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everyone. My name's kept hanging on one of the doctors and self Yorkshire in the UK Thanks for joining us on a Saturday morning on. I'm hoping we'll have seen some of you before. But if not, then welcome to the next Webinar in mind, please. Radiology Siris. So November, December and January will aim to cover a lot the imaging modalities that doctors and healthcare professionals tend to come across in the hospital on. So last week, Dr Huge took us through abdominal and pelvic Teres s. So today we'll be starting the desk, a section of the Siris. So Doctor Henry double will take us through restriction approach to hand in risk Plain films, which are some of the films that junior doctors typically find more difficult to interpret. And that's also included. So you're going how? It's a camera logical approach to interpreting both of these plain films and discuss some of the cases with us. So we'll just crackle with it. So, Henry, I will send over to us. Okay? Yeah. Thank you. Carefully introduction. So I'm hoping that you can call here the and see my presentation. If you can't, then please put in the chat, and otherwise we'll make a start. So, yeah, my name's 100 born with the ST 3 to 30 registrars in Sheffield from the UK So I'm going to talk to you about Byetta graphs in hand and wrist trauma. So we're going to quickly go over some of the bony in after me off the 100. The rest, um, which is something I think getting the terminology correct. Be quite tricky. And there's a lot bones, carp, bones particularly confusing, So we'll go over that quickly. Look, it's a normal alignment and how to look a hand in a rest radiograph in a trauma patient. And then we'll try and spend at least 40 minutes of the talk going through some cases. So you're pushing. The case is giving you 30 seconds to a minute to have a look, and then we'll go through the answers together. So this is a normal hand radiograph on. What I'm gonna do is show you some circles on. I'm going to give you a couple of minutes just to have a look through. And for each circle trying name, you have the joint or the boner and ideally, the specific bit off the bone, which has been circled. So you have a look through those. See if you can work out the answers, and then we'll run through them in a minute to two minutes. Okay, Perhaps a comment in the tract. Ready when you're when you think you've had a chance to look through them all out Pretty useful. It's starting to get some people that already so give, you know, 30 seconds and then we'll run through them. Okay, so let's start going through the answers. So when I look 100 a wrist radiograph, I like to start approximately. I work my way distally say from proximal. So we've got the radius on the radius is the radio star like process This joint here between the owner on the distal radius, the distal radius distal arm A is the distal radio on the joint there is a joint more approximately towards the elbow, which is the proximal joint. Well, the only styloid process, which is this tip to the end of the owner. And then in this space here, we've got something that's called the triangular fibrocartilage, which isn't something you normally see on a trauma film. As particularly important finding. But if we were talking about arthritis, this is important clicking calcifying. Then we got the carpal bones, which will cover on the next flight. So we'll move on from those for now. And then we've got the metacarpals. So one some metacarpal index finger, middle finger bringing finger and little finger. When we're talking about the hand and the wrist and anatomy, it's really important that we don't use the terms first metacarpal or first finger because that could be a bit confusing. Some people will go well, it's the thumb, the first finger. Or is the index finger the first finger? Say, I would always advocate using thumb index middle. Bring on a little finger when talking and describing 100 Ms Radiographs and the metacarpals have a base. The shaft ahead and in the junction between the head on the shaft is the neck. So this would be the base off the right ring finger metacarpal. This would be the neck off the right and little finger metacarpal. And this would be the head off the right ring finger metacarpal, the joint between the metacarpal on proximal phalanx. So the fingers there are three phalanges, so proximal middle and distal phalanx. And this is the metacarpal Phalangeal joint or MCP joint. Yeah, to Dallas. It's this one would be right. Middle finger, MCP joints, all metacarpal phalangeal joint. So this is then approximate fine if I like. And this is the shaft off the right ring finger proximal phalanx and then describing the joints. So there's a proximal interphalangeal joints. So the first joint between the two for allergies on a distal interphalangeal joint sitting on. So hey, think, then that one. Yeah, right. Ring finger proximal interphalangeal joints. This would be the right middle finger shaft off the middle phalanx, right, middle finger, distal interphalangeal joints. And then this is the distal phalanx of the right index finger, but specifically the very end we call the Tuft. So that's the tough off the right index finger distal phalanx in the thumb. You'll see. There's only two following. Geez, so a proximal on a distal phalanx there isn't a middle phalanx. Father's in the fingers, so we refer to this as the thumb interphalangeal joints. This little black of bone here is a sesamoid value so dispositive Bo is actually within a tendon. That's what makes it sesamoid. So the bone itself is within the tender, and that's not to be confused for a fracture. Okay, today. Then we got the arms is coming up, which we've talked through so the couple days. So I think this is where people can get very confused. It it could be difficult to know which carpal bones were looking at. Um, I think it can be quite intimidating to start with, say, we're going to just run through. Which explains, called, how I like to think about one to try and remember them on was a new monitor at the end is well to try and help you. So this is the thumb. So this is the base of the thumb here on this is the index finger trying orientation ourselves. We can see the radius on the only with the almost arctic process here. So this is the skateboard. And in the carpal bones, we've got the first carpal row Usual approximate carpal row on the distal carpal row. So they come in two lines with this being the radio carpal joint. This being inter carpal joint on this being the road where we have the carpal metacarpal joints. So we've got a skateboard and skate. So is Greek boat shapes. And it is sort of, um, boat shaped the navicular in the foot. Sort of an equivalent bones too. Um, I think Medicare is left in the boat and it's got that similar sort of semi present time shapes that's escaped void. This is the lunate someone well on a lateral radiograph. It looks like so if a half moon, which is why it's called eliminate. It looks like Luna. This is the trying quick trump on. Then the piece of form is this P shaped round bone here, which is again a sesamoid bone so skateboarded blue night triquetrum on piece of foam is the first carpal row from the thumb side. So the radial side to be on If I'd and going from the radio science on inside In the distal carpal row we've got the trapezium which is under the thumb. So they running, which is how I remember that So trapezium under the thumb the trapezoid sounds like a pretty easy, um So you it's next door trapezium trapezoid, then got the capitate, which is the biggest carpal bone. So I remember that capitate Sounds like capital. Capital city is usually the biggest city. So the capitate on then the hamate on the hamate has this hook on it. So the hook of the hamate. So this is the hamate. So run two years again. One more time You've got skateboarded blue night triquetrum pizza form peasy. Um, trapezoid, capitate and hamate. It's a skin. Okay, on did the new monitor that I was taught at medical school. And some of you may know there are other new monitor available is some lovers try positions that there you can't handle. So you're looking on the lateral radiograph again. We'll go through where we see the carpal bones and this could be very confusing. I think the people aren't used to looking at 100 s radiographs, but it is important because you can see subtle fractures on alignment up to manage. These are actual radiograph that are really important to pick up. So just get back on. So we got the radius here on the classical. I'm that people talk about is the lunate, which is this off present, Eric. Half moon shape just in on top of the radius. And then this is the capitate here and the should all sit in a dead straight line. So people talk about a teacup with an apple in it, or so off sources teacup on apple. And he should also in a nice alignment. So that's the night capitate sitting in that to the apple in the teacup. The skateboard says here, so it looks like a sideways boats. PC form sits on the bolus aspect, so it's the most forward, most anterior bundle on the twice a creature. All bone is out of the back. Yeah, and this is important to remember, because if you see bony fragments on the door so last acted the rest here, that's often a sign of trying to recall fracture. And you won't see on in a P or from two radiograph. You just see a little bony fragments out the door. So side the couple buddies on that is usually try quick for fracture on the back of the dorsal. Radios here should be really nice and smooth. Any interruption of this long, you've got to be suspicious for just a radius fracture and then the trap. He's always in trouble. You, um, are up here not something you will see much pathology, I lateral. And then again, yeah. So here is the proximal carpal joint on. But when we look at the wrist on the carpet bones these joints face, it should be uniform, and they should be equal throughout a little. Jones, you should see these nice joint space is being pretty even in uniform the whole way around. When we call this off, seeing the light the light of day sign. So if you can't see the light of day through these bones, you have to think about Is there a dislocation or fracture? Said Proximal. Calm floor Mitch Copper. Oh distal carpal joint on on the natural nice straight line radius with the lunate in the capital. Also, if your alignment again just ruined us, so that's we got some cases, but you understand, is once you're like so some of these cases are normal. Most of them they are abnormal, so there's pathology and fractures or dislocations to spot on most homes. They get progressively harder. I suspect you'll find these quite tricky, and that's intentional, because if I just showed you obvious fractures, anyone can spot days, I think what I'd like to do is try and highlights and important practice or the easily overlooked injuries, so that if you're looking at these films overnight or trying to make a decision, you have seen most of the important pathology and the ones that you can miss. And then if you've seen it before, you'll be know what? I don't know what to look for and hopefully was about it. And if we get to the end and I've got about 30 cases, so we might not have time to go through them all, But hopefully we should cover all of the injuries that will likely ever see. So first case. Well, if you 40 seconds to a minute, something like that. And if you put in the chat box what you think is thie correct answer. So either normal or putting the pathology it you can say I'm with these radiographs. The key I'm was radiologist. We try and do because certainly where we work in Sheffield, the any doctors or the less practitioners that working are minor injuries for fracture clinics are very good looking at these films, and they don't really miss very many injuries at all. But what we can add is sort of a slightly more descriptive reports. So if you see a fracture trying to describe how it's displaced, how it's angulated, where extends from in two is it intraarticular? So does it involve the articular surface of the bone that you're looking at on? Are there any of the associated injuries so I can see? Yeah, some fiance's coming in. Okay, so let's start going through the answer, this one. So we've got an AP in a lateral of the 100 the wrist. Okay. Yeah. Nice. So I really, honestly, I can see you've been corrected far. So starting proximally working distal. So the way I look at these is I mean, it sounds quite obvious, but you really have to trace the cortex of everybody to make sure you don't miss any fractures. Say, as I'm doing that, I'm sanitizing irregularity here on the radial aspect of the radius and here, so that's very suspicious for a fracture on the AP. And I think there's some slight jagged Lucent line that crosses the just a radius here. So come back to that when we look at the actual with your carpal veins. Nice joint spaces. There are nice and even I could see space between all the carpal bones between the carpal billions in the metacarpal basis. And I can't see any cortical steps or breaks or listen lines. Carpet burns. Um, likewise, for the metacarpals Um, the base of the proximal phalanges that we're just getting here is well, so maybe this distal radius doesn't look right on the lateral, just in the bones and room. What I said about the dorsal aspect, the posterior aspect of the distal radius should be really smooth on. This is not smooth. There's a step in a fragment here, and we can see the front line comes across to involve the articular surface. Yeah, there is not smooth pregnant here involving articular surface. So I would call this an intra articular fracture off the left is still radius on. It's slightly impacted. So the rate Yes, it's slightly short in the owner here, so slightly impacted, but it's not particularly displaced on the angulations. That's quite normal. Angulations. You should have obviously slightly Cymbalta angulations he distal radius. So this the radius fracture next film. So these are two different films that these are not from the same patient on The reason I bring this up is because these are both distal radius fractures. See, this one has displaced in a bola direction. So towards the palm on its angulated in the voter direction, this one has displaced posterially and angulated posterially. And once I don't think it is important to use upon, um, it's names and I would never use them. In my reports, I would always describe the fracture. People like asking, What's the upon in this name of this fracture, which you want, put them in? So when it goes bowler, we call it a Smiths fracture. Now, when it's posterior, we call a colleagues, fracture the colonies. Fracture is typical of elderly female patient, and we said Smith fracture more common in younger patients. Why, that is, I don't know that as a Smith fracture, and I called the structure, So