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Duration from last week and focusing on lower limb trauma um today and again, like last week, it'll be um like a bit of a introductory tour rather than being completely comprehensive. And it's gonna be at the level of what I would expect you to be able to pick as a fy two working in A&E maybe at the beginning of your rotation in A&E er and so it's gonna be very plain film heavy. Um So we'll start off with this. So this is a normal pelvic x-ray. Um So whenever you're looking at an X ray, especially for traumatic reasons, uh there's no, there's no real shortcuts, I'm afraid you kind of just have to pick a corner and trace around and pick a corner and trace round and make sure you're looking at all of the cortices. Um Now, when it comes to, when it comes to pelvises, there's some uh there's some lines that you need to look at which i it will take you through in a, in a second. Um And um you should always have more than one view when you're looking at uh most traumatic things. So, in the pelvis or in specifically hips. Uh the second view you should get is a horizontal lateral beam through the beer through the hip that you're worried about. So the radio won't do both. But if you tell them that the patients fall on their right side, like in this case, they'll get a right lateral hip if that makes sense. And again, no shortcuts, you kind of have to um trace around everything, make sure you look at the neck in a, in a in good details. And most of the fractures in the hip are neck fractures and we'll go over that in a bit more detail in a second. Um But again, no shortcuts, just check, check all the cortices and make sure. So these are normal uh ap pelvis and normal lateral pelvis. And uh the these are the, these are part of the normal review that you should be looking at uh whenever you look at her pelvis and it, it's basically all of these lines are just lines that look at the acetabulum basically and its relationship to, to, to the femur. Now, the most important of these is Shen's line. So this is this orange line here. So you need to make sure that the that the top of uh so the bottom sorry of the pubic grave, my of the superior pubic gravis forms a smooth curve with the neck of the femur like that. If that's irregular, that's suggestive of a neck of femur fracture. And I've got some examples of neck of femur fractures. We would be able to, uh, uh apply this to that. Er, after that, um, the next most important lines are, you've looked at she's line and you're happy that, that looks fine, but the patient's still in quite a bit of pain. They're not mobilized and they're not moving that hip, they can't straight leg raise. Then you need to start looking about thinking about other fractures, uh that may be causing the pain. And the next most common is are pubic grayi fractures. And you look at and you, you figure those out by looking at the iliopectineal line and the ischial er, ilioischial line. So if these lines are intact, then it's unlikely to be a pubic var fracture. Ano another word, word of advice when it comes to pelvic injuries, er, there's another concept that you need to think about is, is about rings. So if I go back to this normal, you can see that pelvis makes multiple rings. So there's a ring here, there's a ring here. These are the obturator foramen and then there's the big pelvic inlet which forms a ring as well. Now, if you think about it and if I would get everyone to imagine a Hula hoop and if you apply blood like the, the crisp, I mean, um and if you apply blunt trauma to it and you've tried pushing on it from either side, you, you imagine that it'll break in multiple places. It's unlikely that it's gonna fracture cleanly in one place. So, the point I'm making is that if you see a fracture of the superior ramus, there's almost certainly gonna be a fracture of the inferior ramus. So just double check, triple check and make sure that, that you've seen that bottom fracture and more than likely there's another fracture that applies to pelvic fractures as well. I've not put pelvic fractures in this lecture because I think they're, they're a little bit more advanced than they normally sicker patients. And I've maybe for a different day. But if you, if you have a like a, a sicker elect joint, that's not, that's not congruent anymore. And the top of the top of the ileum and the sacrum is, are not aligned anymore. They look for disunity elsewhere. So, pubic synthesis in a location that can, that can break or open book fractures that they're called and you can have it on the other side, you might have a fracture elsewhere. But the take home message is that whenever you have a ring like structure within, within the body, look for fractures, uh look for multiple fractures, they tend to fracture multiple places. So the forearm is another place that you can get multiple fractures in the type of Gallii fractures and uh uh Monte fractures and er lower limb does that as well. Um The mandible is another example that it forms like a ring and it fractures in multiple places. Um So back to what I was talking about. So if you see a fracture of the superior ramus, look for an inferior ramus fracture and these two lines will help you with that. And these other lines here are just examples of acetabular fractures. Now that I think that's probably the third or maybe the fourth most common fractures. So hip f hip fracture is the most common than very and then Aceto that