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So today we're going to talk about radial sided wrist pain, um excluding some bits. And I think the main thing is probably to concentrate on the uh the more common bits. And uh for anybody out there, if you can contribute, maybe you can send a message and say, hey, well, what about this syndrome or that syndrome? And, or what about this? So I don't know whether or not there's the, the opportunity to ask questions as we go along. Um But I'll just make a start. Is that OK? I take silence as a yes. OK. So next slide, please. So thinking about this, I was wondering how you sort of work out, um how to sort of, I don't know, stratify or I don't know, uh organize things in terms of thinking about causes of pain, you know, sort of as in a sort of a essay plan type thing. And I was thinking you could, could go through the various structures from superficial to deep alternative if you could just go for the more common things first. But I thought maybe we sort of try and avoid missing anything we could do it this way. Think about structures. Um So, yes, it, I just think here, first, you've got the skin I, you then underneath that you're gonna have some fat. Then if fat can be painful within that, there's gonna be some nerves, blood vessels, tendon, bone and joint. So in terms of skin causes uh so uh oven burns um are a potential cause of wrist pain. I don't know how many people have seen patients with little transverse scars on their wrists, uh just proximal to the radio styloid, not from deliberate self harm, but from where they put their hand into the oven to get them out and they just caught their self on the oven and burn themselves. