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Yeah, yeah. Hello, everyone. Welcome to the second, um, presentation in plastic surgery today. We've got, uh, Mister Howard to who's going to do a presentation on hand for me, so I'll hand over to him. Thanks very much again. Um, so I'll be presenting the topic called hand trauma. Um, the registrar's in different hospitals of the Southwest scenery. Um, it's a very large topic. So I'll give you a very brief overview of all the different common scenarios and then essentially give you Botox to then delve deeper and in your own time, read on different various topics. Um, so I'll be covering the anatomy, the assessment of the hand, general fractures and how to manage these tendon injuries and infections as well. Um, sometimes of hand anatomy. Um uh, So it's important to describe, you know, the anatomy of the hands you describe where the bones are the distal phalanx. So your most disabilities. Then comes the middle phalanx, your proximal phalanx and your metacarpals. And then you've got the carpal bones, Uh, and then you've got the thumb, which only has a distal and a proximal phalanx, uh, radio and style of they're so important to know these. Especially when you're describing hand injuries and fractures as well. Um, so I'm going to just try and see if this whole works, so start holding. So how many extensive phones are there If everyone can have a look and see, you've got answers here, Got three responses. I'll give it about 10 seconds. So we've got 25% for so I don't know if you can see the response is for 46. Great. So tell the answers. So there's actually ate extensive bones. Um, the easiest way to remember these are that your zone one goes to the I p. J. Your own free goes to p r P j 05 goes to the MCP J. And so in two and four in between these, um so in six is over the metacarpals. So in seven is actually over the retinaculum. And so eight is your muscle belly distal forearm. Your thumbs owns a slight difference. The so one is distorted into your joints. So into is overlying approximate approximate thanks. Um, so free is the N, C. P. J. And so again, let's have a look at the flex savings, and I'll just start another pole to see how many, um, flex savings. Everyone thinks there are did that work. So yeah, the majority focusing at the moment is fine. Flex its own, which is actually correct. So your zone one is up to the distal FPs in session. Uh, so two is from the FDs insertion up to the A one pulley So free from the a one pulley to the distal edge of the carpal ligament And then so four is over your carpel tunnel. Uh, and the so five is just proximal to the carpal tunnel again, your thumbs are slightly differently described. So one is distal to the I p j 02. Is that the A one pulley to the I p. J. So free at the remnants. And it's really important to learn the basics of the zones. Because when you're referring a case to the registrar daytime or nighttime, we want to visualize the the injury. And if you tell us there's a zone to injury to the volar hand or the Celexa has its own to injuries to the flex the hand and then we can think about mechanism. How difficulty is to fix so we can then think about the management with you and the plan from that respect. So these are the basic things you should be learning and picking up when you're making referrals to your senior colleagues intensely. And anatomy reflected that. There's this intricate pulley system houses your flex as the FDs and FDP's um So I described the A one police of the N c e p j. Um, so I think of yourself. So it's like, for some reason, bear with me, Jen, can you help at all? Just make sure it's refreshed for some reason. Sorry, everyone. Let me just otherwise, you can just share the screen way. But well, if you start uploading, it will let you see this light again. I'm not expecting this, but all right, technical difficulties. Just bear with us once we sort this out. I want to do this now. Yeah, yeah, I got a bit of an echo, though. It should be working with that. You got two things long? Yeah, I just got the tough part on. Um, can we see this? Is there an echo? Okay. Yeah, You're good now. Great. Um, see this these as well Yeah, I can see this one. Great. Just accept this. Um, So in terms of your flex is they have we have this house in this pully system. Your A one pulley is over the MCP J um, your a frequently is over. The p i. D. J. A five is over the d i p j. Um, and the main reason for the police is to prevent both shrinking. So if you think of a fishing rod, they have these islands which houses your fishing, uh, line. Essentially, um, and those eyelids prevent the bow stringing of the, uh of the fishing line. And any injury to the police say, if you're climbing can cause both shrinking of the flex attendant and reduce your mechanical load of your hand. Um, So when assessing