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Started last August. Um Basically, I'm just gonna go through um some musculoskeletal X ray kind of tips for interpretation. Um I'm not sure exactly how, you know, uh I'm not sure exactly what level we're I'm going for. So I've made it quite broad, but just ask me any questions at all. Um Literally feel free to interrupt me if anyone wants. Um uh If I'm not making anything clear and ask questions. Um Yes. So basically, we're just kind of going to go through. I mean, the main thing that you're thinking about which muscular skeletal x rays is to do with fractures and kind of looking for looking for fractures, looking for signs of fractures. So we're going to go through that and just kind of develop systematic approach um for that. Um And also just kind of recap some anatomy that we would use to um in order to do that. Um Yeah, but definitely feel free to interrupt me, ask any questions at all. I'm also going to be asking you guys a lot of questions. Um So you have to answer otherwise, that will just be me talking to myself and that will be sad. Um So the times that you're gonna need to be able to interpret x rays, um, it's gonna be mainly when you're working in a any. Um, so I'm not sure if you've been to any urine placement, but when you're on minors, patient's will just come in, they'll have hurt their wrist or whatever, or the ankle and you're just gonna have to examine them, look at the X ray. Is it broken? Is it not? Um And then decide whether they need any treatment for that, um whether they need any referral fracture clinic and whether they can go home or not. Um And that's quite high. That's, you know, that makes a lot of difference because if, if you miss a fracture and any um and a patient gets sent home without treatment, um then they could potentially, you know, just be walking around on a fracture and that can cause some more issues in the long run. Another time that you're going to need to be able to interact for excuses when you're working on the wards. Um So all the time, if your medicine or, you know, Ellie Ward, basically, um patient's will just fall over, fall out of bed today. They tend to do that a lot in hospital. Um And so then you have to, you know, request an X ray, see if they breaking their hip, whatever. So that's kind of the situations. So the main thing with X ray, I didn't, I'm starting quite basic. Um but attenuation is um you know, so you've got an X ray beam and it's going through the body and different parts of the body can look different colors. Um So as you can see there, you've got air is going to be black, bone is gonna be white to bone calcium, anything that's gonna be white and then there's gonna be different colors in between, between black and white. Fat is often like a dark gray. Um and soft tissues are more of a light grey. Um So as you can see the um that is an X ray and you can see kind of white bones, different levels of white and then there's different levels of grain, the soft tissues and in the fat. Um Another sort of principle of x rays is that you'll always need multiple views. Um Does anyone know any kind of X ray views that you might use? I have written one there. So that's a good clear. Um Okay. Um So A P is like anterior to posterior. So that's just a sort of front, back from the front. Um And then you can have a um like a lateral view as well and that's just from the side. Um And then there's lots of depending on what body part is, there's lots of different sort of bleak laterals and things like that. Um So you might want to um get different views because things can look very different as you can see there. Um, on the A P, you can't really tell that this patient's got very dissipated finger, but on the lateral it's super. Obviously, you just don't want to miss anything really obvious, basically. Um, so, um, first thing in these do is go over the anatomy of a long bone. Um, so can anyone tell me what any of these things are pointing to? I was, I'm going to pick on paper that's David. I have to leave my screen. So if anyone can participate, that would be great. Uh huh. Okay. Someone come out, I'm sorry, I'm not seeing the screen basically. So I need you to actually talk because I can't look at both of them at once. I've just seen that someone said P A which is good, but I just literally need people to actually talk if they won't participate. I'm not sure I haven't revised this a long time. Uh It's not, is that the foot or it doesn't matter? It doesn't matter. Um But it's just parts of the bone. So that's fine. Um Number two would be like the growth plate, right? Um Which can also be called the fisa. Um Number one, that's the epiphany sis, which literally just means above the above the Fyssas, which is above the growth plate, this the bit that's just below the Fyssas. Um So the um a bit that's kind of coming