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Okay. Okay. All right. I think people are starting to join. Can everyone hear me? It might still be letting people in. Uh I've made the feedback for Deep Pan. Hey guys, we're just, we're just waiting for a couple more people to join. We'll start and people started joining now. Wisma. Yeah, I just need to know, just need to check to make sure that people can, can hear me. Mhm. That's fine. We'll start at um in about like one or two minutes guys, sorry for a bit of a delay just to make sure people can join. Mhm. Mhm. Okay. Right. I think I'll start now and then whoever joins, they can sort of join in where we kind of sets that off. Really? So, hi, everyone. Welcome back to another kind of teaching session. Um It's nice to see some familiar names. Um Hope you're having a good week. Um So today I was going to do a teaching session for you guys on M S K X ray interpretation. This is one which to be fair. It's um it is quite a difficult one because there's so many different types of M S K X rays that you can get. Um It's not something that you guys get taught as much as things like abdominal x rays, chest x rays. But I hope with the series, I'll go through kind of the common X rays M S K X ray interpretation ones that you should be somewhat familiar with. Um and then kind of in the final teaching session whenever that is, I'll go through other types of x rays you could get but are less likely to, but just so you know how to kind of go through them. Um So I'll just start showing my screen now. Um In the meantime, if you guys have any questions, uh just pop into the chart, either Ronan will answer at the end of the session or I'll be, I'll be here moderating the chart, so I will be there to answer as well. Yeah. Okay. So I've already given the intro. So this is just going to be part one. I predict that there's going to be three parts with the third part being kind of the less likely X ray interpretation. So this is kind of the aims of the M S K interpretation, but M S K X ray interpretation series if you will. So today, I'm going to go through kind of general format of just approaching an M S K X ray. I'll also be going through wrist x rays, what kind of to look for on your X ray in the next session, I'll do lumber spine, x rays and shoulder x rays that I've kind of starred ones which I think are more likely to come up on the day. And then at the end, I'll go through the other two, which you should kind of know how to do, which is cervical spine and ankle x rays less likely to come up on the day, but is a potential. So it's just good for me to go through those. As I've stated that there are other x rays, you know, you can get x rays at the elbow, you can get x rays of the uh knee joint. So what I would suggest is after going through these x rays, after going through these x rays with you in your own time, go away and look up these kind of x rays and be familiar with the anatomy, x rays if you will, is more just an interpretation of anatomy which you expect to see and what is differentiating from that if there's a pathology. Hence, that's what you should be familiar with if you get kind of a random one which you don't know a general format to follow for all of it. So to start off, OK. So general approach to most M S K X rays. So right from the start, you confirm your details, confirm when the X ray was taken and always state that you'd like to compared to previous films that are available, very important more so for M S K X rays, because often you get an M S K patient coming in and you want to see the changes that may have been occurring. Someone with osteoarthritis, you may be looking for those osteoarthritic changes that are occurring. So lots of joint space osteo fights and that kind of stuff. After that, you want to check your radiograph details. So this is checking to make sure that the quality of the film is right and that kind of stuff. So how to start that off, checking the type of film. So ap is almost like them basically saying you're looking at the person from the front. So if it's hands, you're looking from the front there, if it's head, you're looking from the front here, lateral, you're looking at the side and then other films that you can get is like diagonal films and then specific types of films, but they're less likely to come up on the day. Usually it will be an A P film that you get. Then you want to specify which body part you're looking at. So after you said this is an AP film or whatever, you then want to say what you're looking at. So if it was a wrist, X ray, then you're going to say this is a wrist and hand X ray of the left side or right side take sometimes just kind of quickly associate what you're looking at So I'll go go through that more. So with the X ray specifically, that will be going through, then you want to check the adequacy of the film, it's the same full your ABDO X rays, chest X rays. So checking the rotation, usually if it's an AP film that you just making sure that it kind of looks nice and aligned penetration, that it's not looking too bright or too dark and exposure, make sure that you can see everything that you'd want to see for a wrist X ray. Then you obviously want to be able to see all the carpal bones preferentially, the metacarpals as well and the wrist joints specifically. So like the radius and ulna joint, then after that, you want to stating the obvious abnormality that you see on an X ray. If