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and okay, so can you all see? Um, my pack spin screen? Yeah, OK, great stuff. Great stuff. So if everyone's got the link, uh, I'd like you to open this pack spin link, which is entitled peripheral trauma, hand wrist, forearm and elbow. And we've got 15 cases, uh, 1 to 15. Okay. And I'm going to look at number one first. I'm going to open the study, and I want you to tell me, uh, what is going on here? Somebody has fallen on the outstretched hand, so put in the in the chat box. What, you think the, uh what you think the problem is, uh, colleagues fracture? No, no. The wrist looks okay in terms of the ulnar and the radius. That's okay. What are the bones of the rest? We've got the radius, The ulnar. There's the ulna. Styloid. There's the radial styloid. Then we've got the skate forward. The loon. Eight. Try quit from pisiform hamate. And there's the hook of the hamate. There's the capitate Trapezoid. Trapezium are superimposed. There's the trapezoid. There's the trapezium. You see it better when the wrist is oblique and trapezium is the one that's near as the thumb. So a bit of poetry trapezium near the thumb. Okay. And all of those bones look okay. With the exception of one bone, which is the bone that doesn't look okay. So the radius and and the owner are okay? Yeah, the skate void. The skateboard is fractured. Now, can anyone tell me where the name skateboard comes from? Yeah, both. Excellent. Yes, CAFOs is Greek for boat. And so it's boat shaped. It's a boat shaped bone. And, um, the Latin for bait is Navas, and some people call it the scaffold navicula because navicular means boat. But we call it skate forward and it's fractured. Okay, now, one of the things about the skate avoid is that you can still get a fractured skate void, but it's not very apparent on the X ray, and so it's very important to clinically assess the patient. And these patient's tend to be very tender in what we call the anatomical snuffbox. And that's the little, uh, square of soft tissue that exists between the thumb and the wrist. Excuse me. So there's a skateboard fracture here. Now, can anyone tell me in which direction the blood is flowing in the skate forward. Does the blood flow this way? What, does it flow this way? Yeah, it It flows in a retrograde fashion. So the blood supply comes this way. And so if you fracture your skate, avoid this past The skate forward is well supplied by arterial blood. But it's this past the skate forward that is in danger of losing its blood supply. So what would happen in this patient if this didn't heal very well or the blood supply was interrupted? What do you think would happen to this part of the skateboard bone? The process. Yeah. So if you look at the, uh, the next one, this is the same patient. Can you see that the proximal pole of the skate forward three months later has become very sclerotic? Okay. And that's one of the signs of avascular necrosis of the scaphoid secondary to fracture. Okay, so it's very, very, very important to pick up skate forward fractures, uh, clinically and radiologically. Because if you don't, it can leave the patient with a significant disability, uh, for the rest of the life. Okay. And you want to avoid this avascular necrosis If if this is treated promptly, or if even if prompt treatment doesn't relieve the pain, you can put internal fixation. And that tends to reduce the incidents of avascular necrosis. Any questions about that? It looks so good. Okay, so let's go to Case number two and Case number two. Let's open this one. And we can see here on the plain film that we've got skate forward fracture and let's go through those bones again. There's the skate forward. There's a fracture through it. Lune eight. The pisiform and the triquetrum bone are superimposed. There's the hamate bone. I notice the hamate bone because there's the hook of the hamate, That little triangle of bone. There's the capitate There's the trapezoid and there's the trapezia. Okay, and we've got fracture through the waste of the scaphoid. And just to show you what it looks like on an MRI scan, um, let's go for the, uh, T one weighted Corona. All so there's the There's the fracture through here. Okay? And it's causing quite a bit of, uh, bone edema at this pace. Uh, this, um, part of the bone. Okay, So if I This isn't a particularly good slice, uh, probably best seen on the T one weighted image. Okay, so MRI is very very, um there's a lot of movement artifact here, but if you look on the, uh, Corona le t one, you can see very marked bone edema caused by that fracture. So MRI is very, very sensitive at picking up a fracture. If you can't see it on a plane fill. So that's available to you in the event that you can't You can't pick up