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Hello, everyone. Welcome to our sixth lecture of the Fy Survive Guide series. Today with us is Sanji who is a core surgical trainee in the East Midlands and he'll be talking you through orthopedic radiology over to you, Sanji. Thanks Lucas. Um So this is our, well, we're almost towards the end of our Fy Survival Guide, NS uh NST SS got a couple of sessions left next week. Um But as Lucas said, this week is our second radiology lecture on um orthopedic radiology. Just a bit of background about myself. I'm uh or I should say CT two in plastic surgery. Currently, um I'm based at the Le Royal Infirmary in the Midlands. Um I've got two years of split between orthopedics and plastics. My goal long term is to um apply for plastics training. Um I studied in Birmingham Kings uh where I inte in anatomy and did foundation training in London. And then now I'm uh uh TNO, the plastic surgery and plastic surgery themed um core trainee. So the learning objectives for this week um learn about the role radiology plays in the orthopedic MDT, understand the indicated radiographs and pathology associated with the common orthopedic conditions become familiar with radiographic techniques and how to interpret CT and MRI images as a foundation trainee. Um You won't have to interpret CTS and MRI S as much as other images, particularly x-rays. So I'm gonna briefly gonna be touching on these um but not in so much detail because that's not as relevant for you guys, develop an understanding of appropriate management of radiological findings in TNO cases and I'll go through um a few cases. Um and I'll have some polls to help keep it interactive for you guys and then identify potential risks and complications of radiological examinations. If you have any questions, I will check the chat intermittently. Um So feel free to pop the questions in there or feel free to ask at the end as well. So this slide summarizes the investigations that we do commonly in in um orthopedics. Obviously, the most common investigation is x-rays. Basically, every patient who comes in with any kind of orthopedic related injury comes to A&E and has an x-ray. Um A level up is CT scans which can provide more detailed information. Um And the level up on that is MRI scans. Ultrasounds are useful for soft tissue imaging. And then there's other types of investigations like Dexa scans which um can help determine bone density and help uh guide and treat osteoporosis management and scans like uh bone scint toy, um which can be used for diagnosing and treating cancers. The focus of this talk will be on x-ray imaging is that's what vast majority of the scans that we look at will be uh x-rays. So just to start, how do we interpret x-rays? Um some of you may have gone through this through medical school, but it's also important to have this in the back of your mind when looking at patients x-rays. Um also in orthopedics, often, uh for those of you that would have orthopedic jobs or have already worked orthopedic jobs, you'll know about the trauma meeting in the mornings where patients that have been reviewed um and admitted or uh reviewed in A&E will be discussed and consultants will often ask you to discuss their x-rays. So it's important to have a system for this. So first you discuss the patient details and name date of birth hospital number and confirm uh the details of the x-ray when it was taken. What area of the body is it an x-ray of the hand or the tibia left or right side? It's then useful to assess the adequacy of the views. So for x-rays, it's important to have uh two views, usually a P and lateral um to help clarify uh any bony injury or or foreign bodies, then I have a structure of going through looking at bones. So assessing the shape the density of the bones um and then looking particularly if there's a fracture after looking at the bones that look through the soft tissues. So is there a swelling which often you can see on x-rays. Is there a foreign body present? So radiopaque foreign bodies such as metal will show will show up. Is there a joint effusion? Again? Sometimes you can see that on an x-ray and often um we can see lacerations or cuts in soft tissues on x-rays as well. After going through bone and soft tissue, I then go through joint. I look at the joint space. Is there an adequate space? Is it narrowed? Is that other signs of osteoarthritis? Um Similarly shape and erosions can indicate um arthritic changes of the joint. So this x-ray this sorry, this photograph shows why it's important to have two views. So that that's the Prince William swearing at the paparazzi, but actually he's not actually swearing. Um So that just highlights the importance of why we you always need to check two views. Uh When looking at x-ray images. Next slide show is about different types of fractures. Um So it's important when describing a fracture to describe what is a type of fracture. Um So is it a transverse fracture? Is it a linear fracture, oblique, nondisplaced or oblique displaced where the two bone ends are not in contact? You can also get partially displaced fractures where the bone ends are partially in contact, spiral fractures which spiral down the shaft, greenstick fractures which are more common in orth uh sorry pediatric patients. These are un un cortic unicortical fractures involving only one of