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life. Hi. Um, welcome to the Q B. Arthur stock event. And, uh, we have Gary who's the fifth year, and Hannah, who's the fourth year we're going to be presenting, um, uh, more about anatomy, anatomy and pathology of the shoulder. So thank you so much, guys for coming. And I've gone through these slides in their grades, so they're really gonna help us. Um, and yeah, I'm just going to hand over to Hana first. Who's going to be talking to us about the anatomy? Uh, this video will be recorded, so it's there for later on for revision. So thanks. Um, yeah, I'm Hannah. Um, I'm just gonna go through some of the, like, the basic things that when I was a first year, I kind of, like, try to learn about the shoulder girdle. Um, it is kind of a lot, so I'm going to try and keep it as the sink as I can. Um, but just going through bones, joints, muscles are a bit of the neuro vasculature. Um, so you're starting with, um, bones and many landmarks. Clavicles. First bone to look out and shoulder girdle. So this is your long kind of s shaped bone that extends between the manu room of the sternum and the chromium of the scapula. Uh, and you can work out the two different ends from where they're connecting to. So your sternal end is obviously the more medial aspect of the bone, and you acromial end is more lateral aspect of the bone. Um, the bone is this kind of, like, sort of air shape, bone. Um, and it has a convex medial aspect in a concave lateral aspect, the sternal, and has this kind of large facet for articulation with the manubrium. Um, And then the important part of this end is that it has this kind of rough and impression for the cost. Oh, clavicular ligament. Uh, the shaft of the capital doesn't have like too many really important landmarks on it. It's just important to know that this is a muscle attachment site for lots of different muscles of, you know, the upper limb and the shoulder girdle. So it's things like deltoid, trapezius, subclavius, peck, major sternocleidomastoid and sternohyoid. The acromial. And you were slightly smaller faucet. And that's for your attic licking the chromium. Um, it has two attachment points for two ligaments. So, Coronoid cubicle, um, is this rough inning for the convoy ligament, which is the more medial part of the coracoclavicular ligament. And then you have the trapezoid like that kind of comes off it and comes with austerity to the acromial end. Um, and that's for the trapezoid ligament, which is the lateral part of the coracoclavicular ligament. Um, this ligament is really important because it's really strong. And this is the ligament that effectively or the weight of the upper limb is getting suspended off of, uh, the scapula or your shoulder bone, shoulder blade. Whatever you want to call it is your triangular flat bone. Um, this It has attachment sites for 17 different muscles, um, of the upper limb shoulder girdle. It has two main joints, so laterally articulates with the humerus at the glenohumeral joint. Um, and then it also has a small articulation with the clavicle at the acromioclavicular joint, you can split the services of this boat into three. So you are three different ways of looking at it. So you've got your costal service, which faces the rib cage. So anytime you're hearing the word cost or you're thinking about the rib cage, your lateral surface, which is facing the humerus and your posterior surface, which is facing outwards. Um, there's lots of important different landmarks on the scapula. Uh, and you can divide it into borders and angles, which is really important, and we're going to focus on kind of, like important bony landmarks. Um, so on your costal surface, he's on the left. Um, the most of the bone is this kind of like concave depression covering the surface, which is your sub scapula fossa. Um, and this is easy to remember. The muscle that originates from this fossa is subscapularis, uh, the joys of anatomy. Everything is in the name, um, on this. Therefore, you also have the core a quick process, which is kind of inferior to the A crony in, um and it's this kind of a pointy projection superior laterally. Um, this is an important origin site for two muscles. So you've got coracobrachialis, um, the short head of biceps braking. I will, um, come off of this part of the scapula. And then it's also attachment site that picture of minor on the posterior surface, the kind of like main feature of this part of the bone is the spy leading into the chromium. So you've got the chromium up here, which this projects out, and then not so patient's You can actually feel it on par Patient of the shoulder joint. Um, it's arching over the glenohumeral joint. Um, and then you've got articulation with the clavicle at the ACROMIOCLAVICULAR joint here as well. Um, this spine is a really useful landmark because it's basically splitting the bone into two on this surface. So you've got above or Sucre and you've got below or infra. So above this one, you've got the super spinous fossa, uh, which is slightly smaller than the infraspinous fossa. And it's, um it's more convex in shape. Um, so you're super spinous fossa is your origin site of super Spinatus and your infraspinous fossa is your origin site of infraspinatus. Um, I'm actually creamy quickly. Another reason why this is a really important landmark is that, um if you're imagining the humerus and the cleaner humeral joint below here, uh, the axillary