the fracture. Yeah, this is a t one weighted image, and so bone marrow will return a very high signal because it's got fat in it. Whereas, uh, anything with blood or a dumb A or a fracture on t one, uh, tends to appear dark. Okay, so that's that's case number two. Number three. Um, just wanted to show you, uh, here is a patient who's got a wrist x ray. Um, is that a skateboard fracture here? Well, we have to look at various views. Not entirely sure. And that looks okay, but the patient still got risk pain. So we do a 21 weighted MRI, and actually, there's the fracture. Can you see it? So everyone was thinking that This was a fracture of the skate forward. But in fact, there's an occult fracture of the radius. So that wasn't at all obvious on the the X rays. Everyone was looking at the skate forward thinking this is a skateboard fracture. But when you look at the tea warm, weighted Corona all there was a fracture through the radius. Okay, fracture through the rate is just the so, uh, t one, um shows fluid as black tea to shows fluid as white. And, uh, this is what we call a fat suppressed, uh, t two sequence and it shows a fracture. Lighting up is very bright, but T one is very good for anatomy. So there's the skate forward. There's a loon. Eight. There's the triquetrum bone. There's the hamate capitate, and that's the trapezoid. Okay. And these the various ligaments in the wrist. Okay, but we've got a fracture of the radius distal radial fracture. So occasionally when you've got a clinical problem and you think somebody's got a skateboard fracture and you can't see it on the x ray, the patient undergoes an MRI scan and you pick up things that you were not expecting. So memory can be very, very useful in patient's who are subject to trauma in which you are worried about a cult fractures. Okay, number four. Can I just ask? Can you all see these on your own computers? You're all able to to see them. Yeah. Great stuff. OK, some of them might load a bit slow if your internet is a bit slow. And I'm just having an Internet issue at the moment, so it's a bit slow. Um, I might come back to this one, so I'll keep it loaded and I'll go back to. So Okay, so while we're while we're waiting, um, if you look at, um, the MRI. So the MRI is very sensitive at picking up fractures and fractures on T one weighted images appear as a very low signal. Okay, which is what we're saying here. Okay, Now, something's happened to close these down. Okay? I may have to reboot this. Let's start again. This is the problem with modern technology. It sometimes fails you just while we're rebooting. We have a question for you. Um, from Ahmed. He's asking, Could you repeat what can be seen in an MRI while the extra and what the X ray cannot detect. Okay. Yeah, sure. So here we go. It's working now, so if we look at number four Okay. Which is the one we've just seen? Uh, sorry. Number three beg your pardon. So the X ray here is normal. Okay, but if you look at the radius, can you see this, uh, curvy black line? And that curvy black line is a fracture that you can't see on the X ray. So the problem with an X ray is it doesn't always show you the fracture, so the patient's got a fracture, but the X ray doesn't share it, but clinically, you think that patient's gonna fracture? So what you've got to do is you've got to treat the patient clinically, and then you've got to use MRI in those situations where you're pretty certain. Clinically, there's a fracture somewhere, but you just can't see it. And this MRI shows this black line, which is the fracture. Know the cortex is intact, but there's a fracture through the medulla of the bone, which is causing this low signal in a high signal bone marrow. Okay, Does that make sense? And it's on a T one weighted image if you did it on a, uh, t two weighted image and suppressed the fat, I don't I don't want to get too complicated now about the MRI, but if you if you were to do that, uh, you would see high signal, uh, and that's this one here. So I've suppressed the fat. All the fat has become gray instead of white, the bone marrow has become black instead of white. And so any pathology that you can see it looks white. So this is the same anatomical area as this here. But this is t two with fat suppression. This is T one without fat suppression. Okay, so this is what you see on MRI. Is that clear? Yeah. OK, great stuff. Okay, so, um, number four, hopefully this will open now. Oh, yeah, I I was having a temporary problem with my internet. So, um, this patient has, uh, fallen on their hand. Can anyone tell me what the diagnosis is? A careful look. This is probably the best image to look at this oblique image at the end. Uh, trapezoid looks okay. Trapezium looks okay. Look at the metacarpals. Very good. Third