out at the sides. Um number three, um, between those two blue lines that's in the taff Asus. And then the diagnosis is just the shaft um of the bone, um, and all long bones, whether it's your arm bones, leg bones, whatever, they're gonna have those parts to it. Um And there'll be a gap in the growth plate when bones are still growing, turn Children. Um And then later on the, uh it'll fuse but you would still call that fused bit the Fyssas and okay. Does anyone know how, what kind of words you would use to describe fractures? Um Like if you're looking at fracture on the next ray, what what are you going to say about it? Give me anything at all. Would you like describe well, obviously describe the fracture. So like compound like a compound fracture or like, I don't know that's the one I can think of. Yeah, that's fine. So compound fracture and you know what a compound, what you're saying when you're saying a compound fracture? Um not exactly, I mean, in my mind it's like where two parts of the bone have kind of gone into each other. And yeah, I'm not quite sure. Yeah. No, no, that's all right. Does anyone else have any things they would use for describing fractures? And remember you need to talk because I can't go into the chat transverse. Yeah, great if it's the transverse fracture. Yeah, perfect. So um so a few ones that I thought of kind of the site of the fracture. So often with, with a long bone, you would split it into kind of proximal middle and distal third. So of that long bone that we were looking at before, you would say if it's proximal, it kind of nearer to the middle of the body. Um and distal would be sort of more towards the peripheries. Um So you want to say exactly where it is, um if it's a closed or an open fracture, that's more clinical really. That's not really an X ray. Um But you know what that is, that's just if it's kind of openness through the skin fragments. Yeah, and fragments. I think this is kind of what we're saying about compound fracture. So I think compound communicated is another word that's when there's more than two fracture fragments impacted is more when they're driven into each other. Um And that's kind of what you're describing as well. Um So you want to talk about the fragments, um You wanna talk about direction which you said, so it might be transverse, um horizontal might be a bleak or it might be like a spiral fracture. So going all the way around, which happens often, um you want to see whether it's intra or extra articular, which means is it within the joint or is it like not within the joint? Which we'll talk a bit more later? Anyone say whether it's displaced or undisplaced? Um So that just means has it, has it, um you know, is it just a line that you can see or is, are the two piece of bone completely separate and angulations is similar to that, but it's just what direction is the digital fragment going. Um So we're just gonna go through a few cases basically. Um Have, can anyone tell me what any of these arrows are pointing to? Anatomy wise? It can be like the most just like the bones basically is three. The electoral on. Yep. One's the humerus. Yep. Perfect. Who's the head of the radius? Yep. Perfect. Amazing for the epic condo. It's more like like when you say that you call it like the capital. Um but yeah, like the capital um of the humerus. So yeah, like no, basically on a perfect. Um So can you see anything abnormal on this X ray? That's the, that's the starting point or what would you use? Do you know any lines or anything that you would use to be able to tell what's normal in electoral elbow? This isn't how though, by the way, sorry, I should have said that. Oh no, you know that because we get the phones. So there's a few things, there's like a Radiocapitellar line. So that's just this line that goes from, if you're measuring from the radiohead, um you should be out the line that's going out from the proximal road. Your head should pass through the Capitellar Um So if you didn't have that, it will be something like this and that, which basically just mean that you're Radiohead dislocated. Um So that's a good line to be aware of. Um There's another line that we use more in pediatric elbows because it's more useful for um like super consular fractures. So there's an anterior humeral lines that one just passes down. So you're just going the anterior aspect of the humerus and you just want at least a third of the capitaland to lie in front of the, basically when it's normal. If not, then. So like for example, in this one and the supracondylar fracture, which you can see the arrow pointing to. Um that's not as much of the, um there's not as much of the capitellum line ahead of that line. So we've got two lines, we've got an anterior humeral line, we've got a radiocapitellar line um in terms of going back to, yeah. So the al backs, right? Um Do you remember what