I again, I don't think these are important to remember the names, but people will ask you all. What's that say? That's what put them in. So next case. So this is again This is just 11 series of films from the same patient. I'll give you 30 seconds to a minute. Okay, So your chances in the trap when you're ready One on certain so far, you know, 20 seconds. Okay, so let's work through these films together again. So we've just got fingers this time. So you're starting approximately and working this lay tracing bye so much on that little thing. Yeah, here is catching my not quite normal. Maybe a little bit loose in line through the neck here, metacarpal, you know, But I think you could be forgiven for not starting that on the AP dice. Awful. So that's the only thing that that's catching my eye. But it's subtle, and I would definitely be wanting another view to have a look of this to be gone a week. And on the oblique, you could see much more clearly step in the cortex nuisance line across. So that's a transverse fracture through the neck off the hard. That is concept side. But all the ring finger metacarpal neck, Yeah, slightly displaced, but not much. And I can't see any of the injury on the Wii, a lateral film which helps you work out. It's just placed or angulated to the dorsal. The voter aspect. Actually, these metacarpals when you're looking down the hand a real nice in line, so it's not take calculator. So I think everyone that's been answering the track box was correct there, we say. And if we see men, it's there. But it's awful. That's a couple neck, part of the ring finger. Next case. Yeah, it's not getting pregnant is coming from the chance this one quite straightforward going tracing all the bones on the AP looking. Okay, so, um yeah, around here, there is a fracture. Concede cortex here is the regular is broken as a step on both sides with a recent line. Right now, between on on the oblique, we can see again step in the cortex Lucent line but not particularly displaced. So I would probably describe that as a fracture. Transverse, minimal displaced, fracture the base off the little finger, proximal phalanx. So next case. So I think I should have said the last couple of cases they were starting as well, slightly easier cases, but also the ones that really common. So distal Radius French is the most common fracture that we say crunch of the metacarpal next really common, particularly people up punching things on, then fell in jail. French is incredibly common. Okay, that's a starting dose. Mountains is coming through. Some people correct, some people, slightly less correct. Wait for a couple more ounces. Come through through. We get consensus for which cool this very good that I can see your trip. But those of detail insurance or it's well, which is good to see. Okay, so that's looking this film. So in the AP, starting approximately working just really as usual. No, I think on the 80 no whole lot to say something we not talked about so far. So you have to look at the bones, joints, the alignment. Just have a glance of the soft tissues. It's easy to forget that you can see soft tissue on the plain film, but have a look. Is there any swelling, any foreign body, anything that could draw your right once a particular area of swelling, look for injury more closely. So nothing on the AP on the lateral. Yeah, so here the alignments not quite normal. Yes, base off The distal phalanx of the thumb should sit nicely on the proximal phalanx, and they're not. So this is your sleep subluxed um, there's a fracture here that this slights that doesn't look normal loose in line. So what's happened here is what we call an abortion front, just they the flex attendance insert on the basis of the metacarpal or the whole colon. Geez, are here. There's one here, one here, the flex attendant and that's pulled bit of bone off the base of the distal phalanx. So another name for this is a bowl, a plate of ocean injury. You might hear that term. So go to play abortion injury with dorsal subluxation on. That seems to be the consensus opinion in the chat, saying Jeremy's called a mallet injury. Um, so a mallet injury. I will see you in later, um, Ali injuries where you get this off flexion deformity, and that would be an extensive side injury. So when you get the volar play of ocean, you can't flex your thumb so it will be stuck in extension on. These can be really subtle, but they're important to spot because we don't immobilized patients display the play of ocean injury. You can get so a fixed extension deformities so they're ankle spot. So there it says, next case Okay, so let's look at this film together. So again, as always, I think it's important to have your system looking at films approximately distal, won't carpal joint spaces look okay and then tracing the court sees off the carpal bones on there's a Lucent line through the skateboard with a step in the breaking the cortex. But when you see the abnormality, make sure you look at the rest of the film because I might be a second abnormality. But there's nothing else that I'm seeing on this AP. So just this skateboard okay on the lateral on, and maybe just a loose in line to escape our natural that I think would be really hard pressed to call that a fracture just on the natural. On the way I would describe this is exactly as Georgia Mansell has said. I'm saying mild up. So it's a transverse fracture to the waste of the scale, for it's the Skateboard has a proximal pole. The distal poll on a Waste on D. People manage your questions about a vascular necrosis and gait with fractures so the blood supplies from the skate. Boyd comes in at the waist and distally so it comes from distal slash the waist. It's a bit variable and then moves approximately. And the reason this is important because if you get a fracture, the waist you can disrupt the blood vessels that are running this way. Get proximal pole, a vascular necrosis. So you asked, what's the most commonly common bit of the scale for it to have a vascular Croesus? It's the proximal pole on, the more proximal the fracture, more likely you are to get a vascular necrosis about proximal fragment to hurt you here, be really high risk of the small portion. Approximately know healing. So a basket crisis on non union. And if someone asks you if the request says query, skateboard fracture or pain in the anatomical stuff box full on trans tracks hand. But it looks normal. Pray, boy fractures could be really tricky to see, so we will ask for a full skateboard. Siris. They will have as well as a pa and lateral we do you all of what we call resistance view So we get Oh, my only deviation and we're doing it so another obliques projection as well. And if they still look normal, we would recommend repeat followup X rays in 10 to 14 days and treat for a fracture. In the meantime, there were some sense is that rather than following up with X ray, that you're straight to do an MRI scan of the skateboard, which is really sensitive escape, would fractures. But so availability and cost of MRI. In Sheffield, we follow up and treat if we think there's a scape or trench that we're not seeing, so there it is. Okay, so you I will quickly talk to you this film a swell. So I think there's clearly there's an obvious Lucent line step on the court X factor here. But the reason I put this one in so this would be left index finger, approximate phalanx oblique fracture through the shaft. But that proximal failings