there is one and if there isn't, then you can just go through it systematically if there is an obvious abnormality status and then still say you'd want to go, you want to go through it systematically from there with any film, particularly X M S K X rays. You always want to specify that you'd want another angle to look at. I'll go through why that's important later on down the line, but it's very important for M S K X rays. So if it's an AP film, then you may want to get things like a lateral view. Um and, and so on, then for interpretation, this is much the same as what the off ski stop book has. So I, you know, if it's, if it's not broke, don't fix it. So I used to follow A B CS. So alignment, bone cartilage and soft tissue and I'll go through what to look at for each one of those. So the A alignment, if there's any change in the alignment, there's three things. It could be. One is a subluxation which means partial dislocation, dislocation means it's completely kind of been moved from the joint. So there's no joint to joint contact with the bones. And then the third thing is if there's a possible associated fracture, usually what happens there is there's been a fracture that's kind of occurred over a particular part of the bone. It's caused some changes and kind of the muscular show and tendons that hold your bones kind of in place. And as such, it's moved the bones. So it's, it's it often present is a dislocation or subluxation. But that could mean that there's an associated fracture as well, which is why it's important to look for it when describing displacement, you often you always describe the distant part. So in this case, you would be describing the uh the proximal uh challenging. So that's the anatomical bit that you're describing. So in this case, it's being moved to the lateral. So there's lateral displacement of the proximal uh challenging. Uh yeah. Um in terms of subluxation and dislocation, I was never quite familiar with how to differentiate the two. Um So I'm going to kind of go through some quick examples to sort of demonstrate how you can differentiate those too. So what the best way to approach it is kind of almost draw an invisible line where you'd expect your joint to be on both parts of the bone. So the distal part and the proximal part. So in this case, if we were to draw the line which have drawn with the red, there's no contact whatsoever. So this would be a dislocation. In this case, this one kind of shows it even better. Initially, it looks like okay, this one sort of still overlying, overlying the boat and it's not completely moved to to one side. So maybe this is a subluxation. What you're basically looking for is if there's any contact kind of above and below. So in this case, because the bone has actually been displaced inferior lee, there's no kind of overlap of these two bits, you would expect the red, the red kind of line if this was a subluxation to be slightly further up. So in that case, it would kind of be overlapping on some level. So in this case, this would be a full dislocation. Now, in this case, if I was to draw kind of an invisible line over the joint, you can see that the the the distal bone is move slightly to one side. Okay. If I was to draw the line kind of above and below, which would be around here. It looks like it's been moved slightly to if this was the left hand, that's why the right hand, okay, because normally we take pictures with the hand like that kind of coming in from there, then this would be basically being displaced immediately. So the distal fragment would be immediately displaced, but this would still be a subluxation because there's still some overlap of the joint. However, I've used this X ray because it's a very good example of why it's important to state that you'd want another film uh from a different angle to kind of ensure that you're making the right decision or the right observation because this is the exact same X ray of the patient on the right and on the left, they've taken a, a more diagonal view. So this was an A PVM, this is more like a diagonal view on a bleak view and you can clearly see that there's no overlap of the joint. So in reality, this is actually a full dislocation of that uh that little finger, the philandering. Um So that's why it's very important to have those kind of uh additional views. So that's alignment. So you basically want to observe whether there's been any kind of dislocation or subluxation, um any displacement of where you would expect a bone to be, then you want to move on to bones and the best way to approach this is kind of tracing around the cortex, which is the outside of the bone and just looking for any disruption. And that's when you have a disruption of that nice continuity of that line, that sort of outlines the bone. So in the carpal bones, you may trace around the skate void and you may see some slight crack in it where you may see that there's like a little gap that's missing. And that often first that there's a fracture present then as well. This is something which to be fair, is done by much more experienced doctors. So, um you, you, I I wouldn't really know how to approach this and to be fair, it's, it's much more advanced. You can look at things like the internal matrix and whether there's been any disruption to it, that's usually like the hash um kind of appearance that you see in the middle of the bone. And it can tell you about the dense team, whether there's any changes