your hand is always important to adapt the look, feel, move, maneuvers. Uh, when looking at the hand, I always start the elbow, roll their sleeves down, look from the elbow down and performing general inspection. See if they're coming in with any walking aids and Azor in adoptions or any splints at all. Then have a look at the hand both from the dorsal hand palm volar aspect of the hand. See what their natural hand position is, where they've got a natural cascade. They have an abnormal cascade that can indicate a flexor tendon injury to look for any scars, any swellings, any clinical skies of arthritis, which is a pedia nose, swan neck Deformity said from orbit. Tanya's, um, and then importantly, have a look at the remnants. See if there's any muscle wasting in the first Web space. You can also get muscle wasting caused by HPV because of the median nerve, uh, loss or damage and then go on to feel so with both hands. Have a feel with your palms up the temperature is what they are. Okay for everyone. Yes, okay. At the moment, I think somebody said it's getting out. Sure. Um, so it comes up, have a feel of their temperature radio, no pulse, and then have a feel of the Osphena and high protein uh, book, uh, and whether they've got any problems with thickening suggested of Jupiter on any nodes have a feel of the medium and on a nerve sensation, and they simply do it again to the dorsal aspect of the hands and then perform active and passive movement of the hands, assessing the Flexeril, Flexeril and extension Um, wrist extension wrist flexion, and then ask them to do this in passive movement, go onto then assess their motor assessment risk and finger extension against against resistance their index finger abductions for on a nerve from a reduction for median nerve and then assess the power grip the pincer grips and whether they can pick up any small objects as well, uh, and then have to do some special tests. So the Tinel's test, where you tap over the media the carpal tunnel can suggest of median nerve compression suggest that the carpal tunnel syndrome, uh, the balance test. So make them a prayer signs, flex their risk at 90 degrees and ask them to live their elbows up. This is also a, uh, finding of carpal tunnel syndrome that positive, um, and then you can also perform other special tests to lead you to other diagnosis as well. So moving on to the first topic the hand fractures, distal phalanx, most common injury are these mallets type deformities caused by actual loading my metformin balls or cricket ball where they go to uh, to grasp the ball. They have actual loading to the distal phalanx, leading to an avulsion fracture of the extensive mechanism at the distal phalanx. Um, small fragments can be left alone with a mallet splints for eight weeks. Or if there's large fragments in the small because subluxed that the distal phalanx you can adopt Ishiguro technique, which is where you put a wire 45 degrees into the middle phalanx and then hyper extend the distal phalanx to push that fragment back up and then using an actual wire to then push it in. Uh, my preference is normally check the wires in a week's time for infections, and then the wires come out in four weeks' time, not needing any local anesthetic. Just pull the wires out in clinic. Um, very common injuries as well. Are these tough fractures so tough fractures, which are undisplaced and then they can also be associated with the nail bed injuries. So these are essentially open fractures that need to be washed out and the nail bed repaired. Um, this can be done under local anesthetic in the minor, upsetting either an E d or your minor operating theaters. Um, middle phalanx. So here we can see an example of what we call a volar plate injury. So the volar plate is a bullhorn ligament that attaches from your proximal phalanx up to your middle phalanx and hyper extending your finger can cause a stretch of that ligament and where it attaches to to the base of the volar middle phalanx can cause this avulsion fracture. Um, there have been kind of several iterations of how to manage these injuries. Now the thinking is, if you have a small plate injury with a bony fragments, then you can just leave them with a bed for splint or a buddy taping and just get them moving larger fragments. We will need to manage them with a dorsal blocking spin. So that's the splints over the back of the finger at 30 degrees, and then they can increase 10 degrees up to full strength thing. And that's often do done with occupational therapy. Uh, pull up head injuries can also be associated with out bone injuries. Um, and these can just be managed with a buddy tape and just keep them moving. More complicated middle phalanx fractures involving the bone. So this is a peel on fracture. So if you think you have an actual loading off the finger, you can have the two fragments