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Okay, I'll go ahead. Um, right. So, um, this is Mohammed. And, um go, Picca, We're gonna be talking through, um, the hand component off the QB Orthopedic society. Um, lecture series. Um, so basically, what we're going to be covering today is a little bit about the clinical anatomy and, uh, common hand pathologies, because got some factors and some really good questions to go along with that. And then finally, I'll take over for the hand signs of systemic disease, so we'll just start off with clinical anatomy and the bones component of it. Um, which is obviously very interesting for some of the people. Um, so carpal bones are basically a wrist bones, and there's quite a few of those. And there's a interesting demonic there that you guys can use to learn that, um, she looks to pretty try to catch her. And then it stands for, um, scaphoid loon. A tie question pissy form. Trapezium chap is always capitate ham. It's if you do. If you guys want to learn that, that's all good. If not, that's fine, too. Um, the most important one to know is K void. And just know that's lateral and closer to your radius. Um, and then we go to metacarpals in your hand so a little bit further down your palm and finally, you're failing. Geez, in the fingers and those are your proximal middle and distal for the four fingers and then on the thumb is just proximal and distal, cause it's only two challenges present, um, and then more on the muscles. So I've only makes the most important muscles. I feel like you guys should know little bit about, um, ambassador thenar muscles. And those are flexor pollicis brevis, abductor policies, gravis and opponents policies. Um, I feel like the part that got me to learn these was the fact that it's a Latin term. And in Latin, the thumb is known as a pollex. So if you ever see policies in one of the, uh, muscle names, just know that they're talking about, um, the hand, or at least the thinner bit of the hand, which is closer to your thumb. Yep. So that's that and also your hypothenar muscles, which are closer to your little finger. So, um, that's your flexor digitorum enemy brevis abducted digital mini me and opinions digital mini me and again. Your little finger is known as digitalis minimus in Latin. If you ever see a digital, many me just know that you're talking about the little finger or something to do with that. Or a muscle that runs closer to that particular area. And, um, and then a bit about tendons, too. So the tendons, basically they come from your forearm bit. They don't come from your hands themselves. That's the confusing part. But your hands do have tendons, um, for some of the hands muscles, too, but they're not concerned here. Just know a little bit of about your flexor digitorum, profundus and flexor digitorum superficialis muscles. Um, and they obviously come from the forearm, and they're on the flexor bit. So your extensor component or your doors, um, of the hands or back of the hand also has some tendons. But the most important ones to know and the pathology that shows up is almost always to do with the flexor service or your palm of the hand. So know these muscles know these tendons, and then no where they insert on the hand and then continuous innovation. I'm sure this has been hammered into your brain at this point, at least for 3rd, 4th and 5th is, um So the nerves there all the nerve median nerve, radial nerve. So all the nerve it affects or it innovates your little finger and medial half of the ring finger and also the same thing on the dorsal size. Um, media nerve innervates your, um first. So your thumb, your first finger, your index finger middle finger and your lateral half of the ring finger. Um uh and then on the dorsum of the hand, it just affects the tips, basically of all those areas. And then finally, really radial nerve that's mainly concentrated on your dose a site. And, um, it's called affects the area called the Web space. But essentially, that's your ladder portion off the hand and especially the area around the first two fingers. And then this is, uh, basically a table for the innovation of hand muscles. And then I know I haven't talked a lot about the motor, um, innovation, but just know that your median nerve innervates most of your thumb muscles. So you're hypothenar muscles that I talked about their innovated by your median nerve and your owner nerve innovates your hypothenar muscles and those the ones also mentioned before your digiti many meat muscles. But that's the most important base I think. And then you can disregard, um, any other ones. And also, there's some know Monix here. So loaf, um, and h i l a hila, um, that you can use to basically learn the muscles of the hands if you're super into into, uh, orthopedics, Um, Or if you want to impress a surgeon in the hospital, why not? Um, yep. So just going to talk to you to some of the common hand pathologies as well. And the most important one here is your carpal tunnel syndrome. So the carpal tunnel syndrome, I'm sure you've definitely heard of it a little bit. Um, it's basically to do with your carpal tunnel, which is an anatomical structure that's present in the hand. Um, the carpal tunnel is basically formed by your carpal bones. Um, so that's your carpal arch, and I'm sure you can see them