may be fractures and, and those are the two sort of more difficult ones to figure out and often they need CT scans to, to deal with. Um So if you have a patient again, it's all quite clinical. So if you have a patient, you've done an X ray and they're still not moving their hip, there's still a lot of pain, they're still requiring a lot of analgesia. You're confident that there's not a, there's not an actual femoral fracture. You're confident there's not a pubic gram fracture and you've seen those clearly on, on a plain film. Um The next thing you need to worry about is are acetabular fractures and sacral fractures. And that, and you may need act scan to deal with that. Um But more about femoral fractures which are, are a little bit more important. Um There are multiple types and you can kind of think about it in multiple ways. You can think about it as, as uh intracapsular or extracapsular. So the capsule sort of comes around here normally. So these are these, this top line is uh intracapsular. Uh go back this, these tops of the row are intracapsular. Um and then uh these are extra capsular. And now you might ask why is that important when it comes down to um the blood supply? So if you remember back to your anatomy lessons, the the blood supply similar to the scaphoid. If you were here last week, it is, it has a retrograde pattern. So it comes off the circumflex arteries that are branches of the, of the deep femoral artery and goes backwards like that. So if you imagine if you have a similar concept to last time, if you have a fracture through here and it's displaced, you'll, you'll lose the blood supply and this femoral head will suffer from avascular necrosis. Um So that's the sort of thing that the orthopods are thinking. And then you might ask yourself, WW, well, why is that important? Well, it, it comes down to how you fix them and I've got examples of the types of fixations we use in hips coming up. So I, I'll talk about that in a second. So this is an example of a, of a intracapsular fracture of the left hip. And uh this is a, so you can see she's line looks OK here, but if I do it here, it kind of goes, uh it's a bit um, it's a bit what's going on here. It's a bit wrong and, uh, maybe I don't know. Fine. But, and that raises suspicion, but then you can also need to, she's line is not the be all and end all. So you do need to look at everything else and look at all your contours. The other thing that I'd like to point out to you guys is if I can, I'll just erase this as well because it's getting to me if I can get you guys to just have a look around here. So if you look closely, you can almost see the trabeculations and the pattern of the trabeculations in the hip. So that that is another way of, of looking for very, very subtle fractures. If you look at this side, the trabeculations look continuous, they don't look disrupted and over here you're going along and it's just like, oh there's, there's something not quite right here. So one of the fracture patterns you can get is an impacted fracture. So I bought this a little bit bigger here. This is another example. So not all fractures are lucid lines, so not all fractures are black lines, you can get white lines that I examples of a impacted fracture can see you out there. And if you think about it, w how do X rays actually work? So why are you able to see some things on an X ray and not other things on an X ray. So x-rays are dependent on, on the densities of objects being different to each other. Um So what's happened here is that because the, the bone has impacted on each other, it's become focally a bit more denser. So hence, it's whiter than the surrounding bone around it. And we're able to see that fracture, whereas the opposite for lucent line, if it's, if it's a lucent line and it, and it separates an unimpacted fracture, you've now got air within that or fluid within that fracture and that fluid has a lower density than the surrounding bone around it. And hence, we're able to see it. So that's how if you, if you remember a little bit of physics, not that it's absolutely necessary at your level. If you remember a little bit of physics, it'll, it'll help you figure out why things look the way they look. And I have an example of a of act scan showing a impacted fracture. Now, CD has a great problem solving to when it comes to um that comes to uh fractures. Um and just generally hip pathology um and hip injuries, especially bony injuries. So this is a good example of, of, of, of uh an impacted fracture. And you can see that sclerotic line through the middle where the, the impact has occurred and and is therefore, the bone is slightly more dense there. And you will also see that the, the, the, the neck is a bit shorter. Now, I don't have the other side to compare to, but you'll have to take my word for it. And you have this overlap here. So this, that end of the, of o of the femoral cortex should line up here. So the, the, the whole neck is a bit shorter than it should be. And you can see it on this as well on the axial sections and the agile sections. So you, you definitely know it's real because it's on all the planes and it's not, and it's not an artifact that's occurred um randomly. So going back to here fine. So this is another another fracture a little less, a little less subtle. And this is a, a type of intra fracture. Um These are very commonly um very commonly comminuted and can involve the lesser tranter and the greater tranter. Um and these are fixed slightly differently than the intracapsular fracture. So this is a type of extracapsular fracture and these are fixed in a different manner. And this is our uh last type of fracture here, which is a subtrochanteric. So you can see the tr tr are intact here and this is below that level um fine. And lastly, I have MRI here, I just want to quickly show you. So CT scans are, are great, but even CT scans can sometimes be um uh sometimes not big things. So this is an example of can make it bigger of a of a patient, you know, the pain in that left hip and by all accounts, it looks quite normal and if you apply shen's line and all that looks quite smooth. Uh, this uh uh, the idiopa lines, OK? The IIT lines, OK. All the acet lines are all OK? And if you re if you go all the way around, it's, it's not really sticking anything. And now in some centers, centers that have lots of uh MRI capacity will just go straight to MRI for this sort of thing. And what it allows you to do is see the bone bruising or the bone edema. And so, and that's an example of that and we have other sequences that make the fluid a bit more conspicuous and I'm not gonna bore you about the specific sequences, cos you guys don't need to know that right now and now it becomes a bit more apparent that hang on. There's a little bit of commination here at the, at the Greater Jacana. Um And that was a bit more difficult to see on the previous uh X ray examination. And you can see that this is a, the use of MRI in trauma uh for looking for occult fractures or fractures that are quite difficult to see with X ray based modalities uh fine. So, so how do we fix things? So this, this is an example of a of a total hip replacement. And um you can see that there is an acid tablet component here and then there is also a femoral component which goes down there. Um Now you may, this is typically something that's done as an for elective patients. And I believe that orthopods will also do it in young patients who who have sustained fractures, they might, they might do AAA total for the for them. Um But otherwise in slightly more older patients who've had intracapsular fractures. And as you remember, the blood supply will have been lost and therefore the femoral head, it will no longer be viable. So it needs to be replaced, they will do something like this, which is a hemiarthroplasty. So you know that there's no ace tablet component, this is all a big fe head and that is the other way that you can replace them fine. And you can see that the stem goes quite the way down. Now, there are problems associated with prostheses that we need to watch out for. And especially if you're working at A&E, it's not uncommon for patients who've had previous hip fractures and then they fall again on that same side that's already been fixed. And in which case, uh they might, they, they can't get a femoral neck fracture again, but they can get other issues and we'll talk about that as well in a second. Um This is something called a dynamic hip screw. So if you have an extra capsular fracture, so if a fracture that's out here, for example, you can do this instead, which is a slightly more invasive procedure. And it, and the perk is, is that you keep your femoral head, you keep your femoral head. Um N nature produces the best joints basically. So, no, no, not if you can keep your own femoral head, you'll do better. Basically. The outcomes are better than the joint. Um uh the, the outcomes of the joint is just better. So, um this is only available though, if we're happy that the femoral head is not gonna not going to suffer from avascular necrosis. So for only for extracapsular fractures, and then you can just certainly see that this is a intra intracapsular fracture here. You can see. Yeah. So an intertrial type fracture here that you can see that was there before that's been fixed. And then lastly, this is uh ad er dynamic hip screws, which is another option that's available for fractures that are very, are, are not displaced at all. So, again, minimally invasive, it lets you keep your, let's say, keep your uh native femoral head and uh the recovery period is, is a lot quicker, er, a lot faster fines. But you know, the, if you've fallen over on a, on, on, on a hip that's already been already been replaced it, it, you're not out of the woods. So there are periprosthetic fractures that can occur. So you can see here, you can see there's a fracture So this patient's probably broken, this hip once had a hemi arthroplasty, it's fallen over again and has now got periprosthetic fracture here and that could be the cause of their pain. Um So whenever you have a patient who's come in with a traumatic injury and they've got previous metal work, you have to, you have to, you have to look at previous imaging. There's no excuse for not looking at previous imaging. You have to look at it and compare and make sure you're not missing something and it can be quite subtle like it like it is in this case, very, very small fracture. They pay prostatic fracture. And the other thing that can occur is this which is called er loosening. Um So you can see there was cement here before and now all this extra lucency exists here. So this has moved over time and look at the what's going on here. There's a cement fracture here along here and as, as a, as a as prostheses get older and as they get revised, this becomes more common. You can see that this er what's what's going on with this? With this acid