from the door from the volar aspect of the back and the front of the finger split open and like a pile on. Um, and these are quite complicated fractures to fix, and you can use miralax techniques. And one described here, um, is a lag screw fixation. So what you normally do is make a cut over the back of the hand, the dorsum, um and you can go through between the what we call the lateral bands, and the central slipped between the two extensive tendons to expose the the bone itself and then put a couple of screws in. And then what you want to do with these is mobilize them for a very short while and then get them moving. And the premises of, uh, fixing fracture is early mobilization so they don't get stiff. Um, so this is a middle phalanx fracture again. So describing other techniques. So the top is actually what we talked about a peel on fracture. Um, opening. This will be very difficult to fix because you have many, many bits of a fracture. So what they've adopted here is what we call a Giddens frame. Where is essentially an external dictator, putting two K wires into the proximal access of the middle phalanx and one into the proximal phalanx and using tension of the wires to stretch that finger out to give you some traction and then to allow the bones to unite? Um, so that's an example of the external fixation. They're called the Giddens frame. Um, these need to be looked after very carefully because there's essentially metal work going from the outside environment into the um into the finger, and it can cause an infection. So that's why we always check them in a week's time to make sure there's no signs of an infection. And then these normally stay on for a couple of weeks. Your proximal phalanx, um so always successful rotation of deformity and scissoring in any hand fractures, none more so than the proximal phalanx, and these will lead you to think about whether fixation is necessary. Um, you have deformity forces from both the flexes and extensors. Hence it's very difficult to maintain reduction and stability of these fractures Um, and for those that are displaced, you would adopt an operative fixation. And what's done here is what we call an intramedullary screw. Um, so you put a K wire in which is in that middle picture, just as a guidewire once you reduced it and then you can then put a cannulated screw straight through the middle. And what we have in theaters is quite nice and image intensifier, and that helps us have an inter operative screening with an X ray so we can see what we're doing. Um, approximate family structures can also involve a sort of Harris to in, um in pediatrics. And what this subscribes is the fracture that involves the growth plate. So So the house one is a slipped. Above is number two lower is 34 is through and five is round, so solitary is one and five can look very similar. And a communist injuries salt air is to if they're undisplaced, so they're not moved too much. And they've got good, uh, movement, no rotation of sizzling. Then we can leave this alone with a buddy tape displaced fracture such as this in the in the picture, we can put them asleep and then reduce the fracture and then get them moving after a couple of weeks. But kids are very good at remodeling, and sometimes we just leave this alone and they back to full function In terms of metacarpals are Communist fractured patterns. Um, we can treat them in two ways either a conservative or operative fixation. But if we treat this conservatively, there must be a stable pattern. With no rotation of sizzling, they must be accepted ambulation and shortening. Um, so the angles or put here are loose guidelines of what we accept with the metacarpal head. Um, and if we treat them conservatively, there's numerous ways of doing this. We can, buddy take them and show you the picture in the left. We can immobilize them and show you the picture in the middle, and when we mobilize them, will put them in position of safety. So wrist extension at 10 to 45 degrees, your metacarpal phalangeal joints at 62 9 degrees and your P I P. J. Is in full extension with your D I P. J as well, and that allows your collateral to be a maximum tension so that they don't have these contractors. We can also treat these operatively. And then when we think about treating the operatively, we can treat them with open or closed, um, and then open fracture open, open fixation involves over a plate or screws. Close fixation. We can just put a couple of wires in to fix these, uh, fixing them can. We can think whether static fixation or dynamic fixation where we use cruise wires, lot and plates, compression plates or different wires or suture is if they're quite complicated. So there are lots of different bits. Um, so there's different nuances, and different people treat them in different ways as well. Um, so this is an example of 1/5 