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Um So with that for, um I'll pass you on to Doctor Yusa um to start on with this with a presentation. Hi. Yep. Um Thank you for having me again. Um This is a pretty similar talk that I gave last year. Um And hopefully it will be useful again. Um The idea is that it'll just be upper limb trauma radiologist. I've limited it quite, I try to limit it to just that and it'll just be x-rays basically. Um And I'm pitching it at the level of what I, what I would think would be reasonable for you to know as an fy two in A&E basically um about that sort of level. Fine. Yeah. So, and I will try and introduce you to some of the views that you may not have seen before um that are pretty bone specific or joint specific. So, yeah, we'll start off with this. So this is a, a clavicle X ray. Uh and this is a normal clavicle x-ray. Um I know you're probably taught that what you need two views for everything and the clavicle is probably the exception for that. You can get away with one view with the clavicle, um, things to note, uh, the normal anatomy for clavicle when you're looking at the ac joint, especially you're looking at the under surface and I hope I'm hoping you can see the red dot that I'm seeing. So the under surface is the line that you're trying to line up. So, if an A CJ is dislocated, it's the under surface sort of line that you're trying to see is, is, is, um, is, er, er, is, er, er, n not lining up properly. If you try, if you look at the top surface, you'll often find bits of clavicle that are just normal anatomy, which is a bit more knobbly here and it'll just all look a bit, it, that doesn't line up. It quite commonly doesn't line up. So it's the under surface that you're looking for in terms of clerical fractures and stuff. It, it, it's most commonly, um, the distal third or the mid third that are fractured, the, the proximal third is only with really, really, really high impact high trauma injuries. So, if you ever see someone come in with a proximal third injury, you need to go and reassess them again properly for the chest. If you haven't noticed any chest injuries before, it's, it's, it's likely that they might have other chest injuries. Um, this isn't the best view for looking at, er, the gla humaner joint. Uh, we'll talk about shoulder views a bit later on, but just be a bit cautious about over calling and thinking about pathologies about the gla human joint on a, on a clavicle view. And of course, make sure you look at the other bones, make sure you're tracing all the cortices and looking for fractures everywhere. There's no shortcuts. Unfortunately, with trauma radios, you kind of have to look around everywhere and make sure that you're looking at everything fine. Uh So moving on to some pathology. So there's, there's no points for figuring out what's wrong here. This is a, this is a, a clavicle fracture quite a common uh location for. It is a distal like here, distal over here and they do separate quite a bit. So uh II don't suspect anyone's gonna miss this. The, the only clinical point to be made here is the skin tending. Um clinically you out, you would want to look at what the skin looks like here uh over the top of the fracture. Um Theoretically, there's a, there's a, there's a uh risk of pressure necrosis here. So if it's tented quite dramatically as you would imagine it is here on the left side here, uh you could get some pressure necrosis just right at the tip of where that uh skin is. So just make, make a note of what the skin is like when you're documenting for a patient with a clavicle fracture like this. And of course, look at the rest of the, look, look at look at the rest of the lungs. We've got a decent amount of lung to look at here and make sure there's not a little pneumothorax stuck at the top of the ABC there and um and so on. Yeah. So clavicle fracture, that's a nice uh easy one to. No, this is uh a clavicle fracture as well. Um My, this time, the reason I put this one in is mainly to show that you can do separate views to views for clavicle. So there is the option to do oblique views. Um So the right image here, um you can see the fracture, you can see the overlapping there and you can see that there's a slightly extra density there and of course, there's these flakes there, but it gives the impression that maybe that the f the fracture, er the fracture ends a li uh uh er are lined up, but it's only in the oblique view that you can see that they're not lined up at all in the, in the and they're quite badly displaced and communed. So there are um there are oblique views available for the clavicle if you need it. Er If you're working in a, in a department with good radiographers, they'll do that for you automatically, they'll look at the images and they'll, they'll notice that the fractures, you can't interpret it properly uh on a, on a single view and they'll do the oblique views for you and of course, you have the option of asking for the oblique views. Er if you if you feel like you need them after looking at the single view initially, right? So this is an example of uh uh a CJ disruption and if I can get my pen up. Mhm Fine. Yeah. So what I was mentioning here was, yeah, so what I was pointing out is that this is the line needs to line up here. So th that's the lines that need to line up and this is quite clearly disrupted. So this is a type of a CJ disruption. Um The next thing to look at once you've noticed this sort of disruption is to look at this space here. So this is the corona. Uh This is the coronoid process of the scapula and you wanna look at the under surface here and look at what this distance is like. All right, if so, if this is above two centimeters and you're worried about a