over here too. They've been mentioned. It's your capitate Hammett. I'm sure and you know a little bit about that by now. And your t d t m, which is basically your dpz, Um, and, um chop soit. So, um, you don't need to know any of the bones, but just know that it's just bones, um, at the end or the carpal arch that's sitting basically at the end. And then on top of that, it's your transfers, carpal ligament or just the Flexeril tenaculum. I'm sure a lot of you have learned to anatomy by now, but yeah, that's your fiber span that forms the roof. And that's your carpal tunnel. Um, it has some content in it. It's got some tendons and, um, a lovely nerve as well at the same time. That's your median nerve. And all of the symptomatology that you get from your carpal tunnel is basically to do with your, uh, median nerve. So what is carpal tunnel syndrome? Um, so there's some pauses and risk factors that give you more of like a chance of getting carpal Tunnel syndrome syndrome and the pneumonic that queens likes to use is armpit. Um, but they're quite a few other ones out there, too, that you can look up and especially on Radio pita. But yeah, that's your acromegaly rheumatoid arthritis myxedema pregnancy, idiopathic trauma. So These do predispose you to getting carpal tunnel syndrome, but it's also, I think, mainly genetic. There's a huge genetic component. If your parents have it, you're very likely to get it to at some point in your life. Um, so symptoms of carpal tunnel again is to do with the median nerve so you can kind of tell what goes on. Um, and if you remember your continuous innovation off the median nerve, you know that affects your or innovate. Sorry. Innovates your thumb, your first finger, your ring finger, your middle finger and your lateral half of the ring finger so your sensory symptoms tend to show up on these particular areas. So your pain burning sensation numbness paresthesia, which is just a fancy word for tingling, um, and thumb index finger, middle finger. And I don't have a ring finger steps again, your innovation areas, and then you also get motor motor symptoms. But that's because your media nerve innovates your um thenar muscles, which are closer to the thumb. So you get motor symptoms because of that as well. And that's obviously to do with your theater muscle wasting. Because there's no innovation, muscles tend to waste that tend to become weak, um, as well. And you're not able to do the handgrip, handgrip and thenar movements just because the muscles are no longer getting the innovation to for you to be able to do that. Um, so that's how it presents. And those are your causes and risk factors. But the most important part is diagnoses. Um, and also I should probably go up and mention a little bit about like what people describe those. So people always say that the symptoms are worse at night and you'll always get somebody, um, come into the G P practice. It's normally the GPS that tend to see, um, the carpal tunnel. And it'll be somebody who says that they shake their hand, and apparently that improves their symptoms. So that's a big one to pick up more questions in exams. Yep, So your diagnosis There's some special tests. I haven't personally seen tunnels tests being done. But I did get to see a failing in the GP practice a few weeks ago. Um, so this test just basically involves raising your hands, um, up to the shoulder level and you'll bring the doors them together and make sure that your wrists are flexed and 90 degrees. And, um, if the test is positive, obviously you'll get pain and tingling again in those areas that I've I've just mentioned your thumb, your first finger, your middle finger in the latter half of the ring finger, and the management of carpal tunnel is basically a wrist splint. I don't think it's done a lot now, but, um, you do get to see steroid injections being done. But most people like to go up to orthopedic surgery and try to get their Flexeril snack. You'll, um, or the fibrous band that covers your carpal tunnel. Um, get that to be cut off so it can release the pressure that's on media nerve, and that tends to relieve all the symptoms, so it's very easy to treat. But, um, sometimes it's harder to pick up to, because people tend to present with a broad range of symptoms, and the next one is your dependents. Contractually, that's again common, too. Um, and that's basically your Palmer fascia, so you can see that your your palm of the hands got Palmer fashionably neurosis in the Palmer area. And that's what that's what you use basically to grip things, Um, and it starts to thicken eventually over time. This normally happens in older people, so it starts to thicken, becomes fibrotic. And because it's thick now it starts to pull on the tendons and on the muscles that are present in your fingers. And normally it tends to affect your ring ring finger and your little finger first, because that's where your fibers are a little bit lighter, so they're able to pull a little bit faster, so tend to present first with bending of those fingers and eventually down the line. You can just get clumped hand, but mostly when you see people presenting, it's just your little finger and your ring finger. Um, so, yeah, you can see a thick cord. That's your Palmer Palmer Aponeurosis that's being pulled back because it's become