there that's very difficult to interpret on an X ray. Even usually you're kind of taking things like Mri's to comment a bit more on that kind of tissue itself. Um So I wouldn't necessarily worry about that. Your job is more to look for any fractures. Now, in regards to fractures, the best way to kind of approach describing it is I used to use the three Ws. So where, what uh sorry, I've put where twice, um I'll go through it properly. So where is the fracture? So which bone is it? Then you want to describe whereabouts on that bone? So let, for instance, if you talk about the skateboard, you're going to say it's on the skateboard, bone proximal is going to be as kind of the if you basically how to approach describing the fracture is almost split the bone up into third. So imagine that you've literally cut it up and you're saying, whereabouts is it? So if it's in the middle part, it's going to be the middle third, if it's going to, if it's on the proximal third, you talk about it as being the proximal third. And then you want to describe whether it's involving the joint or not. So involving the joint basically means is the actual fracture going all the way towards where the joints would basically be meeting. Okay. And in that case, it would be intra articular. If it's not involving the joint, then it's extra articular. So that's where then there's what, so what type of fracture are we looking at? So first thing you want to describe completeness? So is it completely, is it in complete, complete? Basically means that it goes all the way through the bone, all the way to the other side of the cortex. So there's disruption on two sides. Incomplete means you only have like one aspect of the cortex that's been breached direction is basically describing how is the fracture moving so transverse would kind of be straight across the bone. A bleak is kind of diagonal and then spiral is similar to oblique. But you're almost describing kind of how the fracture has been brought about. So it's normally brought about by twisting injuries. Um That's more something that you get if you have the history. So really, you're only describing it as transversally bleak unless you've taken a history beforehand, but you're almost kind of describing the fine minutiae of the fracture then which is uh you know, difficult. And then from there, you also want to describe if there's any other segmented pieces of bone, if there is, then the fracture can be described as being common, new tid segmental. This is where you start getting into the minutia of how to describe things. If there is, I would more go down the route of saying there's multiple separated pieces of bone from the original bone and then describe how they've kind of been displaced or how many kind of fragments you're looking at and go from there. So these are all the different types of ways you can describe a fracture. So complete transverse spiral oblique, described all of those common noted. This is why I say it gets a bit more complicated comminuted means there's more than two detached bone fragments, segmental means that you've got multiple fractures. So one's coming from one side, one's coming from the other and that's created a single isolated part of that bone. So comma noted means you've kind of got bone fragments kind of coming off segmental means you have multiple fractures contributing to one part of the bone, basically moving away. Impacted means that the bone, the fracture, how it's basically worked is those broken ends have almost kind of compressed together. And usually you'll actually see a bit of uh a comminuted fracture around that region. So a lot of different bone fragments because it's basically been compacted. And then a greenstick fracture is kind of a an epididymal uh name really for a specific type of fracture that you often see in Children because they're bones a bit more malleable, a bit more bending. So it's basically an incomplete fracture, which is a single unilateral breach of the cortex. And because that part of the bone, that side of the bone is weaker than the other side if there's been kind of pressure. So if it was like in the femur bone, for instance, because they're obviously exerting pressure down the down the leg because one side is weaker, it's almost like you kind of got a I think of it as like a pillar on a in a building or something holding up a building. And if one side is weaker, it might be kind of tilting to one side. So you basically get bending of the bone as a result. So this is kind of just some visual representations. So you can describe a factor as well as being closed or open. Usually, um you can tell quite obviously from a, an X ray because you'll see the soft tissue and you'll see the bone kind of sticking out from there. Um The one thing that we worry with those particularly is, you know, risk of infection kind of, it could have nicked an artery is it is, it's been on the outside and that kind of stuff transverse, it's straight across spiral. It's kind of coming diagonally and it's twisting, twisting injury, common ated, you have multiple pieces impacted. It's kind of come together greenstick that unilateral cortical breach, usually seeing Children and a bleak is diagonal again like the spiral one. So this is what I mean with the green stick one, you actually have a bit of a breach here and you've got bending okay because that part of the bone is stronger. It's going to hold more of the pressure. So in effect, it