metacarpal base fracture just in the left picture, uh, which is fixed with a couple of a wise. You can also, uh, doing some screws for the third metacarpal you can see here on the plate as well. Um, and then your top right picture shows 1/5 metacarpal mid shaft fracture, which is treated by a couple of, uh, K wires. And the bottom picture shows a bridging plate fixation construct. So decision decisions is what needs to be made. And if you sit 10 surgeons around a table and give them a picture of a fracture, everyone will probably say different things. And there's no right or wrong answer. It's just what surgeons preferences are, um, and notoriously difficult ones are fifth metacarpal heads with no radiation or surgery. Some people say Fix some people don't say fixed, so you just have to learn about what your seniors like and what they don't like. But there's no wrong answer. The general rule of thumb would be to say, if there's a stable, reduced, acceptable fracture, then we can mobilize them. But we can also mobilizes free, so just let them be and just get them moving. These are often case where I've seen patients six days online after the fracture, and they presented to 85 days online with nothing on them between five days and they've already managed themselves and they got good range of movement. Then I just let them be. Um, they just give them a check In a couple of weeks time, we can order mobilize them, protected so with a buddy tape using the other hand as a splint, or using this in frame, um, those that reduced, acceptable but unstable. We would like to immobilize these with a finger or restaurant or position of safety of the plastic Paris. Those are an unacceptable and, um, reducible, but stable. We can reduce them with an open or closed technique, and those are unstable, unacceptable, introduced. We definitely need to fix these and with those techniques described there. But we also remember that there's other options that we confuse the joints with arthrodesis arthroplasty. We can restrict reconstruct the soft tissue to get a good bony construct. An example of this will be a distal phalanx fracture, where they got really committed to lots of parts of different parts of bone. But if you fix the nail bed, sometimes that just holds all the bones in positions. Um, it allows them to heal, and there's always the option to amputate her later on. So I don't know if I can try and start a pole here. Uh, so would you fix or would you not fix this fracture? It would be interesting to see everyone's views as well. Okay, great. 20 for responses, say we have to know. I think at the moment it's a difficult one. I think if they've got rotation of sizzling, then yes, I would fix this. If they have not got rotation of sizzling, then you again on the fence with these fractures, Some people with some people wouldn't, um you probably would be in the ambulation. You want to see if they've got rotation scissoring? And if they do, then you can fix them with a cross. Kor that K y. You see, it probably is just acceptable. You ideally want to cross of the K y above or below the fracture itself and not at the fracture site. Um, so this patient has 1/4 metacarpal fracture with no rotation of seizure? Uh, I'll start another call. Would you think so? Would you not fix? Yeah, so I've got 66% at night, So with this one, I probably won't fix. I'll immobilize it in a position of safety. That's because with the fourth metacarpal fracture is our undisplaced like this. Um and that's not particularly shortened. So you can see the the the step of the metacarpal, which is a very nice step. And it's held by, um into metacarpal ligaments. So the fourth you can essentially create this box shape with the ligaments. And they held really well in position. So this one I wouldn't fix, I would just immobilize it for a few weeks and then get them moving Last one. So a proximal phalanx fracture with dorsal apex. Um, angulations, uh, with rotation in size rain, Uh, let's start with the whole were saying 91% saying yes. So I agree with you guys. I would definitely fix this, uh, with rotation and scissoring and a daughter quite angulated fracture. Um, you can manipulate it under a general anesthetic and then put a couple of Kyi's in to hold it in place and to allow the fracture to unite. So just moving on to our next topic. So tendon injuries. So some glory pictures to come up. So assessing the tendon injuries assess their hand, as we said before, so look, feel, move, approach. Can they make a fist? Is one straightened out? So that's the pointing, uh, signed. So all the fingers are reflected together, but one of them is pointed out. Assess their individual attendance. So the FDP, the F d s um, they're e p l. So from Retropulsion and the thumb FPL. You can also squeeze the forearm, ask them to completely relax, squeeze the forearm and then