nerve is winding around the surgical neck of the humerus, and that's about five centimeters below this angle. Uh, so you can actually use the point of the Ukrainian as kind of like a measuring point when measuring things in the upper limb extremity, the lateral surface of the scapula. The main thing you're going to see is your glenoid fostering or glenoid cavity. And it's this very shallow, stupid, um, home, whatever you want to go. Uh, it has two tube icals one above it, super or one below it in Franklin Oy to Bickell's, um and they're attachment site. So, uh, the super clean a cubicles. Attachments like the long head of biceps braking. I, uh, and in Illinois tubercle attachment site for long. Head of triceps. Breaking I the way. I kind of remember remember, this is top to bottom, um, like and then the alphabet. So biceps, because is a B. It becomes it comes before triceps tea and the alphabet. So biceps braking I attachment is super to and triceps break eyes infra. So I don't know if that will actually help anyone, but that's how my brain back from China remember, muscle attachment sites. Uh, I'm not gonna go too much detail about the humerus, cause that was that was covered in upper limb. Um, and it's more the proximal humerus. That's more important than talking about the shoulder. Um, there's quite a few important bony features. Obviously, you have the head, which is articulating with the glee. No, fossa, you've got two tube icals just beneath the head. You've got the Greater tubercle, which is slightly more is lateral. It is larger. Hence the name greater. And then more medial is the lesser tubercle. Um, And in between these two, you've got the bicipital or the inter to molecular groove. Uh, you have to next to the humerus. You've got this anatomical head, which is an anatomical neck, even which is just below the neck and with these two vehicles meat and then you also have the surgical neck. The surgical neck is where the auxiliary nerve and the circumflex Hugh numeral vessels lie. They lie in against this bone. So if you've got any damage to this bone, so you've got a fracture at the surgical neck. You're at risk of, um, paralyzing. Um, deltoid, which is innovated by the axillary love don't need to click that, um, the tube icals um uh, little outcrops for muscle attachment. And that's in any bone. So, um, grader, because it's bigger. You think? Okay, you've got more muscles that can attach here. So three of your four rotator cuff muscles are going to come and and on the greater TUBERCLE. And you remember that with, um, sit so super spin, it's infraspinatus. And Terry's minor will all come in and insert on the greater cubicle or a subscapularis is going to come and insert on the lesser cubicle, Um, in this, uh, little groove that you can see on the proximal humerus. Um, that's where the long head of biceps spray key I sits in, Uh, and that's important for stability of the glenohumeral um, joint. Uh, it's also, um, an attachment point for three of your muscles. So, um and that's it on the sole chi. So a lady between two majors you might have heard of if you did, um, anatomy of Abdul. So So you've got latissimus dorsi, which is your lady, um, attaches in between terrors major. Which inserts on the medial lip. Um, and petrol is major. Which inserts on the lateral lip of this sulcus. So it's your lady between two majors. Um, so going on two joints of the shoulder girdle uh, The first one is your sternoclavicular joint, which is the standard kind of the clavicle, plus the manubrium, plus the first costal cartilage. It's a saddle type zone over your joints, so already you know, because it's a saddle type joint, it can move into planes. Um, this joints a bit special in a number of ways, one of which is the, um, it's not actually covered by highland cartilage. It's covered by Fibrocartilage, um, and also has this articular disc within the joint capsule. That kind of allows the clavicle and the manubrium almost a slide over each other in movement. So you're adding an extra axes of movements. You're adding rotation in there as well. So this joint has three axes of movements instead of two that you would expect with a saddle joint. So this is a very stable and a very mobile joint. Uh, there are for important ligaments, the kind of come in and stabilize this joints. You've got anterior and posterior sternoclavicular ligaments, which is the name suggests they're going to strengthen the joint capsule, anteriorly and posteriorly. You've got the inter clavicular ligament, which is, um, supporting the joint capsule superior early and that comes in between external ends and then you've got your cost. Oh, clavicular ligament. Um, it's technically split into two parts by the presence of the bursa. I don't worry too much about that. Um, and it's main role is it acts as the main stabilizing, um, force of the joint. So it resists elevation of the pectoral girdle so your shoulders aren't moving. Every time you're moving parts of your chest and your upper arm, it also acts as a pivot because we've got all these planes of movements in this joint. So you need something to actually allow that movement to occur. Um, and that's another role of this ligament, uh, neuro vasculature. For this joint, you're getting arterial supply from your internal thoracic and your super scapula arteries. And then there's innovation from the medial, um, subclavian nerve and the nerve to subclavius, um, and the their C three to C six, uh, routes. The regular flexes. There's lots of different movements that you can have at this joint. So you've got retraction where the shoulder girdle moves posteriorly pro pro traction, and the shoulder moves anteriorly the opposites of each other. Essentially, elevation is when you shrug your shoulders or if you're abducting the arm over 90 degrees. Uh, also, that is depression so drooping of the shoulders or extending the arm behind the body. Um, you need to move on at the shoulder. Uh, you've got rotation, which happens when the arms raised over the head by flexion, uh, you need the clavicle to rotate here passively is the scapula rotates or you're just not going to get your arm overhead. Um, and that is transmitted by the cargo crevicular ligaments. So when you're looking at any joint, there's two characteristics that you need to weigh up their roles it so that the joint can fulfill its purpose and that stability versus mobility. Uh so we already talked about how this is a very mobile joint that can move in three axes. Um, because of this, it it's also quite strong. You don't want dislocation of a joint that can move in three different planes, Um, and that's particularly reinforced by the cost of particular ligament Chromium. Particular joint is a small joint, um, from the lateral and the clavicle to the chromium of the scapula. It's a plane types that over your joints you already know this super joint, it's not going to be moving as much as, uh, particular joint. This joint can be palpated, especially if you've got, like, quite a thin or a young patient. Um, so it's about two or three centimeters medial from the tip of the shoulder. So that's That's your crow me in, um, the plane type synovial joint again, slightly different to other side overall joints because it's lined by fibrocartilage, and it's also partially divided by an articular disc. Um, but it is more of a it's more of a wedge of fibrocartilage suspended from the capsule rather than like a full disc. It doesn't look the same as other articular discs and other joints. Look, um, there are no muscles that directly act on this joint, so there's no active movement at this joint, but there is posterior reinforcement by the trapezius muscle fibers behind it, Um, and that just helps with the stability of this joint. Um, so every movement on this joint is passive. So if you've got movement initiated that other joints, it may lead to passive movement of this joint, and that's kind that's usually actual rotation or anterior posterior rotation. You've got intrinsic and extrinsic ligaments for, uh, the ex Giants. Your intrinsic ligament is your Crimea crevicular, and your extrinsic is your coracoclavicular ligaments. Uh, and the neurovascular supply is your super scapula arteries and coracoacromial arteries, and you're super scapula. Natural petrol nerves. The scapulothoracic joint, or scapulothoracic junction, is not a true joint, but when you're talking about movements of the shoulder, you can't ignore it. So if you were thinking about articulate services as if it were a joint, it's your sternoclavicular in your chromium clavicular joints, plus the junction between the anterior surface of the scapula and the thoracic cage. And you need this junction to integrate movements of the scapula against the chest wall with movements of the upper limb. They can't. They can't happen in isolations. But you also don't want resistance from rib cage movement or the rib cage not moving. Um, so by having this junction and this sort of joint, um, it allows for elevation and depression, protraction retraction, external rotation and internal rotation glenohumeral joint Um, your your true shoulder joint, um, is your ball and socket. So I know of your joint that's made up of the head of the humerus and the glenoid cavity. Uh, this is a typical board and socket joint that's lined by highland cartilage. Um, this has a joint capsule that extends from the anatomical neck, which you can see on the X ray to the border of the Glenoid Foster. Uh, there's a lot of mobility in this joint. It's more mobile than it is stable. Um, and that's because if you think of all the different degrees of movement that you actually have in the upper limb, mobility is gonna win there over stability. So the head of the humerus, as you can see in the X ray, it's a lot bigger than the GLENOID. Foster actually is. It's about a wonderful disproportion in surface sizes. So one where they get around this so that the joint doesn't dislocate all the time is that there is a cartilaginous rim, the glenoid labrum that is in the glenoid cavity, and that helps to deepen the joint more to reduce some of that disproves. Um, the joint capsule is very lax as well. So the ligaments of this joint, the ligaments of this joint, the majority of them are actually just thickening of this joint capsule rather than true ligaments. To allow for this joint capsule laxity to again to allow that mobility of the joint, um, the neurovascular. Later for this joint, you mentioned the anterior posterior circumflex humeral arteries, and they'll run around the surgical head. There's also branches of the sub scapular artery that run in and around the joint as well. And then the nerves in this region, the axillary nerve, which again is running around the so to connect the super scapula and the lateral pectoral nerves. So, ligaments of the shoulder, the two most important ones to probably be aware of the