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Hi, good afternoon. Good morning. Good evening and night, maybe from wherever you are. Um It's me again, those who have attended my talk on meal, Sanjay Pai. I, one of the emergency medicine consultants in the northwest of England. Um Welcome. Um Now today's talk, uh you was um actually assessment and management of upper limb fractures and spine fractures. Now, when I was going through it, I thought up in fractures is so much even then I can't cover the whole thing in an hour. I've taken spine out of my talk and I've told me all that I could combine spine and pelvis in another talk because next week, uh there's a talk on lower limb fractures. Uh We'll, we'll take Pelvis out of that talk as well. So, um so here we are. Um Right. OK. My slides are a movie. I don't know what's happened. They're not moving. Um You may need to um click the middle circle button. Take it off presenting and put it back on sometimes that helps share a PDF present. Now, try now. Uh Oh, so, OK, so I think it's uh not, I have to click on it. Yeah. Ok. So, um, I've got an hour. Uh, what we'll do is we'll go through these things, we'll go through, uh, which you all know those who have done orthopedics, those who have done emergency medicine. Uh, we'll know uh, classification but we'll just go through it. Uh It will be revision for some, it will be new information for others. We'll talk about initial assessment because remember, fracture could be part of a major trauma. In which case you, you don't want to get distracted away just managing the fractures where the patient has got a life threatening injury. Yeah, then we have a quick look at how to identify a fracture on an X ray. And I'll give you a, a safe system which you can use in your day to day practice. And then we're going to spend most of the time on going through, through X ray pictures of upper limb fractures, uh the common ones and dislocations. And we talk about the, the management from the emergency medicine perspective. Yeah, not orthopedic perspective. So we won't go into operations and things. Um uh we are not talking on spine fractures. It will be another talk. Uh And then we'll summarize and we'll let you ask questions. So as as I usually do, it's an interactive talk and you're free to uh give me answers. Uh What is a fracture? Who will say anyone? What do you mean by a fracture? Commonly? It's known as a broken bone. You know, patients come and tell you, they don't say I've got a fracture. They say I've broken a bone. Um now fracture also, it's associated with a soft tissue injury because if you remember if you imagine a limb, the limb from outside in has got the structures of skin, sub kidneys fat, the fascia, the muscle, then the bone and surrounding it. You've got the neurovascular structures. So a fracture, even though affects the bone per se can also affect all these structures. And you've got to be vigilant and assess them uh when you're examining clinically and that's the important bit of it. So there's not much all these structures you've got to. Now, as I said, you know, you can see a a fracture could be trivial. So think about a finger fracture could be a very trivial thing, but a fracture could be part of a life threatening injury. Yeah. Can you think of some fractures which could be limb or life threatening? Any thoughts to anyone? Some fractures which where, where it can be risking? Neck of femur? Yes. Ok. Neck of femur pelvic fracture. Excellent. Uh pelvic fracture itself can be life threatening because of the extensive bleeding that it can cause leading to hemorrhagic shock. Ok. So in those situations, so we could identify, is it a trivial fracture or it's a fracture that can affect the limb? So a AAA fracture in a limb can itself be limb threatening can you think of a limb threatening fracture, neck of femur and pelvis is not but any limb threatening fracture, a fracture that can risk a limb in terms of um you know, um causing damage to the limb. So so to speak, any thoughts say, you know, the shaft fractures of the long bones, think of femur a shaft fracture, think of humerus, shaft fracture, supracondylar fracture, a joint that says absolutely right. The reason it's limb threatening, why, why do we say it could be limb threatening? Why not just the fracture itself? But what the fracture can do or potentially do in terms of complications. So things like it can burst through the skin making it, you know, open fracture, it can cause damage to the other structures like soft tissue, like nerves like vessels and that can, you know, be risk uh the li risking the limb. Ok. So that brings us to the next point. What structures have been? I think I've said it already and fatima has said nerve, yes. So skin subcutaneous tissues don't forget that. Think about muscle and nerves and vessels, five structures which you've got to assess as part of the fracture because fracture, the bone bit you you you only diagnose through the X ray imaging but the other structures you can assess clinically. Yeah. Um Now the fracture can be isolated. Now, if it's isolated fracture like a trivial fracture, um let's say a wrist fracture. Ok. Now, that fracture uh usually is assessed as part of secondary survey if the patient has got a major trauma. Ok. But when would you consider uh assessing the limb early on in a limb fracture? When would you like to assess the limb early on? And from what aspect can you think of that is very critical? Any thoughts I'll move on if there is bleeding? Yeah. So if the fracture loss of pulse, yes. OK. Loss of pulse means in injury to the vascular structure, neurovascular status. But more importantly, from the uh life and limb point of view, there's bleeding. If there is hemorrhage, you want to look at that fracture first because torrential hemorrhage can lead to