is because the lateral looks completely normal. There is no abnormality on the lateral view at all, which just shows the importance off obtaining so if to projections. But making sure you call the projections. It's really easy to look at the A P really closely, and then you look at the lateral next, but you already made your mind up that it's normal or abnormal and know fully look. But the other view always look at two. Please, anyone is invisible, not be here. Okay, so next case. Okay, so again, let's have a look. See this one together. What? We can do The complications. Spaces look normal. Tracing the outlines Day fracture, metacarpals neck, right job. But on Jay's no fracture, no joint spaces, the alignment and then having just look at the bony sort of detail. Any bone lesions less common in the fingers and extremities, then perhaps in the pelvis. Bone details that normal on the soft tissues that normal on the AP and on the oblique much the same. So yes, I agree with all of you. This is normal. Well done. So keep those comments cream in the trapped. I can see same sort of 5 to 10 people commenting each time is 130 in the chance of the nest of a few more ounces coming through. So let's have a look. See this one together approximates just still no definite fracture on the AP, but we can see that the alignment here is not normal, and that's because they're flexing their finger that perhaps himself tissue swelling and some increased instance. The soft tissues. So you have a look on the natural again. Say, there is a step in the cortex. Listen, line in keeping the fracture on the dorsal aspect off the base. Well, the distal phalanx, soft tissue swelling on. There is a reflection deformity here because when we take these laterals on the AP, we ask the finger to be straightened. So if the fingers bent, we have to assume that's because they can't extend it. So I'll call this a dose level sort of fracture at the base off the distal phalanx with a mullet type of deformity. So, yes, you need it. Well, then I think you're all correct. That answers I seen. So the next case is similar. So I would just talk to this one again. Together. Approximate to death. Still no fracture. But the alignment here is not normal. This finger is normal, not straight line. Everything lining normally. But here there is subluxation towards the only side. Yeah, and then coming back to the way. This is a little wonky. Okay. On the joint space here, See here we should look straight through the joint space. You know it's clear, but here it's just it's just not right on when you combine that with this subluxation and then we look on the actual it confirms that suspicion. But there is dorsal supplication slash dislocation at the proximal force off the metacarpal phalangeal joint. Thanks. All right, proximal in time, diligent in mom's Think. Yeah, is one key, and that's where it should be normally on it dorsally dislocated slash the blocks Question. What is a mallet? So, um, mallet finger is just describing, uh, so I don't if you can see my video. But where you have flexion about the distal phalanx war bones anywhere is a fixed flexion deformity on a mild injury. I need to be a soft tissue, so it's purely a tendon injury with no fracture. So you might just be a bit of soft tissue swelling. Or you can have a bony malice injury where you have the abortion fracture. But it's an injury to the dorsal side, where your flex attendant has been disrupted. Oh, so I can see some answers coming through. Give you another 20 seconds to have a look. I can tell they're getting more tricky now because That's few ounces coming through quite quickly. Trying so interesting. We're having a few different ones in this time, which is good. So three ounces, three different ones are so far, which is? Yeah. Good kitten coming. Be interested. We can get a consensus opinion before I continue. Don't be shy. Keep his own. Is is coming. Doesn't matter if you're wrong. About three different answers. Safe. Also, any one of one of them trying to. Okay, so are usual. Pattern trace in the bones. Proximal too distant. Okay, say so. Some concern for capitate fracture on D little finger fractures. So I don't think there's a fracture. I think these quarter these are all intact. There are. Maybe it was this that someone's looking up. No, this is just very smooth. There's no break in the cortex. I think this is what we call like a nutrient vessel. I don't think that's a fracture. That I wouldn't I think for spotting it. Well done. I think if you're concerned and you know sure. Treating it as a fracture, bring them back for follow is know about plan. Looking at the alignment, the carpal rows look okay. But then when we traced the lines and the space This space here between escape when the lunate is wide they should be symmetrical So all the spaces should be the same size. This is wide Onda a Z Ah yeah, Georgia Mental. You're right. This is the Terry assign. Um, if you don't know uterine Thomases just google a picture of him. He was famous for having gap between his two front teeth on it supposedly looks like that gap between the two front teeth. So this is the only injury and this is an important sign to pick up because what's happened here is there is a ligament that runs between the scale for in the lunate. It's called the skate lunate Ligament on and you can have an injury or a complete transection of this ligament. And if that happens, is the scale for in the lunate start to drift apart from each other, they start get wide wider on If this isn't treated, then they could do to really about deformity of the rest. So this communicating wider on the capitate Well, for my great through this gap, eventually we start to articulate here I may just end up in a whole world of problems. So, yes, this is a staple in eight injury or scapula units association, so there's not damp. That's wide, but there is no fracture, but there is a staple in a ligament destruction. Next case. So you got 10 minutes left, try and pick up the pace slightly just so we can get through his many cases as possible. But I think the more that we can see, think more. You told us one day. Yeah, please keep his arms is coming. Let's say let's look through together. Tracing the quarter sees. Yeah, So if something here is not right, bit of deformity. But there's no step in the cortex. And that's not really loosen, allowing the alignment of the wise looks. Fine. Joints look okay. Soft tissues look okay, so we look on the natural, and again we see this deformity, but no acute fracture. So what? This is it's normal. But there's an old fracture here. So it's a previous boxes injury, So yeah, say someone's said boxes fractured. Their growth normal. So yeah, yeah, but normal. Is it normal? No, over the bait. But there's no acute injury. There's an old French in here. This is what healed fractures look like. Because this is such a common injury. You'll see old French is of these metacarpals all the time. Usually people get into fights because they're punching things all the time. Have a look at it. Okay. Yeah. Take that. Said, don't worry about Tom in there. Yeah, I'm happy to run over and go through the cases. So if anyone wants to carry on, just continue on the call. We'll go through the cases. Don't worry. Yeah. Okay. So you missed stuff I've seen. Your question will go back once it's in this one. There was no bony growth on the previous. It was just It was an old fracture. Balance was old