will bend in that direction and this looks like they actually possibly have some bending of the the other bone on the other side, which isn't uncommon. And then finally the final uh w which was where? Oh yeah, that was it where um uh sorry. Yeah. Where, what, where? Yeah, I always used to kind of go back to the where to remember it was I was kind of confusing myself. Uh And, and this was describing where is the bone going. So if there was another kind of piece of bone that's come off or something, you obviously want to describe whether it's been displaced. Same thing if you're describing, uh if you're describing the displacement, you almost have to talk about in kind of the different planes. So one plane would obviously be the horizontal bit, one would be the kind of vertical part. And then as well as that you want to describe whether it's kind of tilting all it's very you getting quite a lot of difficult territory when you try to explain that. But usually it's better just I I used to talk about it as being it's displaced, superior lee, inferior lee, medial lateral. And if it looks rotated, kind of describe how it's being rotated as being rotated in or is it being rotated out? If you want to go down the road to explain translation, angulations, rotation, you can, but you do get into much more complicated territory when you're trying to describe, describe bone fragments that way after bu then go on to see which is cartilage. So that's describing kind of the joints. Um usually this is related to your like arthritic changes. So osteo rheumatoid psoatic gout and studio gown, I would recommend going away and kind of looking up classic changes of these conditions, osteoarthritis. You have like the pneumonic loss. So l for being lost of joint space, oh For your osteo fights s for any uh sub subchondral sclerosis and your other s is sub articular uh erosions. Um You have different monix for, for the different ones, but best to go away and familiarize yourself with those, then your final s which is soft tissue. This is basically looking at everything else outside the remit of bone and um joint. So your muscles, your um if there's any kind of apparatus, medical apparatus in situ, um if there's any foreign bodies that you can see that kind of stuff. So in this case, obviously, you have the bone and this would be your soft tissue here because you can see that there's like a slightly lighter patch, you can infer that there's possibly some kind of um fluid or a lighter um medium, um basically being accumulated there. And usually if it's around the knee joint, it's probably going to be an infusion or something. And in fact, you can actually see, normally you'd expect the patella to be a bit further um uh kind of connected. Instead, it's almost like displacing the patella slightly anteriorly. Um Again, this is more if you've had the history before and you kind of know what you're looking for. So someone said they've had like been doing some kind of sports and then they heard um a pop or their, their knee kind of gave way and you're thinking like a ligament tear like anti an ACL tear or um what not, then you obviously kind of thinking there might be some infusion associated, this is just for interest. Um The red arrow here is kind of uh again directing to some kind of soft tissue change. If you don't know, then just describe what you're seeing. So there appears to be some kind of um uh decreased opacity um near the knee, uh superior lee to the patella indicating the possible kind of accumulation of fluid. In this case, it was a lipo hemarthrosis, which basically just means kind of blood accumulating in the soft, in the subcutaneous fat. Um And it's associated once there was some kind of arthritic change our process, which is kind of umbrella term for joint problem. Um And here you can actually see an associated tibial plateau fracture which you often see in like elderly patient's. Um and you can quite clearly see that it's uh that there's a kind of breach of the cortex if I was to draw a line and it's, it's going all the way through, this would be an incomplete fracture because obviously, it's not going all the way through the bone. This is another kind of soft tissue change. So, emphysema you'll often see it's kind of got this like mottled appearance to the soft tissue. This can actually be quite common if someone had like surgery. Um So obviously, you're opening someone, opening someone up, which will introduce things like air. So if they've had kind of either a fracture that's actually caused a breach of the soft tissue. So a uh um an open fracture, then you might see some surgical emphysema um or if they've had kind of a surgery, then obviously you'll see it again with that. And usually you actually get this kind of classic description if you were to feel that part of the body, um it will feel like bubble wrap and you might actually here kind of this um bubble wrap like kind of sound to it. Um It's, it's very interesting. Okay. Is there any questions so far with what I've described before? I go on to wrist x rays, Misma, and I've got no questions here. OK. That's fine. OK. So moving onto wrist X rays, this is the most likely kind of X ray that they could give you. Um uh just because it kind of does test you anatomy and usually an AP film, you can sort of work out what you're looking at. So first to go for your anatomy, this is a right hand X ray. Okay. Your radius bone is coming down on the lateral