C images show complete dissociation from the articular segment to the fractured segment. Um is their displacement is their combination. Most injuries tend to be treated operatively but small single column injuries may be treated non operatively. Electron fractures. Again, we we see them reasonably um commonly. Um the key factors here to to look at is, is there significant displacement ie more than two millimeters is there commun and what's the morphology? Is it transverse? Is it oblique? Is it distal oblique? Is it more segmental with multiple fracture lines? Um So if it's nondisplaced, it may be conservatively treated but if there is any significant displacement, but then it, it's likely that there will be um operative treatment required and that may depend on whether there's commun or not. The surgical technique. Coronoid pro process fractures are overlooked cause they can be quite subtle on x-rays but they're important because they can lead to instability of the elbow and then therefore, um early onset of osteoarthritis. And the reason why this is important is that we have a very important stabilizing ligament at the medial aspect of the elbow, which attaches to a segment of the coronoid, which is called the sublime tubercle, which we're just seeing in these um in this image here on the coronal Mr R. So this segment of the coronoid is called the sublime tubercle and this is the ligament. So if we have a fracture involving this, it can lead to elbow instability and then early onset away. So if there is, you know, significant involvement of the sublime tubercle or large fractures of the coronoid process may require surgical treatment given the higher chances of instability. Um So there is, there are various classifications in terms of type 12 and three. But the most important things to, to know about is is there gonna be sublime tubercle involvement which you've seen here and is the fracture large involving more than 50% of the coronoid process. So those factors could lead to more aggressive treatment. So some examples I think we're doing OK for time. Um So here we've got a lateral and an A P view of the elbow. And if we look carefully, we can see that the fat pad is slightly irregular and bunched up on the anterior side. The radio capitellar alignment is still preserved. But given that there is an a raised anterior fat pad which is irregular, indicates there's a joint effusion. And we're also gonna have a, a very um good look for therefore, a radial head or neck fracture. And if we look carefully that there's slight inundation of the radial head here, very subtle. Um But if we look on the A P view, we can see that there's a cortical step just on the radial head and neck junction there. So that would indicate a undisplaced or minimally displaced fracture. X case again, we can see that there is irregularity of the anterior fat pad indicating a elbow joint effusion. And again, we need to look very carefully for any radial fractures of the. Uh these tend to be the more common fracture in the adult age group. And we can see on the A P view that there is an intraarticular fracture of the distal radius, but there's still good contact between the two bones, sorry, the proximal uh radius, not distal radius. Next case. Um So here, if we look at the radio capitellar alignment, we can see that the radius and the capitellum are no longer congruent, the radius is pointing in this direction. The capitellum is here. So this is a therefore a elbow dislocation or at least a radial head dislocation. But if we look at the electron on as well, it's not very um it's not articulating very well with the um distal humerus. So it's a, a complete elbow dislocation posteriorly directed. And what additional findings we can see here is that there is a bone fragment and where is this ari arisen from? So, if we imagine um the direction of force in which the elbow has traveled, the force would have been going up the um shaft um of the radius and the ulnar pushing the um elbow joint posteriorly. And this fracture fragment would have arisen from the coronoid process as it's been pushed backwards. It's impacted against the trochlea and um fractured off. And we can see the fracture fragments also on the A P view and there's probable involvement of the region of the sublime tubercle. But given that the fracture fragment is quite medial, but it's hard to say, it may require AC t to be sure. The next case, again, if we look at the alignment in this case, we can see that the radius and the capitellum are no longer in alignment. So there's the radius and there's the capitellar ossification center, they've lost alignment. And again, if we look at the A P view, there's not good alignment between the radius and the capella ossification center. In the soft tissues, we can see that there's elevation of the anterior fat pad, there's a sail sign and there's slight visibility of the posterior fat pad, very subtle, but it's just about there. And we can also see that there is an ulnar fracture So a few findings here, we've got proximal ulnar fracture, got radial head dislocation and we have got a elbow joint diffusion. So you may, you know, you could call this a Monte variant, a mont fracture dislocation. Uh The epos name given to ulnar fractures with a proximal uh radial dislocation X case here. So, on initial inspection, we can see that the radio cap alignment is is satisfactory on both views. But we can see that there is some elevation of the