loss of life. Yeah. If you imagine if you think of when I did my ABC talk of initial assessment, uh the the the methodology is C ABCD ECs catastrophic hemorrhage and a limb fracture can result in catastrophic hemorrhage. Now, if you don't address the catastrophic hemorrhage, patient will die. So that's important. OK. Or the the fracture can be part of a major trauma. Ok. So the patient sustained a major trauma and from the limb point of view, just to say two or more long bone fractures. So think of the long bones, humerus, radius, ulnar tibia, fibular fibular, not so much tibia and femur. So two or more long bone fractures is is considered as major trauma with or without other injuries like head trunk, belly abdomen or pelvis. Do you know why? Two or more limb fractures? Uh long bone fractures are considered major trauma. What's the emphasis? What's the emphasis of, of, of this? Why, why do we consider major trauma? Because we got to go to the initial assessment process, hemorrhage? I absolutely. Right. And now there is a guide as to how much bleeding can you expect from long bone fractures? Any thoughts, let's say humerus, let's say tibia, let's say femur. Any thoughts roughly in, in milliliters because that can cause hemorrhagic shock, 2 L in femur. So up to a liter and a half to two, up to. So that's a class three shock from hemorrhage and and you've got to address the hemorrhage. You've got to manage the shock as well as the fracture itself. Ok? Tibia can lose up to a liter. Yeah, that's a to two shock. Whereas a humerus can lose up to 500 mils of blood. So it is important to look for hemorrhage or if the fracture causes a amputation that also is a catastrophic bleed that also needs a dressing to stop the bleeding. We'll come to that in a minute. Ok. Now, in A I II from the fracture point of view, can you think of risk factors that causes somebody to have fracture? So there is a patient factor and injury factor. So what about the patient factors? What sort of patient factors results in, in, in fractures? Can you think of osteoporosis. Fatima says, yes. So older people who have osteoporosis have got they do do fall. Yeah, and they sustain minimal injuries. So, fracture of femur is one of them or wrist fracture is one of them. Yeah. And also those who are immunosuppressed, their bones are weak. Uh they can sustain injury as well. What about the injury factors? What sort of things causes fracture? Any, any idea what sort of injuries we, we all know falls, especially falls from a height can cause spine fractures, um can cause uh you know, calcaneal fractures, uh falls, uh you know, just tumbling and falling, fall down the stairs can cause fractures. What about road traffic accidents, high speed, road traffic accidents can cause fractures as well as assaults. So a lot of assaults result in fractures as well or, or other accidents, you know, uh falling off a cliff, falling off a horse or something like that. Ok. Now, coming to classification again, you know, you probably are aware of this. The two main thing. When you look at a fracture, you got to ask yourself, is it a closed or is it an open? What do you mean by it? What do you mean by? Yeah, playground and sporting injuries can cause fractures. Yeah. Ok. The the contact sports, the soccer, the rugby. So, so, so I says absolutely. So coming back to uh what is closed and what is open? Any thoughts open fracture, the skin is broken. Fatima. Absolutely clear if the skin is punctured, even technically that is open fracture. But what's the, so it's important? No, if the skin is intact, it's a closed fracture. Why is it important to know that Fatima or anyone? Anyone, why is it important to know? Is it open? Is it closed? There is a reason. Breathing tendency. Yes. Ok. Ok. To manage accordingly. Yes. But the important bit is infection joint. That is absolutely. So if the skin is breached, you have close fracture compartment syndrome, that's important as well. Ok. So especially if the fracture happens in the compartments, we'll come to that in a minute. So if the skin is breached, there's a potential for infection. And the important bit is that, that, that open fracture needs irrigation. The earlier you irrigate the fracture, get rid of mechanical dirt and debris that reduces the chance of infection. But also if the fracture, if that wound needs toileting or wound management, you there is a window that opens up that within 6 to 8 hours, you've got to address it. Otherwise the potential you, we give you antibiotic because open fracture has got a principle of management. In addition to your analgesia, the two most important thing is early irrigation. And in emergency department, what we do is and, and you can do that is you have the fracture, put a B underneath, pour some warm, uh you know, ringers lactate or normal saline and wash it off a liter. That's the first irrigation you can do in Ed and then the orthopedic surgeons can do it later in theaters and give prophylactic antibiotic. Now, broad spectrum prophylactic antibody. Now, remember the antibotic that you're giving, you're trying to prevent infection. What infection are you trying to prevent in a fracture? What are you worried about? And there's a bug that causes that we know that any thoughts pseudomonas. Ok. If it's dirty contaminated. Yes. But more more commonly it's Osteomyelitis caused by, you know, staph and other bugs. So a broad spectrum antibody but your hospital osteomyelitis, Jha says your hospital will have a policy. Ok. Now, the next thing I Yeah, Clostridium as well. The next thing or, or you know, if you can have gas gangrene as well. Clostridium. Yeah. Absolutely. The next thing I've got is comminuted. Yeah, you've heard the term comminuted. What is comminuted fracture? That's another classification because when you're referring a fracture to a specialty