tablet component? See this cop is quite deep, there's all this extra cement that's free floating and within the pelvis here. So with this sort, this is a fairly complicated appearance and you absolutely need to look at the previous imaging before being confident that something's changed or not, it might be chronic, it might be new. You have to look at the previous imaging. This is another example of, of loosening here. Uh And you can see that this extra lucency that exists down here. So around here, I'll just draw around it for you. So that's a type of loosening around the femoral stem. Um Yeah, whereas on the contralateral side, on this right side, you can see there's no lucency around the cement there shouldn't, there shouldn't be any gaps there. Um Again, you have to look at previously and make sure this is new and not something that's old and known about before we start getting excited about um acute uh pestheic loosening or fractures, et cetera, et so fine. So this is an example of a uh pubic gram fracture. Uh a really nice, grossly um displaced one and you can see our this is very, very much disrupted. There's almost certainly a fracture here as well inferior inferiorly. You can almost see this uh lucent line there if you look very, very closely, I don't know how well that's projecting there, but I would be very, very suspicious that there's a previous, either a previous fracture here or an acute fracture of the inferior ramus there. It's uncommon for you to get a single, either superior or inferior ramus fracture. If you've got one, there's almost certainly another one. Please go look for it. The other thing to look for, especially with superior rami fractures is how does it relate to the acid tablet? So sometimes you can get fractures that kind of creep into the acid tablet roof. Um and just have a really good look around that ace, if there's any uncertainty on the X rays, uh A CT scan is definitely worth doing, especially in someone that the orthopods might be, might be considering fixing. Um Because a table of fixation is is required, you need to know where the fractures are in order to plan your surgery. This is another example, a slightly more subtle example of a pubic gram fracture, you can see it here. So this is a little bit more common. Actually, the last bit to have something so displaced like this is uncommon. This is a lot more common to have just subtly subtly fractured. Um pubic ramus there. Um I'd be suspicious of a fracture here as well there, but it's not, not completely certain there. Um Now the treatment for pubic rami fractures is unless they're horribly communicated and part of a bigger picture. So if this is a major pelvic trauma, you've got P pubic rami fractures and S IJ fractures, you could emerge from an anterior posterior cross injury or you've got other ace tablet fractures, et cetera. So they don't normally get fixed. They're just conservative management. So it's just something that tells the clinicians, your patient has a reason as to why they're not moving their hips, but they don't have anything that needs operative management. Um So it's not, it's not the end of the world if you don't miss, if you miss a pubic grade man fracture, a and you pick one and you miss the other one, it's not the end of the world, but clinically, but there's almost always a second one. Ok. So I think it probably covers all of the common pelvic and hip injuries. Uh that I probably have time for today and I want to go over knees um as well. Uh So this is a normal knee X ray and you get an AP and you get a lateral and again, this is done with a horizontal beam. So uh the whole X ray machine turns around and uh uh the actual detector is put on one side, so either immediately or laterally and then the X ray machine is on the other side of the knee and you get a lateral shoot through again, things to look for on the knee specifically when it comes to trauma. You absolutely have to trace every single cortex. Uh I'm gonna keep talking about it because there's, there's no shortcuts. I'm afraid you need to look at how everything um the other area that's of interest in the knee is this is this uh senna area here. Uh that's to look for joint effusions and, and live or he arthrosis. And I will talk to you about that now. So I always tend to start off with the lateral and look for the lipo uh for, for the effusion. But let's say for exa for argument's sake, we uh we start with the AP and we traced all the way round and we're like, oh, we're not, I don't see a fracture and then we start on this side and we trace all the way round. We don't see a fracture, but we see a joint effusion. So a joint effusion is a good sign that there has been significant injury to this knee. Now, a simple joint effusion, I'll, I'll, I'll so a simple joint effusion, which is what this is, can either mean that there is a fracture, possibly that you haven't seen and you need to go back and look properly again and just make sure or they've got internal derangement. So, remember the knee has significant soft tissue components internally that are quite, quite complicated and important to the way the knee moves. If you remember, you've got the cruciate ligaments, you've got your collateral ligaments around the sides, you've got menisci and they're all, they're all important and all of them if they get damaged can give you a simple joint effusion. The cruciate ligaments can also give you a he a hemarthrosis as well, which is this, it, this