anterior fat pad again suggesting a effusion. We can't see any obvious supracondylar fracture. But what we can see that there's a bone fragment in the medial soft tissues and there's quite a lot of stranding in the soft tissues here. So there's been some trauma to the medial aspect of the elbow and this medial, this is the medial ossification center which is displaced, it should be lying next to the bone. So here we've got a displaced medial ossification center likely due to some form of valgus injury at the elbow, putting strain on the medial side. This is another pediatric case and this illustrates the concept of the um anterior humeral line. We can see if we trace the anterior humeral line downwards. It's not really intersecting the capitellum anymore. So it should intersect the middle third of the capitellum. And we can see that this whole segment of bone is displaced posteriorly. And we can also see that there is disruption of the cortical pattern. And normally this posterior humeral cortex would join onto this cortex here. So there is basically a supracondylar fracture of the distal humerus which is slightly displaced posteriorly and there is elevated, you can see actually the elevated posterior fat pad lying in this segment case here. So this is a bit of a tricky one and it involves counting the ossification centers. So we can see the capella ossification center. We can see the radial head ossification center. We can't see the internal ossa, internal epicondylosis center. We can see the trochlea, we can see the electron on and we can see the lateral epicondyle. So what's missing here is the internal OPI condyle ossification center in this segment should be sitting somewhere here. And if we look carefully, we've got an additional fragment of bone inside the joint. So we've got a displaced entrapped medial epicondyle ossification center, which will require um surgery um to restore the normal location and prevent early joint damage. So, coming on to the wrist. So this will be our, our last um anatomical part that we'll discuss today. And again, we'll follow that similar approach of alignment, bone joint and soft tissues. So starting with the alignment, the I usually look like to look at the ulnar variants, which is the position of the ulnar head with respect to the distal radius. And they should roughly be in line with each other. If we draw a line perpendicular to the shaft, it should be roughly in line and they look like they are at a similar level. If the ulnar head is too proud, we call that ulna positive. So if the ulna head was sitting somewhere here, if it was too low, then ulna negative ulnar positive variants can lead to early osteoarthritis at the ow um carpal joint or something called ulnar impaction syndrome. And it can also lead to tears of the triangular fibrocartilage which sits sits in this gap here, the triangular fibrocartilage and then a negative ulnar variant. So, if the ulnar head is too low, can it increase radial loading on the lunate bone which can then therefore lead to KBO disease or AVN of the lunate. So that's why ulna variance is important. I also tend to look at the scaf lune interval. So usually the distance between the scaphoid and lunate bone should not exceed four millimeters. So if it's abnormally widened, we'd call that um diastasis of the Scaife lue interval. And that could indicate a scaf ligament tear. We'd also look for carpal arch. So we trace the carpal arch. So we've got a proximal arc just here. We've got a middle arc and a distal arc. So these arcs should all be in alignment. If these arcs are not congruent, then it may indicate a carpal bone dislocation. And then one other thing I would say it's important to look at is the C MC joint spaces. So these should be aligned. And normally what we see between the fourth and the fifth metacarpal and the hamate is that we see a nice joint space. If you lose this joint space that we see here, if that is no longer visible, that could be a dislocation at the fourth and the fifth metacarpal uh bases or the 4th and 5th C MC joint joints. And you would diagnose that better perhaps on the lateral view. But always look to see, you can see a visible joint space. People that um have had a punching injury, they could dislocate in dislocation. In terms of the bones, we would again trace the cortices around carefully look for any loss of cortical continuity. Any loss of the trabecular pattern within the bone to indicate fracture. A few areas that I would emphasize are important are the radial styloid because this is tend to be where we miss fractures and they called chauffer fractures. The scaphoid bone which is a very common carpal bone to fracture the ulnar styloid which can fracture when we fracture the distal radius because the TFC which attaches here um can a VSE a fragment of bone in this direction. And I'll also look at the base of the thumb. This is another area where it can fracture. So these are a few areas which I would emphasize looking at in terms of the joints. Again, just like the other joints, we're looking for any obvious joint space narrowing and the osteophyte formation around the joints, um, tends to be that we find osteoarthritis in the hand. It tends to be very common, um, around the base of the thumb and the scaphoid trapezium trapezoid joints. This is the S TT joint. So these are tend to be the very common areas for osteoarthritis around the hand and the wrist. The lateral view can be quite confusing and