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Hello. Hi, guys. Hi. Hi, Doctor Johnson. It looks like your video and audio is working. Great. Yeah, great. II think we can, we can kick it off. So, hi, everyone. Um, welcome to our second talk of this series. Um Our Pit Stop to Proficiency series uh with this F one the um, I'm Faisal, I'm the teaching lead of Ortho. So at U OB um, so this evening we're joined uh by doctor J Deb Deb Johnson. Sorry. Um He's gonna take us through the upper limb. Um And throughout the talk, if you have any questions, please leave them in the chat and then we'll try to get through them as we're going along if that's ok. Um uh what I'd like to say as well. So all of you guys have already got points for joining our talk and you'll get certificates at the end um with our leader board situation that we've got going on, um, we give out points for like participating as well. So please make sure you um keep engaging and obviously, you know, this is a safe, safe space to get things wrong. We can all have a, have a good discussion about, about, uh, some orthopedics. Um, so without further ado, uh, Doctor Johnson, are you ok. Um, getting your slides up. Is that fine? Yeah, let's, uh, share it. Let's see if it comes up. Yeah. Bear with me guys. Can you see the screen? Uh, not at the moment. There, there was before, um, before you click stop. We'll this, there we go. Yeah, that's great. Lovely. All right. Um, how many people do you have attending? Just so that I know I can't really see myself. It looks like six others. Fine. Um Let's get started. Uh More people can join. Um Are these recorded? Like are these like how like how should I pitch it? Um It is also recorded. Uh People can actually afterwards. Yeah, fine. So like not much. Um Like, I like normally I like to do quite a lot of uh interaction with people. Uh ask a lot of questions uh and have people uh come back with answers on the screens on, on the chats, but I can't really see the chat. So I'll just crack on with delivering the uh the teaching that I've had for you. Um And then towards the end, I do have a few questions um that I've got on the slide rather than on as a poll. Uh I hope you guys don't mind that as well. Sure. No. Uh Yeah, we'd all be able to engage. I can let you know about the chat um because it, I can see it on my screen. So, yeah. Um All right, let's get started. So, yeah. Um, welcome everyone. Honestly was like Thursday evening. You've given me your precious time. Uh Happy Diwali and Halloween, er, for whoever, celebrating it's guy folks as well next week, isn't it? So, er, you're actually, rather than going and doing trick or treats or watching some Bollywood that's come up or whatever, you just decided to kind of spend this precious hour with me. Uh I'll try not to drag to the full hour. Uh try and wrap it um, like within about 45 50 minutes or so. Um Like overall, I just want to impart some knowledge, some exposure to managing upper limb orthopedic uh conditions. Um So uh topics I really want to cover for next few minutes is the, how, how, how do you manage like a patient with a trauma with, come in with injuries. Um, and then very briefly about um upper limb infections and upper limb emergencies, like not to kind of forget them as well. All of those are very much of an orthopedic um conditions and things that we kind of manage. Um I work in Birmingham Children's Hospital in pediatrics at the moment. Um, and you know, these are things I routinely see and of course in the adult world as well, we see trauma, infection compartment syndrome and my disease, that sort of stuff. It's all orthopedic bread and butter stuff. The things that I'm not going to cover today are um chronic limb weaknesses. So, um motor neurone disease or cerebral palsy, that's sort of chronic neurological related upper limb problems. They are also upper limb problems but not to kind of forget about them. Um But it's not something that I'm going to cover for this session. Uh Same to, same with bone tumors again, a big topic, but I don't think it's really necessary for me to cover. But something that you guys might come across on MC Qs on past med, uh, that's sort of, you know, you know, you might come across, but I'm not going to cover same for rheumatology problems. So, um, gout uh, crystal arthritis, um, rheumatoid osteoarthritis, rheumatoid arthritis, that sort of problems. Um, you know, it's not something I want to cover, but something you might need to know, I think for my fifth year Os, I had, um, a patient with really bad rheumatoid arthritis and I was asked to do a hand exam. So I'm, I'm aware that it's something that you might need to know, but it's not something that I'm going to cover if that's all right. Um All right. So the things that I mentioned that I would cover, uh, before I kind of go into all the traumas, I just want to get like a few things out of the way. So things like, um, in upper limb. So anything below clavicle scapular and below that all the way down to fingertips. Um of course, or like for orthopedics, you might think about bone injuries, bone, um broken bone or like fractures such uh but of course, like we could deal with uh large lacerations, like cuts um and soft tissue injuries. Um So in order to kind of address the soft tissues kind of thing and should have full, full screen on that. Um So like I hate blurry photos. So sorry, this is a bit blurry. Um This is something that plastic surgeons kind of, you know, it's the bread and butter for plastic surgeons. So um but there is a soft tissue problem. There are so many ways we can deal with it and this is the ladder for soft tissue reconstruction. Um I just want to get this out of the way before I go into broken bones and fracture it and that sort of stuff. Um Hi, Doctor Johnson. Sorry, sorry to interrupt. I think we're still stuck on the topics to cover slide. I'm not sure if it's just bear with me. Can you see this? Yeah, I can see when you're, when you're out of full screen, it works like that. But I think when you go into full. Yeah, thanks for interrupting. Uh If there's any issues, please feel free to kind of let me know, interrupt me. Uh I don't want to just crack on and like for you guys to have stuck on a screen. Um Can you see this? Yeah, we can. Brilliant. Yeah, this is the reconstruction ladder for soft tissues. So let's say there is a massive laceration in your arm but no bone is injured, no important structures like nerves or arteries being