metacarpal we've got an oblique fracture. Now, can you see that? The fracture is much more visible on this view here than it is on this view here. And you can't see the fracture on this view. So it's always very important to look at more than one view when you're looking at Fracture. Okay? And this fracture is going through the cortex through the medulla, but it's a non displaced fracture. Okay, So that would be treated just with immobilization in a plaster of Paris. Okay, that's good. Uh, is this is this Is this what you want to see? Guys? Is this, uh, the kind of teaching you like, where you can actually see the images of yourself? Yeah. Great. Okay, so the number five, this is a patient who has suffered trauma to the to the hand. They've already got it in a cast, but let's have a look at the images before it went into a cast. So if you go into the pa Oblique and yeah, it's okay, though, doesn't it? Things look okay, but when we look at the oblique view, you can see here that there's a slight loss of alignment of the fifth metacarpal. It's overlapping the hamate. You should really see a joint line that this Lucent line, but it's overlapping because it's subluxed, and these are one of the most difficult things to see because you're not expecting to see them. And in a pure lateral, can you see that the bone here and this bone here is not parallel to these bones here. Okay, so there's a subluxation of the carpometacarpal joint of the fourth and the fifth finger. Now that's quite difficult to see, and I would never expect anyone other than a radiologist really to pick that up. But I'm just telling you that there are certain ways in which these can be picked up by very closely looking at the joint line and seeing if there's any overlap and overlapping bones in this context usually mean a subluxation. Okay, uh, and then this has been treated with a cluster of Paris cast and the, uh, bones have been reduced. Can you see that the line is now restored? So there's the hook of the hamate, and the No one has now been restored such that if we look at the, uh, natural view now, everything is now in alignment. Okay. This is, um, nice example of a carpometacarpal, uh, subluxation of the 4th and 5th fingers. Okay, Number six now was the was the lesion. Here was the fracture. See this thing here? It's chip of bone. Yep. There's a fracture of the proximal phalanx of the thumb, and it's adjacent to the joint. And this is due to an avulsion of the ulnar collateral ligament. Okay. And it's caused caused by an avulsion injury. Now, you can either get an injury where you snap the ligament or you fracture the bone that the ligament is attached to. And both of those conditions are called the gamekeepers the okay. And it's called gamekeepers therm because the gamekeepers used to grab the rabbit by the thumb and index finger. Okay. And this caused ulnar collateral ligament injury or in the extreme case, uh, an avulsion fracture. Okay, there's a just the same case we're just using, uh, slightly different window levels. Okay, so it's the same case I'm just using different brightness and darkness. Okay, Now the sesamoid bone, you can just see his hair. So there's the fracture which fits nicely into their Here's the sesamoid bone it was one of them. And there's the other one. And the thing about the sesamoid bones are that they are almost always identical. It's like having identical twins. Okay, so one sesamoid bone is very much like the other sesamoid bone, but this is very triangular, whereas a sesamoid bone is very spherical or elliptical. Okay, so important to remember that the sesamoid bones come in pairs and they often look very similar. Okay, number six. So let's go for number seven. And number seven is a patient. Who, uh, let's go back to the X ray. So it's right down at the bottom X ray, the wrist. Anyone know what's going on here? Mhm. There's the ulnar. There's the radius. There's a flake of bone here that's Lune ate it doesn't look quite right, because it's overlapping the capitate bone, and you shouldn't see these bones overlap ink. Okay, so there's a triangle of bone overlapping the capitate, and we've got what looks like a skate forward fracture. Okay, that skateboard doesn't look right either, and what's happened is you've got the lunate bone and there's the capitate bone, and they should be articulating. So this is what's called a Perrilloux. Nate dislocation. Okay, so there's a dislocation of the Capitate and the loon eight as well as a skateboard fracture. And that's a very, very complicated injury, even for the radiologist to look at. So what we do in these situations is we often subject these patient's two CT and this is the CT in this patient. Got lots of images, uh, taking a little while to load. There's