might be. Now what they shouldn't give you is this. So this is something called a lipohemarthrosis. Yeah, I'll put that there. Lipohemarthrosis and you get this very, very straight line in your joint effusions. And remember how these are taken, they're taken uh with the leg uh horizontally. So they uh the line is, is um it will be perpendicular to do X ray beam or dependent to gravity basically. So the leg is actually resting on something here. Imagine the beds over here. So it'll be dependent to gravity. And why did you get this line? So remember what I talked about with x-ray densities. The only way you can ever see. The only thing in x-ray is if you have two materials that are next to each other, that have different densities. So therefore, we know that they are two different materials within this joint effusion. And if you, those of you uh among you who have looked at the name will realize that there is fat in the ni fat in there and there is blood in there. So the fat is less dense than blood. So it floats to the top and forms this lucent portion. My my drawing isn't very bad today and um the denser blood sinks to the bottom or dependently to gravity and um forms the darker portion. Now it's dependent to gravity. Remember, so it depends on how the X rays take it. If the patient is standing, you can imagine that the the lines would be the other way around. So to just, just bear that in mind, you need to, you know how, how the uh the X ray was taken. So, and what that means is that there has been a leak of fat uh into the joint. Now, where has the fat come from? That could be intraarticular. Well, it's the bone marrow. So what's happened? There's a fracture there, the bone marrow which is predominantly fatty as you know, has seeped into the joint and formed this layering of two fluids. Uh ak a lipohemarthrosis. So if you see this and you haven't immediately seen a fracture, please look again and look again and look a third time and get a friend to look. There's there is a fracture there somewhere, you need to go find it. And if you still can't see it, ask a radiologist and if we can't see it still, then we need a CT scan. That that's how, that's how sensitive this sign is. There is a fracture there somewhere. We need to find it. And those of you who who have looked on uh will notice that there is a very, very common tibial uh tibial plateau fracture here which explains our lipo hematosis. There's also a very subtle uh fracture here of the fibula head, fine, moving on to tibial plateau fractures. This is an example of a tibial plateau fracture of the lateral plateau. You can see that, that this is how smooth a tibial plateau is supposed to be and this one is just, it's, it's all over the place and it's very much depressed, very depressed. Another good sign of plateau fractures is that they will extend out dramatically past the femoral condyle edges. It's just a, a subtle side that I've kind of noticed over the years. Um So if you notice the tibial plateau is kind of jutting out laterally or, or media past the femoral condyle edges, like significantly past it. And there's a sign that it's possibly uh a, a subtle fracture there. This is actually quite a bad fracture because there's also fractures of the fem of the f head here. And there's also some fractures of the o of the femoral condyles here. An example is of this as well, the lipo hemos again, another type of uh of tibial plateau fracture. So you can get them on the lateral side as well. And this is AAA subtle example of that. And you can see that you see that the femoral condyle is just, they don't line up quite right. It's very subtle. Um If you, when you see more of these, you'll know what I mean when I talk about that. Um But yeah, there is a classification system of this and it's called a Schza classification system. Um I don't think you need to know this as, as a mens, but it's if you, those of you who go on to become orthopods or radiologists, uh this is just AAA good way of remembering the types of plateau fractures and these are the most subtle ones. These ones that are just very much a just a depression of the articular surface without any extension, uh any extension um to the media or lateral tibial cortices. And I have act scan to show you guys. Oh, fine. So I did want to show this. Uh I just quickly going back if you have a subotic fracture, we fix it with iron nails just uh as a side note fine. Um It's a tibial plateau fracture. Sometimes the orthopods will like act scan even though it's quite obvious on the, on, on the X ray that it is fractured. And you can see this one is similar and you remember when I was talking about the, the, the plateau can kind of jut out past the, the condyle. That's a, this is a nice example of that. You can see that it's depressed. It's a and it's extending to that lateral cortex there. It is, I imagine this would have been quite obvious on, on the X ray. But what the Ortho bos are actually after is this what they want is this is this 3d vendor that we can produce for them and they use that to get a, a three dimensional overview of the fracture pattern and plan their surgery. Basically, essentially, it lets them get an idea mentally of, of, of what the, of what the er injury looks like and, and how they're gonna approach fixing it. And I also have an MRI scan to show you uh fine. So if you have something that's horribly common, like this one is uh I'll just show you the X ray to start with the CT scan to