fracture, no acute injury. There wasn't a bone lesion have answers. Your question. If not, let me know. We'll control you again. Okay? So let's go through this one. You're going there again. It's not getting more tricky. So the AP, tracing all these bones each finger. So there's argument Here is a fragment here on the alignment between it. The base off the little finger metacarpal on the how may Just don't look right there should be this nice, uniform joint space, but it's no, it's overlapping here. This doesn't look right in this, um, fracture fragments exactly where they come from. Perhaps that's what to say. Is the cortex here abnormal? I think it probably is. And in the lateral looking for fractures. It's difficult with all these over the line bone. But the reason that we're getting this lapse will fill is because it doesn't look right here, and we want to know is the dislocation on? You can see that this little finger metacarpal is dislocated. Dorsally on d. I think it's interesting, anyway, that it's such a novice dislocation. It's so far I have joint here, but it's relatively soft on the AP, and that sort of goes to show how important this, like today sign is or looking at is overlap. And if you spot it and you've only done a piece and obliques, which you're quite common and you know happy get a natural film, that might be a massive dislocation that you're missing would hope that clinically, this would be quite evident that if you see the radiographs, don't be afraid to ask for a lateral view as well right here as pregnant. Fracture here. And this doesn't hurt, right? This we said the alignment of capital. How many does not normal on these? Metacarpals should all be in alignment. So this is a fracture. Dislocation. So it's a French off the ring finger metacarpal base the dislocation off the little thing that it's like you can see that complex injury, but by spotting his fracture fragments is on the quiet alignment. Here. We basically got the answer on bilateral in just confirms that it's starting to get a few answers. Yep. People saying normal. Yes. Um, question Is the transparency normal? So the alignment, but if you use is normal was no fracture. There's no soft tissue swelling, so this is normal. Uh, the bone density, I it is it the bone density that you mean the stream? So, yeah, I think they look okay. Yeah, normal on. Luckily, I agree with myself. Okay. It's the next case. I can't say with where I go through the answer to this one. So it is 12 o'clock now. Anyone have there even thank you for joining, but I will continue until we got here and we've got we got a lot more cases left you. So let's have a look through this one together, chasing the court fees. Okay, so no fracture that I can see alignment this first, so right looks okay here. But then, as we traced this middle carpal row, it's lumpy, bumpy, a labor lapping. If you think of the previous ones you've seen, this is not normal. We should have this nice uniformed line like we do here across the Midcarpal Road. When it's not, it's all it's all over the place. Really. Well, how's your front? Just on these Compal bones? The shape of them also isn't right at all on a p on the lateral shows US wife. It'll looks open e. So if you remember, we should have the sore sir with the apple. But that source with the cup and then the capitate, which people talk about the apple, is dorsal so that they're not saying in a nice straight line with one death. This thing here. So there's discovery dislocation, and there's different classifications. There's lots of complicated terminal issue we can use the protein in my simple, well being. Important thing, I think to learn is whether it's a parry leaning toward reunite dislocation on the way I think about this is a looney dislocation is when the lunate is in the wrong place. But the lunate here is normally cited on the distal radius is the capitate on the distal carpal row that's dislocated. So this is a parry noon eight. This location that's again showing us there's carpal lines are not normal the night and then the capitate Dawson for that. So yes, perinatal location. Next case. But I just realized that you will know. But when we describing angulations or displacement, we talked about the where the distal bit has gone. Relatives, the proximal, that thing. We get some samples, we'll talk about three. But you all I've been describing cracks. Any answers I've seen? Okay, so you have some more ounces, please. Anyone else to safe on? If you question at the previous film was the gap between the older and the complements normal, um, condition quickly. Flashback. Uh, yes. This is normal. It because we've got this strangler fiber cartridge that sits in this triangle shaped out. Yeah, but this contour isn't normal. But this specific gap, yes, but probably is normal. Okay, just the onset of this film. So I think this is tricky. I think that's reflected in the comments and the lack of answers. So we do have some vascular calcification. So that is the range of last year, which is calcified chasing the bones. So this is catch my eye. I can't remember the answer. So we're looking at this fresh together, but this doesn't look normal. There's a I think there's a step that but the joint spaces themselves otherwise look okay. And the rest of the bones look okay on the lateral alignment. It's okay. I'm actually we thought the skateboard looked not all right playing close attention to skate void. I can't really see anything on the natural, so I would want escape. Would Siris on this one, particularly the history with skateboards. Tendon us Good. I've called it normal before, So that goes to show that these can be really tricky on D. If there was a history of skate with pain, then we would definitely put treating them escape with furniture doing escape, would Siris and bring them back for a follow up film. But no definite injury on that one. Ah, cause of the constipation. So the calcification is It's never normal, but it's you can debate. What? What's normal for age. Most people in their eighties and nineties gonna have some bastard calcification. But the more you got, um, could be due to renal failure. Could be my attention. Hyperlipidemia. Yeah, all the normal causes off afterwards for assessing arterial disease. Um, if they were 90 and probably ignore it. But if this patient wasn't known to have any history, both any medical conditions and they were in their forties or fifties, I would probably comment on it is an instant finding because that's that's quite a lot of calcification. And it could be the first sort of sign that maybe they do our high risk of cardiovascular disease. Okay, it's the next case. Okay? Yeah, on a world. And I'm glad you spotted the soft tissue swelling, but do you think that's a fracture or not? Yeah. So, looking through this one together, the bone course to seize the alignment looks normal. Yeah, no fracture. But there is soft tissue swelling here on. You can appreciate the slight soft tissue swelling as well on the AP, but on the lateral. Yeah, vial. A soft tissue swelling, No fracture. This could be due to multiple reasons about history. Be difficult to say. It could be that there's a tenderness injury. It could be that this is an abscess infection. Lots of things, but the soft tissue swelling Don't forget. Look at the soft tissues. Next case. Yeah, the coach will think this was an average, I think in the previous film. Grace. Yeah, For all of these films, I