to see if they make this natural cascade. So next time you have a patient, just have a go. Just squeeze the forearm, see if they naturally curly in their fingers. And you can also the teen a decent tests and ask them to get their hand. Um, nice and relaxed and then just put their wrist back and back and forth. You can try it now and then see if their hand moves as well. So that's a teeny dose effect. A very common injury. Actually, when I was in Bristol is this avocado hand. So when they're using the non non hand using a knife to cut the fruits and try to remove the stone, they can slip, and then they can injure the flexor injury, Um, at the level of the A one pulley. So just at the metacarpophalangeal joints, and it's always important to ask what they're doing or how they're holding the implement when you're assessing or asking the history because we want to know how far back the tendon is retracted, so classed hand with the Flexeril, and then they've injured or lacerated the finger. The flexor tendon can go back into the palm itself. Um, this is a ring of option. So commonly, when they have a ring around, uh, whichever finger they wear, their rings, the climate, we're friends, they catch the ring, and then it causes a developing of the distal part of their finger, and they can pull out the whole of the 10 as well. Um, you need to assess where they've still got. You need to have a look at both of the parks to see where the neurovascular bundles our and ensure they get urgent management in A and B for these when they have a closed tendon injury. So, very commonly, what we call a rugby tractor injury. So when they're playing rugby, they catch the tip of the finger on the opponent's shirt and it closes a closed rupture of the flex attendant. Um, you assess them the same as the laceration, and they won't be able to make a full fist because they've lost the flexor tendon that bends the distal phalanx. Um, and what's described here is the lead. A pack of classification, which can be used, describe how far back the flexor tendon has retracted extensive injuries. So your extensors our house in six different compartments is described here, um, the else's tests you can use to assess the central slip injury to ask them to put their finger on the side of the table at 90 degrees and then ask them to flex and extend their finger. It's positive if they have a week extension the PPJ and hyperextension the D. I. P J. It's counterintuitive. So you would think that they have a week distal phalanx because of the central slip injury. But in fact, the lateral glands, so the too extensive at the side of the finger takes over, and it forces that finger to become more stiff at the distal phalanx. Um, as opposed to being weak. Your extensive injuries can also happen at the level of the mid dorsal aspect of the hand as well. Um, and you just need to see where the extensive injury is, and they describe it to the seniors ligamentous injury. So this is a sternal lesion, so they can have pain and swelling and bruising at the site of a ligamentous injury. They reduce range of movement and instability of joint. And you also need to x ray the hand to exclude an avulsion fracture and to refer to trauma clinic for any closed injuries so attendant to put it back into place. Otherwise, they will not heal that fracture moving on to infections. So Paronychia is a soft tissue infection of the proximal nail fold, very common in finger nail biters. And they get this collection of pus just around the nail fold Very early on, they can get redness, and we would just advise warm soaks on antibiotics and elevation. But those were problems. Um uh, tense swellings of their fingers would advise and the local anesthetic and incision and drainage and then removing just that part of the nail fold and just removing that nail forward. You'll see the past just being released. From that point of view, if they're quite severe, then we would admit them for Elevation IV antibiotics of their federal and, well, if they've got a recurrence, a long standing history of the foreign body considering X ray or ultrasound and then you can also excite the whole of the nail plates and then cereal excisions to treat the infections. A felon is on the other side of the hand. So the Palmer aspect you've got a new receptor in the fingertip and they can lead to deep space. Infections of the fingers pop. Maybe very painful, because the receptors don't stretch very well. And when you get a tent swelling in them, you can see that there's a big collection often caused by staph aureus and treatment, early incision and drainage with antibiotics. Um so always X rays. These because they can have signs of osteomyelitis on X ray, they can cause flex chief infections and also pulmonary oysters because of the tent swelling of the fingertip. So the most important thing to note here is your flex chief infection. These are one. This is one of the commonest, uh, hand emergencies in plastic surgery and one that you need to know about when you're under taking the plastic surgeon rotations. Uh, the flex tendons and closing this flex chief. And that allows glide when you get trauma or any bites into the flex chief Plus can collect, and it can cause rapid destruction of the chief. And that's where your tendon gets his blood supply from, um and it can cause a tendon necrosis and tendon rupture, um, again caused by staph aureus. So the four Canaveral science is that this finger is held in the sausage digit. You got uniform swelling along the entire finger. They're very painful along the flexor, Chief. There pain along the pain with passive extension, and they held in passive flexion all four sides with pinpoint it to that. If you get one sign, you can get an early flex chief infection. Um, and I have a low threshold for admitting these in hospital because they need antibiotics, elevation and observation and start them just in case if they need an operation the next day. Um, and how we manage these. So for a history for examination and investigation, As I said early 20 less than 24 hours and not systemically and well, admit them. Give them a trial of antibiotics. Sometimes they recover very well. If it's more than 24 hours and it's quite established, then it's a surgical emergency. So if you have any patients that presents with these, start them just in case. Admit them following your senior colleague and tell them you have a flexibility of infection that you think may need greater theater, and what they need to have done is a decompression of the flexor chief. And then you wash out. So we, as we mentioned before, make a decision of the A one pulley and over the A one and over the A five fully, and then you wash from proximal to distal and just washing. Keep washing it with three liters of saline. Leave these, um, incisions open so that the pus can drain out there. Arthritis. These are normally managed by our colleagues if it's more proximal. But for us, we mentioned in the hand established in the history of direct trauma. Um, any comorbidities, such as being diabetic or smokers examine the joints. So actually loading of the joints can cause extreme tenderness suggested, except of arthritis. Run your investigation. Set your blood your X rays. You can aspirate the joints and send it off. Urgent gram stealing and then bacteria joint infections, normal staph aureus or H influenza in pediatrics. Admit them for surgical progression and wash out elevate. Mark them. Market is actually a very good indicator, So just mark the redness, but back in an hour, mark it again, see if there's any progression. Start them just in case the theater and consent them. If you're happy to do so. Deep space infections these are incredibly rare. You have other deep space is within your hypertension and your fena in your mid space. There are very, very rare infections, but they can be kind of they can cause severe necrosis of the soft tissue. And again, these need washing out very urgently. Human bites. These are very common down in Plymouth, actually. So punch injuries the metacarpal phalangeal joints as the punch catches the teeth and the teeth are laden with bacteria. Um, and they can cause an infection of the metacarpal phalangeal joint rupture of the extent attendant and what you need to do again admit, elevate antibiotics, make sure their tetanus is up to date and they're not giving of access. Consider, uh, HIV, hep B and hep C prophylaxis. There are high risk bites and then a bit them as well, Always been controlled in nonaccidental injury because this is an unusual pattern of injury. Um, so I don't think I've created a pole for this, but Let's do that now. So I have to think of what sort of, uh, animal rights. You think this is? Uh, I'll put question up now, so you've got 50% in camp, right? At the moment, That's actually correct. So that's a cat bite. Um, what about this one here? Whatever. What is that one Think so. Two options here, dog or cat bite 50 50 at the moment. So 56%. 59% dog bite, which is again correct. You can see the difference is between the two. So dog bite. They have much broader teeth, and they can cause a tear of the tissues. And there's high risk infection. Um, with a cat bite, there are more triangular, and they kind of raise a sharp cause puncture wounds, and you can find them on the other side. As they grasp down onto the structure. They can cause a razor sharp. They can damage the nerve attendants rather than a dog bite. They just tear the tissues, Um, and they can inject essentially the bugs from the bottom of the teeth into the base of the wound for a comedy. So 80% of normal dog bites. 