coronoid ligament uh injury or oc clavicular ligament injury. So, there's two ligaments here. There's a trapezoid ligament and a coronoid ligament that joins the clavicle to the scapula. Um Obviously, you can't see that on, on, on the X ray, but you can infer that they are ruptured if this space here is, is above 2.5 centimeters. And um that makes the basis of, of this basically. So this is the Rockwood classification of, of occ clavicular joint injuries. Now I'm gonna cross out type six here because this is basically a unicorn. Er, and what I mean by that is ridiculously ridiculously ridiculously rare. Um I'll give you an indication. I was recently at a sports injury conference at Liverpool, uh where there, it was full of specialists. I sk radiologists, there must have been a room full of about 50 people and I think someone asked if anybody had seen one of these and one person put their hand up and it was like an old dude. He was in his seventies and he's just been doing M SK forever. So, so yeah, so forget about this as far as you're concerned, this isn't real. Um Let's see. Yeah. So type one is basically an A CJ sprain. Um And so there's no displacement here. So this isn't a radiological diagnosis. That's a clinical diagnosis. So you can forget about that one as well. Type two is when the dis when there's a bit of disruption here. And um but the distance isn't that bad, it's just slightly off. Type three is when the distance is above here. So when the bottle on the surface of the clavicle is above the top surface of the chrom type four is when there's posterior displacement. Yeah. Er type five is when this distance is above two, is above 2.5 centimeters, I think. And that indicates that there it is very, very, it's, it's definitely ruptured Yeah. So just, I don't expect you. I don't think this is something that you need to know in and out. Just have an idea of what happens to occur, clavicular joints when they, when they rupture. And of course, you can forget about number one and number three and number six, cos they're not real. Number one, it's not a radiolog log diagnosis and number six is mythical. It's not real. Um Yeah. So this is a, a normal shoulder X ray to start with. So these are two views uh that exist for shoulders. So for shoulders, you'll always get AP view, which is this one on the right. So this is an AP view. You'll always get this and your alternative view will depend on where you work and also what position the, the er, the radiographers can get the shoulder into and also what pathology you're looking for. And this is called something called a Y view. And the reason you can think of it that way is if you can almost see the scapula forms A Y shape. Yeah. And the glenoid is here fine now. And I find the Y view is probably my favorite alternate view. There are, there are lateral scapular views you can do, there are auxiliary views you can do as well. But I prefer this view. And the reason for that is that it, it helps with dislocations um for me anyway, um and we'll talk about dislocations in in a bit. Um things to look out for, for shoulder x rays, in particular, we'll talk about the cations in a second. But this is how a normal, normal um uh shoulder articulation, glenohumeral joint articulation is. And you can see that the glenoid is roughly center central within the humeral head there, right? Um In an in an anterior dislocation, of course, the human head will be this way and in a posterior dislocation, the human head will be that way. I've got examples coming up. So that's fine. And again, when you're looking for fractures, there's no shortcuts. You need to trace round all of the uh all of the cortices when it comes to human fractures, they commonly fracture here. So that's the surgical neck of the humerus. Whereas the anatomical neck is this thing here. You can sort of see this slightly more sclerotic line. It's an uncommon place for it to fracture. So we've made up this term called the surgical neck of the humerus. So it's much more likely to fracture here. Uh Let me see if I can undo some of my notes. Yeah, we'll get rid of that and, and it can then progress up and then fracture into multiple parts. So if it's gonna commun it, it will fracture across the surgical neck first and then then comming it that way. So it to include the er the greater tubercle or into the articular er articular surface. And I've, I've got an example of that as well in a second. So we can talk about it a bit more then. So, move on. So, yeah. So this is a uh example of an anterior dislocation. And you can see this is the glenoid surface here over there and you can see this is the, the human service here and you can see that it's definitely not, er, they're not lined up, they're not congruent. Er, and it's, I think that's a quite a nice obvious case. Um, clinical thing to be wary of, um, with anterior dislocations is you want to just document the axillary nerve function. So it's, it's, it's called a regiments patch. So it should be around here. You want to just document that, that the sensation is intact there before you uh relocate that joint and then you want to document what it feels like after you've relocated the joint, just uh it's more of a medical legal thing. Um, it's a nerve that can be uh damaged during dislocation and during relocation as well. Find uh another thing to be wary of with dislocations is just make sure there's no fractures, of course. So if there's a, a fracture and a dislocation that makes things supremely more difficult to do and then there's a low, a low, a low, a low threshold to taking this patient to the theater and doing it on the general anesthetic with the orthopedic surgeons doing that for you. Uh fine. So this is a, a example of a posterior dislocation. And