hardened. And, um, it can be very debilitating in terms of functionality because you're not able to grip or do normal things with your hands, and you've got some risk factors For this. There's a diabetes, epilepsy, family history against same thing with carpal tunnel smoking, alcohol dependence, bolivar and thyroid disease. So, um, these are some of the ones you might see. But again, risk factors matter less when it comes to actual diagnoses and treatments. But no them. Because then that can give you a little bit of a chance to know what that is. Instead of just simply thinking, maybe it's trigger finger or some of the other, um, common pathologies you might see. Um and then, yeah, there's a tabletop test, a very easy test that basically get them to put their palm of the hand on the on the table and try to get them to basically move the palm of the hand completely flat so that they're able to touch every part of the table that you've got them to put the hands on. But normally, people who have depends Contractor would not be able to do it because they're just not able to bend fully because again of the Fibrotic band that's running in their fingers. And the management is basically two options. Conservative versus surgical Um, normally, it's surgical because people will tend to find that this disease is very debilitating, so that want to basically try to, um, relieve that pain and be able to do normal things and There's some surgical options mentioned that your new Epineurotomy you're limited fasciotomy or dramatic fasciotomy again. Is it all done by orthopedic specialist in the hospital and basically what the what the involve is, um, cutting the cord and taking away the Palmer aponeurosis especially dramatic fasciotomy to just take away all of that. So there's nothing left for you to basically get thickening of the hand. Yep, that's me. And I'll pass on to go pick a for a little bit that she can talk you through common hand factors. Thank you very much, Mohamed. Um, so yeah, So I will be going through a few common had fractures, and, uh, first of all, Well, to begin with, let's talk about how to read a limbex ray and, uh, some important salient points that you need to remember when you're describing a fracture. All right, So, um, to the left of the image, you can see five points that you can use when describing an X ray. Uh, this is a very common Noski station in medical school. Um, and you can start off by talking about the alignment of the bones. Then you can talk about the cortex which is the outer edges of the bone. And in this case, as you can see, um, on this image, you can see the cortex is broken, and that can be a sign of a fracture. Then you can talk about the medullary cavity. So the medullary cavity is basically, uh, the inside of the bone. And in this case, um, apart from the fracture, the bone looks healthy because it's quite white and dense. But sometimes in elderly patient's, uh, you know, physiologically because, uh, you know, uh, their bones become less dense over age or even patient's that have long, long term steroid use. They can have very low, dense bones. And in such cases, the midday notary cavity would look much gray in color. So it's important to, you know, talk about that as well. In some cases, with metastases to the bone, you might see some spots in the medullary cavity. And that might be, uh, you know, uh, that might actually indicate metastases or primary bone tumors. Uh, the fourth point you need to discuss is joint space, and joint space is basically the articular surface and the joint cavity. And the most important, um, you know, frightening feature that you might see is a fracture. And usually, um, fractures in that area can be very, I mean, highly unstable, and then soft tissues. Soft tissues are very difficult to describe by using an X ray. That's why you would usually do, um, an MRI or a CT. But, um, you can You can still talk about soft tissues, depending on the history of the patient. Uh, for example, if a patient comes with a history of septic arthritis or gout or rheumatoid arthritis, and you might see some white fluffy bits surrounding the joint space or even the bones, it's it's good to talk about that as well. Now the five points to the right of the image are the points that you can use to describe a fracture. All right, so first of all, describe the location of the fracture. So that is which bone Very simple, Um, and whether it's proximal or distal, and I'm going to give you a few examples in, uh, upcoming slide, so it'll be easier for you to understand. The second point is fragments. So, um, is it a simple fracture? Which means, you know, it's just one fracture in this case is a simple fractures. It's just one line. Or is it fragmented or multiple fragments? That is community fracture. It's eggs, for example. If you break a glass piece and you might see like shards of glass, that's exactly what you you can see on the X ray. And that is highly, highly unstable. Well, kind of common sense. Um, and then orientation or the angle. So there are three angles that you need to remember whenever you're describing a fracture transverse angle, which is basically horizontal oblique angle. In this case, this is an oblique fracture. So that is, um um, uh, slanting. And you can even have a spiral fracture, which is basically