start with. There's, there, there's no prizes for, for this. Like um everybody knows that's fractured. We knew it on the X ray. Why are we doing the MRI scan? Now, you remember that the knee has other things inside it as well. So there's cruciate ligaments, there's menisci and there's uh the clutter ligaments, et cetera. So on, which can also be injured alongside, alongside um the, the, the, the obviously heavier comun to tibial fracture that we have here. Now, in this case, we can see the menisci, the lateral meniscus, which is uh uh this one here, er is torn as well. Now, it should look a bit like the medial side, which is nice and jet black and should form a nice disc and attach in near the tibial spines. All right. So the one on the left, uh the lateral one here is not doing that and you'll have to take my word for it, but it, it, it is very much pawn. And in fact, there's a fragment here that's flipped into the intercondylar notch. Now, that's something that the boards would be very much interested in knowing about because they'll need to not only fix the fractures, but at some point fix that meniscus as well because it's gonna, it's gonna possibly cause locking. Um And you can see here it's flipping into the medially medially there. But the PCL, which is this dark band, which goes from the uh from the femur to the posterior tibia here, that's intact. This is the ACL, this sort of fan like structure here and that's intact. Uh You can see a nice example of the lipo hemarthrosis here as well superiorly here. Um I can see it again here. The different sequences give you different er different different materials, have different sequence, um uh characteristics and you can see the layering of the lipomatosis here. There is a nice example of that. Um But the collateral ligaments are OK. So this is the tl this black line going across here. And uh this is the lateral collateral ligament here, which is this line here. And you have the medial collateral ligaments here, which I which are intact. But in this case, it's a very, very hurt. It is quite a bad uh tear of that lateral meniscus. So just bear in mind there's more going on than just um there's more going on than just bony things. And if you have horrifically bony, horrific bone fractures, you need to think about what could be else be going on. And now I've put this example in just to just, just to reiterate that again. Now, on the face of things, this fracture here, this lateral tibial uh just sub subarticular fracture here on the face of things. That's it, it, it, it doesn't look that bad, does it really? Um, but this is, has a synonymous, er, eponymous name and it's called a Sagon fracture. Yeah. S EG O ND fracture. Now, these are highly, highly sensitive for ACL injuries. Um and I've actually got an example of that here. ACL injuries. Now, if you remember the other MRI that I looked at just now, this is the normal PCL and you remember the fan like structure that we were looking at earlier. Um And now this ACL doesn't quite look, right, does it, it's almost flopping over on itself. It's starting here and it should be a nice straight tight band like l uh ligament. I said it kind of flopped posteriorly, that's indication of a of a full thickness or high grade tear. And this is a patient who's got a little Sagon fracture here. You can see that there's, there's other injuries here as well, which I won't go over, but they have, they have a Sagon fracture and that's resulted in a ACL tear. So there are other injuries that are, that have synonymous uh the other other sorry eponymous injuries that are um indicative of significant soft tissue injuries um within the knee. And those of you are interested, I can, I can point you towards a lecture that uh that was done on ever like, um I'll put a link in the chat later on which is worth looking at, I think, I think it is an interesting lecture about that. So that's the MRI scan we went over. Um Next is ankles, I think ankles and ankles and hips probably make up the majority of the lower limb injuries that you will see in, in A&E. And uh the images that you'll get are uh you'll even get either one or number two and you'll definitely get number three. So number one is just an AP view. Uh Number two is something called a more test view and this is a lateral. Um The difference between number one and two is that number two brings the ankle mortis, which is the talus here square with the beam. You see how you can see the talus. It's a lot nicer on this mortice view than you can on this normal AP view. That's cos the foot has been rotated out in order to line that up a bit better and give you a much, much better view of the ankle mortis than, than you would do a normal at AP view. Um Things to look for, I'll just get rid of my writing things to look for an ankle x-ray again. I'm gonna go on about it over and over again, but you need to trace every single cortex, um common injury sites. Um So they are fibrillar injuries are common and we'll talk about the weber injuries in a second. Uh needle malleolar fractures are less isolated. Mediale malleola fractures are less common. Um And then we'll talk about that in a second um places that you are commonly missed. So, if you do have ama mort view, make sure you absolutely make a, make a habit of tracing the talus. And if you see small little irregularities in the, in the cortex, that could be a sign of a osteochondral defect or I think nowadays it's called an osteochondral lesion, um