there's, this ap view is classical here. So this is something called a light bulb sign here on the left here. And if I draw it out for you, it'll be nice and obvious. So if you think of this as the light bulb fine and if you think of that there, there, you got the squiggy bit there fine. So that's the light bulb sign there. And um it's a common sign that you see in posterior dislocations. And of course, this alternative y view just confirms it for you. So I'll just draw it out again here. So you can see the hang on, you can see the wire of the scapula and you can see the glenoid there and you can see the humeral head uh is mostly posterior to where the glenoid is and you can almost see the g the humeral articular surface here. OK. Give me a while there. Let me just uh um you can see the human articular surfaces just pointing posteriorly. So uh this is a posterior dislocation and this is a uh light bulb sign. The one caveat to this though, the one thing. So not every humerus that looks like the light bulb is posteriorly dislocated. If you have a patient that's holding their arm very, very internally rotated because they're in pain. And we've got an AP view where their arm is like this. They're just holding it like this because they're in pain, you can sometimes get a view that looks like this as well. So I, if once you guys are all working in A and D, er, and you see a patient whose AP view looks like this, like a light bulb, what I want you to do is instantly look at the, the second view and look at whether it is truly dislocated and, um, and, er, er er before bef and not just internally rotated because they're in pain and there isn't like a fracture somewhere else that might be causing their pain. Um, posterior dislocations are, are, are much, much, much more rare. So I think they account for about 5% of all dislocations compared to the 95% being the anterior dislocation. Technically, there's a third type of dislocation as well as called an inferior dislocation, uh which is again, really, really rare. So I'm not going to talk about it. That's just it, it'll be like a once in a career sort of thing. Um But yeah, so light bulb sign and just confirm it with the second review. Um Yeah, this is another example of a posterior dislocation. Um just to conf show you that sometimes the AP view might not give you a light bulb. Uh but you can still see it, it's dislocated on the er, on the Y view here. It's completely, completely off fine. Uh Yup. And these are fractures. So this is a surgical neck fracture and you can see it's communed up here. So this is the greater tubercle has, has come off and it's also this further commination over there. And up here here, this is a nasty fracture. Not uncommon. Actually, these are, these are quite common. Er, if you did an ad job, I'd expect you to come across more, one of some of these during your tenure there. Um, the orthopedic surgeons quite like, um, seating these and, and they're becoming more and more, uh, more and more reliant on ct scans in, in, in helping plan the surgery, um, for these type of things. And they also quite commonly want to know what the glenoid, what the glenoid looks like. Um, but yeah, so there's a, there's a fracture, um, just remember surgical neck is the common place for them to, to fracture and then they commun it towards the, the articular surface. Um, yeah, I think that's about as much as I've put on for shoulders and I think that covers the common shoulder pathologies, um, and the ones that I would expect you to know about as an Fy two in A and D. Um, moving on to elbows now, elbows are more of a pediatric, er, joint to get injured, to be honest. Um, much more common for the pediatric A&E department to be doing elbow x-rays. Um, but that's pe, is a little bit beyond the scope of today's talk maybe we can do that at a different time. Um, but I'll take you through elbow x-rays. Um, so you get a AP view, which is this one and you get the lateral view, which is this one. And, um, the things that you're looking for are, of course, you're tracing all of the cortices and you're making sure there's no breaks or fractures that you're looking for. And the next thing you're looking for is alignment. So I've got another slide on it and I'll talk you through there. But you're looking for radio capitella alignment. So you want the, the radius and the capital of the, of the humerus to line up and you're looking for anterior human alignment. So if you draw a line down the, oh, not very straight here, imagine that's a straight line down the, the anterior cortex of, of the humerus. It, it should, it should transect about a third of the distance through the capilla. Um And if it doesn't, then you're worried about a supracondylar fracture. And if this doesn't, you're worried about a uh a radial uh radial capitella dislocation now, that applies to kids as well. So it applies to P as well. Um Let me just get my razor fine. Um The only caveat is the way you draw your in kids, especially the way you draw your radio capital line should be not the full shaft. So not from down here, it should be the normal angle that the radius has. It's a bit more evident on Pete's, it's a little bit more difficult to see on, on uh on adults. Um And this applies on the AP as well. So the really capital line should work on the AP as well. Um The other thing to talk about is fat pads and, and joint effusions. So elbows will often give you joint effusions which make you very suspicious about fractures and then you look for a fracture and you look and you look and you look and sometimes you really, really can't find a fracture. Um So joint types of joint effusions is that if you look very carefully, I don't know how well this is projecting, but there is