tried Teo some but they will almost all of films that I've reported in the last couple of months in traveled, but I tried to pick ones that are otherwise normal apart from the injuries, So avoiding ones without much to change change clothing that could be whilst probably reflects the real world. It's more difficult to learn when does suppress it. Janse, You change. I want to different folks on the fractures in the alignment. So the bone density is probably normal cause I'm actually gonna patients. Okay? Yeah. People are spotting fractures at the face off the thumb, So Okay, here is the bone fragment separated from the base. Well, the thumb That's Coppell on this oblique. I think even more nicely shows that fracture frankly on its intraarticular. It's a step here there, says the injury outage of fracture base of the thumb metacarpal on Jeremy, you are exactly right. This is upon his name's have been. It's French. But I as I said, the colleagues in the Smiths fracture. I think remembering the names shouldn't be important because it doesn't actually affect management. Will effects Management describing the fracture on these base of some French is well important to know about clinically, and I don't think it necessary effects how you manage them immediately in the any department or is already ologist. But these often require surgical management because they're unstable fractures, and the reason for that is the thumb get pulled so on abducted duty abduct tendons because the our doctor 80 duct attendance insert on to this part different in here. See, what you have, in effect is from having that lateral pull, but no media Paul, So it also blocks. So this is an unstable injury, but it is called a benefit furniture just the interest, like if this is common, you did. We'd call that real Ando fracture. So it's the same base of thumb intraarticular, but it's common. It'd that would be a real and a fracture. So next film. Oh, I'm sorry. I just seen a comment. Old injury getting to the fracture of distal phalanx off thumb. Um, I mean, that could be, but if there is, I can't necessarily see it. Perhaps something here, but I think it's probably normal. Maybe they've had an old injury that's healed completely, almost completely normally that Yeah, not ignore that. If you think that's an old fracture, I think it's normal. How are we doing for cases? Okay, about 10 left. Okay, so looking at this film, the's carpal bones on the AP Not all normal. Um, this is all all over the place. This road on this middle, right? I don't even know where that's gone. The lunate here is a very funny shape. So it's pi shapes Onda once again. I don't think it's necessary, Porton, but this pi pi side is what it's called. Is indictable the night fracture? But I think it really the real world. And outside of radiology exams where they might describe this, you'd see that this is not normal and you do a natural and then you very clearly see source of the radius on the Cup is pointing the wrong direction. So this is a loon. Eight dislocation. So if we compare it to the previous, they capitate is sort of in the right place. But it's the lunate now that's dislocated, so that's a lunatic dislocation on. But I don't think it was spotted by anyone in the chapel, but bonus marks if you spot this skateboard fracture and lunate dislocations are associated with skateboard fractures. The reason for that is because to dislocate your lunatic, you have to disrupt escape. The units ligament, which often results in a spray for a fracture, cause that disruption. So there is obviously line. So that is showing this car bones are just completely not normal. Um, particular injury mechanism. So they you, they are usually still falls onto outstretched hands. Um, yeah, there's there's not. There's not typically classic mechanism, but fall on 23. And I would say from what I've seen is the most common. They're not particularly associated with massively high impact traumas. Um, it is usually simple. Full. That's not new night. Um, well, I didn't highlight. Yeah, there is. There is a skateboard fracture that just no highlights on The answer is on down The peri lunate dislocation of you saw previously is associate with trying quit for fractures If anyone ever osteo the next case, Uh, it was peri loon. Eight dislocation was associated with traffic for fractures. Where is loon? Eight French is no sorry. Lunate dislocation is associate with skateboard fracture. Uh, is there a reason for the association? So Yeah, What I was saying was that in order for your new Nate to dislocates, you have to injury the scale Fokker lunate ligament the lunate in the skateboarding, usually health together by a ligament. And if you disrupt that ligament, you can then display case urinate. So because it attacks it, then you can often have a skateboard fracture, which would be the mechanism to the destruction off the ligament cools the dislocation of the night. So that makes sense. I would say it's probably more advanced than more inactive than you would ever need to know reporting these films unless you were either doing a radiologist or doing a hand surgery orthopedic job. Otherwise, spotting findings, it's more than adequate. Okay, So, waiting for a few answers. I'm going to take the slow answers to be This is attention slightly more tricky. Yes, they're probably most your arthritis mild osteoarthritis of the distal on proximal interphalangeal joints. But but you could ignore that. Okay, so let's get a CT ounces. So, um, uh, tracing the bony courses, it's harmless. Boston authorize this. I mean, this is really mild on I Probably Maybe this joint is the one that's most catching when I the way we look for osteoarthritis is narrowing of the joint space on osteo five formation, and you also see your the hallmarks would be osteo sclerosis and substance chondral cyst formation. Um, so this is just a little bit narrow, but it's really no severe. It'll go, I would say, Let's not focus on the osteoarthritis. So the steps step here, um, lines across these middle on drinking a matter Coppell's. But these are cold. They look like healed old French is. But what catches my eye is on this sort of bleak for you. The metacarpal alignment is not right. These are all bunched up. And then there's a big gap. And then there's this index finger, and if we look at the counts between the metacarpals, although it's not a dedicated rest fell space here between confidence couple joint space here. But this face off the index finger, there is no space, and it's overlapping. Couple buddies here, so that's not normal. So I, um, confident that is going to be a dislocation here. So, yes, there's a gap and that's again throwing overlap there. So that's a dislocated index MCP joint. And if you think that subtle, which if you're used to looking at risk pills, you should be looking at that Jones based on spotting now that goes to show the value of the lateral because I would be very obvious on Electoral. So next race. Yeah, uh, yeah, right dot um so in most centers and taking Sheffield when the radiographers take the films, if they think there's a acute abnormality, I'll put this red dot um, on the film. Some of them have actual red circle. Appears, um, yeah, right red dot If they think they can see a fracture now, the reductions are usually quite good, so if they say you're adult on overnight, you're looking at the film and you can't see a fracture if you're very confident, then you can disagree. But