it's probably worthwhile discussing some of the anatomy on here before we look at the search pattern. So we can see the ulna styloid around the back here. We can see the radial styloid around here. And if we just get rid of those lines now, so we can see the lunate bone just this shadow here which articulates with the distal radius. We have an additional shadow projecting forward following some kind of pattern like that. But this part this bone ar forward, that's the scaphoid. And this is the scaphoid tubercle which can sometimes fracture. We have the capitate bone here which articulates with the lunate. This bone here, which is this rounded ossicle is a sesamoid bone that's called the pisiform bone. That's the pisiform bone and then the other bones are very difficult to perceive. Um So at this level, this is probably going to be the hamate because it's the distal carpal rope and this is going to be the trim because it's the proximal carpal row. So I'll just show you them on the A P view. So we've got the scaphoid bone in this, in this. Um This is the scaphoid, this is the lunate, this is the triquetrum. That's the pisiform. That's the hamate, that's the capitate, that's the trapezoid, that's the trapezium. So trapezium with thumb. So you can see that the distal carpal row is made up of the hamate, the capitate and the true trapezoid bones. The proximal carpal row is the scaphoid lunate triquetrum and pisiform. So if we go back to the lateral, you can see the lunate, which is part of the proximal row, we can see the scaphoid bone, we can see the piss of form this bone at the back is likely the triquetrum looks at the proximal carpal row. This bone at the back is likely the hamate cause it's at the distal carpal row. We can see the capitate and then we can see the overlapping trapezium and trapezoid bones just here. So in terms of the alignment, what's key on on the lateral view is to make sure that the capitate and the lunate and the radius have co linear alignment. If that alignment is not there, it could indicate a lunate dislocation or a peril lunate dislocation where the capitate and the other bones get dislocated. You also want to make sure that the ulnar and the radius are overlapping with each other. So they're in alignment. There's some angles here which we can talk about in an perhaps another session which we go into a bit more depth in terms of describing fractures. But one thing important that I would like to mention now is the volar tilt of the distal radius. So we can see a volar rim of the distal radius and a dorsal rim of the distal radius. And normally, if we draw a line across them, they tilt slightly in a volar direction. So volar being a palmer or yeah, a palmer direction or anterior direction. So you can see it's tilted in a volar direction and that's normal and that's about 11 degrees to the horizontal. So that should be about 11 degrees. So the reason why that's important is that when you get distal radial fractures, you lose this normal volar angulation. In terms of the lateral view, I'd also say it's very important to look at the cortices of the distal radius on the lateral view. So we have a few different cortices. We have got 31 of them. These will be the lister's tubercle, probably the most proud one, but any fracture may disrupt that subtle, those subtle cortices. So if you see any slight disruption of those cortices, think that there could be a distal radial fracture. And then another common fracture we see on the lateral view is the triquetra avulsion fracture where you may see a fragment of bone at the proximal carpal row. In terms of the joints and the soft tissues, we've kind of already discussed that you do. You do sometimes get um, osteoarthritis at the hand and wrist, mainly around the base of the thumb and the scaphoid trapezium and trapezoid joints. And then finally, is the pronator fat stripe, which is this uh stripe of tissue that we can just see here, this fatty tissue and it sits on top of the pronator quadratus muscle, which is just seen underneath. Some people say that you get bulging of this fat stripe when you see distal radial fractures. But I think it's a very nonspecific and subtle sign. It's not always, you know, 100% specific for fracture. You could just be bulging because of soft tissue trauma. So coming on to pathology. So distal radial fractures, now you may be familiar with a number of different um names for fractures. I tend not to use these names. Strictly speaking, I tend to just describe the fracture. I describe if it's intraarticular extraarticular because it can be quite difficult to distinguish in a plain film because a Coy's fracture is your typical distal radial extraarticular fracture with distal or sorry, the dorsal displacement which we can see here, it's displaced in a dorsal direction and it's extraarticular. A Smith's fracture is the opposite extraarticular fracture but volar they displaced. So this is displaced in the volar direction. Then you have your Barton type fractures which involve intraarticular extension of the fracture line. And here you can see that there's intraarticular extension of the fracture line and polar displacement. And then this is the opposite where the true Barin, where you've got a dorsal fracture line with intraarticular extension and dorsal displacement. That's your chauffer fracture, which is your radial styloid fracture here. But I mean, th those are the names given to describe them. But in my reports, I