injured. This is the sort of, you know pathway that we kind of follow. The plastic surgeons usually get involved. But in units where we don't have plastic surgeons like orthopedics, we get involved as well. So at first instance, healing by secondary intention, that is if the wound is relatively next to each other, um but they're not fully opposing um to each other, you can just do nothing and leave it be and like gradually, secondary intention is new granulation tissues, new epithelialis, epithelial tissues and form and that will just heal by itself. Uh Primary closure is when you actually pull things together and then stitch it, like do a suture. Um like you might do this in A&E er or in theaters depending on the severity or whether the patient can tolerate it. Um So that's primary closure, delayed, primary closure is, you know, you just simply can't close it at first instance. So you leave it before um you, you wash it, you put some steri strips or something to kind of cover it, but then you come back two or three days later to kind of bring it together and suture it. Um and then like, you know, anything about, this is pretty much like plastic surgeons kind of area. So you do skin graft, you do either split thickness, you go to um um up to the subcutaneous fat level or you go even like you just take the hyper hypodermis layer or you go all the way full thickness of all the skin, all the way down to subcutaneous fat level. Um and then uh flaps for you can either do a flap without, with, with the same blood supply or free flap. Then you take the arterial supply with you to kind of, you know, reconstruct. So those are like the ways that you can cover up for soft tissue injuries that happens in upper limb. I just want to get this out of the way before I go and discuss about uh fractures, um which is like the main topic of what I'm here to discuss. Um So, um you know, I just want to cover from top to bottom really. Um from all the way from clavicle injuries to uh finger injuries and just, it's just quite difficult to like, you know, not bombard you guys with too much information, but also to kind of cover um some of the basic things that you get asked in exams like for your, for your med school and of course kind of give you get you going when you're f one starting in orthopedics um in the DJ or major trauma centers. So, um in general. Um When there is a broken bone, the trajectory of that healing again, don't get too um bogged down with all this information here. Just pay attention to this time frame when there's a broken bone, this is the way it heals. This is the time period it takes to heal. Uh There's four stages, it kind of goes through. At first instance when there's a broken bone, the blood vessels within the bone are damaged. So as a result of that, there is hematoma or blood pooling in that area forms a blood clot at the fracture site. That's the first stage. And that hematoma itself would be roughly about like immediate immediately after the fracture to up to about a week to us. The second week or third week is when you start to see the blood vessels bridging and starting to kind of form new blood vessels in that area. And that's an important stage um for for the blood vessels to kind of cross and form bridges. And then the bone edges would dump a lot of bone healing material. So you guys probably heard of um in histology like osteoblasts and osteoclasts and all those sort of. And then the bone, the bone osteoid cells like the bone cells itself. So they would dump a lot of those cells there. And then we call that specific thing as callus. So callus is a, a healing fracture area. And at first stage, um when all of those bone cells are dumped in between the broken bones. They will be, they won't be hard, they will be very spongy. They will be um easily, you know, malleable. You, you can literally hold and wiggle and they would move like a sponge. Um And then like that will take up to about a month. This is why most of the fractures that we tend to treat. Um We tend to kind of immobilize them or provide them a sling or provide them a brace or a plaster. Uh some sort of a restriction to allow up to this stage. Uh to kind of you reach this stage after this, it's still, the bone still goes through about a year worth of remodeling and consolidating to become hard bone. But we don't need to kind of restrict them for up to a year. So after about four weeks, you just tell the patients you're in a good trajectory of healing. So you can literally get rid of everything, get rid of brace, get rid of plaster, crack on with what you want to do, but just be a bit careful because you're still going through that healing stages. Does that make sense? So the bone healing does not take four weeks uh or a month, bone healing takes up to a year. Uh But in about a month, you get a clear trajectory of where we're going. So clinically, you can make that decision to kind of OK, to let them go free to kind of do whatever activities they want to do, get back into sports, get back to football, uh that sort of thing. All right. So, uh bear this in mind as I go through each and every fractures, each and every things that I want to discuss. So to start off with clavicle fracture. So, um again, so most of these injuries or falling onto an outstretched hand. So in, in uh M CQ stents, you might have a patient who had a foot falling onto an outstretched hand and mechanism of injury, uh or if you're falling off a monkey bar or a trampoline or something. Uh So that, that's an important step really to kind of break the fall with an outstretched hand. If they don't do that, they could injure um you know, other areas they could literally hit their head, hit their face and you know, have a concussion. So falling onto an re hand is actually a defensive thing. But that's really the mechanism of injury for most of these um upper limb fractures, upper limb injuries. So, clavicle fracture thing to notice with clavicle fracture is the um the deformation of like where the forces are acting. So the mastoid and all the muscles that central uh to the clavicle are all pulling the clavicle upwards. Whereas gravity uh with the weight of the arm is pulling downwards. So quite often then not for clavicle fractures, you will see x- uh similar to this. It's very typical with the middle part of the clavicle going upwards, the uh distal part or the lateral part going downward. Um indications for treating this. This surgery is really whether the sharp part of the