orthopedics, they would like to know all these descriptions. Yeah. Any thoughts what is called minute bone, broken into fragments? Ok. Now, when a fracture happens, you got two pieces of bone that's not comminuted anything more than two fragments, no matter how many, anything more than two is comminuted. Yeah. And that's important because you will need to fix when you're fixing the bones, bits or the bone fragments that has to be taken account and, and also when, when you're when I said you could do when you refer a fracture to an orthopedic surgeon, there are other ways you can describe a fracture. Can you think of things? There are other ways? So one is open closed, one is comminuted or non comminuted. What else? What other ways you can describe? And that's basically depending on your radiological findings, you can't tell clinically any thoughts. Thank you for your contribution. Open close. Yes. Spiral. OK. So the nature of displacement is it, is it your compound? We said uh so displacement is it displaced? Is it not displaced? And, and the nature? So is it transverse? Is it spiral? Now, a spiral fracture has got an implication. So a tibial spiral fracture in a child is you got to think of non accidental injury. A spiral fracture of a finger phalanx can be associated with lack with rotational problems. So they are important. OK. The other thing to notice is angulation. Is it angulated or is it not angulated? Because if it is then IMA imagine the tip, the apex of the angulation can poke through the skin or, or cause pressure to the skin? And that's a feature of ischemia that can cause ischemia? OK. Or it's not angulated. And also you've got to correct the angulation and bring the fracture into alignment. That's important. Yes, Suai says Greenstick fracture. Uh We'll come to that in a minute. OK. In fact, the next point is related to Greenstick have you heard of Salter Harris classification? Salter Harris classification is a way to describe pediatric fractures fractures that happen in Children. Do you know why? Because to do with the um you know the growth plate, the epiphyses? Ok. Fatima says intraarticular says green stick. Now there is a, a way to classify it and, and there are five such classifications. Yeah, from Salta Harris type one to type two I II don't want you to let me know because it will take time. Uh I'll show you a picture and then we'll go through that in a minute. Yeah. So when you're describing a pediatric fracture, rather than saying, oh, you, you, you still got to say open closed, comminuted. Yes. But Salta Harris uh way to classify. OK. So this is the picture. OK? And, and these are the five types. So Salta Harris one. So if you imagine the bone is divided into uh the epiphyses, you can see the growth plate below the epiphyses is called the uh you know, diaphyses and metaphyses. Yeah, proximal and distal. Uh and and if there is no fracture but only a slip of epiphyses is type one, OK. There's no fracture, the moment you have fracture, then it's either a 23 or a four. Yeah. Now two. So two is when there's a fracture through the uh metaphyses above the proximal to the growth plate. And type three is when there's a fracture in the epiphyses. So, distal to the growth plate and when both a metaphysis and epiphys is involved, that's type four. Now, the importance is the higher the grade, the worse the prognosis in terms of recovery and type five is the worst of it of prognosis because it's a crushed fracture when the epiphysis is crushed. Yeah. So that's important to know. I thought we would mention that now. So if it's, if it's a limb or life threatening fracture or part of a major trauma, II II, you know, I don't have to say you've got to start your initial assessment as primary survey, I won't dwell on the, on, on most of the things because we don't have time. You've got to sort the airway, you got to give oxygen because you need oxygen to uh you know, through the blood, you've got to assess the breathing to see if there's any chest injury. Now, the important bit to the aspect that you stress on is c circulation. Now, I should have said C ABCD because if there's catastrophic hemorrhage in a limb, upper limb, how can you stop the bleeding? Any thoughts because you've got to do that to save the life of the patient. Any, any idea how you can do that and this, this happens, we do that in Ed, it happens on the battlefield by the army surgeons. Yeah. Any, any thoughts what you can do to stop the hemorrhage. This is just temporary. You're trying to save the limb and the life. Tourniquet. Fatima says excellent. Yes. Now, I haven't got a tourniquet picture. Tonique. Yes. A pelvic binder for pelvic fracture. Suspected splints as well. But don't forget a pressure bandage is important. Now, a pressure bandage is not slapping some dressing and wrapping it up. This is, uh, lots of gauzes into the limb, put as much as you want. Wrap it up and pressure. But that limb is may not be salvageable. So that limb needs exploring as soon as possible. But you've got to do that. Breathing control and lift it up. Upper limb, lift it up. So elevation and pressure bandage or tourniquet. Um So that's the sea before the ABC. When you come to the sea, the circulation, what are the considerations in circulation in a limb fracture? That's uh limbo life threating of major trauma. What sort of things you going to consider in? See pulses? Yeah. So look at heart rate. Is it tachycardic? Look at BP, is it there's a drop in circulation? Is the patient in circulatory shock or hemorrhagic shock if they are in shock? What do you do? You start shock therapy? Yeah. What does shock therapy mean to you? What does fluid resuscitation before you start fluid resuscitation? What do we do? You can't just start fluid, you need certain things to have in place. What do we do? We, we get some