a subtle lucency here. So that's the anterior fat pad and that's a normal structure within joints and this is a normal position for it. So I'll take that ra off. So if you look very, very closely, you'll be able to see that hopefully. Um And that's uh it's normal location. There's also a posterior fat that which you, which you should never be able to see if you can see it. It means it's pathological and I've got a slide on that and it will make a bit more sense on the next one. Um So this is that this is a radio capital line. They should line up and that's one thing that you need to check on every uh elbow X ray that you look at, uh this is the anterior humeral line and you should have roughly about a third in front of it and two thirds behind it roughly. All right. But if it's, if it's dramatically off and, or if the capitum sat over here somewhere, then be worried about supracondylar fractures, um fine. So this is the example of um, a joint effusion and fat pads. You can see how be previously that fat pad was down here. But now if I can convince you that it's up here, so it's been pushed upwards. And previously, there was no fat pad posteriorly, but there is one now here and again, that's the fat that lies on top of the er uh articular capsule. So the normal joint capsule that's been pushed up. And that's because the joint capsule is now full of fluid and in the context of trauma that it, it's, it's essentially a hemarthrosis and you're looking for a fracture somewhere. And in adults, the most common fracture is a, is a, is a radial head fracture. And uh if you are very, very eagle eyed, those of you, you would have noticed that there's a fracture here. Yeah, I've deliberately not given you the other view because it's, it's, it's too easy, easy. Otherwise, but the point of this slide was to show you the fat pad sign. So I'll remove the razors again. Yeah. But yeah, so this lucent area that you can see um anterior and posterior to the humerus is fat and it is um so this is this loosen area that you can see is fat and uh you should never be able to see it posteriorly. So if you can see it posteriorly, that's abnormal. And that's definitely a, a joint effusion and anteriorly, you can see it, but it should be a thin line down here. If you see it up here, that's abnormal as well. It means there's a joint effusion and in an adult that means you need to now go look for a fracture and most commonly, it's a regal head fracture. Uh Yeah. So that's just arrows there for that to point that out. And this is a bit more obvious. Yeah. So there's a radial neck fracture here. So that's another common place. But er radial head fractures can be really, really sneaky. So they can be just like that and that can give you a joint effusion. You can get just over there that can give you a joint effusion. So you really do need to in interrogate it um properly on all the views that you have available to you. But when it comes to, for adults, really, um what I would want you to remember is this. So remember the joint effusions, remember your alignments and look for radial head fractures. Basically, um dislocations are really uncommon with adults and if they do dislocate, they dislocate properly. Uh in that the whole, the whole of the humerus goes that way and all of this would be lying over here somewhere so they dislocate properly and there's no prizes for figuring out that it's dislocated. Every, everyone knows that everyone will know that, um, super coul factors as well. That's more of a pediatric thing. Um, but it's worth just getting your iron, uh, with these lines, uh, moving on to, uh, what was this supposed to be? This is uh, wrists. Yeah. So wrist x-rays now, wrist x rays, you'll always get uh ADP or an AP view here. You'll always get a lateral and er, sometimes you can get an oblique as well. Um, so these are normal wrist x rays just to show you um, how they look, um, things to look out for are the carpal alignments. So you want these arches to look smooth like that. Um, other thing to watch out for is the distance between the scaphoid and the lunate. Make sure that's not widened. Other things to look out for is here. I used to miss loads of little old styloid fractures when I first started, I think that you can get little sneaky fractures there. Um, and of course, look at the rest of the hand if you ii, the tempting thing when you, when you have the patient in front of you is to concentrate on a bit that, you know, has an injury because you've seen the patient and, you know, they, they've got pain somewhere and you concentrate on that and you forget about the rest of the hand. So make sure you look at everything else as well. Um I have an isolated lateral view here because there's again, some alignments to, to bear in mind. So this is a busy, this is a busy x-ray. That's because you're looking through all of the, all of the carpal bones. Uh It, it's difficult when you first start looking at them, but if I draw out some lines for you, so that is the capitate, this is the lunate and this is the radius here. So this is an important uh alignment that you want to see on all of your lateral wrist x-rays is that these should line up like that, they should line up on top of each other. Um They should line up on top of each other like like like that and I've got examples of when that doesn't happen. Um And what those pathologies look like. Another good review area, sorry, another good review area is to look at the posterior er cortices of the of the radius. Um So a very, very common risk fracture injury is uh falling onto an outstretched hand. And um if any of you ever do an ad job during the winter and it snowed recently, there'll be a flurry of uh older women who have fallen over and fractured their