side. Your owner is coming down on the medial aspect and then you've got your M C one which is your thumb all the way to your M C five, which would be your little finger and then tracing your anatomy kind of for your carpal bones. I used to you, I still use the Pneumonic. Some lovers try positions that they can't handle So, starting from the lateral side, you have your skate void, your lunate bone, your triquetrum, your P's a form which kind of sits on top of the triquetrum, trapezium, trapezoid capitate and Hamate. It's just something that you have to learn. Okay and being familiar with where the kind of rose are, those bones is quite useful. So you know that the first four bones in that bottom and then the rest of the bones are kind of sitting on top. Your most important bone, really kind of which you want to look for kind of fractures and stuff is your skateboard bone. Okay. And there's a reason why for that. So to go through the views very quickly, this would be a P Avian. So you're looking at the, looking at the person's hand head on, okay, the lateral view, which basically you're coming from the side and then you have your bleak view, which is your diagonal view less likely to come up because it's much more difficult to interpret your carpal bones. And also your radius and owner usually we do it to have a better look at the thumb and kind of the joint, the joint between the thumb and the trapezium. Okay. So to go through the wrist X ray, start again from your your basic kind of approach basic format. So a for alignment when you're looking at an AP view the most likely, well, you first want to assess your distal radius okay. So that's on the lateral side. And you basically want to see whether it's making contact with the carpal bones and they're kind of sitting on top of it quite nicely. So if I was, if I'm to go back, you'll see that your scaphoid and lunate should kind of be sitting almost being like cupped in effect by the radius. After that, you want to assess the carpal arcs, okay. And I'll go, go through this and see whether there's any disruption to the Ozarks because that can suggest a fracture or some kind of ligament injury. So your carpal arcs are basically if I was to draw an invisible line, like I said, the radius is almost like cupping these bones, okay. So if I was to draw the line where it's like cutting them and then from your lunate bone coming up to your triquetrum, okay, you'll see that it, it forms a nice line. And then if I was to go up to the next row, drawing a line at the top of the proximal row of carpal bones and then the second row underneath it, you should expect to see these nice lines, okay coming up. If there's a disruption to this, then you can assume there's either a fracture dislocation, something that's basically affecting the nice arrangement of the carpal bones. So for instance, hair, so some lovers try your triquetrum. Uh So yeah, your triquetrum okay is kind of a scheme. So that nice natural um line that you should be able to draw is disrupted because it basically, it's coming around like that and then it goes oh down. So this would be illuminate dislocation or TriCor usual dislocation. It, it doesn't matter. The bones are basically dislocated from each other. Now, describing in a lateral view, it's a bit more difficult because it kind of is where all the bones are basically uh overlapping each other. So it can be difficult to interpret a lateral view, but it's, you know, it's doable. So uh to start off with you first want to look at your radius, okay, assess the long access of it and also look at the access of the lunate and capitate. So you're loo Nate sits above and you're capitate sits above the lunate bone. You're basically looking if I was to draw a line, kind of coming up on the access, you sort of expect it to be coming up nice, uh nice, normal kind of unbroken line, they basically kind of align with each other, how I used to remember them. In fact, it might even stem from the Latin, I don't know, capitate, I always used to think okay. Which bone is the capitate bone or this one looks like a toothpaste cap, cap cap and then the bone underneath it is the lunate bone because it looks a bit like a lunar eclipse of the moon. And right there, you kind of already found your two most important bonus that you're kind of looking at on a lateral view. Okay. After that, you then want to distinguish your scaphoid bone. Now you'll see this because obviously you're looking at the, the hand from kind of the lateral view. So the scaphoid is kind of your biggest bone that you'll see on the lateral view. And if you're to draw it out, it will be this kind of blue outline that you see here. Okay. If you found the skateboard bone, then you kind of know where the P is a form bone is because usually it overlaps with it. So it will basically be kind of situated around her. Okay. And then your trapezium, which is kind of your other bone that you be else in the lateral view is sitting above that. Okay. The most important thing on the lateral view really is checking the alignment here, okay. And also checking to make sure there's no breach of the cortex on the scaphoid. Okay. That's basically as good as you get with kind of interpreting the lateral view. That's as far as you probably need to go. Other things that you know, you can interpret on lateral view is something called volar tilt and you expect it to be between 10 to 25 degrees. It's quite an advanced thing to