I said about the fact, the fact attenuation? So these darker gray bits are gonna be um fat on the left, you've got a normal fat pad. So you can normally see the anterior fat pad um lying just on top of the anterior humerus and you can't see the posterior one normally. However, on the right, with what raised fat pad, that basically just means there's a larger fusion um and it's probably blood. So it just means there's loads of blood in the joint and that's a sign of a fracture. Does that make sense? Um um So what, what are we thinking at this point with our elbow X ray? Now that we've seen that we've got raised fractures, raised fat pads. Um Yeah, so we're gonna think about there being a fracture and oh yeah, this is what I was saying. Sorry. So displaced fat pad, that's a joint infusion, which shows that there's a significant injury, probably a fracture. So we're going to want to look at another view um to be able to find the fracture. Can anyone see a fracture on this one? It is a bit difficult without zooming in. So if you do, man, that's the radiohead. Um and that's a non displaced. So that's what I'm saying, like you can't see kind of two separate fractures to separate fragments. Um There's just one um there's just a kind of a line there and that radiohead. Um and that is the most common fracture for adults in the elbow. So if you see raise fat pads on the elbow, X rayed, they've probably got a radiohead fracture. If you see it in the Children X ray, they've probably got a super clavicular fracture of the humerus. Um So that's basically the, that's what you need to know about Albert X rays. Um So the radio has met, that's the most common fracture in adults and the supracondylar fractures are most common in Children but fat pads really useful and also the different lines, the red cap patella and the anterior humor line. Um So the next case um is a Pelvis X ray. Um Can anyone tell me what any of the numbers are is for the pubic synthesis? Yeah, perfect. It's one the head of the femur. Yeah, perfect. Yes. Uh sorry. Yeah, I was treated obturator foramen. Yeah. Is five the greater trochanter to Yes. And then I guess six is the lesser. Yeah. To the Iliac crest. Yeah, perfect. So that is everything that we just said. Um and we also, you know, is there's a left and a right. So we'd say that as well, but I haven't even put that on that. Um Can anyone see anything abnormal in this X ray patient's fell over on the ward? There's literally no stupid answers that don't you just tell me anything I might be reaching but is there a break in the neck of femur on the left? What makes you think that I just feel like I can see like a white haziness across but I don't know, I think that is, that is good. Why do you think a break might look like a white haziness? Um actually couldn't tell you. I'm not sure that's all right. Um Can anyone think of anything that you might use in a Pelvis X ray? Um to kind of help you decide if it's normal or not, I also don't know, but it looks like on the left, the greater trochanter is like a bit higher, so bit raised. I'm not sure if that's the thing. Um Let me see. I think it might just be possibly a little bit rotated, but that is also, um, that is also a valid point. I think I'm just thinking in terms of like, have you heard of Centonze Line? So that is basically just when you follow up the up that sort of medial aspect of the theme. Uh and you follow it around um onto the, the lower aspect of the, the superior pubic rapists. And that should be a smooth line which you can see on both sides. I think that's quite a smooth line. Um Does that make sense? So it's just following that line um up that I've marked over. So that's one thing you can use often when pay patient's have hip fractures, they, that line will be completely off a little bit like, whoa, this looks odd. Other things you can use. Oh yeah, they're, yeah, sorry. So I'll look like that. Um That's probably a fracture. Um Also, there's like the pelvic rings you can use, you can just kind of trace through the pelvic rings. So that's your main pelvic ring and the two of curative for Mina. Um So you're just tracing everywhere to look for any regularity. So for example, here you've got breaks in the pelvic rings um which you can tell us uh pubic remi fractures um in pubic array of my fractures. Um You often have to because it's a ring. So often if you've got one fracture in the ring, then you're going to have another fracture in a ring because it's like a ring like so um situation, so it breaks into places. Um However, this one, you were right there was this sclerotic line at the left neck of the femur. And so that was a subcapital neck and femur fracture. Um And it's a sclerotic line because it's the two fragments, like we said before, they like communicated. So they've been driven into each other. So you're seeing two lots of bone, one on