the Radius. There's a little flake fracture on the radius. There's the loon eight bone and the capitate bone should sit in the groove formed by the upper surface of the lunate bone to form the Capitate Luna joint. Okay, And so this is completely disrupted. And as we go towards the skay forward, which is this way, we've got a scale for fracture. Okay, so there's the scaphoid fracture. There's the capitate bone, which should be articulating with the lunate bone, but the lunate bone is in its normal position. It's just that capitate bone has gone posterior to which you can see here. Okay, so it's a very complex injury. Um, this is such a complex injury that it can't really be treated unless it's reduced in theater, so everything is nicely in alignment now and then. What happens is the patient then gets screws, uh, to stop these bones from moving. So it's a very severe injury, and this severe injury will cause massive disruption unless it's picked up and treated appropriately so again, at medical school level. Um, we wouldn't expect you necessarily to to know about these injuries in any great detail, but just important to know that the radiologist can use further investigations to get, uh, some more information prior to treatment. And this was a case in point so that that was double 07 Double oh seven. A. So on the same theme. We've got a patient who has had wrist trauma and you can see there's the skate forward. There's the capitate and the loon. Eight has now become triangular again. There's the pisiform. There's the triquetrum bone. There's the hook of the hamate, and you can see the nice, clear joint line that exists between all the bones. But here it's disrupted by this triangular loon. Eight. On the oblique view, it looks even more triangular. And then on the lateral view, you can see that the loon eight has been pushed forwards, so it's no longer articulating with the Radius. It's been pushed forwards, and here is the Capitate bone, which is articulating now with the Radius. And this is called illuminate dislocation. And it's a bit like a Perrilloux Nate dislocation, except it's the lunate that moves, Uh, rather than the capitate. Okay, And again, this has to be reduced very carefully with, uh, orthopedic surgeon and an operation. Now, in order to get this injury and the previous injury that I've just described, you have to have ligamentous disruption. So the ligaments, uh, the scaffold lunate ligament gets disrupted. Either it gets stretched or it gets torn, and these take a long time to heal, so they often have to have internal fixation. Now here's a great case, and you guys will know the answer to this now because I'm going to tell you, this patient has been hit on the back of the hand and they've had an X ray. And when we look at the X ray, there's the scaphoid. There's the loon. Eight. There's super imposition of the triquetrum bone and the pisiform. There's the hook of the hamate just here. There's the hamate bone. There's the capitate bone. There's the trapezoid. There's the trapezium. And I know it's the Trapezium, because I, um understanding poetry trapezium near the thumb as the hook of the hamate. There's the loon eight bone. Everything looks okay. Everything looks okay here. But when we go to do the lateral, we can see a small flake of bone posterior. Now, we don't know where it is posterior, because it could be anywhere from here to here. Okay, but we just see a flake, a bone posterior. Now, when you see that flicker bone posteriorly, you know that this must be due to a trick wittle fracture. Okay, so a trick Rachel fracture is the cause of this particular, um, appearance. Okay, so it's a triquetrum fracture, and it's only ever seen on the lateral view. So if you press somebody's posterior wrist and you get pinpoint tenderness, okay, you suspect a trick electoral fracture. You definitely do need to do a lateral view. Uh, for a try. Cultural fracture. Okay. Number eight getting through these, um, quite nicely. Number eight is a patient who has had an injury. So young patient, because you can see epiphany sees. There's the radio epiphysis. There's the ulnar epiphysis ISS. There's the radial meta facist. There's the growth plate. There's the skate forward. There's the loon. Eight. There's super imposition of the pisiform and the triquetrum. All There's the hamate. There's the capitate. There's the trapezoid. There's the trapezii. Um, notice that the thumb metacarpal has the epiphany, sis. Approximately. Whereas the other metacarpals have the epiphany sees distally. Okay, that's just an anatomical fact. And what, uh, where is the fracture? Look at the medical apples. Nice and smooth. Nice and smooth. Nice and smooth. Nice and smooth. Nice and smooth. What's this? Is that smooth? Or is