would just tend to describe the fracture rather than give it the eponymous name. Um But the most important thing is whether the fracture is intra or extraarticular frac intra extraarticular. Does it have a number of fragments? Is it communi to is it displaced as it angulated? Normal kind of assessment criteria for distal radial fractures are um the radial height of the length which is the length of the uh radial styloid with respect to the ulnar head. And it should be about 12 millimeters radial inclination which is the angle that the distal radius makes with the horizontal. It should be about 23 degrees ulnar variance which are touched about before it should be near neutral. In this case, it's slightly negative and volar tilt, which we've already discussed. It should, there should be volar tilt to eight of the distal radial articular surface. So these factors are important when describing distal radial fractures because if there are, if these fractures are significantly abnormal, then the patient may be considered for surgical management. So potential factors are you know, dorsal tilt. So dorsal angulation in the opposite direction to what we see here, more than 20 degrees a loss of the radial inclination by at least five degrees radial shortening by more than 10 millimeters or positive ul the variance or severe com or displacement of the fracture. Intraarticular involvement can also be important to mention a study from the UK did demonstrate that surgeons were most interested in ulnar variants and dorsal tilt more than 10 degrees as well as articular surface step off of two millimeters. So those the ulnar variants, dorsal tilt and articular surface step off were the main criteria scaphoid fractures I think are important to mention because they are common carpal fractures and they have a risk of avascular necrosis given that the supply is retrograde and you can get proximal pole avm. So generally speaking, there's a about a millimeter of displacement is, is deemed, you know, ok, if it's more than a millimeter or more than 1.5 millimeters, they may require surgical treatment. Perils um are mainly diagnosed on the lateral view and you're looking for that loss of the capitate lunate alignment that you can see in this diagram on the bottom right hand corner. So peril lunate dislocation where you get capitate movement with respect to the lunate and the lunate stays normally aligned and a lunate dislocation where the lunate pops out anteriorly and then you can have somewhere in between, which is called a midcarpal dislocation. So got only a few minutes left. I just want to cover some examples. So this is a patient with a distal radial fracture. It looks predominantly uh extraarticular, but there is significant loss of radial height. There's some positive ulna variants as well. So there's quite a significant deformity here and there's quite a lot of volar um displacement of this fracture. So this may, you know, require surgical fixation if the patient is a good surgical candidate, given the significant deformity, given the positive variance, given the loss of radial height, given the significant solar displacement. Another example of a distal radial fracture here and what we can see here, it's very important to mention here is that there in there is intraarticular extension which we can just about see on the A P view. And in addition, we've also got an ulnar styloid fracture which is due to traction of the TFC, which runs in this area. We can also see that there is positive ulnar variant. So that may be a criteria for the patient requiring um surgical um uh reduction of this fracture if it fails reduction closed as an example to show you a disruption of the carpal arch. So we can see on this A P view, it's can be traced the proximal carpal ar but the middle carpal lock cannot be traced in this segment. Um which indicates that there's going to be some kind of carpal M alignment on the lateral view. We can actually see that the lunate is tilted in a volar direction and it's almost as if the capitate has come down somewhat into this gap here. So this is a lunate dislocation. Some people refer to this appearance on the A P view as a piece of pie appearance or a slice of pizza appearance. Another example of loss of the carpal arx. So you can see the proximal carpal arc is interrupted. So if you just draw a line across that it's interrupted in this segment here, the proximal carpal arch. And again, if we look at the lateral view, the lunate is sitting mostly within the distal radius, but the capitate has slipped out dorsally. So this is more of a peril lunate dislocation. And we can also see that there's a fracture of the triquetrum in this location so that we would call this a trans Tril perate fracture dislocation. Another example here, we can see that there's a subtle sclerotic line in the distal radius. And if we look carefully on the lateral view, there's cortical irregularity on that dorsal surface, which is in keeping with an undisplaced distal radial fracture. Another example here we can see is that the ulnar variance is slightly negative, the ulnar head is sitting slightly lower than the radius and the lunate is looking rather sclerotic. And if we look carefully, there's a fracture line through the lunate in a sagittal orientation. And this is kin Boxx disease or AVN of the lunate um with secondary um fracture in indicating more advanced stage of AVN or avascular necrosis of the lunate bone. Couple