top of the other instead of just one bit bone. Um because you can get a lucent line when the bone has separated, but in this situation, it's communicated. So, um yeah, so next three femur fractures as you know, most common during the elderly doesn't even need to be, they don't even need to have fallen over. Um They might just have osteoporosis and done a funny twist, but so common, um they can show up as like a black line through the neck of femur, which would be like a lucent line like I said that the gap was sclerotic line um when they're more communicated. Um If that undisplaced, like, for example, this one I think was probably undisplaced because none of the like the centonze line is still normal, you can still see that centonze line is intact. Um But so they can be quite difficult to detect. Um they can be intracapsular or extracapsular. So that is to do with the capsule of the hip joint. Um And that is really important in hip fracture specifically um because of the risk of avascular necrosis um which is basically explained here. So the hip capsule, you can see that's that whole area on the, on the, on the picture. On the right. Um It's got a, so it's got its own blood supply and then there's another separate blood supply coming up from the femur. So if you, depending on where you break, so if you break within the capsule, so the kind of across the neck of the femur or just below the neck of the femur. So, subcapital, um if you're within that capsule, um then you've got very high risk of a vascular process because you're just going through those, those vessels and there's nothing else essentially. Um whereas if you have extracapsular fractures, you have no risk of avascular necrosis. Um And they're the ones that are sort of this line basically at the counter and bought the, it's called, but just sort of above the toothpick and the into the end of the truck and direct line and basically, um which you can see between two and three. Um that's kind of where the capital attaches. Um and So that's gonna be where above which you're going to be worried about a vascular in the process. Um So that's why hip trash is very important and avascular necrosis, literally just the hip, the femoral head just crozes. So it just dies, it's got no blood supply. Um And that, that basically will define what interventions um also will do. So will they be more likely to do a complete hip replacement because the femoral heads gone or will they want to try and put it back together with a nail? Um So basically to summarize the kind of hip and pelvis X ray, we've got pelvic rings and centers line to help us. And we just look for any bony irregularity traced over all of the bones. Um And we're looking for lucent and sclerotic line um which you correctly saw earlier on. Um And you want to know whether it's an intra or an extracapsular fracture. Um So just to confirm, is this an intro or an extracapsular fracture? Yeah, perfect. Um And that's just because it's sort of at the level of number two on that one. All right. So can anyone tell me if this is an adult or a child, child? Yeah. And how do you know that? Um is it the perfus iss three? It's not fused. Yeah, perfect. So um three. So the, so the three would be like the Fyssas. So the growth plate and yeah, you're right. It's not fused and then the epithets iss would be the bit above it. So the, the little, um, the little blue above above three. But yeah, so that's what three? Can anyone tell me? And what is the, what is that? The Fyssas of what? Bone? Oh, no. Yeah, perfect. So four would be the owner. Can anyone tell me any other numbers? What's five radius? Yeah, perfect. Um, same one. Know what one or two are. Um, I think choose a cup of tight. Yeah. Yeah. Yeah, perfect. Um So uh just for Bones of the rest a quick aside because, um, yeah, I think that's what we said. Yeah, because I found it really difficult to learn both of the risk because the, some of those positions, whatever. I don't know, it just doesn't work. Whereas this one, I don't know if you've heard this one so long to pinky, here comes the thumb. That one makes a lot more sense because you start the skateboard. So you start at the very deal aspect. So then you've got the stuff skate forward, lunatic, try quicker and pit form and then you just go up instead of instead of starting a whole new row. So you get to p for Pinky. So you're on the, you're on the pinky side, pinky, pinky side and then you get up and you go, here comes the thump and then you're, you've ended at the thumb and so I don't know. I think that one works a lot better than someone of us try positions. Um So hopefully that will be helpful for you. Um So on a laughter rule breast X ray can look really confusing. But basically this is the only image that you really need to that you really need to know. So the capitate sits on top of the lunate which sits on top