the uh cortices and then comminuted fractures which are the most difficult to manage. Um They're essentially fractures which are smashed, smashed bone buttons. So again, to describe fractures, in particular, it's important to say which bone is it, is it the humerus, the femur? And again, we classify bones um usually into three sections, proximal middle or distal. And is it intra or extraarticular? This is important because usually extra arti sorry, intra-articular fractures are more difficult to manage. They're more likely in general to require surgical management. Um because a it's important to get proper alignment of the articular surface. Otherwise that will increase the risk of posttraumatic arthritis down the line is a fracture uh open or closed. Again, this is really important because it time it management open fractures will um always need surgical management um for washout as there's higher risk of infection and particularly Osteomyelitis. And then is there displacement? So usually we describe displacement in terms of the distal fragment compared to the body. So now I'm just going through some cases um and I'll put some poles up in a, in a few moments. So hopefully they will work for you. So our first case is a 90 year old lady um who had a fall at home whilst mobilizing to our bathroom on examination in A&E um she has a shortened extern I rotated right leg. So based on this clinical information, what do you think the diagnosis would be? So I should have started the pole. Hopefully, you guys can see that some responses coming through. I'll wait a few more moments. So, based on the clinical confirmation of a 90 year old falling at home, um and having a shortened and externally rotated right leg, what do we think the diagnosis is? Do you have a few more moments? Ok. So the onset answer is a right neck or femur fracture. As you can see from the x-ray uh fracture through the right neck of femur or right hip fracture. So, hip fractures are the m one of the most common orthopedic injuries. Um They're very common in elderly patients. Typically elderly female patients because females have high risk of um osteoporosis uh when they're postmenopausal, which means essentially reduced bone density and weaker bones. Um So, on a typical night shift, I may see anywhere between two to around 56 neck of femur fractures. Um and management of neck or femur fractures are almost always surgical. You almost always need surgery. Um Otherwise patients will, will be bedbound for weeks if not months. It's important to classify neck of femur fractures, um which we can do using x-rays. And that's because different um fracture patterns have different operations to, to fix them. Two broad classifications are intra and extra a uh capsular fractures, intra cups of fractures. Um are those proximal to the intertrochanteric line. So this is a, a image from teach me anatomy. Um very good website for anatomy and you can see the head of the femur, um the neck of the femur, great trochanter, lesser trochanter intro line. So, fractures which are proximal to the intro line are intracapsular. Um These include subcapital which are fractured just below the head, trans Cervi which are fractures through the neck and ba cercle which are through the base of the neck. These fractures are high risk of uh avascular necrosis because the blood supply to the head of the femur um is quite poor and a lot of it relies on blood vessels in the capsule. So the capsule is disrupted, often the blood supply is disrupted and therefore that affects the surgical management. Extra capsular fractures. Um Two large classifications are intertrochanteric in the along the intertrochanteric line or subtrochanteric garden classification is a very common classification for um intraarticular fractures. And there's four types. Type one is um a partial fracture which is nondisplaced. Type two is a complete fracture which is intra-articular but nondisplaced. Type three is a complete fracture which is partially displaced. So you can see the two bone ends um are partially in contact or type four, which is the worst type and that is a complete fracture. So, across both cortices and is completely displaced, the bone ends are not in contact at all. And again, this can help guide surgical management. So for example, a type four garden clo uh intra capsular fracture is more likely to have avascular necrosis of the head of the femur and therefore an operation such as a hemiarthroplasty to completely replace the head and replace it with a uh prosthetic femoral head will be more likely to be appropriate. So, another pole, what type of fracture is this in the photo? Does our patient have some responses coming in? Good sir. Most people have put subcapital um which is correct. Um Some of you put transcervical, which it possibly could be trans vial. It's a bit difficult to differentiate on this x-ray. Um CT would be more sensitive to, to, to finding that um a few of you put in intertrochanteric and subtrochanteric. Um but this is, this is a subcapital fracture. It's an intraarticular fracture, sorry intra capsular fracture. Good. We'll move on. So it may seem obvious certainly in when you read in textbooks and go to lectures like this, often, it, the cases are quite obvious when there's a neck of femur fracture. But in reality, I've seen many patients who have had maybe had a fall