broken clavicle is gonna be a threat to the skin or not. Um If not, vast majority of these are managed uh in a sling. Uh again, in terms of sling, you need to have like a bit of an understanding of which kind of a sling to use. So this is a broad arm sling, which kind of supports the entire arm, entire forearm, including the wrist, including the elbow and supports it all together. And we'll come across some of the other slings as I discussed, some of the other fractures as well. All right. So um vast majority treated with non operative venous sling uh if we were to treat. So I mention that if the sharp part of the broken bone is a threat to the skin, um then, you know, if that's the case, we could offer them a surgical intervention. So this is a typical way of managing. So uh you uh put a plate and put several screws and then that screw, uh you don't need to know too much, but we call it a lax screw, lax screw goes perpendicular to the fracture and it kind of brings the broken parts together and it kind of brings it next to each other, it's allowed to heal uh large screw principles. Like if you literally buy some furnitures in IKEA, you'll find them there as well. Uh It's a very much of a carpentry um uh technique, but we use, you know, it's offloading screw that's just missed the plate. It's, it's actually meant to be there. Uh But yeah, um surgical uh treatment, the things to be aware of uh lots of neurological um vascular structures in that area. So brachial plexus subclan vessels, of course, the lungs. So risk of pneumothorax um from drilling, drilling and putting these screws. That's all something that we'd be quite careful about. So on MCQ S, if you get, you know, patients with desaturating after a clavicle surgery, you know, it's an i some sort of a pneumothorax that the surgeon of cost. So, is that caliber of questions that you might be asked in your um med files? Um rather than like, you know, like what is the LA group, for instance, that's like, you know, a bit beyond med school. Um But you get what I mean? So it just simple things, but then no, the common complications that happen with some of these surgeries as well. And then if they say like a pale arm um after a surgery like this, then we know the subclavian arteries is injured. Um and that sort of stuff. All right. So this is an X ray of uh how uh that would look like. So exactly this on an X ray. Uh So clavicle fractures, we've covered uh scapular fractures. Vast majority of these are managed conservatively. Really. There's not much to say on scapular fractures. Um Cardiothoracic surgeons would fix it if it's uh it's really severely injured uh on a major car accident. And you know, if, if, if, if we're really trying to fix it, uh humerus again for um all the long bones, I want to discuss proximal middle and distal. And then of course, each of those joints as I come down. Um So humerus fractures and so before fractures joint, I forgot the shoulder joint. How can I are there? Right? So, shoulder dislocations, um you can go either way, you can go in any directions. But the most common is anterior dislocation, which is about 9080 85% very rarely, um 95% is anterior dislocation quite rarely, about 5%. You get um posterior dislocations. The thing with posterior dislocation is in the stem of your MC QS. They will say the patient was electrocuted or the patient had an epilepsy, uh epileptic attack. So you need to have like a high energy jitter kind of a movement to actually get the shoulder behind your glutide fossa into the posterior. Yeah. So area. So any other anything other than that like falling onto no hand or having any other trauma other than electrofusion uh or uh epileptic attack? Um You know, you can lean towards anterior dislocation rather than a posterior dislocation. And the, and the thing, you know, that's one of those key points that they could test you. You know, uh, and another reason why they could test you on posterior dislocation is because the light bulb sign, um, when you see an X ray, um, the way that, um, it presents is the humerus would look like a light bulb similar to, uh, the picture that I've just put up there. All right. Um, well, it's, yeah, um, relocating your shoulder, you just give some sedation, some painkillers. And this is the position that I've, um, you know, always relocate a shoulder. So someone giving some countertraction, pulling with the bed sheet, uh, and then you're pulling the, uh, arm in the to, to allow the shoulder to kind of get back into where it's supposed to. Uh, we do this in A&E, uh, quite often and once the shoulder is in joints burst ling and send the patient home, but it's not going in or if there's a fraction or any other complications do, then we do it in theaters, but just as kind of an exposure of what we do in terms of shoulder dislocations. Um, well, yeah, this is another technique. So, uh, if you're really, really busy and if you can't be bothered to kind of pull, and if you're really pulled to kind of go other areas to get like other patients are sick to kind of handle. This is a good technique where, you know, using gravity to uh shoulder to kind of relocate, we call it the technique uh lie them down, put some weight to it. All the uh tendons, ligaments, all the muscles will just, those tendon stuff will just really relax um all the time and then the shoulder will just get back into where it's supposed to be uh rather than you having to push and pull. Um So yeah, there's various different techniques. And for shoulder dislocations, again, you give a broad arm sling um to support your um wrist, your elbow and everything to kind of support the whole thing. Uh For posterior dislocations, um you tend to not give one of these things, you do an external rotation brace to kind of keep the hand out. You don't need to worry too much about it, but just be aware that, you know, it exists to kind of manage the posterior dislocation that's relocated in an external rotation brace. Um Yeah. So that's pretty much shoulder dislocations. Um proximal humerus fractures. Um Oh Yeah, this is, this is the fracture where you don't give a broad arm sling. Does that make sense? Um I'll go through in a bit of a detail. This is kind of important in a sense. The proximal humerus is broken here. You just want to allow gravity of the elbow to hang like gravity to pull the elbow down so that this uh proximal humerus structure can all the time get back into where it's supposed to be. Um So you tell the patients