of the radius just like this. So you can see that there on the side and it just all should make a nice line. Um So it's just radius looney capitate. If it's from wrong, it'll look something like that. Um So as long as you've got on your, on your um lateral wrist, as long as you've got a line that's kind of all lining up like that, then you're all right, got something like this. It's all gone wrong. Um Can anyone see any abnormalities on this? There's no stupid dances, you see anything at all? Um Okay. So can you see where I'm pointing to that? There's like a little like a little like ripple you can see. So I'm trying to like, I don't think I shared my mouse pointer, but essentially as a little bump on the bone. Um And then you can see that on the image on the left and then the lateral at that point where there's a bump on the radio, um the bone becomes angulated. So it's kind of gone off in a different direction. So it's just coming up vertically and then where the bump is, it's going more positive anteriorly. Um So that is a buckle fracture, which is really, really common in Children because they've got different bones much, I'll explain um like their bones kind of break differently to adults bones. Um So it looks just like this. So you get, it's not complete fracture, it's just kind of a bulging of the cortex. It's to do with actual loading of the long bones. So happen in your wrist. Really common. Children might hear it being called a tourist fracture, but buckle fracture is kind of more common and it's just to do with the children's bones. Bit more flexible and less, they're less breakable. Essentially. Another childhood fracture is there's so much as a Greenstick fracture you might have heard of and, and that's where it will break on one side and it hinges on the other side. So it's kind of half snaps which you can see in that X ray. Um And then you can see here that's the greenstick fracture is when you fall kind of on the outstretched hand in an angulated an angle to the floor. But the buckle fracture is when you fall just completely vertical and that's why it's buckling instead of changing direction. Uh huh. There's also just while we're talking about kind of other pediatric fractures of the wrist, um those fractures were both far away from the, from the growth plate they were well into the shaft of the bone, but sometimes you can have fractures that go into the shaft of the bone. Um And they are like into the sorry into the growth plate. Um And they're more worrying because they've got a poor prognosis. You're going to have all kinds of issues. If you've gone through your growth plate, it's gonna really mess up your ongoing growth of your bones. And there's a classification for that, which is called Salt Harris classification, which is just summarized here. So, um one is when you've just gone through the growth plate, but you've not gone through any of the bone too is where you've got a break above the growth plate if you're looking at it upside down, but I guess that works. Three is break below the growth plate as well. Four is all the way through and then five is when it's kind of communicated fracture. So it's being pushed together and that's going down in terms of prognosis. So, uh Salter Harris one fracture will have the best prognosis, the Salter Harris five, she'll have worked prognosis. Um And that all depends on how this place that is. Um But yeah, if you remember, that's just a easier way to remember. It's with this kind of S A L T Delahanty. Uh And so if we're using this classification, obviously bearing in mind that the bone is the different way up. So we're now looking at the proximal growth plate instead of know we're now looking at the disor growth plate instead of the proximal, does anyone know what number this would be for themselves to Harris classification? If I'm looking at that would have been number three. Um So I think it will be number two, but it's just because we're upside down. So this is the proximal growth growth plate. Um So the, it's not, it's not, it's gone into the metaphor Asus which is kind of below the growth plate, not into the f emphasis, which is the bit on the end. So I think it will be three. No, I don't know. Maybe two. Uh huh. Yeah, too. Okay. I've confused myself. Yeah. Let's take um die to summarize. You just want to check all the bones in these risk X rays, specially Children and you can look for any bulge or any angulations that might um show you a buckle fracture. Yeah. Um We have got two cases left and there's the second last one. Can anyone tell me what any of these numbers are? Does anyone know what one is the tibia? Yeah, that's right. Anything else? Two is the fibula? Yeah. How's that? For is lateral malleolus? Is it? I think so. Sorry. Say it again. It's three lateral. Yeah. So the fibula is always lateral. So Fibia is that towards the titular