I would say Is it clear? Quite junior, and you're not sure, but they've been reductive. But you don't see the injury. Go and ask the right doctor. For what? Let's see, cause they take lots of these films and they get quite used to. Yeah, disporting abnormalities. Okay, so you don't see this film? Yes, I would describe this as it is French. You hear otherwise normal alignment me displaced. So it's a minimally displaced common. You did right. Index finger distal phalanx fracture on the reasons common it'd, which means broken into multiple parts is because we can see there's at least so three fracture lines. So it's fragmented. More common. It'd Yeah, yes, through the tuft of the index finger distal phalanx. Okay, Okay. So I'll run through this one because I I have a sneaking suspicion. This is the same film that we saw one before last because we can see base off the index finger. Not in normal. I'm mint here on there. Also old fractures here and here. So I think that's not coincidence. I think that's the same film. Yes. No, She has come up twice a polygene. Ah, yeah Is yeah Index finger trout. You second, CMC It could just need to confusion. I would strongly advise Kate thumb Index middle, bring on little fingers in the toes. It's okay to your numbers, I think. But in the hands use the name when you're old, French is And it is just a close up to really demonstrating Hum that home. So this is thing home again and then they've had it reduced so it's been manipulated on. Now we can see about joint spaces returned on there's no longer overlap base with carpal bones and that's again but light of day or daylight Sign that this is normal The nice demonstration off injury on then relocated. Okay, Okay, so yes, I agree this is normal. Uh, someone's apparel unit dislocation. So apparently unit dislocation would be the capitate. It's not a clearest natural. It's not a true lateral. So when we do a lot of radiograph pees, a form which is here should be projected. So they have the middle of the skateboard. There is no quite centered properly, but that capital is here sitting on the lunate on the radio. Yeah, normal. Yeah, So you're all spotting the fracture. Quite an obvious fracture. Transits, man Chair for you, proximal shaft. All the base off. What I think is little finger proximal phalanx. Ah, but as someone spotted, there is a bone lesion. Yeah. So this is normal bone architecture. Track your pattern here. There's disruption that lucency Probably some slight expansion, tiny degree of expansion. So the bony margins have widened on. The cortex is thinned from the inside, but ignoring the French, the cortex, there's no periosteal reaction. Let's see what we call endosteal scalloping, which is thinning from the inside of the cortex. Both sides say French bone lesion there can shake nicely that endosteal scalloping. And that's just a close up off, um, normal for comparison. So this lesion is, um, be on the scope of the talk. It's probably enchondroma. The most common benign bone lesion in the hilum. Geez isn't chondroma. But I think for any of your reporting the vin, any auras, junior doctor's nurse practitioners, things like that, I would say spotting the fracture is the key. That clotting the bone lesion is important. But I think it's where your limits of like pathological fracture, fracture through a bone lesion. I don't leave it for orthopedics on radiology to work out what the bone lesion is. So yeah, pathological fracture. Next case. And so so you are limited answers. I'm gonna take this to be that we're not sure. Okay, so we're going to get towards the back end now. We've got five cases left. They're gonna get tricky. So if you're not spotting these, I would not worry too much. Okay, Uh, what we've got here. So this one is quite old radiograph. This one wasn't a current case, which I think is why people thinking it looks a bit sclerotic, these bones, I think it's just the way the films taken there isn't really much to Janet to change my way. Um, and these bones are probably normal density. It's just another film, um, which was given to me. But what we're seeing here is that we're tracing the the capital here. Sorry. Hum eight. Yeah. Homemade. They're the furniture, this bone fragment hair. Where's that come from? Yeah, exactly. Where's that come from? This cortex here, lucency. Something's not right. There's a ham, a fracture, So yeah, that's probably come from the hook. of the hamate. Which is why, if we go back, um, something's not right. But there's no clear break in the cortex. But there's this fragment. That's probably because it's the hook which projects. So on top of the hamate, which is fractured and then move around the side. Yeah. How many fracture? Ah, line through the skate, Boyd. That, uh, that's just normal skate void. And it's where the plane of the scale was not entirely in line with the film, so it's slightly oblique, which is where we get this overlapping. That's just that's normal. Nice. And to me, of course, the court. Um, yeah. So how my fracture, Which is difficult. The spot. Um, I could very easily be missed. Okay. Um so which one for this one? There's a fracture to the base of the thumb some days fracture. Okay, He's the one. So are you looking through this one? I'll show you here. This again. How many on this bit here would have been the hook. Which consult. See how a fracture here might be difficult spot on. Then It is displaying displaced here. Okay. It's something where we want you that say yeah. Anyone can quickly put Answer. Okay. Say this one is normal. Uh, capital, This location. So this cup here's the capital. There's the lunate. That's the register, That role in a line. So this is normal. So Okay, so this one, anything carpal veins on? Yes. Well, don't. All of using. Spotted here is a hammock fracture. But let's make sure we look at the rest of the film. So the alignment, so carpal spaces look okay on edge. A film base of metacarpals. Look. Okay. Someone said carpel joint space. It widened. Um, I can see what you mean. There is slight gap, but it's quite uniform. They all look very symmetrical on this ap, and then on the oblique again. They do look symmetrical, but here, we've got this hum. A fracture. There is. There's that fracture. Two films left. What? Okay, It's who had a range off answers. So? So I've no seen a fracture. Some people said lunatic proctor capitate fracture. No, I I think they look okay. There's no break in the cortex. There's no use in lines. And then let's look at the joint spaces. So this row looks okay. The middle row looks okay. and they're just still space. Space looks okay. And then between the carpal bones, this is wide. So that's capable, Luna Interval is widens. Now it's not as obvious is that first clamped that we saw That was really wide that this is not a symmetrical space. If we compare disc out this capital to this capital to the scalp, it's wide. If you measure it, it should be less than three millimeters. Normally say 3 to 4 is borderline more than four is grossly decisive acted. Yeah, so yeah. Scrotal unite association or escape Eliminate ligament disrupts room. Correct ounces. Okay. And this is the final film on this one is quiet. Good. Really Well film. The bone density is reduced their osteopenia and they do have a way. So typically here in the S T t joints escape. Oh, trying quick from they try trapeze trapezium tract is always scared. So trapped museum trapezoid joint STT joint on the base