to get rid of armrests in their home chairs and wherever they're sitting and tell them to knock, to lean down on the elbow. When they lean down on the elbow, you can, you can imagine what would happen. Um The broken bones would just collapse, but this part would just push upwards if they lean their elbow down. So you want their elbow to hang, feeling gravity and the best way to do that is a collar and cuff sling. Um So as you can see it goes around the collar and it goes around the cuff, um and it leaves the elbow free so the elbow can just hang in gravity. And with time again, like all the tends to muscles and tendons, ligaments and everything just nice, nicely relaxed. Uh It would just get back into a better position to how it's broken and how it's displaced. Does that make sense? So, initially, I've mentioned about, I'll talk about different types of slings, but there you go, I've just given you the rationale for uh when we use what type of slings. Um So avoid, you know, using these for shoulder dislocations and clavicle fractures. Uh because, you know, it's a bit painful to kind of um hang the whole um hand with just collar and cuff. Whereas for proximal humerus fractures this would be useful. Um Yeah, vast majority, you treat this non operative uh non operatively in a sling four weeks later. If you just re X ray, it would be in a better position or a position where they can still do activities. So for elderly people, they don't need to kind of, you know, reach things on top CTS and put Christmas decorations and that sort of stuff for them, writing, brushing their teeth, drinking cup of tea, that sort of function is quite good. So you don't need to kind of subject them to um surgery. But whereas like a young athlete, young person who want to do like throwing activities or overhead activities, you want to kind of consider a surgical intervention, but again, not for everyone who sustains these injuries. Um But if you were to do surgery, this is um um one of the ways you can fix it again, plate screws, voiding the axillary nerve that comes around the surgical neck. And then again, the radial nerve that goes around the proximal humerus. Um This is um reverse shoulder dislocation and reverse shoulder replacement. Um reverse geometry. So as you can see the shoulder joint is uh the humerus has the ball and the glenoid uh has the socket, whereas you reverse the geometry where you put the glenoid um to have the ball and then the humerus part to have the socket. And this will help with um this, this gives a better stability than doing, um, the anatomical geometry, shoulder replacements. Again, something for you to be aware of that. Most common, um, shoulder replacements are reverse geometry, uh, purely because it helps with the rotator cuffs and for us, for us to do the surgery as well. Um, so we've come to, uh, talk about the proximal humerus fractures. Next is the, um, humeral shaft fractures, I believe. Yeah. There we go. So, humeral shaft, it just, you know, it's humerus, a long bone, you can break um anywhere like distal middle or proximal third shaft. Um The main thing to be aware of is the spiral groove, which is where the radial nerve kind of spins quite nicely around the humerus. It goes to the back of the humerus and it comes out laterally. Um and quite often at the distal third fractures, um you tend to have the radial nerve uh being injured. It's about 30% of the time your radial nerve is injured. So these kind of fractures, if you're assessing an A&E, it's quite important to just document neurological vascular status and just documenting them whether they have a wrist drop or sensation issues to the first dose of the web stays in the hand, uh that sort of stuff. Um Yeah, for humerus fractures again, color and cough is good because allowing elbow to hand uh is a great thing. And then uh there are humeral braces similar to what you can see in the diagram that we tend to use as well. Um You can fix it with intra medullary nail. So putting a nail from the top approaching it in a grade fashion. So from top to bottom, uh a retrograde would be like going from this direction by going from top to bottom and then putting some screws to stabilize at the top, stabilize at the bottom. And um if you were to manage this, you won't even reach the the fracture site at all. So you're just making a small cut at the top to get the nail in and then a few little cuts at the bottom to get the screws in. And you, you know, you're avoiding risk of injury and allowing that area to fully heal without having to meddle around with that area. And then of course, plate and screws is main marriage. So you, you might, you guys are familiar with or open reduction, internal fixation. So open uh open by making an incision to kind of reduce the broken bones, uh the fracture and then the internal fixation is plate in or some sort of device to restrict it and keep it in that position. Um Yeah, so we've done proximal humerus. Distal humerus is really supracondylar fractures. Um Children, um between the age of 5 to 10, they tend to whenever they fall on the ultrasound, it is quite common to have uh supracondylar fractures. So this is between the two condyles in the humerus sustained injury, um very high risk of median nerve, radial nerve, uh ulnar nerve injury, uh very high risk of brachial artery injury. So, quite serious, uh if they are displaced, then we tend to take them stay at. Um e either do it the next day or if artery or nerves injured, then we might do it overnight. Uh But the vast majority of it's undisplaced. Uh We do an above elbow uh back slab to as a cast, to protect it in that position. We stay in theater. Um So so far I'll talk about joint replacements and plate and screw fixations. But in Children, you do know like that they are growing so fast. So we can't offer some of the treatments that we offer for adults. We have to do a surgery, um, in which the implants can be taken out quite easily. And one of the ways we do is using these uh pins, um, we call it wires for some reason, but, you know, to me, they are just pins, we call it K wires. Um So these are the configurations that we put it in. Either you can do it as a divergent wires from laterally or to cross wires. Um So this is the configuration to manage these fractures. Um Again, uh even after surgery, you put a plaster and you give them a sling. Um, so that, you know, you just can't keep a seven year old boy to kind of not do anything after a surgery. So you've got