tip, tip, your tibia fibula fibula is lateral to the tibia and so you're the fibula will have the lateral malleolus. And so number four will be the medial malleolus, which is the tibia. Um So you want to what? Five or six is five is the Taylors? Yes, perfect six. Sister Calcaneus. Yeah, exactly. Um That is, that's what we've got. And so when we're looking at ankle x rays, um there are a few things that we would use to be able to tell whether it's normal or not. One of the things is looking at the Cinders mouth and the Cinders mouse is this syndrome assis is where the tibia and fibula overlap. So you want them to be overlapping, you don't want them to be separated because that would show that there's breaking into osseous membrane that's between them. So you want them to be overlapping just a little bit like this. Another thing that you would look at is like the ankle morty. So that's basically tracing the area around the superior aspect of the tailor. So, and it's just looking at everything all of the articulation with the tibia and with the fibula is completely uniform, this a around kind of formulated, but as long as it looks very uniform and you're going to be happy with that as opposed to just been way off on one side and that would be um suspicious for a ligament injury. Um which is this basically, so that's just looking, that's the interosseous membrane, that's where they would overlap if it was not overlapping um then you'd be thinking about disrupted interosseous membrane which is more suspicious for further injury. Um And you can see on that, that the the ankle, more teeth is not um completely uniform on this one, that the gap is a lot wider on the tibial aspect than it is on the fibula aspect. Um Another thing that you can use when you're looking at for an ankle, X rays is this bolus angle. Um So that is basically drawing line. Um see draw one line that's from the most. So it's the superior aspect of the calcaneus at the back um to the kind of highest point which is where those two lines cross over and then another line that goes from the highest point um to the anterior aspect and that you want to be about 30 degrees. Um If that's flattened, then that can be suspicious for like a calcaneal fracture um or further abnormalities on our X ray that we were looking at um previously that would show a normal villas angle. Um That's about 30 degrees and more um like it's KV dancer. Sorry. Um Can anyone see the abnormality here? Can anyone describe if they can see anything abnormal too? Is there like a break going through? Um I think that's one of the metatarsals. Yeah. Which metatarsal would be? I'm gonna go with the fifth. Yeah, perfect. Can you tell me anything else about the break? Is that displaced or run placed I think it's undisplaced. Is it like a transverse one because it's going straight through? I don't know if it's the trans first undisplaced. Um, do we think it is intra articular? It's not, we can't see it going all the way to the, um, to where the joint articulates with other phones, but it looks like it might, could be and it doesn't look angulated, does it? Um, so this is something really common that you will see on a lot, a lot of ankle x rays and for x rays, um and often people can just present with pain in the ankle. Um It will be the, so it'll be the ankle pain I think can be a bit buried. So they might not necessarily have like lateral malleolus tenderness particularly. Um It can just be like a generalized ankle pain, but it's usually to do with inversion injuries and basically what it is. Um it's avulsion fracture. So an avulsion fracture is when you've got a tendon that it's pulled off. In this case, it's the Peroneus Brevis tendon that comes down. Um the posterior aspect of the fibula um behind the lateral malleolus trial malleolus and then um connects to the base of the fifth metatarsal. Um So when you've got an injury like an inversion injury, um so like twisting ankle, it just pulls off the end of that. Um And it can sometimes unless you're looking for, um it can be difficult to see especially because does anyone know what an apothesil sis's? So and hypothesis is it's kind of like an epiphysis, iss except it's not part of the joint and it's something that you would see um in pediatric X rays. So like a secondary ossification center. So just where pediatric X rays often have a lot more kind of ossification sentence on uh adult X ray. So on the on the left, you can see this is just a normal office is right. This isn't the basis fifth metatarsal fracture because it's vertical. And whereas on the right, they've got both. So they've got a transverse um basic fifth mass tassel avulsion fracture and they've also gotten confused a prothesis. Um So that's a bit confusing but it's, it will come up often I think when you're in any and stuff and seeing patients with did I cause? Uh so yes, it's a