it kind of goes like in a spiral. Um uh, spiral design and goes to the back of the bone. Um, and these are just some words that you have Well, you can use to describe your fracture, um, displacement again. Um, displacement is whether the bones are displaced from one another, and in this case, it is so again, that is highly unstable. Um, and, uh, angulations, uh, sorry. Just another important point before going to ambulation. Is that Sometimes instead of the bones being displaced from each other, they can have They can be impacted on each other, and that is highly, highly unstable. All right, so basically, the two ends of the bones are basically squishing on top of each other, and that can be very unstable. Um, angulations something that I'm going to talk about in the upcoming slide. So let's hold it there. All right, um, next side, please. Yeah. So, um, so this is the first fracture that we're going to discuss. I've given a few risk fractures as well, so? Well, I've given that away now, but if you can just guess the fracture you can put put in your, um, you know, your guess is in the chat. Please feel free. You know, no judgment zone. Um, if you can tell me the name of the fracture as well as where you can find the fracture or where do you see the fracture? That would be great. I'll give you, like, 15 seconds. Okay, so we've got one. We've got one. Anyone else? Okay, I'm gonna give five more seconds. Can someone tell me where the fracture is? You can just describe the fracture. Okay, so, um, going with one of one answer That's the colleagues fracture. And that is the right exactly? Yes, distal radius fracture. And that's the colleagues fracture. Um, so next slide, please. So, colleagues fracture is an extra articular fracture. And what I mean by extra articular is that, as you can see on the picture in the right, the red line is outside the joint cavity or outside the articular space, and those fractures are called extra articular fractures and, uh, colleagues. Fracture is a type of extra articular fracture, and it is of dorsal ambulation. Now, this is where I was going to talk about what angulations means. All right. So dorsal ambulation, Uh, there are two types of angulations you need to know with respect to hand and wrist fractures. One is dorsal, and the other one is Well, are ambulation an easy way to kind of understand what dorsal and will are? Angulations is is apologies. Um, an easy way to understand what a dorsal and a will are angulations is is that a dorsal angulations means that the bone is shifted towards the palm of the hand, whereas well are angulations means that the bone shifts towards the back of the hand. So if I'm just going to, um, apologies, I think my, um my partner, I think his WiFi connection stopped. So I'm just going to check if everything is okay, because he's moving the slides. Sorry about that. I'm back. Yeah. Oh, sorry. Okay. Sorry about that. No worries. Uh, do you mind if you can just go up, like, to the previous slide? Oh, yeah, that's okay. No worries. Yeah, that's fine. So as you can see on the right image, you can see that the bones are, you know, angulated. And it's angulated towards the palm of the hand. Um, and if you can just go to the next slide Sorry. Perfect. And that's what dorsal angulations means. If the bone was angulated towards the back of the hand, that would be That would mean Will are angulations. So Kohli's fracture is defined as an extra articular, docile ambulation. And as you can see very clearly, this kind of looks like a dinner for deformity. And this is a very common word that they use in M. C. Q s, um, kind of like catching you there and whenever you see dinner folk deformity. That is a colleagues fracture. All right, uh, mechanism of injury is, uh, fall on the outstretched hand. Uh, and it is very commonly seen in elderly osteoporotic patient's, especially women. Um, investigations are ap lateral and oblique X rays. Okay. And a 50% of the cases can actually even cause an ulnar styloid fracture. All right, next slide, please. Okay, so this is the first question that we're gonna discuss. So the patient is neurovascularly intact, and you have administered analgesia. What is the most appropriate next step in management? Give you 10 seconds. Okay, so we've got one. We've got one answer. Anyone else? Um, I wanna try challenging that answer, or you're okay with it. Yeah. Okay. So, um yeah, exactly. So B is the right answer. So we're going to go to the next slide? Um, it is close reduction under anesthesia. Now with any type of fracture. Um, there are three important steps that we need to remember when we're treating a fracture or managing a fracture. And those are reduction, stabilization and rehabilitation. All right. So, reduction. The first thing that you have to do is to reduce the fracture. The fracture is basically a break in the bone, and you have your bone displaced from one another. And as a result, um, it's it's literally sitting in a in a different angle in a different position and without reducing. And what I mean by reduction is that basically, you're bringing the bones back into the normal anatomical position. So without reducing the fracture, you cannot go into the next stage. That is stabilizing the fracture. Because only once you reduce the fracture into its normal anatomical position, can you actually stabilize the fracture? All right, so the first step And if you read the question clearly, I've asked what is the next most appropriate management? So it's not the most definitive, because we're going to talk about that later. But the next most appropriate management is close reduction under anesthesia. All right, next slide, please. Okay, So which pattern of neurological deficit is most strongly associated with the colleagues fracture. And if you can tell me which nerve it affects, um, again, Bonus points again. 