to protect that fracture and allow it to heal. Uh supra, recovered. Um, elbow dislocation is very similar to shoulder. You just want to relocate it, um check with x rays and then put a plaster to allow it to heal. Uh Now we've come down to radius and ulnar um two bones. Um because of the pronation, supination function, you treat it almost like a joint. So when uh radius or ulnar is fractured, um and if it doesn't heal in a proper, in, in an adequate uh position, um you lose quite a lot of super pronation and that's quite significant. So you want to kind of reduce it in a better position and hold it in position with either the K Ys that I mentioned or res um or if you're happy, just leave it in cast, do a backslab or a cast kind of in place. The thing that they always test you is uh Montia and Gis uh Montag, like, you know, I'd really struggle to be honest in my second year, third year, fourth year med school to kind of get my head around these eponymous names. Um There's ways to kind of remember it, I forget nothing really worked for me. Um But it, it is basically an fracture. So Montia is a ulnar fracture with a radial head dislocation. So radial head, which is supposed to be in line with cap cap cap. Um So we call it the radial capar line. Um If it's displaced, then that's radial head being dislocated. Um Yeah, so that I can remember quite easily because yeah, capital radio. So cap and you know, radius that I can remember. But II just can't remember one for my first few years in med school. But there you go. That's, that's what it is. Radial head dislocation is Montia again, this is something that quite often get tested purely because they can put you a stem, ask you a question and they can put Montag Gliz all sorts of other eous names in it and it's up to you to kind of choose the right answer. Um But again, ii keep referring to MC for me school, you have about uh five or 10 and to use on orthopedics. Um It's, that's pretty much it, it's not going to be, you know, super um high you for orthopedics, uh do focus on cardio rest all the other medical subjects and general surgery subjects uh within orthopedics, the questions will be not, not many. So you don't need to like worry too much. And if there's one area that you can afford to kind of not revise for like it's OK to kind of leave orthopedics as that. Um But if you kind of, you know, learn all the other areas you wanna cover and then you're interested then learn a bit more about or the, but don't get too bogged down about all these things that are imparting. Um but it's just have it as more of an exposure kind of opinion. Um Clii, yeah. Um So clii is radial fracture with radius and ulnar dislocation. So here you can see that, you know, radius and ulnar uh is meant to be in line with each other and they have the radius and ulnar ligaments that support the intra membrane in between them. And then the ligaments that support them, they are now disrupted. Uh And there's a dislocation of radius and ulnar distally and a radial fracture. That's the gli fracture again. Um When Montas and Glia are involved um that the function is really, really affected. So you have to do something surgically to kind of correct it, not have to, it's ultimately a consultant decision really want to at least get an orthopedic input on it. Uh Yeah, it's not something I used, but they go grum is a mnemonic that um I recently come, came across uh kind of help to remember what's what. So GTI is for radius fracture montages for ulnar fracture. Um Are we Yeah. So for distal radius fractures, you want to treat it with um below elbow, uh backslap. So this would uh overcast. So this would prevent the elbow to get stiff. So you can still move your elbow, you're just restricting the wrist. Um and the distal radius is being injured uh carpal bones if you come to fingers now, um By the time you come to fingers, the X ray orientation, you won't see it. It is mostly this, it's gonna turn it around like, um, so you, you guys, you know, from first year, second year, learn the anatomy of all the carpal bones. It's like various in the morning, Sunday. Um The thing that you need to be aware of is KPHO fractures. There's like three bones. Um Well, not quite three bones, two bones um that purely have a retrograde blood supply. And that's scaphoid and the scaphoids counterpart in the foot, the talus, those are the two bones that has pure retrograde blood supply. So the artery that supplies, that bone would kind of cross that bone and turns around like au turn and goes through the bone supply the, the bone and there's like other blood supply to it, but the main blood supply is retrograde. So if you have a fracture through Ekho, um the risk of that um the the proximal part getting a blood supply um being disrupted is quite high. So the bone could actually die, you could lose function and with the first world and you know, the, the way it is, if you miss something like this, there's no catching up to it if you lose function. Um The next is just lawsuits and going down like the area, the place where you don't need to get to. Um if you would just put something like a splint or a cast at the first four weeks. So, take these quite seriously if someone complains of pain, uh, just around where the scar is after an injury falling onto my hand, something like that. Um, you just put a cast or a splint at least for the first few weeks, first few, um, first four weeks and then you bring them to Fracture Clinic where they can have an MRI scan or further examination to see if it is just a soft tissue injury or if it's actually a broken um quite often and not um the fracture won like it's not quite clear on x rays. You might have to get an MRI scan. But why am I asking for an MRI? You might think MRI is just something we do for soft tissue injuries. Like why would bone fracture show an MRI the rationale behind that is when a fracture, like when there's when there's a broken bone, the area around that like gets will will have an edema. So at the start, I mentioned about hematoma formation at the fracture site and that edema and hematoma can be picked up by an MRI scan. Does that make sense with the fluid? And how the MRI S are done? Um So that's why an MRI scan in acute setting. But of course, to kind of study um how the, if there's a displacement in the fracture, the CT scan would be quite helpful as well on top of an xray. Uh but clinical indication, two weeks later, you, you saw the patient in A&E was complaining of