10% of cat bite caused by staph aureus strap stuff, strep pasteurella and anaerobic acute bites. X rays. Make sure they don't have any bone injuries. They can cause bone injuries. Wash it out on the local anesthetic. Um, give them a first aid. So wash out better than saline with a liter bag dressed with codeine. Temporize. The wound. Admit them if they're quite acute cellulitis or the federal. If not, they can be brought back in 40 hours for review. Excites the wound. Edges. If you're happy to do so, examine for tissue loss and, uh, perform for assessment. Make sure the tetanus is up to date. Give them oral antibiotics and follow up in 14 hours if they're not acutely cellulitic and you've done the washout and you're happy to treat them as an outpatient infected bites need admission invited antibiotics elevation and wash out. Um, so just to summarize, this is our pathway. Um, how I normally think about things that need immediate Eddie attendants. Treat with those who are open fractures, flexor chief infections, which is one of our plastic surgery emergencies, open joints, bites, vascular compromise ring of, uh, lesions or uncontrolled or bleeding just to stay open. Fractures We are, with the exception of distal phalanx, which can wait until the next day. But anything else other than met? Perform your first aid so local anesthetic. Wash out the wound. Betadine Taleline Temporize The wound. You can use any dean to make sure there's no, um to control the source of infection. Give them antibiotics less urgent ones, which can come to the trauma drink in 24 to 48 hours. Does have lacerations not involving any distractions. Um, there's a tendon injuries and nerve injuries. Uh, what I would advise to you is that wash these out and tack the wound close so that it doesn't cause desiccation of the underlying structures and despise us. A few days of trauma is quite busy. Closed injuries for fractures, tendons and ligaments, and we need to know the provisional diagnosis. It doesn't matter if you're wrong. Make a diagnosis. Suggest the management plan will be always helpful. And it's always useful for your teaching. And you're learning age, mechanism of injury and the other medical issues of drug users. And do they need an X ray before clinic? Anything more than three weeks old. We normally say our routine referrals and or non trauma hand conditions can can go to a routine referral. Um, so just to reiterate Thursday, clean it close. It's usually if it's possible, even with dog bites. But there are slight nuances. Some people like closing them. Some people don't. But the general view is, if it's a large wound, take it close with one future just so that you can cover the soft tissue. Can you do you need to split this or buddy tape? It is the tetanus up to date. Give them antibiotics and then give him Augmentin or Claritin if the pen allergic. So that is a very brief overview of all the hand trauma conditions. And you can put all the pieces together with the different topics I've given you here. So, um and, uh, and an acute amputate of all four fingers. So we talked about hand fractures. So using intramuscular excuse screws here to fix your medical fractures, you then need to fix the neurovascular bundles on one side, then flexor injuries. So we talked about that flipping the handover. You need to then fix the veins and then fixing the extensive tendon injury as well. After that. Um, but that's just to show that we work on principles. So different techniques of different, um, different injuries and then putting this all together in a huge tricks or muscle. So in summary, ensure you have a clear examination and clear history. So same description to your seniors with pros management plan. We want essentially a one line summary what you think and what your management plan perform basic first age and the initial management. And just think whether they needed a mission, thank you very much. And I hope it is still there. Yeah, thank you very much. Howard. Um, if anyone's got any questions, can you post them in the chat, please? And then if you use the QR code, um, or the link to give feedback, then you'll get your certificate for the attendance. Yeah. Can you see how many are fed back or you want me to move the next slide? Uh, that will get an email, and then it will happen. Yeah, but if anyone wants to join the next, um Webinar in the plastic surgery series, it'll be on the 13th of September, and I'll post a link in the chat where you can sign up. All right. Thanks very much again. And I hope this was informative. Talk that I can learn about. Just wait a minute if I don't post any questions, Okay? I can also put my email in there. If anyone wants to email me or have you called my email? If anyone's Yeah. If there's any questions later, then they can email us. Uh, it doesn't look like there are any questions. Great. All right. Thank you very much. Thanks very much. Thanks everyone for attending.