wrists. Um So this posterior cortex of the radius needs to be absolutely smooth if there's any crinkle or any sort of divot in it, that means they fractured the wrist basically. So that needs to be absolutely smooth. So that's a good review area that I want you guys to get into the habit of looking at. And of course, alignment is another thing to look out for and that is it really. So those are the normal things to look out for, make sure the carpal bones uh uh keep their arches, uh look out for sneaky little fractures in the ulnar styloid, of course, trace all your cortices and make sure there's no obvious fractures anywhere else that includes the, that includes the, the copper bones. Another another sneaky place is this the hook of the hamate and that can fracture as well and it can be quite difficult to find. Um and that's it really. And then of course on the lateral, make sure the alignments are OK. So we've got some examples of some fractures now. So this is uh a distal radius fracture. Uh The history for this was almost certainly falling onto an outstretched hand and you can see there is a communist fracture through the radius here and very, very commonly, this is very common is that they show a dorsal tilt. So when we, when we talk about hands, uh just to be just to be difficult, there's extra er terminology to think about. So the, so the back of the hand is dorsal and the, and the, and the front of the hand or the palm of the hand is volar. Um So you can see that this is tilted posteriorly or dorsally. And um this is gonna need er when it's reduced, it's gonna need pulling er this way and also that way. So he's gonna need reduced lengthening and also um reducing its um dorsal tilt by pulling it volar, giving it a volar, um a volar vector during your tilt. Um Unusual there's no uls fracture. So a very common, a very, very, very common associated fracture that goes with the radial fractures. There's an ULS fracture, but it unusually on this one, I've picked out the one that doesn't have it there, there normally is one there as well. Um So this has an autonomous name. So this is called a collies fracture. Don't go away. Whereas this has a separate pou name. Um and this is called a Barton's Barton's fracture. Yeah, Barton's fracture. So it's a radial fracture, but it's got extension into the uh articular surface and it's got a dorsal tilt as well um slightly. And so this is something called a Barton fracture. Um And this is just a sort of summary of the different types of fractures and the different names they have. Um Ultimately, I think, generally speaking, um for radiology anyway, we're moving away from names um because they're confusing and they're not very, they're not particularly descriptive to be honest. Um So I would think about the things as as descriptors more than anything else. So think about is it communed? Is it displaced if it is displaced? How is it displaced? So this is dorsally aul er and is it is it extending into the intra articular surface? So that those are the sort of common things that you want to mention uh or think about when you're looking at x rays. So this is the type of these are the type of wrist fractures that you get. Um This is a scaphoid series. Now, you'll have, you'll recognize er the first two images because they are similar to the wrist er images that we've seen. So this is the lateral and this is an ap but for scape forwards, you get these extra views, these, these 3rd and 4th extra view that just give you better views of the scape forward, they just kind of elongate it out and just give you because it's, it's a weird shape of the skateboard. So you need these extra views to look at it. Um And here's an example of a scaphoid waist fracture. Uh There's a fracture right there. Fine thing about scape practices is that because they're so difficult to image if you don't see them on the first uh radiographs that you take, imagine, let's imagine that you're seeing this patient in ad um that doesn't necessarily exclude the fracture. So, different places will have different uh algorithms and how they deal with this and different protocols. Um Traditionally, you, you would have been taught that you'd get an extra set of x rays in two weeks time. And if there was a fracture at the time, you'll start seeing signs of healing and signs of sclerosis. And, and so when I say sclerosis, you start seeing extra white bits along the edge of it. So this is a slightly older fracture. You can see there's a bit of sclerosis around the edges, the fracture there. Um and you can in inadvertently then infer that there was a fracture originally. Now, in a moment, I'll show you one of the repercussions of what can happen if you miss a skateboard fracture. So, um that that's kind of not acceptable anymore. So I if the hand surgeons are, are truly concerned about a scaphoid fracture, um and the x rays are equivocal, they're nowadays, we would do um either an MRI or you would do a uh act scan to look for the fracture. Now, I don't, I don't have examples of those to, to show you because I've been trying to concentrate on X rays today. But um depending on where you work, you'll have different protocols and different pathways to try and sort out the suspicious er scaphoid fracture. So, a normal scaphoid series does not exclude scaphoid fractures on the acutely. So if it's the same day, you haven't excluded that skate foot fracture, we're still concerned about it. You need to follow the pathway that you'll have locally, whether that's repeat images in two weeks time or whether that's cross sectional imaging. And er the reason it's, it's important is that the blood supply for the, for the scape for is retrograde. So it, it, it, it, it goes from distal to proximal in that sort