a scape foot fracture. Two weeks later, they have uh you put them on a AAA splint or a yeah, or a cast. And two weeks later when you examine the area, which is super pain free, then yeah, it's safe to assume that it's not safe for fracture. Um So clinical assessment acumen is quite important in that as well. So that's why I offer any fracture clinic and we'll take over from there and look after these patients. Um, yeah, mentioned about blood supply. This is an X aid fracture. Um Yeah. So for scaphoid fractures, you could do a scaphoid splint where you're restricting the tongue movement, uh to really stop that area from moving too much. Um, you don't need to worry too much. Uh, the nuances are really, uh, become, doesn't need to be restricted. So quite a few surly become free to kind of mow as well. Um Yeah, if you, there is a skateboard wear to be broken, really displaced. Uh, you can manage it with a single screw across it. It's a tiny teeny screw, it's tiny microsurgery if you guys are interested. Um, having surgery, anything below the wrist joint, uh, can you can get to that stage by either doing orthopedics or plastics, plastic surgery to kind of, you know, get to that. So both of those subspecialties can merge when it comes to your hand below the level of risk. And then of course, Blas Cruise, you can see it there. Um Yeah, so I think like, you know, fs metacarpal, um these fractures can be managed with um K wires um because you don't really need platelet screws but plates and screws do exist. And um yeah, I think you'll be really asked much about s and couples. Um So a couple like the trauma and injury side of things. Um There's um that's like the, the the big meat of like everything I want to cover uh infections briefly. I do want to mention about this quote called upper limb infections. So infection like a invasion of bacteria or virus or something like that, right. So for an infection in the skin, that's the cellulitis and the best way to manage that with oral or IV fluoxac. Um that's the choice of antibiotics and it's four times a day. Um If this were to get worse, um there is a potential that the skin infection can go below into a joint into um the muscle. And then surgically we need to get involved because if they were to kind of spread to structures underneath, let's say tendons in your forearm are affected, then the infection could destroy the tendons and as a result of that destruction, you could lose your function in your hand and that's quite serious. So that's why, yeah, cellulitis and things, we kind of try and stay on top of it. Um But infection of the skin is cellulitis. Um You guys seen cellulitis, right? So, um, like you will come across if you haven't seen it, it's like bright red skin infection. So you'd know when you see it that it's isolated, it's down to, it's just the skin. Um, and then patient status influences your management as well. They're really unwell. If their heart rate, BP, septic markers are all showing, then you might want to admit them, give them IV antibiotics or if they, they're walking around fully. But all right, they can have some antibiotics as tablets and go home um and come back to see your like strong safety netting that if things don't resolve, can see you um underneath the skin, the fascia layers, the these layers get infected, then we call it the necrotizing fasciitis. This is an orthopedic emergency. So it depends on where it is. If it's in your um upper limb is an orthopedic emergency, plastics emergency. So plastic surgeons can get involved as well. The aim of this is really to kind of, you know, get rid of that infection because along the fascial plane, the infection can move quite fast, quite spread quite fast. Um And life threatening. If you look at microbiology guidelines for necrotizing fasciitis, you quite often see they have like five IV antibiotics, admit them I to them, take them to theater uh and uh deprive quite aggressively. That's the management. So something to be aware of fascia layer infection, necrotizing fascia, which is quite a serious matter. Um if the bone has an infection. So your humeral child radius and ulnar sort of a bone infection, uh you treat them with IV antibiotics. Again, the way you manage is uh investigate with CT MRI scans um overall like multidisciplinary team management and IV antibiotics and then most important, again, not emergency uh or like an urgent thing to manage is septic arthritis. So, infection of a joint. So upper limb, shoulder, elbow, wrist, all the little finger joints. Um if the joints are involved, um the bacteria, the pus um and the invasion of the bacteria can erode the cartilage the smooth surface in the joints. And that could cause, you know, immediate arthritis for a young person with septic arthritis, but just managed by the immune system or the tablets antibiotics. But the invasion of the bacteria is just, you know, severe enough to kind of corrode onto the um uh joint surface. Then that's it immediately after that infection, they got arthritis. So we take it quite seriously. So even before they get to that stage, we take them to theater um do a wash out like dilute all that pollution with uh lots of saline and just clear that uh it's kind of save that joint. That's why septic arthritis is quite important. And of course, you know, you, you want to prevent sepsis, um you want to prevent a life threatening problem. So that's why you take another thing I didn't mention there is um infection in the tendons, um particularly in the hand is um flexor uh tenis. So that's agains emergency because within the tendon sheath, it can, infections can spread. Uh And again, surgical intervention is something that we have a very low threshold. Uh It becomes a serious battle between the infection and the patient's immune system and your allies of the immune system to help that help the immune system to clear that infection. So you do surgically help them to, to clear that uh infection. Um that's pretty much for the infection side, uh compartments and drugs. So, um again, another emergency, um imagine having a rubber band around your hand. Um and that's what really the pathophysiology of compartments and drum is your venous blood is lower than the arterial BP. So, venous BP is lower. So, arterial BP pumped from the heart is pressing the blood into the hand and the blood's going past that rubber band going into your fingers. But because the rubber band is constricting, the venous um veins, the blood flow is not