more examples, I think we've got, we've got left to discuss um and this one very subtle but we can see a additional fragment of bone on the proximal carpal row and this is a Tril fracture. Mhm This is the final example we've got and to draw your attention to this area here, we talked that we should be able to, we talked about how we should be able to see a clear joint space between the fourth and the fifth metacarpals. And we've got loss of that joint space indicating that there could be some malalignment in this location. If we look at the lateral view, we can see that there's a fragment of bone which will be from the hamate because it's the distal carpal row and that the fifth metacarpal is articulating with this fragment. So it's dislocated. So this is a fifth cm CJ fracture dislocation, carpometacarpal joint. So fifth CM CJ fracture dislocation with fracture of the hamate bone. Final example, this is a four series x-ray. So usually we do additional views to get good views of the scaphoid bone because of its oblique orientation. And here we can see that there's a fracture through the waist of the scaphoid. On the second view. Second, oblique view we've got here. Um it's not very visible on the other se on the other series hence why we do so many views for scaphoid fractures and these are very important to, to pick up. So, in this kind of uh very brief and uh session, we've approached uh trauma upper limb radiographs and discussed how you should um evaluate the radiographs in the sequential approach and not to miss anything. And we've discussed a few specific pathologies and some case examples. So I'm happy to, to take any questions now, I'll just uh close the share screen. Thank you so much for that Gerard. That was, that was fantastic. Um As I said, if there are any questions from the audience, please pop them in the chat box. And er hopefully we have, we still have some time to answer some of those while we're kind of waiting for people to type in some questions. There was one from Medal as well and so one of the, one of the learning objectives for this session was of course, to kind of participants will be able to be proactive in now seeking out and integrating feedback on their radiograph interpretations. So, Jad was there any ways that you would recommend that clinicians seek feedback on their radiograph interpretations, especially if there may be uncertain about their findings? Yeah, absolutely. Um I mean, always approach your seniors. Um I'm sure there will be in the institutions that you work, there will be um orthopedic surgeons, there will be radiologists. Um there'll be other uh physicians from other disciplines that may have experience. So uh if you are unsure about any pathology, then, um you know, do, do discuss with your team, do approach your local radiologist. And I understand that quite commonly radiographs, you know, may be left up to the interpretation of the referral. Hence why we were doing this session today because it's very important that each and every one of us is able to interpret muscular through radiographs as a doctor, I would say that um there's a number of um resources out there that you can use to, to, to learn things in, in greater detail. Um which I can, I can provide some resources after this session potentially if it would be helpful. Yeah, that would be fantastic. What we're gonna do is keep this recording as an on demand. So anyone that wasn't able to make it to this session today will still be able to catch up with the content in their own time with your permission as well. We'll make the slides available to fantastic. Any other additional questions from the audience today? There we go. We've got one from, from Joshua here. Is there a more basic way to recognize elevated fat pads? Uh It's a good, it's a good question. Um It can be difficult. I mean, what I would say to you is that the anterior fat pad should always be visible. So it should, it should always be um flat, uh smooth and almost parallel but not quite parallel with the distal humeral cortex. So it should be very closely adherent to the cortex. And you shouldn't see a posterior fat pad. If it's um I if it's, you know, if there's no pat pathology, no joint issues, you don't see a posterior fat pad. When you do see a posterior fat pad that should ring alarm bells in terms of the density of the fat pad. If you're struggling with the density, maybe you can compare it to the subcutaneous fat of the on, on the radiograph. So the subcutaneous fat will have a very similar density to the fat pad. So you can use that as a guide. But if you see any irregularity, kind of any um bunching up or kind of um coiling of that fat pad, then you know, do do think that it's abnormal. Um and it, it does indicate an effusion. Um and then if you do see an effusion and you do see elevated flat pads look very closely at the radial head in adults and at the supracondylar region in Children. Fantastic. Well, I think that that brings us to the end of today's session there. Um So thank you everyone for joining us today. Um I hope you enjoyed the session. Um as I mentioned earlier, don't forget to follow medal education. Um And I'm going to post a link in the chat. Now we keep you informed of all the future events that we'll be hosting. But thank you again, Doctor Jawa. That was absolutely fantastic. And we look forward to seeing all of the attendees in our next session. Thank you very much. Thank you. Thanks for the opportunity.