Glenohumeral and the Karaca Acromial um Glenohumeral has three bands superior, middle and inferior, and it supports the anterior aspect of the joint the coracohumeral. As you can probably guess from the name, it's running from the base of the coracoid process to the great typical of the humerus. Um, it supports the superior aspect of this joint. The transverse humeral is running between the 22 because of the humerus, and that helps to hold the tendon of the long head of biceps. In its group, Coracoclavicular helps maintain the alignment of the clavicle in relation to the scapula. And this coracoacromial, um, ligament creates this arch superior Lee. Um, so if you're thinking about having that arch there, it's going to help prevent superior dislocation of the humeral head in the joint. Um, and this is the only one that is actually a true ligament. The rest is just joint capsule thickening. You mentioned the joint capsule and its role. Um, there are also a lot of important birther, so your kind of synovial, fluid filled sacs that kind of act as cushions in the joint and there's five major ones in this joint. But over the five, there are two really important ones in terms of function and pathology. So you have the sub acromial births, which you can see. It's lying underneath the A chromium. Um, this one helps promote free movement of the rotator cuff tendons. Um, and it takes stress from deltoid and super Spinatus attendance of which lie over it, um, and just help support those muscles in movement. This is a bursa that commonly gets inflamed, Um, because it's supporting to the major muscles of the shoulder. Um, and that is subacromial bursitis. And then the other one that's important is your sub scapula, Um, bursa, which can be seen like underneath. Um, and that one just generally reduces wear and tear during movement, and that one can also get irritated and inflamed. But not as much as the chromium. Um, stability and mobility. We talked about mobility and how this is a very mobile, Um, and that's joint stability rotator cuff muscles, um, as well as being know important muscles of the shoulder there. Resting tone together helps compress the humiral head into the glenoid cavity, trying to give some more stability to this very mobile lax joint. Um, and then biceps tendon is also a minor humeral head depressor just to keep it in that joint. Um, and this is just to help prevent dislocation of a very mobile disruption, joint muscles of the shoulder girdle so we can split muscles into two groups. We have intrinsic muscles and extrinsic muscles. Intrinsic muscles are ones that originate from the scapula and all the clavicle, um, and they attached to the humerus. So that's your deltoid, which is your big, big muscle over the shoulder. Your Terry's major, your rotator cuff muscle muscles, which can be remembered by six. So super spin. It is impersonated subscapularis and Desmarais liner. Um, so deltoid is the big triangular shape muscle. It's named if anyone is interested after the Greek letter Delta because that looks like a triangle. Um, it has three points of origin. Um, so it's the latter. Also the clavicle, the chrome in the span and scapula. And that should help you remember that it has three band 33 different sets of fibers because it has three origin sites. So it has anterior posterior and middle fibers. They all joined together and attached on the Delta a tuberosity, which can be found on humerus. And it's innovative by the Good enough, Um, So again, if you've got someone that has a fracture or they've damaged their shoulder in some way and you're worried about the muscles and paralyzing that nerve, you can test what's known as the regimental bad area. Which would you imagine in soldiers that would have badges and stuff. Here, you can test sensation there to see if the folks that are you nervous, still intact. Um, the movement of this muscle kind of depending contraction of the fibers so you can have, um, contraction of the anterior fibers, which will lead to flexion and media rotation. And then it's just the opposite for the posterior fibers. So they're responsible for extension and lateral rotation. Um, and then the middle fibers of deltoid are the main abductors of the arm. So anything that is greater than 10 to 15 degrees, depending on where you read, um, that's gonna be contraction of Deltoid. Terry's major, um, forms the inferior border, the quadrangular space, which sometimes you can get questions on because there's a lot of neurovascular, um, entities there, Um, it originates from the posterior service, the inferior angle of the scapula, and then inserts the media lipids, the inter to molecular groove. It's innovated by the lower scapula nerve, and it has rolls. An abduction of the shoulder and media rotation. Beyond your rotator cuff muscles will come from the scapula. So supraspinatus comes from super spinous fossa. Impersonates comes from the info, uh, infraspinous, uh, and they both insult on the greater tubercle. They're both innovated by, um, super scapula. Nerve. Supraspinatus is responsible for the 1st 10 to 15 degrees of abduction, whilst Infraspinatus is responsible for lateral rotation of the arm sub scapula Aires Um originates from the sub scapula fossa, and is there any rotator cuff muscle? The inserts on the lesser cubicle of the humerus. It's innovated by the upper and lower sub scapula nerves, and it's a medial rotator of the arm. Terry's Minor comes from the posterior service of the scapula. Intercepts on the Great cubicle is also innovated by the axillary nerve, and it's responsible for lateral lateral rotation of the arm intrinsic muscles of the shoulder. Um, these will originate from the torso, and they're gonna attach the bones of the shoulder. You can split these into two layers of superficial layer and, um uh, deep layer, so your superficial ones are your big back muscles. So it's trapezius and latissimus dorsi, which is in the yellow there, and then your deep muscles are your levator scapula and your rhomboids. Your trapezius originates in the skull. The neutral ligament and the spine is processes of C 72 to 12, and then so on the clavicle, a chromium and the spine of the scapula. They receive innovation predominant from the access arena, but then also received C three and C four fibers that have more of a role in appropriate reception. Um, it has a couple of different actions, so superior fibers will contract to elevate the scapula. Middle fibers will contract to retract it. An inferior of fibers are responsible for depressing the scapula. Latissimus dorsi It is basically just below trapezius, so it's your spine is processes of G 7 to 2 12, your iliac crest youth auricle number fascia, and you're inferior. Three ribs it inserts on the, um, socks of the humerus. It's innovated by Thoracodorsal nerve and has rolls and extension, abduction and your rotation of the upper limb. Levator scapula is this kind of neck strap muscle. It originates from transverse processes of C one to C four and inserts on the medial border of the scapula. It's innovated by dorsal scapula. Nerve has a role in elevation of the scapula. Your rhomboids, um, your minor is smaller than your major but sits above your major. So minor comes from the spine is processes of C 72 T one. Whilst major comes from T 22 t five, they're both in on the medial border of the scapula, but at slightly different levels. So major is gonna sit between the inferior angle and the spine whilst minor take the level of the spine. They're both innovated by dorsal, scapula, nerve and both of rolls in retraction and rotation. So these muscles work together in a unit, um, to support the scapula, thoracic junction or joint. So this is stabilized. It synchronized actions and passive tensions of three functional muscle units trapezius around a Santeria, which is one of your back muscles and then levator scapula and the rhomboids together. So, um, this is important for the proper positioning of the shoulder joint in space, the scapula can move by gliding against the chest wall in three degrees of freedom. So you've got elevation, depression, pro traction retraction, external rotation and internal rotation, and they they all have varying degrees of movement. Uh, to get external rotation, you need contraction of trapezius. That's going to bring the chromium and the spine of the scapula. It does appear immediately, uh, elevation you need. You need trapezius to be working, and then you also need levator scapula to contract. Depression can happen passively or actively. So passively depression and internal rotation. If you relax trapezius and you relax. Levator scapula. Eight. Uh, your then going to get a consequential drop of the scapula by gravity. For active depression, though, it's contraction of peck minor and psoriasis. Anterior. To get active internal rotation, you need combined contraction from the Vegas scapula, the Rhomboids and Peck minor. Uh, for Prairie Traction. It's the pull of Surat is anterior plus pectoralis minor. Um, and then it's just again kind of opposite retraction is gonna be Axion of trapezius and rhomboids. It's kind of difficult to get your head around just reading it out. So, like, I think the best way that I found her turn this is to kind of draw out and physically do the movements of my shoulder and think, What what is contracting? What is working? What is moving here? Um, and just like like any any joint region, any junction, any muscles involved has innovation. So the main nerves here to think about with the accessory nerve, which innovates trapezius long thoracic nerve, which innovates serrata, Santeria and dorsal scapular nerve, which innovates levator scapula and the rhomboids. So that's me. I did have empty qs, but that was why a lot of information that anatomy on one and a lot of the anatomy. What questions? It's gonna be applied anatomy. It's gonna be related to pathology. It's gonna be related to. Everything in that gallery is going to cover now. So I hope that was useful. Yes, that was I'm gonna I learned a lot from that as well. So thank you so much for that, Hannah. And obviously, I know your questions would have been great, but like, we have to, uh, Gary might have to start off with pathology, and hopefully, after that, people will be able to answer your questions better. So thank you so much. And I'm going to leave it to Gary now. Who's gonna be explaining pathology of the shoulder? Okay. Perfect. So I My name is Gary in one of the final layers and this Hampton hospital. Um, I also studied as a radiographer before, until I worked there, um, Jonas Summers and weekends. So Children do. These are quite a common injury and see, and something I see almost every day and work. And so I'm just going to talk through some of these injuries and you got X ray heavy images, which it's probably a little bit biased towards that. But I think it's helpful just to look at them as well because