access? Yeah, intravenous access. You send bloods, you send group and cross match. Yeah. And if the, if the patient is really in hemorrhagic shock, you start the uh major hemorrhage protocol, you get the o negative blood because blood typing and cross cross matching takes time. So you send the bloods, you send routine bloods as well. You know, the full blood count, urea electrolytes, et cetera. Cross match is absolutely important. And I've got a figure for you if you come across a hemorrhagic shock and you're requesting blood, you as part of a major hemorrhage protocol, you'll get F FP as well and and was he says, and o negative blood, but if you're just requesting blood to the blood bank, think of 246. So ask for two negative O negative, it will be there now then it takes 10 minutes for time specific. So ask for four times specific and ask for six full crossman. By the time you get all these bloods, the full cross match takes about an hour will be ready. Yeah, 246. It's a good figure to remember. So you get the blood, you start IV fluids and doesn't matter, isotonic fluid but not massive. Remember we talk about hypotensive resuscitation. Yeah, uh slowly and uh balance resuscitation. So you're not giving loads and loads of fluid. What you need is blood. So small amount of iso isotonic electrolytes, uh you know, normal saline or uh plasmalyte or or or um Rous lactate and then blood of course. Yeah. And then once you've done that, then obviously d now in e you might have some considerations from the fracture point of view, limb fracture. What consideration can you think of? So you've sorted this hemorrhagic shock, you have managed it. Anything in e you might need to consider any thoughts. So this is when you're looking at the patient from top to toe plaster. Yes. OK. So you're looking at the limb now, isn't it? Is there a wound you've, if it's not massively bleeding, put a dressing. Ok. If it's compound, start the compound management, which we've talked about. Yeah, but the important bit to know is your neurovascular. Is there a neurovascular? And if there is a vascular uh impairment, uh you might have to do Doppler if, if it's a diff the other thing is, is deformity. Yeah. If the limb is deformed, then you have to have to have to, I can't overemphasize. You have to realign it, you have to reduce it, especially if the skin is at jeopardy. So if a fracture fragment is poking through your, through the skin, yeah, like that a skin is stretched over a fracture or pale, that skin is at jeopardy of ischemia, you've got to reduce it before X ray. We reduce fractures under sedation or analgesia in before x-ray and put a plaster slab. Ok. So you've got to reduce. Now, a classical one, but you might need to put splint on. Now splints can be custom made splints or even plaster back slab. So if your ankle is dislocated, then we reduce it and put a plaster back slab. If it's a fracture, neck or fracture shaft or femur, we put them on a Toma splint. If it's a wrist, then we put them on a plaster back slap. But you've got to reduce it. Yeah. And bring it into alignment. Any thoughts, the reason why you have to realign it and, and reduce it. What does it do to the fracture? What does it do to the limb? Any thoughts? What does reduction and putting it on a plane? Does something else and, and the ee we have to consider as well a big big need of the patient. The patient will be screaming for it. Any thoughts stop hemorrhage, pain. Yes, pain. So address the pain. They will be in pain. You've got to give analgesia. This is not paracetamol, this is not Ibuprofen. This is intravenous opiates given by titration. So you're not banging in 10 mgs of morphine. You're giving one mil a minute and checking the response. You might have to give nerve blocks in in fraction femur we give Yeah. Morphine was says in fracture, neo feur, we we use what's called fascial blocker. I'll deal with that when we come to the lower limb. But yes, IV analgesia or nerve blocks and then put them in a splint when you put them in a splint few things happen. Remember if a fracture is broke, the fragments are moving and when they're moving, they cause soft tissue damage. When they cause soft tissue damage, they cause bleeding and pain. So what the spleen does? It reverses all of that? It reduces the pain as well as analgesia it brings by bringing the fragments into alignment, it stops the soft tissue injury and stops bleeding. And so you're addressing a lot of things by bringing into alignment. So reduction is absolutely key. Yeah. So those are the considerations now, very quickly, I'll give you a system that I use and II teach others to use this as well. If you see a fracture on X ray, a hemostatic bandage, fine aga says you all have seen x-rays on, on uh fractures on x-rays and you all have a system. But this system a avoids uh you know, uh concentrating on one particular thing so that when you see an x-ray, this is an ap view of a knee x-ray, you will, you will realize and what you do is you first check the right patient. Yeah. Is that the right patient's x-ray? And it is very easy to cause mistake by looking at the wrong patient's x-ray, check the number, hospital number, date of birth name, et cetera. Is it the right x-ray? And is it the right date? It has happened with me that I've seen the right X ray of the right patient with the wrong date because they've had similar x-rays on another date. So, that's important. Yeah. Once you've done that then in a limb. Yeah. Follow the ABC. No, this is not airway breathing. These are different ABC S. So what is a, any thoughts? I, II won't wait long because time is passing. I got to go through some fractures. Any, anyone heard of this? So, a, is, is alignment. So, is the bone or the bone in alignment or they displaced? OK. And the there's a second day called adequacy. OK. Are they? So