a few weeks ago, then they mobilize and they've come in with hip pain. Um And then you have to work out. Is there a fracture there? Um And it's often not clear cut and x-rays again are not the best uh investigation. Often they don't look like oops like this where it's a very clear and obvious fracture. So one way of determining if there is a fracture is to look at what's called sheen's lines. So on the um left side of the image, you can see the green line where the sen's line is smooth and it's continuous. On the right hand side, the red line is uh not continuous and is altered, which means that there is, it is that's a sign that there is a fracture uh of the neck of the right femur on this x-ray also for patients. Um We often consider further imaging if the x-rays are not clear, for example, CT would be the next line or MRI um can give a better clarification if a fracture is present. Next case. Um An 18 year old gentleman had a fallen outstretched hand to fos fallen outstretched hand off his electric scooter and he's complaining of pain in his right wrist. And this is his um pain from radiograph A P in lateral views. So, what is the eponymous name for this fracture pattern? Can I start the PT, I'll give you guys a few minutes onset, give it a few more moments. So most of you have put a Colles fracture, which is the correct answer. Um As you can see the fracture of the distal radius. So this is the ulnar and this is the radius and the distal radius is a fracture and the fragment is dorsally displaced. You can see on the lateral view and also from the, the photograph is what's called a diner fork deformity of the wrist. Um And that's classical for a Colles fracture, boxer fracture, the fifth metacarpal fracture. Um So a fracture in the hand or the fifth metacarpal pots fracture, the type of ankle fracture. Hangman's fracture is a fracture um of the cervical spine and the forth fracture is a um facial bone fracture. So college fracture is the right answer which we got that. So dis a fractures can come in a variety of patterns. Um Again, it's important to know the pattern because this can affect surgical management as well. So, collis fracture is the most common. As I mentioned, this is a dorsally displaced fracture uh of the distal radius and it's extraarticular smith fracture um is similar to collie, it's extraarticular in that regard, but it's vally displaced. So it's sort of thought as the opposite of collis because it's vol displaced far than dorsally displaced. A Barton's fracture is an intraarticular fracture of the distal radius. So these fractures are a bit more difficult to manage. Um and a higher risk of post-traumatic osteoarthritis, chauffer fractures, the radial styloid fracture and then finally, diap punch fractures are fractures of the lunate fossa of the distal radius. So another question, what type of fracture based on what I've just told you, what type of fracture is this? Wait a few more moments, still a few more of you to respond. Trickier question, I think. Ok. So all of you are right in that, none of you have said it's a coli fracture. Um around half, just over half of you said it's a Smith fracture. And that would be the correct answer. Um Because as you can see, it's from the lateral view, it's distal radius fracture and the fragment is verly displaced. Some of you put Barton's fracture, but that's an intraarticular fracture. If you look at the articular surface, it looks quite smooth and regular. Um I think one or two of you put chauffer fracture, but the radial styloid is, is OK. Actually, the ulnar styloid, you can see that has a little fragment off the end of that. So actually, there is an ulnar styloid fracture as well, but the right answer is a Smith fracture because of the distal radius fracture, extraarticular and verly displaced. It's the opposite of a fracture. Last question on wrists fractures. Um What is the name of this fracture? Just put the pull up still awa from a few more responses? OK. So a tricky one. this is actually a Shaffer's fracture. So this is the radial styloid. I don't know if you can see my concept but there, there's a fracture through the radial styloid. Um So was it a Chauffer fracture? Some of you have quite a few of you put Barton's fracture and I can see why um the x-ray does look like it may be going to the articular surface. So really you need ac t image to clarify if, if it does or if it doesn't, it's difficult to say from this x-ray. But certainly it is a, you can 100% say it's a fracture of the uh radial styloid. And the name out of interest, the name Schaffer's fracture um came from the old first cause. Um when the chauffeur had to wind the car motor and the kind of the wrench that they wind the motor up with would often kick back and that would hit and land on the um radio styloid and cause this kind of fracture pattern. So that's why it's called a chauffer s fracture cause they're more common in, in chauffeurs when they were driving the older cars. So distal radius fractures um are again, really common fractures on an onco shift. I will, I sometimes have to manipulate four or five each day. Um Generally, if they're in a good position, particularly if the articular surface is in a good position, um then they can be managed conservatively. So hand uh initially in a back slab and then convert to a full cast and patient put in plaster