summarize and collect rays. So you would look at the A P more teeth view, that's just what they call it. And that's when you've got that kind of the way that the um to be a fibula and the Taylors all line up, you're looking for a sort of roughly formula meter equal distance um surrounding that Taylor and you want that to be a bit of overlap, contribute and fibula. Um You can use bowlers angle to tell if there's anything unusual and you need to keep an eye out for any fractures of the money on either Taylor's or the basic check metatarsal. Um Okay. Last case is um this one. So can anyone tell me any of the numbers is for the fibula head? Yeah, perfect one is the fever. Yeah. By this the patella. Yeah. Or is that of fibula? Yep. Yep. Um Okay. So, so what have we said? We said one C four and we said five. So the other ones that we've got our uh my arrows aren't lining up, sorry. So the tibial spines are these two little pointy bits right in the, in the center of the superior surface of the tibia. Um So they're just called tibial spines. Um And that's where your ligaments attached. So you can get avulsion, practice of them as well, your tibia tibial plateaus, basically the meeting on natural aspects of the. So the whole kind of area on each side of the tibia at that um a proximal proximal proximal aspect. Um And then the other thing that would be looking at here is the super patellar birth uh um which is the, which is kind of an area um super patellar area where you would get any infusions or anything. Um If you're looking for a near fusion, um can anyone see anything anything at all on this extra except normal, anything to um okay. So if we just look at the super tell Aversa again, so that's this area that I'm pointing to on here. Um And it's that whole area, um sort of, and it's between fat pads, essentially. Um We always have that on the latter on the X ray. So normal Super tell Aversa um is fat density because you just look at the fat pads. There's no, there's no fluid in there. Um which you can see on the fact that the first X ray at the top. So that's all fat density. It's the same, um It's not the same density as the soft tissue. It's whereas on the lower X ray, you've got um fluid density, fluid, soft tissue density, that's a light grain through the dark rate. And that's how you can tell that the patient's got a large joint infusion because there's fluid in that, in that inversa. Um So, in this case, in our picture, this is going back to the one that we were here, this has got a fat fluid level. So it's got both, it's got um this sharp line across, um which is below. You can see there's there's fluid and above, you can see this fat and it kind of separates out. So the fact sort of rises to the top. Uh fact this is a sign of uh intra-articular frack Chester like a like they've got a fracture. Basically, if you see this, this line on the lateral, the answer, right. Um Because you get a lot of fat that's released from the bone marrow when you get an intra articular fracture. Um And then it sort of rises to lie above the fluid, the fluids, blood. So that's why it's called life oh, hemarthrosis. Um, like salad dressing like vinaigrette basically. So it just kind of rises and separates and that's the same thing. Um So we can see that we've got that, which means that we've got an intra articular fracture. Um And so we would look at, we would really look very closely at the um, superior and the inferior kind of the joint space. Um to look for any intraarticular faction, you can see there's a uh an undisplaced lateral to the old plateau fracture, um which we can't receive, it looks very pixelated. Now, actually, so don't worry about that. But the point is the the life of chemo after assess because that's just a sign to look harder. Basically. Um tibial plateau fractures are an impaction injury. So the lateral femoral condo um will just go down into the lateral tibial plateau exactly like this picture. Um And that's why it kind of it's like an impaction kind of thing and you can get associated ligamentous injury with that as well. Um And that is, that's that basically. So, and you might also see like small bony fragments. Um for example, if you get avulsion fractures of the tibial spines, um and you might and yeah, and it also just shows you would check, you would use the lateral x rays to look at joint effusions or fat fluid levels. Um Yeah, so basically just to summarize what we've done, um we've kind of decided systems for describing batches. We've got system for interpreting common muscular skeletal x rays. Um So those are the joints that we've gone through. Obviously, there are more joints but we can't do everything. Um And we've kind of just touched on like using different clues within the X ray. Um aren't just bones to look for bony abnormalities. Um, yeah. Does anyone have any questions? Oh. Um, in which case? Uh.