what can you see what you can see? Is it adequate or if it's inadequate, you see what you're seeing and then tell the radiographer to repeat another view. Now remember any fracture, any limb X ray, we do two views, ap view, lateral view and sometimes oblique view as well. Yeah. So make sure you have the views but each view, you look at it this way. So that's a what is bone B is bone? No surprise. And you look at each bone individually starting from the cortex. Yeah, starting from the cortex all along, come to the medulla, then the next cortex, medulla and looking for fractures, looking for breach of cortical irregularity and looking at the joint line as well. Yeah, as well. So that's BC is cartilage. Now, if you look at this knee X ray, you can see a joint space between the femur condyle and the tibial condyle is the joint space where the cartilages are, is that uniform symmetrical. That's what you're looking at. This is also used in spine X ray when I do it. Uh next time, uh this is is disc, but that doesn't apply to uh limbs. It applies to disc spaces in spine and this is soft tissues. Now, some X rays which I'll come through. When I show you another X ray, there are some soft tissue shadows that are indirect evidence of fractures. One example is, um, can you think of a soft tissue shadow that can indirectly indicate a fracture indoline, if you've seen it, otherwise we'll, we'll, we'll go through it in a minute. Have you heard of fat, fat sign? That's one soft tissue shadow that you have to look at when you look at an elbow X ray, we'll come to that in a minute. Ok. So you've seen the x-ray and now I think what we'll do is go through some, ok. So secondary assessment, but before you start managing the, the, you've got to uh talk to the patient, isn't it? So let's say this is an isolated limb injury, upper limb, you've got to take a history. Yeah. And what sort of things you will, will you be asking the event? What happened, the mechanism of injury? Yeah. What symptoms have they got? Have they got pain? Have they got um, you know, pain in the, have they got um any, any nerve symptoms pins and needles or anesthesia or weakness of muscle or have they got any vascular symptoms? Coldness, et cetera? Ok. And then uh you've got to ask, examine, uh as I said, you examine the, the limb uh the fracture site. Uh and then also looking for absolutely must neurovascular deficit. So, for neurovascular, what you do is you look for distal pulses, you look for cap refill and for neuro, you look for sensation and motor um involvement. Yeah. Once you've done that, then you consider the treatment, the treatment is depends on what the fracture is. So you've got to diagnose it through X ray and then you consider the treatment right here. We know. So I can't cover everything. You can ask me questions later on, but we'll go through some of the common fractures. I hope you're able to see this. I'll go in order the top left. Any idea what fracture? That is? No surprise sport diagnosis. Anyone fracture clavicle. Yeah. Was clavicle fracture. So fall on outstretched hand fall. A typical injury is falling off a bike. Yeah, and injuring the shoulder, they get pain. There's deformity clearly, you can see the deformity and the the proximal fragment poking through the skin. Um they have pain, give them analgesia do the X ray. But the treatment interestingly, even for this fracture is conservative in a broad arm sling. Now, the broad, what the broad arm sling does is by supporting the lower fragment. It tries to bring the fracture into alignment. Yeah. And you send them to the fracture clinic to be seen by the orthopedic surgeons. Ok. Yeah, ab says clavicula, uh the one the next to the clavicle fracture. What do you think that is for diagnosis? Any thoughts if you've seen it, it may not be clear. II hope you can shoulder dislocation says absolutely right. Anterior dislocation even better because this is the commonest shoulder dislocation. It's anterior. You can't say anterior from the AP view. But if you do a lateral view or an axial view, you can see it's anterior but this is inferior as well. Can you see that it's below the glenoid glenoid uh ca cavity, glenoid cavity. Uh again, common way is fall on the outstretched hand or fall uh or, or assault or fall from a height. This fract, this dislocation can be associated with fracture. The fracture could be of the glenoid can be of the of the of the greater tubercle. They need a manipulation to reduce it as soon as possible because to reduce the pain and get the function going, one nerve can be injured in this uh injury. Any idea what nerve it can be injured can be injured and you need to test for that. Ok. It's axillary nerve absolutely Conason and, and you got to test for sensation over the regimental area. OK. Now you got to do that. And yeah, regiment patch R says Fatima said lot of, of a deltoid. You've got to document that because it has happened that no one has uh documented it. And there was axillary nerve damage post reduction and the patient sued the patient complained. But if it was documented that there was already, then it would make a difference. So important is not just uh examining, not just looking for it but documenting. Ok. Now, I can't go to the details of reduction, usually done under sedation. But in this day and age in emergency departments, we do this by using a what used to be in the old days, an anesthetic drug called Penthrox, which is used as an analgesia. And we reduce this. So we don't have to do sedation because sedation means in resuscitation room with a lot of monitoring, et cetera and you give a lot of drugs. So we do it under penthrox. Yes, Jan says then one after that one after shoulder dislocation, um that is what is, what is that any again for diagnosis, quite commonly seen in older people with a fall um surgical