for around six weeks. The reason we put patients in a back slab first and back slab, I mean that it's essentially half a cost is because over the first week or so, there will be an element of swelling. And if you put a full cast on a patient, when they're gonna get swelling, there's a risk of compartment syndrome, which obviously you want to avoid cause that's an emergency. So that's a bit about management of distal radius fractures given the mechanism of injury for our patient. Um the fall and outstretched hand off an electric scooter. What other fracture would you be considering? Good? So vast majority of you have put scaphoid fracture, that would be the right answer. Um So scaphoid fractures and distal radius fractures are two of the most common fractures from a fouche, a fall and outstretched hand. Um scaphoid fractures are difficult to diagnose on x-rays. But really they, if you have a clinical suspicion of a scaphoid fracture, then they should be treated as a scaphoid um in the acute setting such as if they have pain in the anatomical snuffbox, the pain on palpation, pain on um a compression of the thumbs, pressing the thumb down like that if they're tender, um that can be thought of as a uh scaphoid or high suspicion of a scaphoid fracture. Patient should be placed in a, a splint and then referred to fracture clinic um in 1 to 2 weeks time where they'd be reexamined and have a sca forward view x-ray, which is a particular type of x-ray and often they'll need CT imaging because scaphoid fractures are quite difficult to see um on, on x-rays. The other type of fracture, which common are common in fall and outstretched hands are humerus fractures, humeru shaft fractures and also clavicular clavicular fractures. If you think about the forces traveling through, if you fall on an outstretched hand, usually a force goes through the scaphoid, through the radius, through the humerus and through the clavicle. So if you have a patient with a fouche, think of those and examine those bones uh for tenderness, next case, 13 year old, um gymnast, she develops sudden onset pain in her left shoulder and on examination, she's refusing to be examined because she's in a lot of pain, she's crying. Um She's not letting you touch her. This is the x-ray which you managed to take. What do we think the diagnosis is again, a bit of a tricky one? But what, what do you think this is good? So, so spread of s um aro clavicular joint dislocation, ac joint dislocation. Um 13% of you have said that the ac joint looks actually, ok. Um ac joint dislocations are, are pretty rare and usually they're high impact injuries. Um So that's not the right answer. About half of you have put anterior glenohumeral dislocation, which that is the correct answer. You can see that the humeral head is not quite in line with the uh glenoid fossa, it's subtle, but that, that is the correct answer. Anterior glenohumeral dislocation or anterior shoulder dislocation. Some of you put posterior dislocation. Um you can see from the radiograph, it looks more anterior um but also posterior dislocation is much rarer. Um typically uh these would only really occur in patients that had seizures um or direct blow to the anterior shoulder. I get off in a, in a sort of road traffic accident setting. Um anterior and humor dislocation accounts for, I think over 70 or 80% of, of dislocations. Some of you put about 10% of you put clavicle fracture. But if you look at the cortices of the clavicle, both sides look intact, they're smooth. There's no disruption to the cortices that the there's no clavicle fracture. And I want to do is put a scapular fracture, um difficult to say from this view, but from what you can see of the clav of the scapula, it looks the courses look intact. So again, there's no clav sca uh sorry scapular fracture. Also, scapular fractures are, are very difficult uh to cause again, they're very high impact injuries. Um Usually patients with a scapular fracture will have often many other fractures, often rib fractures. Um humeral fractures, generally, they're patients who have uh road traffic accidents or high impact injuries. So yeah, this is an x-ray of an anterior shoulder dislocation. So to manage anterior or shoulder dislocations, um we usually reduce these in A&E um often patients need to be sedated because they're in a lot of pain. Um Going back to the examination where she was in a lot of pain, refusing to allow examination. That's that's classical. Patients often need loss of morphine. Often use when if you're an orthopedics and you're call down to see a patient with a dislocation, they'll already be in recess. Um, and often they need sedation to allow for reduction. Um, on examination, you may see that the, um, head of the humerus is, you can feel it or you can see it and then the shoulder joint, the shoulder contour is distorted, it's square rather than round. Um, so these are usually quite difficult to miss and they often patients would not allow you to actively or passively move their shoulder. Um They'd be in far too much pain. So we've dis we've relocated this patient's fracture. Um But you've read through her A&E notes and you've seen that she's had four previous dislocations. Um and this is her fifth dislocation. What further investigation would you would you consider? Mhm. Ok. Good. Um So a few of you have said CT or ultrasound, most