10 seconds. I'm going to try this question as well, actually. Oh, go for it. Yeah. Very good. Yeah. Median can you tell me which, Um well, you actually discussed this, like, a couple of minutes ago. But can you tell me which option would that be? Which, um, signs or symptoms. Yeah, that's your e perfect. Exactly. So, um, I'm just gonna go through, um, each of the, um each of the case. So basically, um, a is for ulnar nerve injury, and this is usually sensory loss over the fifth digit. What? Mama just, um, explained a couple of slides before This is an ulnar nerve injury week finger abduction and adduction is all the nerve. And this is usually seen in elbow fractures and elbow dislocations. Be is very simple to understand. If you see dorsal first webspace and weakness of finger and wrist extension, that is clearly a radial nerve injury. And this is usually seen in humeral shaft fractures. Okay. See, again, If you see regimental badge area, that is always axillary nerve. Um, and weakness of shoulder abduction is actually enough. Um, um and D is actually a palsy, So weakness of the lateral shoulder rotation, elbow flexion and hand extension is C five to C seven, brachial plexus injury. All right. And it is associated with shoulder dystocia traumatic delivery and a lot of other causes. But these are the main two. That's on the top of my head. Um, so yeah, so e is the one. As as Mohammad mentioned before, um, the inability to make the okay sign. Now, this is a very simple question, because I'm sorry. It's not a simple question. Uh, the the the answer. I've given every single information in one answer, but in your final exams or your MCQ exams, they might just give you, like, 111 option, for example. Inability to make Okay, sign or, you know, weak grip strength or something like that. So remember the main points, um, that they can actually ask you. All right, um, next slide, please. All right. So before I go into the next one, I just wanted to mention that colleagues fracture, as I mentioned before, has to be reduced, and you need to ask them to come back after a week. And you need to do an X ray again. And if it is, um, stable and undisplaced after the reduction, then you just have to treat it with a below elbow. Um, cast for 46 weeks. But if it's undisplaced, then you have to refer them to an or if that is, open reduction, internal fixation. So it depends on how their, um you know, uh, they're fracture is in a week's time. Okay, Uh, so can anyone guess the fracture? And, um, if you can just tell me if you can describe the fracture, that would be That would be great as well. Um, yeah. So I can see someone saying Smith's Yes, it is. Um, so this is a Smith fracture, and, uh, exactly very good. So we'll are angulations. Very good. So, as you can see the Smith fracture I'm going to describe in the next slide. But just before we move on from the slide, Smith's fracture is an extra articular fracture. So again, it's outside the joint space. And as you can see, the angle of the bone, it's shifting towards the back of the palm. So this is actually the palm, Um, and that is actually Yeah. Thank you. So that is a bowl. Are ambulation and Volare angulations are highly unstable angulations highly unstable fractures and therefore the well, I'm not going to give it away because that's the next question. But yeah. Uh, next light, please. Great. So, yes, Smiths Fracture is also called reverse colleagues fracture. And the reason is, um, it is an even though it's extra articular. It is a volar angulations rather than dorsal angulations as we talked about before. Um, and the mechanism is also quite the opposite. So, um, colleagues was fall on the outstretched hand, whereas Smith's is fall on the flexed hand flex wrist. Um, and there's extreme pain swelling and, um, uh, you know, inflammation. Um, and the investigations include similar to collies, ap lateral and oblique views. And as I mentioned before, it is highly, highly unstable. Okay, uh, next slide, please. Okay. So, again, um, this patient is neurovascularly intact, and you have administered analgesia because they are, you know, writing in pain. What is the most appropriate, definitive management plan for this patient? Do you also want to try Mohammed or Yeah, sure. Why not? Yeah. Go for it. Yeah. Very good. Yeah. Um, so it is, or if so, you, um I'm sure that you guys have, um, you know, seen that definitive management plan So any and you know this is literally, like, kind of a bonus thing. Any any fractures that are highly unstable? Um, it would they would definitely go for or if All right, so that is open reduction. Internal fixation. And another point that I would like to mention. Is that just the same? Just as similar to colleagues. Fracture a median nerve can get damaged in, um, Smith