look at. And in fact, you need to use a computer to interpret it, uh look forward, but I'll kind of explain it to you now, just so, you know what it is if you want to impress an orthopedic doctor or something. Um, volar tilt basically as if I was to plot a point where the radius sticks out. So if I was to go here, sticks out there and it sticks out there, if I was to draw a line horizontally between those two points, and then as basic to go to the tip top of where the radius bone reaches. So in this one, it would be around here is that angle between 10 to 25 degrees. And that's basically it, if there's um some you'll read different things in different text. Um Normal here, I put 7 to 15 degrees. That that's in theory the most likely one. If there's a kind of a greater and more than 15 degrees, you suspect that there's been some kind of disruption, if anything that you could literally just mention it to the examiner and it will still look quite impressive. Oh, I'd like to assess the volar tilt if I could um you know a plot the specific points and check the angle. And that can tell you about things like distal radius fractures, or it can tell you that there's been a fracture or dislocation more proximal, whether wrist X ray kind of breaks off. So you might have a disruption where the elbow is for instants. Um So it can tell you that you might need an additional X ray of a different body part. So one thing that I would have said they're really for ap view, things that you want to check is the distal radius. Make sure it's couple of the carpal bones assess the carpal arcs as well. So the role there called the gluteus lines. The, that's the other name for them. If you have a lateral view, check the alignment with the radius lunate capitate and this and your um C three and also look at the skate void as well, make sure there's no kind of cortical breach, although that's kind of bone related. And if you want mentioned viral article moving onto bones, it's the same for every single one. You basically want to trace the court's the cortices of all your kind of main bones. So radius, the older styloid and all the carpal bones and make sure there's no breach of them, okay and breach. I mean, there's no like disruption if you to draw a line, outlining it. The most important one to look look for is the scaphoid bone. Basically, all the carpal bones of the proximal row are the most likely to get injured. So that's where your best bet is to start. The skateboard is the particular one where you want to spend a lot of time or not a lot of time, but just be very pedantic and checking because that one, you have a risk of something called avascular necrosis where the blood supply, if the fracture is at a particular point, it can impinge blood supply. The bone can be can the crows away and you can be left with permanent disfigurement of the skateboard, meaning that you have pain or joint problems when you're using that hand and then from after beat, you want to check, say so cartilage. So it's very difficult to use measurements in the exam because you know, you don't have a uh you're not on a computer, but just make sure that there's no significant gaps in between any of the carpal bones. That's your best way to approach it. And if there is, then it basically just means that there's some kind of pathology affecting it. So either it's dislocation fracture or something and then s soft issues. Just go about looking at the outside, outside the bones and check to see whether there's any uh uh lighter part sides of maybe an infusion, any emphysema or something like that. Okay. So I was just going to quickly go through some common fractures show of hands or people can put in the chat. What, what do we think is going on here? And MS mccann, shout out what, what kind of the general consensus is maybe um run in my chat is not working, it seems um unless can anyone, can anyone see my messages? I couldn't see anything? No. Okay. That's fine. That's fine. Okay. So I have to go about explain this one. First off, if I was gonna going into describing this, the obvious abnormality that you're going to state is there appears to be a complete fracture of the distal radius. However, I want to go through it systematically. So looking at the alignment on the AP view, there does appear to be some disruption of the alignment of the radius bone. The distal fragment appears to be displaced laterally laterally. In terms of looking at the lateral view. It also appears that the distal radius fragment appears to be angulated. So it looks like it's um uh being uh dorsally displaced. Um You know why it's dorsal because you can sort of see that this is if you were to look at the hand coming in from here, this is the top part dorsal, this is the palmer part. So part of your palm is basically going to be sitting here. Your dorsal part is going to be sitting up here. I'm going to give you all a hint I won't give, give the night I won't give the uh fractional way. But if I was to draw a kind of line, basically outlining the bones, okay. On the lateral view, it's basically coming up here and then you sort of have this slight bend and it's created what we call a dinner fork deformity. Okay. So if you didn't know what the fracture was called before, then you might know what it's called now. But this is a fracture called a Colleagues fracture. And it's kind of sister fracture if you will, is a Smith fracture, which is basically the opposite kind of