I often get asked enough skis as well. And so the shoulder injury is going to cover. Um, mostly fracture. So we look at the clavicle, approximate humerus and scapula and ribs, and and then you when with Children these on a special fractures you want to assess. If there's any neurovascular damage that can result from these fractures and as well as that, we look at some joint pathology, so mostly dislocations. And then we look at some, uh, we'll talk about some S E N S E joint disruptions and then as well as that, as, uh described earlier. So much soft tissue and muscle muscles around the area that when you injure your shoulder, is high likelihood that something will will land damage from here as well. And so, just in terms of management of shoulder entities, um, just because of the bone, I think it's important just not to forget that, um, the area in which the injuries in you can often have chest injuries, which and rib fractures which could lead to the pneumothorax and just be aware of that, um, as well as the mechanism of falling and hurting shoulder these There could also be a head injury. Um, so just in Charlotte to do a full 80 assessment. And as I said to me how to force injuries and you need to assess neurovascular status as well. So, as with any, um, joint assessment, you want to look, feel and move again. Shoulder injuries. You probably don't want to be moving them. Too much of the patient probably won't be too appreciative. Removing your shoulder around dislocated or trying to move it around. Um, in terms of imaging, usually actually the first line. And more often than not, you would do a pre, uh, actually, uh and then one post if you've manipulated. And I think that's important. Just because if you look at somebody's shoulder, let's say you think it's dislocated may actually be fractured. And if you want to try to reduce that, you can make the situation even worse. Um, and again as well as look looking and feeling moving. Also in to examine and assess the joint above and blood injury and often few kind of damage in the middle of Let's say, if you damage the middle of the humerus, you can also have an injury and your elbow or up and, uh, the shoulder joint itself, and then the mainstay of management of shoulder injuries is to reduce it. If it's out of place or if it's a displaced fracture, then immobilize it and keep it in the right place. And then we have afterwards. Um, and I suppose if you're taking the history from the patient, it's important to find out which hand dominant there. And if they have into that side, you may want to get, like, ot input. Well, just to make sure that they're able to cope. Okay, so this is, um, to normal X rays and just popped up so people can get used to looking after normally. So the image on the left is an AP view. So you're looking straight on from the front and and the image on the writer is, uh, we'll leave you, which has taken pee a lot of textbooks and things say to do uh, XL view, which I think they're having to slide on the next side. But in reality, when people injured their shoulders, it's way too hard for them to be able to do that. And these doing these two positions requires very little movement. And patient's are much happier with that. Yeah, so this is an injury took from the Radiologist page on Instagram. Very little page, if anybody hasn't looked at it before, but it up all sort of extras and image interpretation, which is good for us. Um, and the image on the really here, that's the eggs injury. So I'm not sure if you can tell me, but the patient has to be able to lift your shoulder up to about here to get that extra and again if dislocated, or if they have a fracture, they won't be too impressed to do asking them to do that. So I'll set with some clavicle fractures. So usually the mechanism is direct trauma. So what you'd see is sports players usually rugby, kind of swooping down into a tackle and getting hit into the capital. Um, you've also seen pediatrics as well. A lot of the time, it's, uh, kind of a fall they have, or maybe doing a handstand. And the force kind of goes up through and, uh, clavicle, I suppose is the weakest point there. Um, some of the features you'd see is patient's are very specific on where they're sore. A lot of times that other fractures in the shoulder there more of a. But they usually can point to exactly where it will be. Um, as it's quite close to the skin surface, a bad fracture may actually be open and the end of the bone maybe sticking out through the skin. Um, And when you look at it when you look at somebody with a, uh, clavicle fracture, you could usually tell as well they allow quite prominent lump if it if it hasn't been used again. Um, and then usually the management is conservative. You want to swing with an edible support to keep it, uh, immobilized for about 4 to 6 weeks and then, if it's very common, muted. And if it's an open fracture, or if there's significant shortening of the the fracture parts, uh, may need to have, uh, an order for just to keep it in place. Um, so some complications would include non union. So if the parts are very fair apart, they may not come back together. Um, the break up axis is quite close to that as well. And it's suppose very bad fracture may damage to that and as well in around that area you have your ribs. So if you got a direct blow to your upper chest, there's a possibility that you could break a rib, um, and even result in in your threats. And