of direction. So if you have a fracture that goes through here, uh you can potentially, especially if it's displaced, you could potentially disrupt the blood supply to the proximal pole. Uh and it will so fractures that are the more proximal fracture is the more likely it is to not unite. So malunion is more I II is more risk and avascular necrosis is more, is more of a risk. The more proximal a fracture is and you might think, oh, well, is that too bad of a problem? Well, this is what happens when you, when you have avascular necrosis of a malun uh scape fracture and you get, and you can see that this wrist just doesn't quite look right and this is the remnant of the scaphoid. And if you remember if I go back to what it looked like on a normal scaphoid, where's the rest of it? You know, so this is a normal ap on that patient, this whole proximal pole, I'll show you again in a second, has a has crossed. You can see where's the proximal pole gump. And that has uh quite a drastic impact on, on the rest of the carpal bones. The other thing you'll notice is where's the lunate gone? The lunate doesn't look quite look right either. It's like they should be here. This capitate is too low and everything is gone. And there, there's a name for this. It's called snack. So it's called scaphoid nonunion, advanced collapse. And what happens is you start off like this and you've got a normal wrist, you get a fracture and then it doesn't unite and then it's like collapsing down and everything kind of squashes down and the whole of the carpal bones move because they, they, they all, they're all dependent on each other for their, for their support. Um Yeah. So thi this is what we're trying to avoid by picking out scaphoid um scaphoid fractures in a timely manner. We're trying to avoid this sort of wrist and the morbidity that comes along with it fine. Let's move it along fine. Yeah, so this is an example of a another common carpal fracture that we could get. Um It's something called uh it's a triquetral fracture and this patient also has a skway fracture as well. So they've got two. But the, the what I really actually wanted to show you was this, this thing, there's this triquetral factor here. So you if you and they're only really visible on a lateral X ray. So, so if you have a normal wrist, otherwise just interrogate the lateral x-ray, I think, uh make sure again the alignment's fine which it is on this. But if there is a little fleck of bone on the back there, it's possibly a trach regional fracture. Incidentally, this patient's also got a skway fracture there as well, but you're fine. So rational fact has little fleck of bone on the posterior or the dorsal uh dorsal surface of the wrist. Oh yeah, I finally got one. So this is on a side fracture. Um But that's not the reason why I've put this here. So if you look at this lunate, it doesn't, it looks very triangular in shape. So if you see that on an AP start thinking about carpal dislocations and uh when I've been banging on about uh the, the radial the alignments, this is this is why. So look at that radius, look at that capitate, I've not drawn that very well, but look at that capitate. But where's the lunate? The lunates over here? Yeah. So that should be sat underneath there, but it's not. So this is called a um a lunate dislocation. So the lunate moves to a volar direction but the capitate and the radius stay aligned to each other. So this is called a lunate dislocation. Yeah, fine. Uh This is uh something similar but a little, a little, just a little bit different on the AP you get a similar sort of view you get this um triangular lunate. But on this example, you can see that the lunate is here. Ok. It's slightly off but it's, but it's still on top of the radius, but the capitate still on top of the radius, but the capitate is over here, the capitate should be sat here, but it's not. So this is something called a perilunate dislocation. Um There are other variations that come with this that come along with um scaphoid fractures. So you can get transscaphoid fracture, perilunar dislocations and then you can get midcarpal dislocations, but they're just, they're, they, they get, I'm getting progressively rarer and progressively more complicated. So, II I'll leave that for you to you guys to uh look up in your own time so fine. And this is just AAA cartoon of that, that kind of explains it. So it's the lunate is not sat on top of the radius. It's a lunate dislocation if the lunate is set upon the radius, but the capitate is not set upon the lunate. And that's a perilunate dislocation. And just remember the normal alignment, lunate capitate radius. Very important. That should be something that you look at on every single wrist, lateral x-ray that you look at. Yeah, moving on to hands. So um ha what I mean has I mean, fingers and metacarpals uh and the views you get are an ap you'll always get ADP, you'll always get a slightly oblique one and, and then you should also get a lateral. So, so you should get three views whenever you look at fingers and hands. And um again, there's no, there's no, uh there's no shortcuts. I'm, I'm afraid you just kind of have to trace every single cortex to make sure that you're not missing a fracture and with hands. Um I've got some examples of common fractures that we get, but I've not gone through every single one. Um I've not gone through like the obvious oblique ones. Cos they're very commonly you just get oblique fractures through the car. There's no, there's no autonomous names to them. They're just, they're just fractures. Um, and again, remember the wrist, I'm gonna keep going on about it because it's very important. Wrist injuries have high morbidity if they're missed. So to remember the wrist and, and every