of you have said M Ria, few of you have put Dexa scan. Um The correct answer is MRI. MRI scans are really good at determining soft tissues and soft tissue injuries. Um They're very sensitive CT scans are less good for determining soft tissue injuries. Um CT S are better for clarifying fracture patterns with this patient. Um We'd be suspicious of a soft tissue injury which I'll go through in a second. Um So that's why MRI is useful. Ultrasound could be useful. Um Generally, MRI is a better investigation. It's more sensitive ultrasounds often rely on the um person, the radiographer doing the ultrasound. Um and they're not as useful when considering operative management. And for a few of you put Dexa scan, Dexa scan, you would consider um if you want to assess bone density, if you think your patient has osteoporosis. So if a patient has uh fragility fractures, for example, a distal radius fracture or neck or femur fracture, then you consider doing a dexa scan to see if they should be started on bisphosphonates. Um But so this wouldn't be appropriate in this this case, but MRI would be the most appropriate here. So this is an an MRI of the shoulder. Uh on the left hand side, you can see the humeral head which is the kind of the blackest um part of the photo. And then the white part of the photo around shows the glenoid labrum. The labrum is um a soft cart las structure uh in the glenoid fossa um which helps to deepen the fossa and in increase the surface area. And the shoulder joint, you probably remember from med school is one of the most unstable joints. Um Well, sorry, the most unstable joint in the body because it allows the widest range of movement. It's a ball and socket and allows huge range of movement. Um But that means it's prone to dislocations as we as we found out there are ligaments that hold the shoulder in place. And these can become injured um in dislocations. Um but also the labrum can tear. So the MRI shows an anterior labral tear and a posterior labral tear. And that can uh result or sorry be as a result of recurrent dislocations and also predisposed to further dislocations. So often patients with um one dislocation will have then developed multiple dislocations. Um and then they may require surgery depending on their age, their activities. So for example, if this is a patient of a gymnast, then she would most likely want to have surgery to uh correct this. And usually the surgery is done arthroscopically, it's a keyhole um to repair any labral tears or any soft tissue injuries. An MRI is very useful investigation to have um before surgery. So I think we're coming up to a second to last case. Um This is a 17 year old who was playing football and was tackled from the side. Um He's come to A&E because he's struggling to weight bear and he's complaining of pain in his left ankle and this is his x-ray, um his A P view x-ray. I know I've said before you should get two views, but unfortunately, you only have one view. As you can see quite clearly, there's a fracture uh of his ankle. So you can see the fibula is fractured. Um the fibula on the left side of the image and the uh tibia on the right side, there's quite a clear fracture through the tibia, sorry, the fibula. So ankle fractures can be classified via the Weber classification into A B and C. So this is important because this helps determine management of ankle fractures, whether they managed conservatively um or surgically. So, with the A fractures are those that are fractured below the syndesmosis um and are stable fractures. So these can be con managed conservatively. Usually patients are placed in a um air cast boot or walking boot are told to um not weight bear for 4 to 6 weeks. Um and then have a chest x-ray at some point in a week or two to check the fracture hasn't slipped. And over time, this would heal by itself. I mentioned syndesmosis. Syndesmosis is the tissue that stabilizes the tibia and the fibula. So on the photo where you see the two bones in communication, that is the syndesmosis. So you can see in a, the fraction is below the syndesmosis F fracture. B uh Sorry, I'll go to fracture C is where the fractures above the syndesmosis. Um And these fractures are unstable, which means if a patient was to place weight through that fracture, what we call the ankle mortis or the ankle, um this the articular surface between the tibia and fibula and the talus would all open up like a textbook almost. And that would mean the ankle joint is unstable. So it's we c fractures are almost always managed um operatively. So in this fracture, usually a plate and screws will be placed across a weber c fracture. Finally, fracture pattern B are fractures that occur at the level of the syndesmosis. So you can see in B, the fracture line goes across at the level of the syndesmosis where the tibia and fibula are coming are in connection. These fractures can either be stable or unstable. So typically, patients will um have an x-ray putting weight on the joint and then you assess the articular surface. If the articular surface between the tibia fibula and talus has opened up, then you can tell it's an unstable fracture. If the articular surface looks even and doesn't look open on x-rays. And when the patient is standing and putting weight on the joint, then that's a stable fracture and can be managed as class a conservatively. So that's