that got a little step in it? Yeah. So that is called a buckle fracture of the base of the fifth metatarsal. Okay, Book or fracture of the base of the fifth metatarsal. Everything else where you see the cortex. It's nice and smooth. Okay? And that's treated with immobilization. Okay, so it's a book or fracture in a child. Okay, Number nine, and we've got a thumb injury. What do you think about that thumb injury? And he thought, Yes. So it's a fracture of the base of the thumb metacarpal. So can you see this fracture here? There's the Trapezii. Um, and there's the fragment of bone that's fractured, just the and that is called a Bennett's fracture. Okay, the benefits fracture is a fracture of the base of the thumb involving the carpal metacarpal joint. Okay, so the way to pick up a fracture is always look at the X ray on more than one view because you may miss it on one of the other views. So on this view, you probably wouldn't see it. You've got lots of overlapping bones. So look at the other views. There's the oblique view. There's the DP view, and you often see the fracture coming out. Okay, Number 10. Well, there's nothing to see on this view. Nothing to see on this view. But what can you see on this view? Anyone? It's not smooth as it. So Look at the cortex here. Nice and smooth. Nice and smooth. Nice and smooth. Nice and smooth and not entirely sure about that. But look at that step there. See that small step? That is a fracture of the distal phalanx. Okay. And then if you look a bit more carefully, you can see a Lucent line coming through here. And that is a crush fracture of the distal phalanx. So quite difficult to see. But if you go through the images in a very ordered systematic way, you will see that there is a step in the cortex, and that step represents a fracture. Okay, what does the area of bone look darker to the other bone? Uh, this here, you mean? Yeah. Okay, because that's because of the fracture. So what's happened is you've got a fracture, and the two fractured ends have been pulled apart a bit. Okay, so that's the That's because of the fracture. Okay, let's go to number 11. How are we doing for time? We've got 15 minutes left. Uh, we're into the elbow now, and I just want to show you this image here. So we've got a fracture of something here, and we've got See that lucency that black area here? That black area is due to the fat pad in the elbow. Okay, Now I'm going to send you, um, a link after this lecture with some videos on how to look at elbow injuries and wrist injuries. Okay, so those videos on YouTube, and I and my colleagues have produced them, and it just helps explain why you get these particular injuries. So let's have a look at the CT that goes with it. So let's put this up here and let's put this up here. No, this is a bit back to front, I'm afraid. Okay, so it's just a mirror image of what you're seeing here. And can you see that the joint capsule is normally covered by a very thin sliver of fat? But when you get a joint effusion the blood in the joint from an injury, it forces the fat backwards. And in the case of the anterior fat pad, because this is anterior, it strips it away from the bone, and you can see this. So that is the fat pad that's been stripped away from the bone. Okay. And in this particular case, they've got a fracture of the radial head, which you can see here. Okay. Looking at on bone windows, there's the radial head fracture. Okay. And you can just see the elevation of the fat pad just there. So it's very, very important to look for that fat pad when you're looking at elbow injuries because the fat pad, uh, will tell you that there's a joint effusion. And whenever you see a joint effusion, you must always consider an injury to the rayed your head, even if you can see it, or even if you can't see it. Okay, so I'm going to, uh, just look for see fat pad. Armah is Here we go. There's the There's the YouTube link, which shows you about the fat pads. So have a little look at that video. Copy that link and, uh, you know, work out what is going on with the fat pads when you get a fracture. But it's a very sensitive way of picking up a fracture in the region of the elbow joint. So the fracture through the radial head causes a joint effusion to strip away the fat pad. And that's the most sensitive way of picking up a fracture in the elbow. Okay, and there was a very complicated comminuted fracture. Comminuted fracture, uh, means that you've got a a more than one fragment to that fracture. Okay, uh, but the fat pads get stripped away, and it's a very sensitive waste. This is anterior This is anterior. It's a mirror image. There's the capital. Um okay. Or is that the capital? Um, or is that the trochlea? What do you think? What's what's that bone? Uh, anyone