of the thumb. So this some carpal metacarpal joints these and narrowed you can see scar assist. Um, some cystic change. So that's a way, uh, I think the office the old looking bones gets a clue to the injury. It's a on the 80 no particularly remarkable going with that narrowing here on lowering hair. But otherwise alignment looks okay on when we look on the natural, tracing the course of these, uh, here. So that's that. But remember, I said, Distal radius should be really, really smooth, and it's known as a step. Um, that's a disarray DS fracture, which is minimally displaced. No particular ated. Everything's all lining up again. It's not seeing on this AP, and that's why reviewing the distal radius door sleep ticket on the natural is really important to just arrange is French, I think. Just the way up here. Yeah, that you guys, that's your on bones marks. There was a capital bright general. It's Yeah, I got distracted and I hadn't looked. Arrest the film properly. There is a step in the capitate. They have a loose in line that's very suspicious for a fracture. Purses. So yep. I got caught are going to quickly on the last case trying to wrap up in time for you, but they are just the radius fracture and a capital fracture. So that is all of my cases. Well, don't tell everyone that's made it to the end, and they will run over. I didn't know how many cases get three, but we got through them all. So thank you for listening. Big. Thank you. To those of you there have been participating in a chapped. So Jeremy Grace summary roshni uh, stuff. Uh, just name a few. There are more of you, but yeah, Melvin for kind of wants real questions. I'm getting most of them, right. So if you want to take my email address, if there's anything else you want to ask, please do be happy to quite 20 questions or take any questions from the tracks if you want and can feed by home. He really useful as well on I have lows of cases off osteoarthritis or authorities. Rheumatology case is if you want another session at some point on arthritis in the hand, which is a really, uh, of classic medical school questions where they show you the cases that they could describe from the findings knowing the difference between osteoarthritis rheumatoid CPPD, if you want not happy to do one just last night on the feedback form. Yeah, that is that I hope he mashes spot some of the abnormalities on. But I think you remember all of those hiding then. That's not gonna be much that you'll see in your work in practice that hasn't been showing on these cases. That covers pretty much all the common pattern of injury, including some of the more rare injuries on the important injuries. Not to mess. Thank you. One question. Sorry. I'll chance it different. Um, my left finger and bony my lip. So the mallet finger describes the mallet. Finger is the deformity. Where is a flexion deformity? Uh, bone email. It sort of is where there's a fracture causing that. Yeah. Kept my hand back. You? Yeah, you told him about this morning on. Thanks for everyone is watching for being so interactive because it definitely makes these sessions more interesting educational on. I'm sure everyone will agree that the high rolling off cases was particularly helpful for their learning. Think as we all know, it's about seeing as many of these as we can. Definitely applying this when I go into my neck. Shit. When someone decides to push themselves at three. In the morning. Um, just to review you're Henry's comments about the red dot because there's being a couple of times I've seen red dots with films in the emergency department, and it's quite difficult to identify the injury on a quick chat with the road Radiographers will often reveal, but it's conscious. It'll injury, and that will sometimes just get reports of the next day we can't find with ourselves. So depending on your trust, if you have access to the imaging software, then sometimes the radar because we'll leave a comment on why they brought out of diminished quite helpful. So you should have all had feedback links. Email three to you already if that hasn't arrived, and then that should come through in the next couple of minutes or so. But I'm also going to paste into the chapped box. They'll give you seconds, so there's a few minutes in that. That first one is just a go through the feedback. Think so you can leave it for us on, but it's how you get your certificate the mail through to assume that you feel that, um, two weeks from now. So that's Wednesday. Date of December 8 in the evening. You, Kate, I'm Dr Joe Can will be presenting a structured approach, common cases and pitfalls off lower limb escape. So that's gonna cover knee, ankle and foot X ray interpretations. Um, I'm going to sign up fast is also the chapped box on that last link is going to take you through to the mind a bleep a website where you can sign up for a lot of the radiology webinars at a left as well as some of the other weapons that we do. So we do. Surgery medicine as a finance one is a pediatric. Want to sign it, too. So if you're interested of those, have a quick looking off websites. I think there's a couple of questions uh, pop took since I've been talking to the, um um, sure s I think we have you up to date with the questions. Yes, are like the's will allow get saved on metal so it takes time because it's quite big file book. Uh, they will be able to be seen if you go back to a link of how you signed up. If you look in the left hand side, it should say recording sessions or added content. And if you go on that, then you can watch this entire thing because it all gets recorded. Um, I'll leave a couple minutes or so, just in case or any other burning questions. But if no thanks everyone for watching. Thanks, Henry, for, um, doing so many cases and four teachers, all these different things. Thank you, Kevin. Three invites to come and speak on D again. Thank you for being so interactive. It really makes clearing the sessions much more informative, I think. Also more enjoyable for me presenting. Have knowing you guys are there listening. Thank you. There's we're must comment with that finger. I assume that non bone injuries canaries ultimately in that example tender in the injuries. Yes. So the mallet, all that affection deformity could be you to any injury that destructs the extensors mechanism on the finger so it could be a tendon injury or on abortion injury. Um, most commonly, it's not motion injury, but it can also just be a purely tendon, this injury. So if you have a rather, like fall in the front door, if it was a so they saw injury or laceration, um, you can cut the tendon, which would give you the monitor deformity without a fracture. So yes can be just tendons. Ondo. Don't forget Teo. Come back into each times that's Wednesday gave of December for the lower than on escape. Be looked for that is just above. And please don't forget to do the feedback form on that links above his well be should also also had a female come through on. Once you feel that in, it means that you'll get your certificates and also means that we know how you can improve things. Because we do. Look at the feedback on DA. One of the common themes is that they want to. People wanted more cases. So that's why we were trying to include that in the session. All right, doesn't work. There's no questions. So thanks Henry Ford delivering the session. Thank you, everyone for watching on. We'll see you on the eighth of December. A little bite