why knowing the classification system is really important because it helps to determine the operative management. So, upon which, what classification is this fracture? A B or C OD? Mm. Good. Wait a few more moments. Good. So most of you put we ac which is the correct answer. Um So the fracture is above the level of the syndesmosis. Um So that is we ac fracture, it's unstable. And so the patient most likely be managed um surgically with most likely a plate and screws across the fracture to stabilize it. Uh It's not web array because web array would be below the syndesmosis. It's not we b because that would be at the syndesmosis and it's certainly not d because we class patient doesn't have a ad, a bit of a trick trick on that. Moving on to our last case. Um, an important case. 50 year old gentleman, sorry. 50 year old lady presents with pain in her lower back for three days. Pain is however worse today and she's complained of pain down both legs and hasn't had an episode of urinary incontinence. And do you have an MRI? Just a sagittal view of a MRI scan, MRI spine? We can see that there is a compression there of the spinal cord. What level is that compression tricky one? Because probably a lot of you don't have practice um at interpreting MRI scans, but it's important often I found in practice, the spinal consultants are the most scary during our trauma meetings. So they will ask you to interpret the MRI scans when you have, when you're admitting patients with spinal issues. Um and they'll ask you what level things are to interpret the scans. So it's really important. Um Do you guys know how to interpret? Good. So 80% of you have put L5 to S one, which is the correct answer. Um You can see that there is a, a protrusion of the, what looks like the disc at the L5 S one of the inter disc into the spinal column, compressing the spinal cord. So the patient back to the history has symptoms of corder equina pain down both legs and an abs episode of urinary incontinence. So the patient has Cordona syndrome, MRI corroborates with this. And so this is a surgical emergency, one of the few orthopedic surgical emergencies. Um This slide just shows how to interpret the um MRI scans and determined level. So it's often the easiest to determine S one and L5. So, ss one is the first bone in the sacrum that has the, is kind of the most uh inclined. And then L5 is usually the largest um lumbar vertebrae. And so those two are usually the most easiest to work out and then counting up from, from L5 onwards. Um That's the way to determine the vertical level from a sagittal MRI spine. Ok. So, Quina, how do we manage it? As I mentioned, it's a surgical emergency. Um It requires urgent surgical decompression. And that's because if patients are left with compressed chona, um they will develop long term neurological complications such as incontinence, urinary and fecal, um which the longer you leave it, the more likely they'll have these longstanding problems. So if you see a patient in A&E, they have these symptoms and they have that MRI spine that we've just seen, it's important to keep them no by mouth, keep them fasted in preparation for theater, admit them to the spine ward. Um perform regular neurological observations. So most spine units use what's called an Asia chart. And that helps determine if there's changes to the symptoms, if there's worsening or improvement in symptoms. Um when patients that kept over mouth, give them IV fluids. So they're not dehydrated. I take preoperative bloods including two group and safe samples. Um in case patient need a blood transfusion, either inter or postoperatively. If you feel confident, then you can consent a patient, but probably for spine operations, they're quite high level. So usually it's best for the registrar to consent patients for theater. Um but they can be marked and then always important to escalate to your senior escalate when you have a surgical emergency, to your registrar uh and to your consultant on call as well. Perfect. So that completes our uh presentation. We've covered most of the learning objectives. I've covered all of the common orthopedic and most common orthopedic um injuries and the emergencies as well. Um I'll be very happy to take any questions you guys may have, feel free to pop them in the chat box. Um Our next lecture will be on Tuesday and that's how to make the most of your f one job. So if you're thinking of applying for core surgical training, um how can you make the most of your time? Because it is very, very useful to have an F one surgical job and it's important to make the most of that valuable time if you could scan the QR code on the right to the screen. I provide feedback that be really useful for me um for my portfolio, but also to help me improve, help us improve these lectures for for future. I think Lucas has also put the registration for uh next week's talk in the chat box as well. Thank you very much Sanju. So that is the end of this lecture we'd really appreciate once again if you could fill out the feedback form which you can find in the chat. Um And like Sanju said, we hope to see you at our next lecture happening next Tuesday. At the same time, I've also popped the registration link for that in the chat, which you can check out. Um Otherwise, thank you for joining us today and we hope you have a great evening. Thanks guys.