neck of humerous fracture. So this is this is the surgical neck just below the greater, just below the greater tuberosity. And they, they it's not dislocated because it's aligned, the fracture is aligned to the head is aligned to the glenoid cavity. And again, these are managed conservatively and the theoretically practically it doesn't matter what sling you use. There are two types of slings for upper limb as you know, broad arm sling and collar and cuff. But for this one, a collar and cuff is good because it allows the elbow to, to sag bringing the distal fragment into alignment. Uh Again, you refer to fracture clinic, make sure you give analgesia, analgesia has to be considered. If you don't, you are not compassionate, you are not courteous. Ok. Right. One the top, right. Um Any thoughts what that is upper limb injury again, quite commonly seen in ed typically fall on a extended elbow. It's uh sport diagnosis. Again, anyone elbow dislocation. Ok. So this is dislocated elbow commonly posterior. As you can see, the olecranon has moved posterior giant is an, it's not anterior, it's posterior Giana because it's the the oon is moved posteriorly, they are reduced again in e by from the flexion to extension of the of the arm of the elbow and pushing the fragment. So if you think, if you think if you think simply what happens with dislocation is the bone has come out of the joint and what you have to do is replace the bone back in the joint. So think as to what has happened and just reverse the, that's what the technique is. So you just reverse. So soy is only not dislocated. Absolutely right. So that is reduction. And I'm in a sling fracture clinic again. Now some people put them in a po a back. Uh you know, in a, in a, in a back slab as well. The middle one, the left middle one is what this is. Upper limb humerus is, is not surprised. It's a shaft of humerus fracture. As you can see, quite displaced. Now, middle shaft fracture risks a nerve injury because if you remember your anatomy days, you remember the uh humerus, there's a ridge on the posterior aspect and the nerve runs around it. What's the nerve and what nerve injury can you expect? And you go to go looking for it. Yeah, radial nerve GTA. Absolutely. So if it's radial nerve, what you go to look for has the patient got a wrist drop. Fatima says brilliant. Um Now this this fracture, um we would refer to orthopedics. It's up to the orthopedics, whether they treat conservatively or they want to fix it. Ok. You got to look for vascular damage as well. Ok. The middle, the middle, middle one. Well, it's two together. Uh what can you see? That's a quite a nasty fracture. You can see humerus, you can see the lower part of the humerus as part of the elbow. This is supracondylar fracture, com commonly seen in, in kidney falling or fall on the, on the arm and the elbow, but also seen in adults that fracture will need fixation will need. So all we will do is analgesia, a temporary back slab or a sling and the patient will go to theater from the orthopedics uh uh by it, it can go straight from Ed to theaters. OK. Right next one again, top left, this fracture has got a name. Uh it's, you can see the, the, the fracture is in the shaft of radius and there is some dislocation or subluxation of the radioulnar joint inferior. OK. And, and there's a reverse type of fracture which has got another name. Uh and this, this, this fracture will need analgesia, temporary splinting. Giai says absolutely. This fracture will need analgesia, temporary splintage and theater. OK? For fixing. And if you can see this one, the middle top, middle one, you can see a shaft or fracture of the ulnar. So it's in the radius is ulnar and it is a superior radioulnar joint dislocation or subluxation. OK. So what name is that? Jana says Montagu? Absolutely right. So Montagu fracture and, and you can see the deformity of the limb. Yeah, we call it banana limb sometimes and again, strong analgesia temporary splintage. Sometimes the patient says just leave me alone, leave the arms supported, just on a pillow. Don't need to put nothing until they go to theater. But that's important. OK. The top right uh is uh is I don't know whether you can see it. It's, it's not, it's a common fracture. Uh It's one of a, it, it's, it's, it's a very, very minor fracture, but it's an interarticular fracture. Can you see this? It's a radial head fracture. Yeah, radial head fracture, John that says spot diagnosis is well done. Um and radial head fracture. If the radial head is not dislocated or completely knocked off from the neck cause radius has a head and neck and it's in the art. The the only problem is is intra intraarticular. So intraarticular fractures tend to be unstable. So, orthopedics might need to get involved. Ok. Uh bottom left. Um You can see now this is the one what I was talking about. I don't know whether you can see it well or you can see the arrows. These are fat pad signs. Yeah. Now fat pat sign is an indicative of what any idea when we say fat pad is. Yeah, oppo fat pad you can see. But what does fat pad indicate? What's the inference effusion? So there is effusion, it's and if it's trauma, it's blood says, yeah. So what happens is anteriorly there's a fat pad. Normally, what you're looking for is, is the fat pad elevated and you can see it's lifted up from the anterior border of the humerus. And if it's elevated, it looks like a sail sign or a bat swing, remember bat bat swing sign. But if you see a posterior fat pad, like you see here, which is a, a soft tissue shadow, fat, uh radiolucent shadow against the posterior border of the humerus, that is pathological. Now, when you see that fat pad sign, you go looking very close. If you're a, you know, you might have to speak to your seniors to find the fracture as best as you can. Sometimes you would like to treat