time you do get a lateral, just make sure you line up the wrist, er, fine. So this is a common injury. Uh, this is called something called a boxer fracture and it's a metacarpal neck fracture. So 1/5 metacarpal neck fracture, um, and it occurs when someone punched something and it's normally it's normally in A&E and someone is in a fit of anger punched like the wall or something. Um, so you can see that this is volarly tilted, so towards the palm and um, and um the fractures can be complete or they can be incomplete. Um So this one's slightly incomplete because you get the impression of the volar cortex is still intact. Um, clinically, what gives this away is there'll be quite obvious tenderness at the top of that, um, fifth metacarpal. But also when you ask a patient to make a fist, there, there will be scissoring. Um, as in the fingers don't, won't make a fist properly. I don't know if you can see my hands properly but they'll kind of overlap or underlap like that. So if you ever get a patient whose, whose fingers aren't making a fist properly and they're overlapping and under lapping, er, be worrier, think about metacarpal fractures because if you think about it, there's ligaments that are holding all of these joints together. So they're actually quite firmly stuck to each other. Yeah. But if you have a fracture here, that'll allow the whole of your finger to rotate and therefore it won't WW when you try to close that finger. Remember all of these joints are still gonna be perfectly fine. So they'll be able to, even though they're swollen, it, it'll get in the way of the other finger and, and, and it'll scissor underneath. So if you ever get scissoring, I'm sure there'll be youtube videos if you look it up. Uh, uh it's a good sign that there's a metacarpal fracture. Fine. Yeah. So this is just another example. Um, and this one, II think it's healed. Um So when they heal, if they've not been put back and straightened out, they'll just heal like that. So this patient will just have constant, the fingers just don't, they can't form a fist properly. Um And then again, of course, there's always that that person that just has anger issues and will fracture something repeatedly and it'll become progressively more deformed and it becomes more and more difficult to know whether it's fractured or not. In which case, looking at previous is, is, is the key. Um So, ii, if you, if you're worried about whether something is an old injury or, or a new injury, that's where previous imaging is, is will, will, will bail you out. So, uh or, or if you have it available, so you always look at previous imaging fine. Um So this is when it comes to radiology exams. Um this is the sort of nightmare scenario when you give it a hand like this and you're just like I've got so many bones to look at, oh, it's gonna take me ages, but there is no, there's no, there is no um shortcut. Unfortunately, you just kind of have to look around every single bone and every single view and then eventually you'll get to hear. Um And so that is something called a male fracture. And um I've got a zoomed up view of the of that for you there. Now, clinically, this patient will have a, a uh a th a distal interphalangeal joint that is sort of in a fixed flexion, fixed flexion position. Um Now, I appreciate that this finger, you can see the soft tissue quite nicely and it looks nicely extended. Um But the idea is that you look like this. So this is something called a mallet finger. And the reason they get that is because of this. So the the extensor tendon attaches to this distal to this proximal aspect of the, of the, of the phalanx on the dorsal aspect of the falx approximately here like that. And if you have a fracture, you can imagine that tens, unable to do its job anymore. So you'll have flexion, the flexor tendons however, are still intact and they'll have unopposed action. So therefore you'll have a fixed flexion deformity. Um And of course, you can get injury of the tendon alo alone. So if you ever see a patient who's had, um, so you, you get this with sporting injuries, you get it with Diy as well. A lot, a lot of builders come in with this sort of stuff. Um And they come in and go like, I can't really move my finger this to le very well and it's kind of like stuck like that. You need to do an X ray just to make sure it's not a, not a, uh not a fracture basically. Uh And that's it really, that's all I wanted to go over. I've tried to pick out, er, what I think are not so obvious examples of injuries in various places in the upper limb. If you guys are interested, this is a book that I would recommend. Um, it's, er, er, it's done by some guys, some radiologists in London who are run the red dot courses. Quite a famous course. Um, that a lot of the registrars radiology registrars go on to, um, to prepare for our fellowship exams. It's a really good, a really good, uh, really good book and I would recommend that book if you guys are interested. Er, and thank you very much, er, and Radio Pia is another great source. I've basically nicked all of my x rays from today, uh, on, from radio Pia. Well, that's it. Any, any questions from anyone, anyone who want me to go over anything again? Thank you very much, Doctor Theresa. Um I'm happy to read off any questions if you have just put them in the chart. So, um, no questions so far. I'll just send off this feedback form. In the meantime, we'll be very glad if you can fill it in. Um, and I've just uploaded the slides and a link to our PIA case playlist um onto our me page on on demand content. So if you like to review the slides and the cases, um we can access that. Um, and thank you very much for joining us tonight. And again, if you have any questions, just let us know. Sorry, Doctor