which could be a subtle thing that's often missed. Another common injury site that's overlooked. Uh base of fifth fractures, which are a common place for you to get fractures that are um that sometimes are picked on ankle x-rays rather than a foot x-ray. So make sure you have a look there. Um Other things to look out for um calcaneal fractures. I don't have a, a slide on this, but since we're here, we'll talk about it. Um something called bowler's angle. Uh If I can remember how to do it, not like that. So if that, if this angle, if you draw a line from here to the middle and from here to the middle and this angle, if it becomes very flattened or below, I think 20 degrees or so, is indicative of a calcaneal fracture. And you don't wanna miss Calcaneal fractures because they have quite high morbidity to them. So it's called bowler's angle. Um Another important place to look is just because it has such high morbidity is to make sure that the talus and the, and the navicular are still articulating and there's not a dislocation here. Um, but that's, that's really rare. Um And that's it really. And let's go over the more common ones. So this is uh seemingly a, a uh isolated needle malleolus fracture. Um And he, he, he always got to be a bit, a bit wary of isolated medial mall malleolar fractures because you remember, well, I was talking about rings and how the tibia and the fibula also form a ring. Um And if you don't see the other fracture, you, you should look for it and the fibula is a common place for its fracture. So if you haven't seen the fibula fracture and you've got a medial malleolus fracture, you should image the knee. I don't have an example of it here, but it's just good practice. So, isolated medial fractures, think about the knee being injured. There could be a fibular fracture somewhere and that, that's not necessarily going to be distal, there might be a proximal fibular fracture. So just, just, just bear that in mind. Um These are your Weber injuries basically. So this is Weber A. So this is a fibular fracture below the level of the synosis. This is Weber B, this is at the level of the sys mosis and this is Weber C and this is above the level of the synosis. Now, why is that er important Weber A is conservative management. So that's not surgical. No. Uh So that's not surgical and other parts will just conservatively manage this. They, they, they're not very interested in that. This is surgical management. So the orthopods are interested in that one. They'll see all of them, but this one, they'll definitely a is, will be conservative management and they'll just follow up routinely. Whereas b on the other hand is a bit more interesting in this case, they might be surgically managed and it might be conservative and it depends on the stability of the joint. And this is where mortis views come into, come into it, come into uh come into action. And what you want to know is that the gap between the mortis and the tibia and the medial malleolus and the lateral malleolus is equal. And if it's not, what will happen is that it'll widen like this if this joint is unstable. So you can see, so C is a by definition unstable joint and you can see that this, this gap here, this clear space here between the medial malleolus and the mortis has, has displaced and it significantly wider here than it is here. Yeah. So this is by definition unstable. Now, bees can also be unstable. So you, you, you want to assess that how the mortis is sitting and whether it's displaced or not, and you can do things to try and aggravate it as well. So you can do weight bearing views and those words might ask for weight, weight bearing views and what they're doing is looking at that basically is the, is the mortar displacing, if it is displacing, they need operative management. If it's not displacing, you can trial a conservative management. That's, that's what we're looking at there. Um Yeah. So this is just an example of this. Uh web is A and B and C and so on. Um Yeah. So if, if, if it's a webers see that's disrupted significant portions of, of the, of, of this sys fibers here, it'll be unstable and, and the, and the mortars will displace whereas a weber see by definition has disrupted it. So it is unstable and it will displace. So whether it be may or may not displace depending on how much of this uh sys fibers are, are disrupted. Uh Whereas what we see uh they are definitely extracted. So that's all I wanted to talk about ankles really. I think that they're quite common injuries. And I, and I think I've covered the, the common injuries that you'll see on ankles. Calcaneal fractures are quite rare as well and just make sure you double check basal fifth. These are, these are, these are fairly common as well lastly moving on to feet. Um Again, I don't have a, a massive amount on feet. There's just one type of fracture I really wanted to make you aware of because it's, if it's missed it, it it, it could be, have quite a high morbidity for patients. Um So these are normal x rays and you'll get a ADP view and you'll get an oblique. Um And the, what you're looking for is again, you need to trace around every cortex and that includes these distal phalanges here, which can be tricky to look around, but you have to look around them and make sure there's not a small little uh fracture there. Um You're looking for alignment um of the lis joint, which we'll talk about in a second. Uh Navicular fractures is another sneaky one. Uh So you can