it. You would like to treat it as if there is a fracture and bring them to fracture clinic. Ok. The effusion doesn't need anything doing. You don't need to stick a needle and take the effusion out. You don't, they will get resolved but you might need orthopedic input. Ok. Now, the one in the middle, very common, the weather in UK is coming to such that a lot of elderly people will have that and sometimes on each day, we can have 20 such fractures in the department. Collis fracture. Alex says wonderful. Now it's easy to say so. So I'm going to ask you a question. What's the difference between collis fracture and a lower radius fracture are all radius, low radius fracture, colli fracture, but all collies fracture are low radius fracture but not all low radius are col fracture. To, to say collis, you've got to have certain things in place and, and they are here in this picture. So any points I I'm going to add on, I'm going to say I I'm not going to wait because time is running out. So, so one is the the classical definition is, is, is named after. Yeah. So that's the dinner fork deformity. You can see the picture. Yeah. If you imagine the dinner fork, the fork, the hump is is the dinner and these are the fork blades. Yeah. The deformity, typical deformity of col structure is dinner fork and and and uh so there is a posterior displacement Karen says, yeah. Now to look at posterior displacement, you can see the lateral view. The the the the left of the the three views is the lateral view and the thumb is is ventrally and above the thumb is is dorsal or posterior. And you can see the fragment here. So there will be posterior dislocation, uh dis displacement, there will be impaction. So it means the fracture will impact against each other and reduce in result in shortening of the limb. Also there will be radial displacement. The importance of knowing this is that when you're reducing because this colleague needs reduction. Yeah. And we do it either with panx or with uh hematoma block inside the fracture site. You do the reverse. So the mechanism that causes this fracture is what forced dorsiflexion, yeah, forced dorsiflexion. And what you do is you do ventral flexion, you do ulnar deviation and you do disimpaction and then you do a chest X ray. Remember every single reduction needs a chest X ray do not, you need. So before reduction, you need an X ray. Before after reduction, you need an X ray as evidence. It's medical legally. So that's colli also the median nerve can be injured. So you've got to be careful of that. Yeah. Uh and I'm coming to the end, I think. Now top left spot diagnosis, anyone can see it. There's an arrow pointing towards something scaphoid fracture. Fatima says, ok. Now the, the carpal bones you need to be aware what they are. OK? Because each one can be broken and they range as you know in two rows, approximal row four bones, a distal row four bones. So there is a pneumonic uh which I've got II I'll tell you which I use. So the the bones from radial to medial uh to ulnar is lunate. Then there's a triquetral and pisci foam bone. And the, the distal row is uh trapezium trapezoid. The biggest bone is the capitate and there's a hamate bone called the hook of Hamid. So the, the, the, the morning she looks too pretty, try to catch her. But that's uh uh you know, I don't, I don't want to use this anymore. It, it, it sounds sexy. So ignore that. But remember those two rows of bones, scaphoid is the commonest fracture bone that gets broken. The important bit of a scaphoid is that there are risk of a vascular necrosis. So if you got a fracture, the commonest place is the waste of the scaphoid and then you got a cubicle, OK? And even if you don't, so, so the way you diagnose a scaphoid fracture clinically is by looking for tenderness in the anatomical snuffbox. So II don't know whether I can show you anatomical snuffbox is just below the thumb and the scaphoid tubercle compression and the thumb compression test. You do a scaphoid view. So it's not just a simple ap view and a lateral view of the wrist. You need special scaphoid views. If you can't see a fracture, you're still treated as if the patient has got a fracture because to avoid a vascular necrosis and the fracture can be diagnosed 10 days later. So you put them on a splint and bring them back to Fracture Clinic for re X ray or MRI scan. If you see a fracture, you need to treat them in a cast. Yeah, you can get fracture of the triquetrum, you can get fracture of the, of the, of the capitate. Um The one in the middle, I think um Abdullah already has said this is called the, the, the colloquial name is Boxer fracture because that's how it happens. People box either they, they, they get it during boxing or out of frustration or anger. They punch a wall. Um Now, sometimes they can punch a window and you can have glass injury as well. So this is fractured through the neck. Uh So all these long bones have a head and a neck and a shaft and a base. So it's fractured through the neck of the fifth metacarpal. You can see there's an angulation. Yeah. Now, uh normally it doesn't need a anything, any intervention unless the angulation is too big more than 20 degrees. But what you do is you treat them with a a ulnar back slab, ulnar back slab and then you adjacently strap the fingers together and bring them to Fracture Clinic. Yeah, for re X ray. Now, the one at the top, right, as you can see, these are metacarpal bones and they're oblique fractures to the shaft, quite a multiple fractures, usually from a uh you know, uh a direct trauma on the hand or a fall or an assault. Um They need intervention. Uh Now, oblique fractures of the metacarpal or phalange can cause what's called rotation. If you see the the the bottom left fing uh picture the way you find rotation is you ask the patient to make a snake's hood. Can you