Moosa, are you able to briefly go over that part. You know, when you talk about the capitellum and using it as a guide, um, not just for the er anterior of the humerus, but the, um, when you use it horizontally, are you able to just go over that part again? Sure. Yeah, of course. Um Fine. Where was it? Fine? Yeah. So can you see my crosshairs on this or do I need to go on a slide show again? Uh No, we can, we can see fine. Yeah, it's fine. You you can see my, you can see my mouse. Yeah. Mhm Fine. Um Yeah, I mean, so the I think I need to show you a pete's um thing first let me just find it pediatric to make more a sense if I show you a pediatric elbow. Fine. So the uh you can still see my screen. Yes. Um so the the distal humerus I II in a pediatric um patient is uh this is already too ossified. I want something a bit more. There you go. In a pediatric patient. You'll see that there will be multiple ossification centers and there's the the acronym CTOL er er wonder if you've come across that before. Um but essentially, once it's fused it all, it's all essentially the the humerus but you can still think of it as being, being um separate bits. So this is the capitella. So this is the capitella radio capitella joint of the ulnar er of the elbow, sorry, the trochlear hasn't really appeared yet in this age group in this age of this patient. And then there's a, er, er, an electron os ossification center which hasn't appeared yet as well and there's, there will be an internal and external as well. Um So when we look at capital radial alignment, I, if you look at this radius, this is what I was talking about, um about how there's a bit of a kink in pediatric patients. So if you took this, uh if your eye was to draw lines on how can I do this? Ok. So if I was to draw a line along the whole shaft um from here, now, this is obviously normal but um you, it's, it sometimes makes it look normal whereas what you should be doing is drawing it along there along like that along just where that sort of angulation is. Um again, the the point of this wasn't pes. So I'm not gonna dwell on this too much, but in adults, um you can just draw it along the full shaft and it should match up. And if it doesn't, you've got a radial, radial, um a radial er er capitella dislocation or just a approximal radial er dislocation cos the capitella doesn't really make sense anymore. Cos once it's fused, it's just humerus, but we still call it a radial cap dislocation because it makes sense. And in terms of anterior humeral line. Um so So would would that go through the middle of the capitellum and then when you're looking at the the radius, it will go through the middle of the radius. Yeah. So, so just, yeah. So if you draw along the radius, it should just hit this portion of the humerus. Now this is in adult. So the cap is fused. So it maybe that's what confused you. But this is, it stems form this thing, it still applies to adults. So if it's off and the and the radiuses appear somewhere, um and the line doesn't cross the humus, then you, you've got a radial er a radial dislocation which is, which is rare in adults, but it's it, I wanted to talk about it just because if you come across elbows, it's mostly gonna be peds. And um this is important and when it comes to anterior human alliance, it's, it's essentially just for this, this, this this injury. So you can see if I, if I was to draw a line along the anterior surface of the humerus here, it doesn't cross the capilla. That's because there's a fracture here. There's a supracondylar fracture. Yeah. So that, that it, it's kind of tilted the distal humerus posteriorly. Does that make sense? It's this, this is a nice example of that. If I draw a line down that anterior humerus, if you visualize it yourself, it's not crossing the cap. So therefore, there's a, there's a, there must be a supracondylar fracture, but there's a, this is quite obvious sometimes it's very subtle and you rely on the line to show you it fine. And did you, did you also want to talk about these as well? Fat Bs, did you say? Uh No, I mean, I've understood those quite well, those ones. Yeah, it was just the, the two lines. But yeah, that's great. Thanks, sir for that. Yeah. All right. Any other questions at all? Um Thank you very much. I don't see any other questions. So um just before we close up the session, I wanted to mention that doctors also deliver a session next week on lower lymph trauma. So I'll just leave you the link for the next session and if you're interested in and learning more professional, all general pathologies um attend a session as well. So again, thank you very much everyone who attended and thank you very much, Doctor Rosa for your time and hope you enjoy the rest of the evening. You very much. Thank you, Lee Lee. Will you be alright presenting on on Thursday? Yeah, that's fine. Yeah, it's in the morning. You mean presenting remotely, is it? Yeah, yeah, I'll just be presenting from head to be honest. So Wi Fi is good. Um ok. Yeah. Yeah, no worries. I think I've got the slides. So yeah, I'll be, yeah, I'll be on the call. So, yeah, that's pretty much the same as last time, right? No, No, I did. You just got to keep the time though because there's, there's, there's always an issue with tiring, so not meeting. So just, just keep the tired would be fine. I doubt there will be any questions at the end than the normal. To be honest. I think she said 67 minutes or something. That's pretty quick. But I can, I can definitely get through it. That's no problem. No problem. No, you'll be fine. I'll just practice it a few times before and then it would be, be good. Yeah, no worries. I will see you on Thursday. Yeah, for sure. See you Thursday. All right. See you later. Bye bye bye.