then, as I said, if you have a kind of occult fracture, you want to check the joint any other side, too. You want to check the SI joint? The SC joint can just make sure they're both in place. Um, tropical fractures can look very dramatic on an X ray and can look like parts are really far apart. And a lot of time we're still dis managed conservatively. Um, so this is an actual left shoulder, and it just shows a fracture to search connected humerus, which goes across to the bottom. And then I entered the, uh, greater tuberosity. But it's still within the joint. So this is an AP and away view, um, and then the way that you conceded the human head is still within the joint. So sometimes when you get a human head fracture like this when it's an intra capsule fracture, the blood within the capsule king and, uh, push the headed, humorous down, and they can make it look like there's a associated dislocation as well, which is called a pseudo subluxation. And so human fractures again a lot of time. They are just direct trauma. So sports injuries, people getting hit into the shoulder. Um, they may also be pathological as well. So it's the shoulder and humorous are quite a common place for, uh, metastases to develop. Um, and then the other group who got humor fractures, uh, elderly patient's who are osteo project may be on long term steroids, and their mechanism is usually kind of a real low energy follow. Maybe you can just fall against the share or something like that and end up with a fracture, Um, and again their clinical features that they'll have really reduced movement they made of swelling or bruising over the area. And as I said earlier, um, actually, it's very similar to a dislocation, so you wanted to make sure you have the extra first before you try to try and put that back into place. Um, and as was discussed earlier. So the axillary nerve runs along Nurse of day. Uh, fracture. They may get damage to the auxiliary nerve, actually. Result in reduced, sensational the regimental badge area and also reduced power. The deltoid. Um, again, management to these fractures are often conservative unless they're very displaced. Um, are the very common uses, uh, you may need surgical surgical fixation. Um, so some complications include you may develop a vascular across the human head. You may get neurovascular damage. And and again, as you're close to the area, you may get rib fractures and especially you see that more often in the old osteoporotic patient and even though they've had a low energy fall could result in that and and actually, even on this, the bottom extra. Here, you can see a small little joint diffusion enough that's just post surgery. Or, um, um just go back to the side here. So I think it was covered in the upper limb letter as well. But if you got a fracture slightly lower, so and in the mid shaft of the humerus, um, the radio nerve runs along there. And if you get a fracture there, I can damage that So what you need to do is assess the, um lower. And so the radial nerve, um, innovates the extensors on the forearm. So once has damaged the patient's could end up with the wrist drops that her handle kind of beef locked down like that. And so this is the next, uh, injury. We move on test to this is showing a anterior dislocation. So the image on the left of the AP view and the image of the rate is the way of you. And you can see the humor head is out of the socket of the glee night. Um, citizen, anterior dislocation, As you can see underway view it's moving towards the ribs. If there was a posterior dislocation would be moving out the other way. And here this locations account for the vast majority of, uh, humor dislocations, or 90% and they usually are a result of kind of a direct trauma to an extended, abducted and externally rotated arm. So feeling somebody kind of reaching out, playing football, trying to block a ball. That's the kind of movement that which resulted in a dislocation. Um, and I have a normal extra cut in here just so refer to it back. Um, so the clinical features really restricting pen for the movement and the kind of empty green eyed saying so if you palpate ically night, um, just it there's nothing there, so it feels empty. Um, and then as a seller, that can look very similar to a fracture on presentation. Um, some management this needs, it needs to be reduced. Um, patient's often notice out. And so there's two options. The traditional kind of traction method is to kind of extend the arm out with traction across the body. So they put kind of a sling around the body, pull the opposite way, and any kind of externally rotate at the same time. And then another one, which I've seen done a couple of times, is actually amazing. That it works is called the Cunningham Techniques of You. If anybody wants to look that up on YouTube, basically, put the patient's hand on your shoulder and then the massage, the biceps, triceps and the trapezius and just pop back in itself with little, very little traction needed, Um, and then some of the complications that are associated with, uh, Glenohumeral dislocation, particular and anterior dislocation. Um, so you have Hill Sachs Hill sac defect. So when the HUMERAL head comes out and end here, it can hit the the inferior part of the sphenoid and leaves kind of a kind of a multiple fracture on the humeral post area, part of the humeral head. When it's going back in and then the same the humiral head can hit the glenoid and knock a bit