fracture. And it can also cause a long term carpal tunnel syndrome. Something like an important thing to remember. Um, the other options. Close reduction under anesthesia? No, because, well, our angulations highly unstable, so you would directly go for open reduction. Um, and conservative management with analgesia That's not going to fix the fracture. Close reduction and key wiring is again, not the appropriate option. Amputate the arm? Obviously not. That was just I just put that there, but yeah. So, um, next slide, please. Okay, So this is, um, again, a fracture. That is, uh you can if you can tell me the name of the fracture. That would be great. And also also, just tell me where do you see the fracture? Like the location of the fracture? Um, because that's very important for the structure. I have to be honest. This is hard. It is hard. It is hard. Sorry, I didn't Oh, yes. Barton's in particular. Yes, exactly. So this is a Barton's fracture, and it's an intra articular fracture moment. If you can just zoom into the left image. Uh, sorry. On the image on the left. Uh, yes. Just zoom in. And as you can see, if you see the line apologies, that's my reminder. If you see the line pass through the joint space, uh, that is actually the black line very clearly when you can see when you actually zoom in. Otherwise it's quite difficult. That is a Yeah, exactly. That is your intra articular Barton's fracture and any fracture that is intra-articular. It is highly unstable because you know it is babe. Basically, the fracture is in the joint the joint space, the joint cavity, the intra articular articular surface. And as a result, um, it's basically the the region where two bones lie on top of each other. So if there is a crack in that, um, in that region, it is highly highly unstable. So next slide, please. So as a result, as mentioned before um, yes. So batons fracture is an intra articular fracture. Um, it can come with. So you can either see it as a dorsal angulations or Volare angulations Volare Angulations is highly unstable, and it is also called Volar Barton's. And in this case, you would have to do an or if that is, open reduction, internal fixation, because it is a highly unstable fracture. Um, and a very, uh, two important complications you need to keep in mind with buttons is that there's a risk of re dislocation and malunion, uh, because of the unstable nature. And what I mean by malunion is that fractured bone heals in an abnormal position. Um, and this can lead to impaired function of the bone so it can cause three dislocation and malunion. These are two important complications that you need to remember. And as with all fractures, you know, there is going to be paying there, is it might, you know, change into a chronic arthritis picture, and you could even get neurovascular damage as well. So next slide, please. Okay. So this is our last, uh, fracture. So this is, um if someone can, uh, tell me what fracture you can see and where it is, uh, again, it's fine if you don't see the fracture as well. Because, uh, that's how it is. Yeah, so, yeah. Scare fight. Exactly. It's a scary part. Fracture. Um and, um I mean, if you can just zoom into the left picture on the left. Um, yeah, exactly. So if you can see the scaphoid bone and you can see a black line passing through it And that is why this is a trans worse fracture, Um, transfers. Fracture is basically, um uh, you know, horizontal fracture. And so our next slide, please. It's a transfers fracture of the waste of the skip Cope. Sorry. Whoop. No, it's a transfers fracture of the waste of the scaphoid. And hence it's called scaphoid fracture. There are some important things to remember about skateboard fracture. Okay, So first of all, what are the signs that, um, someone with a skateboard fractures and signs or symptoms? First of all, tenderness at the anatomical snuffbox is a is a very important sign to look at as well as tenderness over the scaphoid tubercle. Okay, so if someone comes in with pain around your wrist and tenderness will be anatomical snuffbox and you do an X ray and you don't find a fracture. You still have to consider it as a scale part fracture because skip out fractures highly deceiving on the X ray. Okay, So as a result, if someone comes with tenderness at anatomical snuffbox, they have some media nerve damage they have. They have a very good history of, um, mechanism of injuries. So just fall on the external fall on the outstretched hand. Um, this is, uh, you know, you cannot exclude scaphoid fracture, and, um, along with that, you know, along with any Whenever you're examining a fracture or injury to the wrist or injury to any of the limbs, you have to do you know you have to check the neurovascular status. You need to check if it's open or closed fractures. Um, you need to check its functions. So you you need to you need to also check if there are fractures in any other areas of the hand. For example, the carpal bones or any other carpal bones or the wrist, or even, you know, do an entire upper limb examination. So scaphoid fractures are really important to look for because they can be highly deceiving on the X ray. Uh, next slide, please. Um, yes. So a 21 year old falls onto his outstretched hand whilst playing lacrosse. Examination is unremarkable. Apart from pain in the anatomical