displacement. So call these fractures. Uh I've got the chart sorted. So you can, you can do the interactivity now. OK. That's brilliant. So I'll kind of just go through this one at least. So Colleagues Fracture, they're normally brought about by something called a few sh and you'll hear this a lot and you'll see this a lot on the walls. This is basically it stands for fall on outstretched hand. So it's the classic person's fallen over and they put their hand out like that to stop it. And all the impact has come to the part of the hand. It's a fracture of the distal under the radius. So it's a complete fracture and it's created this dinner fork deformity. I never, sometimes it's a bit obscure whether there is a dinner fault deformity. Sometimes it can be a bit more subtle. So, rather than remembering it as you get this classic look of the dinner fork, which some patient's might not have necessarily. I used to actually remember it as the D stands for dorsally displaced, the distal end is going up and that's the best way to kind of remember it DVD. Oh And then as I said, it's Smiths Fracture is kind of the sister one where it's, it's in fact the opposite kind of explanation of the uh the mechanism of action of the fracture. So colleagues was falling outstretched hand like that where they're going forward. Instead, Smith is like they've fallen back and the impact has actually come from, from this part of the hand. So, rather than the palm, it actually came from the back of the hand and it's, it's going back onto it. Um And they get this very classic palmer. Um uh although lot displacement of the distal and okay, this is another kind of uh fracture, a little more subtle. But in fact, does anyone investment, does anyone want to come up on stage? Because I can invite people on stage to go through things. Um Someone put in the chat, whether you want to give it to go and try and go through this and don't be shy, you're probably due for that. Pardon? Misma. Anyone brave? Come on, that should be, that should be someone. No, we're brave enough. I might stop. It might, it might pick someone. Oh, there we go. We got to take a good Sophie. Okay. So I'll invite you up now. Okay. There we are. Okay. One second everyone and just let you know, just let everyone know doing a M S K doing an M S K X ray in your risky is quite difficult. Chest X ray and abdominal X ray is much more likely. Um because they're more, they're more well taught, I think a cardiff. Um but don't necessarily panic. Hi, Sophie. Um don't necessarily panic with an M S K X ray. Just try and go through it systematically as you can. Okay. So I'll share my screen now. Okay and give it a go safe thing. Um Okay. So first after check in the details and everything and whether we have any past X rays to go through, um this appears to be a wrist x ray of the um would that be the left hand? Um And then on just like general inspection of it that I think there appears to be a fracture of the scaphoid bone and a bit of the distal radius as well. That's just the main thing that's pointing out at the moment. But going through the structure, the alignments or seem fine, there doesn't seem to be any displacement and then the bones itself. Yes. And there's a bit of um a fracture and the distal part of the radius, the oldest Dilaudid looks fine, doesn't appear to be any fracture there. Um The cup in of the carpal bones to the radius, there might be a bit of overlap there suggesting some compression possibly but appears to be largely intact. And then looking at the um that's carpal bones itself, the skate avoid looks like it has a fracture. Um The chip esium looks fine, I think. Mhm. Um So describe the fractures to me, you mentioned too. Yeah. So the first one in the distal radius is a sort of transverse fracture. There doesn't seem to be any associated displacement with it. Um It's an incomplete fracture as well. Um And then moving on to the skateboard fracture again, that's a just transverse instead of the middle sector in the skate void that is also incomplete and not associated with any displacement. Um I think there's some soft tissue swelling um on the left lateral side. Good. Okay. That was, that was really good. So well done Sophie, that was a really good interpretation of that wrist X for actually, so I would very much agree. Okay. There definitely is a unilateral cortical breach of the distal radius on the lateral aspect. Okay. It is transverse in nature for the 1st 50% of the fracture and then it's not as clear, but I will kind of uh outline it. Now, the image isn't the best and technically, you know, you need to, to see in a darker room, possibly the fracture does go slightly up, you can sort of see a break in the bone kind of coming down there and then it's kind of coming off to the side here. So this would be intra-articular. So it is involving the joint, but there is no displacement to the bone. It still looks like it's a joint to the radius. And I would agree as well with Sophie, there is possible evidence of a unilateral cortical breach on the scaphoid bone as well less obvious. So it was good that you picked up on that. The cupping of the carpal bones does look like it. There may be some disruption there still being cupped though. So I wouldn't say there's any like obvious displacement. I think you're quite right there. Alignment looks like it's intact and there, there may also be some soft tissue swelling or changes. It's more kind of a clinical uh I