really returning back to the heart. Does that make sense? So the hand kind of swells up and swells up and it becomes a vicious cycle where the arterial blood coming in venous blood not returning back and then that swelling just makes it extremely difficult for those compartment, which is just squeezed by the tension building up. And as the chain of evidence that happened is because of the compartments came squeezed without the blood supply, there's no oxygen and glucose being delivered to soft tissues. Without oxygen, the cells are gonna die and the cells are dying, they get damaged and destroyed. And as a result, tendons are rupturing um and that becomes an emergency itself. So when someone's having a compartment, that's why we call it compartment syndrome, the compartments being pressed and squeezed. When that happens, it could happen because of trauma and infection, tight bandage. So when we do all these casts that I mentioned plasters, we could do like a tighter wrap burns when they have circumferential burn and like all those um healing SCS in that area could constrict postoperatively from uh all the swelling from operations. All of these can um or reasons why compartments in those can happen when that happens. The priority is really to relieve that compartment. Um So again, there's no cosmetic related uh issues or concerns. At this point, you really want to save that hand from dying or save that tendons or structures from damaging you further. So you want to kind of um take action and that's what we uh we get quite, we get involved in the hospital. If a patient were to have any of these concerns, we take action for orthopedics So, and again, another important orthopedic condition to kind of be aware of. Um, and that's pretty much like all the things that I said I would cover and I hope I've covered those. Um, the ones that I didn't cover, um, you might have to just have a brief, uh, understanding of what's going on. So, limb weaknesses, bone tumor and rheumatoid, uh, topics. Um, I, the past med questions and just practicing some of those patients with your friends would suffice for your exams um for, for these topics that I haven't covered. But again, don't build too much on these. Um take, this session is more like an exposure to orthopedics. Um It's practical, isn't it? It's not, it's not very daunting. Um like, you know, there's a broken bone, you're fixing it, you just keep it simple. Um Of course, there's more to it, but just, you know, try my best not to bombard you with too much information at this stage before you guys. So there no questions, show some questions. How are we doing? Who's around? Has everyone left? Uh No, no, no. So, so we have, we have um six people in the chat. Um So guys, um after in to do the questions, if you wanna type your answers in chat or you want to um unmute and just speak your answer. So feel free to do. So, remember again, we have a leader board going, um you know, top three, top 10, we'll all get prizes for engaging, interacting and you've already got the points for attending. So, um, yeah, let's try keep engagement up. Um, ok, so first question I may or may not have covered. So if I haven't covered, uh I do apologize but I don't really, because, you know, some of these things you will have covered in second year uh anatomy sessions. Um It's, you know, it's something that you could potentially get asked. Uh But if you don't know, don't worry, that's the teaching. I could give you the answer and teach you a lot of that. So, surgical neck of the humerus is related to which nerve. Let's get some sis coming on the chat. Sure, brilliant. All right, everyone's got that. So, um I think for the leader board, we just go with the first person who came over the answers and like the second person. So the timing of getting the right answer as well be fifth on uh getting back with your answers. So, yeah, that's right. So surgical neck axillary nerve. So if someone comes in with a shoulder dislocation or a proximal humerus fracture, uh you know, as part of shaking hands. Hello. My name is, you need to be like tickling the shoulder and to be like, oh, can you feel me uh touch there? Like, you know, do you have sensation in your axillary nerve? Can you remove your deltoid muscle at all? Um You know, check those sensation, document that down. Um So, you know, that, that point kind of applies to everywhere. So if you were to assess a patient with, um um let's say, um an elbow dislocation or um forearm fractures, just, you know, neurovascular, is it part of introduction? You're just checking all those really quickly. Um And then after doing any intervention with it, sort of reducing it and putting your plaster, um you want to kind of check again to see if your cast is just too tight and that's causing this, no problem at all. Um um Or if it's an injury that's caused it. So you don't want to kind of, you know, be a blame bearer. So if that were to happen, you wanna quickly take the cast off and do another one. All right, next question. Um uh the back of media that they can't know is to which I have. It's a bit harsh. I don't think I really talked about it. Really didn't talk about it, did I? Uh but it's a bit harsh but yeah, let's see. Uh sis any other anyone else, any other options. So we're just sticking to all the Yeah, well done. So back of the me back of the medial epicondyle is the ulnar nerve, uh front of the lateral epicondyle is the radial nerve in the middle of the anterior um uh humerus is the median nerve. Um So something to be aware of. Um And then the next question is uh most common nerve injury in elbow dislocation. I didn't really talk about elbow dislocations. Um I briefly briefly mentioned uh in like II mentioned all of those nerves, but I'll mention them in a sense in order I don't know if you've paid attention to it. It is a bit harsh. I do acknowledge that. So uh what nerve injuries common on elbow dislocation? Come on. Have a, have a guess. Faisal, I'll go for owner. Median. Yeah. If in B go for median, yeah, median nerve is the most common but the other nerves are also at risk. They're all in that area, aren't they? So, ulnar nerve uh sorry, median nerve is the most commonly injured, particularly the the median nerve branches off, it goes into anterior and troch nerve and the median nerve proper. So the median nerve stays as itself and then there's another branch. Um Anterior re nerve supplies three muscles. You don't need to know too much about it. But that