sometimes get little navicular fractures. So that's one that you always should make a habit of looking at, make a habit of looking at the distal fibula as well. Remember, you might have assessed the patient incorrectly, they might actually have an ankle injury and if they've got a, a Weber C fracture here, it'll just be visible there. A little sneaky one there. Uh Medial malleolus as well, remember a foot and ankle, they kind of go together to make sure you assess them properly together. Uh make sure this joint is aligned. So the talar navicular joint is aligned properly. And most importantly, the list round joint and we'll talk about that now. So these are the alignments that I want you to get used to looking at and thinking about. So on the oblique view, you're looking for the lateral cortex of the third metatarsal and this medial uh form the lateral uniform uh line up properly. So that should, they should form a nice line and the second should do the same with the intermediate uniform. Uh that's on the oblique only though. Yeah, on the ap it's the first and the, the, the medial uniform should form a nice line there. And this gap should be consistent here. And an example of it when it's not quite right is is here. So you can see this gap is just a, just a bit, a bit bigger than it should be uh on the AP and um on the oblique, uh the oblique looks OK. Actually, the other thing you need to look out for here is just small. If you see small fragments of bone, that's the other thing that's quite suspicious that sometimes the fracture on a lis frank injury can be quite subtle. Uh This is not so subtle and you can see that all of the, all the metatarsals have shifted this way. So the f the first toll has come off the media of the P uniform. The second toll is that, that should be lining up here, roughly, this should be lining up here that should be lining up like here somewhere and all of them have moved it. So this is a quite a quite a bad uh list injury. This is another example. And again, you can see how some of the fractures can be, uh, quite small and communed. You got little, little fractures here and you can see that all of the toes, none, none of them are lined up quite right. Um These last two are quite obvious. I think, I think most people will grab that, uh, and get that, but this is a subtle one and these are the sort of ones that I want you to just make sure you look out for them and thi just think about them. If you haven't thought about them, you're not gonna, you're not gonna look out for them. And you can see there's a, a very subtle flick fracture fleck there that is indicative of a Liss Frank injury. Uh, and although the alignment is all, ok. So this patient will need to be non weight bearing for a while whilst this heals. Um, if they, if I think if they weight bear, uh, don't quote me on this, but I believe if they weight bear too quickly, it, it, it predisposes them to having fractures that move. And that's when the morbidity goes up. Uh, fine. Ok. So where was I? That's the, uh, torsos. You can see there's a small fracture there as well and the tors bones, another one here, uh, coming up. So they can be quite subtle little injuries. And that is it really, um, before I go, I'll just talk to you about, this is a very good, uh, trauma, a, a book I think, um, I think it's well worth a read. Even if you, I don't think you necessarily need the newest edition. You can, even if you find, I'm sure you'll find it in a library somewhere. I think it's a good book to go over. Those of you are interested and they'll go over everything, not just they'll go over all the things that I've had to skim over because I thought of the time for it. It'll go over PS for you as well. It'll go over spinal things. Um I think, I think it's a great book and thank you very much. Those of you. If any of you have questions, please do, um please do email them to me and I'll just find that um uh lecture. Thank you very much Dr Musa for doing so, food talk. Um If everyone has any questions, you can type them in the chat and I can collect them um, as well. Um I've also included the feedback form. Um and once you complete that the video, the recording as well as the slides would be available on our page. Um um I'll be here around if you have any questions um post in the chat all, just give her a minute or two. So, yeah, it's this one. It won't let me send you a L I don't know if it'll send you a link. I can, I can put this in the, in the group. But yeah, it's, it's this one here by professor you, er, the knee where you got subtle findings of major ligament injury. So those of you are interested, uh, this, I think this is well worth looking at, even at your level, I'll just give you an indication that you can have very, very small avulsion fractures in sp specific parts of the knee that are indicative of quite dramatic soft tissue injuries and they're worth knowing about and, and, um, and just being aware of them. Um, so I'll just put a this in the chart. Yeah. What? Ok. Yeah, if anyone has any questions, please do. Ok. All right. So, um, if anyone doesn't have any questions, I think we can close the session. Uh, thank you very much for attending and thank you, Doctor Musa for taking your time to teach us. It's been very useful and, uh, as well as the first session on upper limb trauma and both sessions will be our web page to revise and rewatch if you need to. Ok. Ok. Thank you very much. You have a good evening. Bye. Thanks. Bye.