wants this bone? There's the coronoid process of the ulnar coronoid because it looks like one of the pieces of a crowd. Coronoid. So this is the truck Clear? Absolutely right. And this is the capitate bone, which is supposed to be articulating with the radial head. But of course, that's been fractured. Okay, number 12. Uh, we haven't got number 12. Um, I missed that one out. Number 13. Mhm. What sort of fracture is that? Yeah, there's a fracture of the distal radius. There's a flake of bone here. There's a fragment there, which is the radial styloid. And this here. So it's a comminuted fracture. And there's posterior angulations of the distal fragment. And there's also a fracture of the ulna styloid. Can everyone see that fracture through the ulnar styloid and a fracture through the distal radius? And this is called a collies fracture. Okay. A collies fracture after the Irish orthopedic surgeon who first described it. Colleagues fracture. And we call this a dinner fork deformity. So it looks a bit like a dinner fork because it goes like this. Like that. So it's called a dinner for deformity. So, clinically, you see, um, this kind of appearance, okay. And this is treated with reduction and demobilisation in plaster of Paris. Okay, um, number 14. We're getting to the end here. We'll go into the forearm now, and this patient has got a fracture of one of the forearm bones. Which forearm bone is fractured? On that view, it's the radius. Yeah, well done. So there's the radial head. There's the capitate. There's the trochlear. There's the ulnar, and the fracture has occurred in the distal third of the radius. But also, can you notice that the ulnar and the radius So there's the radial styloid, and there's the owner are now dislocated. So we've got a situation where the patient has got a dissociation between the ulnar and the radius in its distal portion. So this joint is disrupted, so it's a fracture of the radius with a distal ulnar radial joint disruption. So there must be a ligamentous disruption here, and that's called a gal IATSE fracture. Okay, gal iatse fracture and then finally, number 15 on a similar theme. We've got forearm fracture. Which bone is fractured? The ulnar. Yeah. And what happened to the proximal radioulnar joint? What's happened to the proximal radioulnar joint? There's a dislocation. Yeah. So this is the owner and the humerus that's intact. There's the ulnar fracture, which is common muted because we've got more than one fragment. There's also some soft tissue injury here, as you can see, but the radial head is no longer articulating with the capitate. It's been dislocated. Anteriorly. Okay, so the radius should be articulating with capitate. And it's been dislocated anteriorly. And this is called a montage. A fracture. Well done. Yeah. So you've got it. Montage. A fracture. And so we've got a montage of fracture where you've got an ulnar fracture with dislocation of approximal um, radioulnar joint and also the radiocapitellar joint. And the other one, which is the, uh, sorry. It's, uh, this one here. The gal iatse fracture, where you've got a radial fracture with disruption of the distal radioulnar joint. Now we've got two minutes to go. How to differentiate a Galbiati fracture versus a montage versa. Colleagues. Okay, a colleagues. Fracture is where you get a fracture of the distal part of the radius. Okay. And the distal part of the radius causes an angulations. Okay, so there's the Carly's fracture. There's a distal angulations, but the fracture is of the distal radius. There's no dislocation. Okay, The gal IATSE fracture, there is a dislocation of the ulnar from the radius. And there's a fracture of the radius, which is dandy diaphysis iss. And then the montage a fracture. The radius is dislocated proximately. So in other words, around the elbow, and there's a fracture of the ulna. Okay, so I hope that was useful. Uh, please do have a look at the images again. Uh, write down all the answers that I've given you. Have a look at the videos and for those people who are watching on feedback. Um, could the moderator please give those links to those people watching on video so that they can fully appreciate the images that I've shown? So thank you very much for your attention. I'm going to see you guys next Thursday in two days time at 8. 30 in the morning UK time. So thanks for your attention and I will see you soon. Thank you so much, Doctor. Thank you for the great lesson. And we hope to you soon, everyone, I will forward the links that were shared by the doctor during the session and also ensure you do fill in this feedback form just to provide us with some understanding regarding how beneficial the sessions are So we can continue providing these sessions. I'll leave the sessions.