see a snake's hood? Yeah. And if there is a rotation of a finger, then the finger, they all point towards the same. Yeah. But if it's a rotation, the finger will either go point down or up. Yeah. Now that means there's instability that fracture needs in, you know, fixation. OK? I don't know whether you can see a fracture in this, in this, but you can see a fracture on the base of the, that's another common one fracture to the base of the uh middle phalanx. Can you see that usually caused by hyperextension injury of the finger due to you know, the ball coming and hitting the hand, football, cricket ball, whatever uh all they need is uh if they're not unstable. Uh there's no other so uh soft ish injuries, neurovascular injuries, they need conservative. The conservative treatment is adjacent. Strapping. Yeah. And then re X ray. Ok. Sorry, I have, I've got a few more. Now, top left, there's a deformity of this finger who will tell me what deformity it is quite common. Anyone mallet finger fat musa is excellent. And can, can you see this is the typical, the the finger is bent at the D IP joint, distal interphalangeal joint. It can be associated with a fracture which you can see in the middle picture. Can you see the uh the avulsion fragment or there may not be a fracture but just the extensor tendon, extensor tendon which attaches to this, to this uh distal phalanx base can be torn. Ok. Now what happens usually is due to uh hyperflexion injury, the tendon snaps and it pulls a fragment of the base of the distal pharynx. And all you need is provided there's no neurovascular deficit. You put them in a mallet splint which keeps the finger straight and then you keep it for about 14 days, the fracture and the and now if, if the fracture is as big as that, that might need fixing. But if it's not a, if the fracture is the small or only tendon injury suspected, you can treat it. Mala spleen. Yeah, the one on the top, right. Um So top right is what? Any thoughts? It's, it's quite obvious, isn't it? The finger is deformed. Why is it deformed? What has happened? Um This is trauma abi so I'm not going to touch on rheumatoid arthritis. This is trauma. What do you think has happened? This is acute swan neck deformity, pip joint. So there is now swan neck deformity is usually a chronic thing, but this is pip joint dislocation you right joint from trauma and if you see this finger, you give analgesia. Now any thought on what kind of analgesia we can give to be more effective. You can give oral, you can give IV, you can give but what a good analgesia will be very specific to this finger. Any thoughts and we do that, we use that we give digital block giant is absolutely spot on. So you give lidocaine plain, remember no adrenaline at the base of this finger here to uh ventral and dorsally and then on either side, ventral and dorsally, it's also called ring block, but it's not like a ring, it's a digital block, the finger goes numb but check neurovascular deficit. Before you give the block document, it, send the patient for X ray confirm it's dislocated. You can see on the top left, bottom left. And then what would you do? You need reduction. This is such a satisfying procedure because all you do is somebody holding the proximal balance for you stabilizing the finger and you pull the finger create the space and push it ventrally and the finger snaps back into position and the nurse is ready there to put adjacent strapping and you send them for X ray. One of the satisfying procedures we do in. OK. So that's, I think that brings us to the end. I II, I'm sorry, I can't cover all the fractures, but I've tried to cover common ones. I've given you a classification. Remember, Salter Harris and some common presentations and X ray findings and management. From the ed perspective. Not from the orthopedic of upper limb fractures. Hope you find those that was useful. I'm happy to take questions. Thank you so much for your attention. Thank you for your participation and that's so important and that i it's really enjoyable and great knowledge. All of you. Brilliant. Thank you, Vim. Thank you, Fatima. Thank you. Uh Lilian says, is it also called triggering? Um No trigger finger, Lilian is a different injury. It happens when the flexor tendon. Uh If you imagine there are two flexor tendon, the flexor tendon from the sheath gets snapped. Uh Then you get a trigger finger. Um It's, it's different. Um R says any further question? Um Yeah. Any other questions, Abdullah, thank you. Please provide feedback. Absolutely. Chantha. Thank you. Thank you for your participation. Apply what I've told you, you know, these are very practical and I use it and I wouldn't say anything that I don't do myself. So please Lilian asks what will be the management uh management of what Lilian management of anything in particular? Uh Yeah. No, thank you of a trigger finger. So, trigger finger, if it's acute, we uh you know, it doesn't cause so much of pain. So we refer to the orthopedic surgeons. It needs a repair of the tendon to correct the trigger finger. Uh There's nothing acute to be done in Ed. Thank you. Hope that answers your question. We'll just wait for maybe a minute or two just to see if there's any more questions. Um But if not, I'll take us off live. Thank you. Ok. Thanks, Lili. Hope to see some of you uh in my next door. Thank you. Ok, I think there's no more further questions. So I think we'll um leave it there. Um just for the people who are remaining, don't forget to follow medical education. So you get notified of more educational initiatives such as this one, but also other talks. In fact, there's an ophthalmology talk happening tomorrow and there's lots of other educational talks that you can look at in the schedule. So please do follow me education and take a look. Thanks so much, everyone. I'm gonna take some time.