snuffbox, you suspect scaphoid fracture, and you order scaphoid series of X ray as a good junior doctor which do not show any discernible fracture. So you're perplexed. You're like, What is this? What would be the next step in management? Yeah, very good. So plaster and repeat X ray in 10 days. That's exactly the answer. So, um, um, I'm just gonna go through each so basically, if even if you don't find any fracture on the X ray, um, that doesn't, uh, that doesn't exclude a scaphoid fracture. All right, so you need to reduce. As I mentioned before, the next step in management would be reduction. So reduce the fracture by, uh, putting on a plaster, um, and or provide a splint or a cast, um, as per protocol and repeat the x ray in a in a week's time or 10 days. Um, request an MRI. MRI would be the second investigation that you would do in a week's time. So you would do an X ray in a week's time and you would see whether it's displaced or undisplaced. Um And then you would also request an MRI scan. But that is basically a second line investigation, not the first step. Reppetto. Physiotherapy. That is not going to, you know, help with the fracture. It will. It will help with the fracture. That's the third stage. That is rehabilitation. But you need to, you know, you need to cure the fracture now or you need to start with the treatment currently, um, plaster for six weeks. No. Um uh, that's you. You need to You need to intervene. So when I mean by reduce, stabilize and rehabilitate the reduction is basically putting on the splint. Um, um, stabilization is is your or or if so, open reduction internal fixation. So without doing your or if you cannot keep you cannot, like continuously, ask the patient to keep on the plaster for six weeks. That is not gonna help with the situation. Analgesia and discharge is very, uh, that's not the right answer, because you're not helping the cause. Um, yes. So next slide, please. Okay. So a repeat X ray is done one week later, and this demonstrates a displaced fracture of the waste of the scaphoid. How should this be managed now? I've kind of given it away in the previous slides, but yeah, I was just gonna say it's it's already there, but yeah. Yeah, exactly. So internal fixation. Um, so because it's displaced, it is a highly unstable fracture. You cannot do anything else apart from internal fixation. Now, the thing is, um, the reason why I said that scaphoid fractures should be, uh, you know, it's it's important to, um you know, um, start the treatment and start the splint as early on as possible is because scaphoid bone is has a very poor blood supply. So as a result, it has a high risk of nonunion. Uh, sorry, Mala union or avascular necrosis. Um, And if there is delayed treatment or delayed presentation as well, um, or even, uh, inadequate, uh, splint. It can actually carry a risk of causing avascular necrosis. Another risk factor for avascular necrosis in such patient's is smoking and, um, prolonged non steroidal anti inflammatory use. Um, and if someone presents with malunion, as I mentioned before. They are at a risk of chronic arthritis and pain and inflammation, which is something we don't want to get into. Um, so at one week's time, you call back the patient, you do an X ray and you find out you can see a clear transverse fracture. The patient should then go to, um uh, you know, the patient should be referred to, um, internal fixation. All right, so, uh, thank you very much. Uh, well, that's the end of the fractures bit. Oh, yes. Sorry. This is the This is an image of, um, you know, after after the after internal fixation. So that is basically the, you know, the wiring. And, um, yeah, that's basically after. Or if that's how the fracture looks like now. Um, So, yeah. Uh, thank you so much. That's the end of my presentation. I'm just gonna give you back to Mohammed. Yep. That was great. Um, I was actually gonna say this looks like a Herbert screw, but I don't know, like, I don't know if you've heard about that before, or anyways, I've never heard of that. What is that? I'll put that in the in the chat. Um It's a Herbert. So I think I saw this in. Oh, Herbert, Screw. Okay. Okay. Yeah. And that was on first Gateway factor. But we'll see. Very good. So that's that's good. That's good. Something new? Uh, yeah, I know. Always learning. Um, but yeah, I'm going to move on to, um, hand signs of systemic disease. Honestly, this part is very easy. I'm sure a lot of you know what the hand signs are at this point. Um, but we'll just run through some of them over here. Um, so the first one is your Raynaud's phenomenon. And I'm sure all of you know what? This is at this point, but basically, this is for connective tissue diseases. It's a lack of blood flow in some of the peripheries and gives you white, um, areas or white, patchy areas, um, which can often, sometimes even look like vitiligo. It just depends on the presentation that the person is showing at the time. Um, it's also linked to scleroderma or a systemic sclerosis and sugars. So dryness essentially in all of the body and the middle one finger clubbing, big one always mentioned in, um, cardiovascular diseases and also lung respiratory problems. So brown cactuses, lung abscesses, lung cancer, cyanotic heart disease makes sense. Clubbing happens essentially the lack of