nerve, the A I is most likely injured at that stage. Uh And then the median nerve and then followed by that is the radial nerve. The ulnar nerve is injured in uh elbow dislocations if the elbow were to come forward. Um if it's like a flexion type uh dislocation, but again, we don't need to go too much median nerve common. Um uh I think this is the last question. I don't have too many questions. Uh oh second last really? Uh I think I've discussed about this. So, you know, expecting you guys to get this one. Not really a harsh one since I mentioned about in my talk. Uh which of the following fracture patterns is a higher risk of radial nerve. Yeah. So like a hu humerus uh fractures um have given um all sorts of humerus fractures from proximal to middle third. Um all the way to distal um uh humerus fractures, which of those really causes um the highest risk of radial nerve injury. It's called a house tab stabbing the dog acas. Yeah, see see in these, yeah, distal pa um distal third really because after the spiral grove, um the distal third fractures. So it is really the um is where the ra radial nerves at risk, about 30% of radial nerves are injured. Uh But you know, that's why it's not like distal third like MC Qs would want you to think that way, but 70% of distal third radius does not injure the nerve, the nerve kind of escapes. Um So yeah, it's something to kind of be aware of. Um So again, standard M CQ style, uh 23 year old male sustains an injury. Uh What kind of injury I will tell you uh which of the nerve is most commonly injured? I hope the X rays are not so bad on your screens if you're seeing on mobile phones. I'm terribly sorry. It's gonna be a bit tiny uh, to kind of work out what this x-ray shows am I flicking between the screen? So this really annoy you guys? All right. Let's see. What kind of answers are we getting? Well, still, no, let me know if there's some nonsense coming through on the chat. What do you think guys have a guess? Go on, face off, bail them out? Uh I'm not too sure myself. Uh I'll um I'll, I'll give the diagnosis if that's all right. Uh You guys got that right? So anterior shoulder dislocation, it's not like a light bulb. So it's a shoulder dislocation here. Um So what nerve is injured of a shoulder dislocation? I think I mentioned this a couple of times might talk but probably didn't emphasize it enough, but high heel stuff. Yeah. There you go. There's more coming through. Uh Yeah. Axillary nerve in particular uh is a high risk uh in shoulder dislocation. Sure. So you patients sitting in A&E and you go and see them, the shoulders discus on X ray again as part of shaking hands. You kind of like test. Uh Hi, my name is, can you feel me touch here? Um uh straight away to kind of check for the x-ray nerve. Uh Fine. I think, I think that's all the questions that I really have. Um I do have a feedback form. Um It just literally got five questions whether you found this teaching helpful or not, whether you want me to make any improvement or not. That's sort of, you know, simple one word, uh questions, one word, answer questions. Um I'd really appreciate, I know there's only six people that showed up. Um But it'll be recorded for others to see as well. If you can kindly do a feedback form, I'll leave the Google Forum for this link open. So if anyone's watching this video at a later date and catching up to this teaching, um you can also fill in this feedback form and see whether you found this helpful or not. I'll find that quite helpful to kind of improve my teaching skills and delivery, like my material and all those things. Um But yeah, um questions now really uh six of you. Um Any questions including Facebook, um Anything you want me to clarify, I'll hang around for a couple of minutes. Um I didn't say 45 minutes to 50 minutes and I actually dragged the session for a whole hour. I'm terribly sorry. But anyway, go and do trick or treat and whatever you had in mind the as well. So, um yeah, it's, yeah, not really in the spirit of any of those things, but thanks for giving me your, your hour on a Thursday evening. Brilliant. Thank you so much, Doctor Johnson. Um I'm sure everyone. Um Yeah, it's just a general thing since you're all here. Um After passing the surgical exams in UK everyone's addressed as Mr and Miss, um, so on the teaching session as well, just change your schedule to Mister and Miss for, uh, like the girls and boys who are doing the teaching and then for us as well. I mean, it's not a big deal. I'm not being pets. I mean, like Ame America, Australia, they still call them doctor. Uh, but in UK Commonwealth country like Canada, India, uh, they all call them mister and miss it. There's a history to it. But um the like, I'm genuinely not petty at all. II really don't mind but just when you come to clinical se settings like in the hospital, uh joining an orthopedic team or a general surgery team or any of the surgical team like ent K, you want to kind of, you know, address them in the right way, it just helps build rapport with them and get you going at the early stages, med students. So I thought like, you know, that that's the only reason why I'm mentioning it. But um no worries, apologies. We, we, no, no, no, no, there's nothing wrong, you know, we, we're doctors, we're all doctors, we've got the M BBS. We fucking worked so hard to get an M BBS. So, you know, like don't apologize but it's just something in the UK but it is petty petty stuff. So um no worries. I thank you so much for the talk. I think um myself as 1/5 year and I'm at the end of my trauma block, this is a very useful talk to have because I think especially UB, you get very little uh trauma teaching and that's almost the fun side of TN O. So, so it was a brilliant talk. Thank you so much. I'm sure everyone enjoyed it. So if, if we can um have a go at doing um Mr Johnson's feedback and then I've also put in uh a link to a, a feedback form in the chat and that will ensure that you get your certificate for attending the talk. So if you can have a go at both, that would be brilliant. Yeah, so sorry guys, I'm just duplicating all the feedback you're giving. Um I, yeah, I really don't mind. Um Whichever. Um No worries, no worries. Um Yeah, if uh does anyone have any questions? No questions? Oh, brilliant. Fine. Thank you so much uh for attending. Um We uh we'll move on to the next one in the teaching series, next Thursday. Thank you so much. Sure, pleasure everyone. Catch you later. Thanks. Bye bye bye bye.