off the labrum. Um, which is called the bank or occasion. And then you want to just check your vascular status, um, of one of these dislocations, because that can be quite fair out and they can cause some damage. Um, so you just want to feel the pulses, um, check for sensation and movement in the lower limb as well, or in the in the hand. Okay, so this is the next, um, injury or move on to. So this is again a race ap view of the shoulder. Um, and this is a posterior to this location. So this is the classic lightbulb sign, which you see on postaer dislocations and the common presentation, which I've never actually seen. But you often see um for a ski schemes and, uh, sample questions is somebody who has, uh, this post seizure or has been electrocuted? Um uh, an MD seizure. Mixed, uh, postaer dislocation. Um, And then you can see an e c g lead here in the middle, just next to the coronoid process. Um, so post your dislocation, they can be very subtle and examination to examine the patient. Um, they may have really reduced movement. You wouldn't really be able to feel anything out of the ordinary, um, and have that stereotypical lightbulb, the parents and the extra So it included The top one is the pulse here in this location and the bottom X rays. The normal view as well, just so you can compare them. And it's it's kind of external. It is and gives that kind of light bulb parents to moved away from the clean. I'll as well. Um, and as I said, a typical presentation is post seizure or somebody who's been electrocuted. Um and then this very likely to cause damage to the it's early nerves. You need to check sensation over that a regimental badges area again. And so some other injuries, Um, as I said earlier. There's a lot of joints around the shoulder. Uh, you can have some a si joint injuries as well. Probably less, um, common than the other Injuries, uh, included a day around here of, uh, the grades of each one. Um, obviously, the more the more ligament corruption there, the worst injury. Um, when you dislocate your shoulder, there's a high chance as well that you damaged some of the rotator cuff muscles there, there to move and hold the shoulder in place. So if it comes out of place, you're likely to have damaged. So once it's relocated, you probably want to assess the shoulder again, check the newer vascular status, and then maybe just check some of the movements to assess for any rotator cuff injuries. Um, rotator cuff injuries are mostly diagnosed by clinical exam and usually an MRI. We won't see one extra, of course. Um, and it is a complication of, uh, Glenn hormone dislocation. Um, most are treated conservatively, so a physio rehabilitation, but so many arthroscopy. So that's, uh, involves injecting me today into the joint capsule and then taking some either extras. Or am I just to see the, um see the consistency of the labor and see if there's any tears in which mainly eventually may need to lead to have some surgery. And then, um, I had a cuff injuries as well, mainly to some adhesive capsulitis or frozen shoulder. Uh, if they're not working properly, then you'll have some reduced movement in whichever one is a deficit. And and then I just include this agenda. We had a, uh, approximate here more fractures for a rosky. And so I think it's useful just to know how to kind of describe fractures, be able to identify them, um, and even just have a system for like, looking at we're doing shoulder today. But upper, lame or lower limb hips, whatever. Um, and the image on the left ear is good, um, diagram, just to describe which type of fracture you do. And the more you can describe the more marked you pick up. Um, and then, as I said earlier, this is, uh, this image. On the right is a checklist, which I've taken from the red. I'll just scram Page um, which is really, really good. She puts up loads of kind of tips on how to interpret extras and some pathology. There is also very useful for us in terms of asking prep. And then this is just some of the resources. Are you? So a lot of the images I got from Radio Pedia, which who knows? Anybody use that before. But they put cases up and they kind of work through the management again. Geeky medics are really good, um, system, as does the Askey stop book for, um, looking at how to interpret images and then large amount of them as well. And then, um, teach me surgery, which is very good, um, and comprehensive resource for looking at other things. Orthopedics. And that's me. Done. My e email is there as well. So anybody wants to get in touch with me. Please do. I'm based out in Antrim, and and I said I worked as a dog for before, So if anybody has any radiology, you guys questions Q three task. Thank you. Thank you, Gary. That was That was really good. And, uh, thanks for the useful resources. Um, so basically, this whole lecture is regarded and you have access students. So will the others. Who who joined? Uh, our members so that actually brings us to the end of the session today. And, uh, if you have any questions, please, you reach out. Gary's really nicely, actually, given his email address for everybody. So thank you so much. Yeah, that brings us to the end. So I'll just have to log out. And that's us. Yep. Hi, guys. Do you have any questions for me? Uh, Gary or Hannah? No, I don't have announced Thank you very much for no worries. Thank you. No, that was good. Thank you. Perfect. Thank you so much, guys. You did great. Thank you. See you later.