blood flow and also, um, venous Stasis in the area. And then last one over here is got trans papule. So that's a very interesting one. I don't know if a lot of you know what Dermatomyositis is, but basically it's inflammation off your muscle cells in the body, and then it's got dramatic manifestations. And actually, there's two types. There's a matter myositis and polymyositis and Polymyositis has got no, uh, dramatic manifestations. That's how you differentiate between the two. But, um, it can actually resemble PMR polymyalgia rheumatica a lot because it starts with pelvic girdle and shoulder girdle pain and also, um, a little bit of stiffness in the body in general. So that's that's a big one to pick up sometimes. Um, next one is your osteoarthritis, Um, so your osteoarthritis can show quite a few hand signs, and the biggest one here is Herbert know her Burton's nodes and Bouchard's nodes. So Herbert nodes are basically in your distal interphalangeal joints. They're basically closer to your fingernails, and your Bouchard's nodes are osteoarthritis again. Osteoarthritis sign and they're common in the proximal interphalangeal joint. Um, and basically, these are ballooning off your joint space because osteoarthritis can cause disintegration. And with this integration, what happens is your joint starts to get inflamed over time. This is not the inflammatory arthritis picture, though. This is just inflammation, secondary to wear and tear that happens in in those joint spaces and finally squaring of the thumb. So this is your carpometacarpal joint, and especially in your first carpometacarpal joint, which is closer to your thumb, you tend to get squaring, which is again, uh, separation. More joint space. The typical signs that you see in in rheumatology. So loss of joint space osteophytes subchondral sis. Yeah, subconscious this and then, uh, some other ones, too. I think I've forgotten the demonic at this point. Um, but yes, that's your signs that you would see on on an X ray. And then that's basically what's causing your squaring of the time as well. So if you do X ray on a person who's got squaring, you will tend to see osteoarthritis signs. But it's just become exacerbated over time. And that's produced the squaring. Um yep. So final that your rheumatoid arthritis and that's your ulnar deviation. Basically again, very easy to pick up as well. So again, rheumatoid arthritis is your inflammatory arthritis, and that start tends to produce a lot of inflammation. And because it's one of inflammatory, it can affect your tendons as well. In all the deviation, there's no tendon involvement per site, but in Bhutan, ears and room swan neck deformity there is tendon involvement. Um, and the only difference between Bhutan ears and Swan neck is in swan Neck. You get hyper extension in the proximal interphalangeal joints, you can see that's kind of going inside a little bit, so it's kind of bending inside, and then it flexes in the distal interphalangeal joint. But for Bhutan ears, you see that the tendon is inflamed in that particular area, and it's basically is producing, um, extension in the distal interphalangeal joint and extent infection in the proximal inter planted joint. And that's producing kind of like a corkscrew picture as well. At the end. Um, and those are the references that we use. Feel free to go over radio pedia, osmosis, these books that we mentioned and yeah, that's us. If you have any questions. Put them in the chat. Or you can admit yourself as well. I hope so. There we go. Go pick subchondral Cirrhosis. Just saw that. Yeah, Yeah, in the middle. I was like, What? What am I talking about? You know, don't worry. No, I always think about los Pneumonic. I think that's like, That's so good. Um, when describing. Yeah, I think if you just describe all of that, if you see an osteoarthritis X ray in your rosky just describe all those four points and then it's like, tick, tick, tick, tick. That's the most important thing. Um, but yeah. Thank you so much to everyone, um, for coming in, Um, and listening to our little session, If there are any questions, please feel free. We'll try our best to answer them. Uh, we're not orthopedic surgeons, so we're gonna try our best. Um, thank you very much, Dean. Thank you. Um, and, uh, if they run, please, uh, you know, just a small request. If you can just fill out, fill out the feedback forms for both of us, it'll be really helpful for our portfolio as well as for are even learning as well for our next sessions. Um, so it would be very grateful if you all could do that. Um, yeah. I think that's all anyone else? Um, feedback link. Um, I think I think you will be sent a feedback link after the session by QB Arthur society. Um, I think that's that's how usually, like in metal. So I think if you click Yeah, Yeah. So you you'll get a feedback link. Um, um um, sent to you to your email. Um, after this, uh, session. Okay. Thank you very much. Anything else, Mohammed? No, not really. I mean, you were really good, by the way. Have to say, um, I learned a lot. You know, I I had to, you know, I had to, like, revise my anatomy from 1st and 2nd year because finally, or is like, you don't You don't. Well, you have to, but you don't. You don't, so yeah, but thank you so much, ma'am, And take care. All right. You too. Thank you. Bye.