guess opinion of whether you feel there is some there or not. You, you'd be entirely right for thinking if there is some kind of fracture. Um then there may also be some kind of uh liquid building up. So you did really well, there does anyone know the name for a fracture of the distal end of the radius that involves the joint between the radius and the carpal bones? Is it like a galleys galleys? What was that? What does that say for me? I don't know how you transit. Uh I got a light is fracture. Uh Yeah, I'm not sure. Yeah. No, no, that's fine. That's fine. So I've got one more person saying Barton, ok, bosons fine. Anyone else that's fine if there's no more guesses. Okay. So this quite rightly would be a bar since fracture. Okay. So again, this is something where it's kind of like in the actual exam, you don't need to, you know, know the names of these fractures, okay. This is more just of interest, but the two which I've kind of shown you are like very common fractures that people get of uh which they present for like a wrist, wrist X ray and you can see them. So barcenas fracture, it's fracture of the distal radius that you can sort of see here. And it involves the joint, that's literally literally it. And you'd be quite right in assuming if they have a fracture of one of the bones, then they may also have a fracture somewhere else. And I think there is possibly some kind of involvement of the skateboard so well done. So that was really well done. And in this case, if there was suspicion of the skateboard, which there could be, you can order something called a skateboard series. This is something you can mention your investigations. And a skateboard series is basically multiple angles looking at the skate foid with an X ray. If there was still nothing shown on the X ray, then advice is Frisky suspected skateboard fracture you, you know, um give them a cast, okay. Can't I can't remember the name off the top of my head, sorry. Um And basically review them later down the line in a couple of weeks by having an MRI and checking um with a skateboard fracture, you definitely don't want to miss them because if you do, then obviously, there is a significant impairment to the person's hand if those complications arise and that's the talk. So thank you everyone for listening. I hope it was somewhat helpful. Um If you have any kind of questions, feel free to feel free to ask. I've got the feedback phone. Oh, yeah. And I'd really appreciate, we'd really appreciate it for uh some feedback. If, if you have time, um our next session would be next Wednesday. Um This time the 6 30 it would be on blood, blood test. And um yeah, I mean, blood test in computation, maybe A B G if there's stuff by saying this or work through systematically. So I would, I would mention that there is an obvious fracture, okay. And you can describe bits of it straight off the bat. So if you see one which is like a complete fracture, you don't want to make it seem to the examiner like you haven't seen the blurring, the obvious fracture, staring right at you. Um In fact, some examiners will just be like they want you to move on quickly. And as such, if you said the right thing, they'll probably just wish you away on to the next part of the station and they'll be happy with it. Hence why it's important to state the obvious. If there isn't an obvious one initially on first glance, then obviously you need to go through it properly, you know, looking around the cortex of bones. And if you see, you know part of it where it's been breached, then you can mention there appears to be a breach of the cortex indicating a likely fracture and then describe the fracture itself. If anything, I would just drop an idea of if it's a massive break all the way through. But the bone, you can simply say there appears to be a complete fracture of X bone. However, I'd like to go through it systematically and then go from there. That's fun. So just for everyone, the next uh next talk, which I'll do on this will be um because we've already kind of covered the basics um for M S care X ray interpretation, I'll be doing lumber, spine, x rays and shoulder x rays. Um with that one, they'll be a bit more time of people to actually come on stage um and you know, practice um and go through from there. It was the last X ray right or left hand, it was left hand. The best way to know is most of your A P films they're coming in from the palm. Okay. So wherever your thumb is on the film is basically going to tell you where, which hand it is. So in that case, it was on the left side. So in fact, if your thumbs on the left, on the X ray, then you know, it's a left hand X ray. If it's on the right, then you know, it's a right hand X ray, sometimes the wrist X ray will actually cut off bits of the, the digits where you can't actually tell and that's fine to say. So saying this is a wrist or hand X ray, I'm trying to tell what which side it is, but I can't distinguish it as part of the X ray has been cut off at the digits and then go from there and that's, that's fine. Mhm. Mhm. I think that's it. The, does anyone have any other questions? If anyone has a more verbal question then put in, invite me on stage or something? And I can always do that as sometimes it's difficult to type out one. But if no one has any more questions, I'll end this in a minute or two. Okay. I think that's it then. So under there, thank you, everyone for coming. Uh, and yeah, I'll speak to you soon. Wisma.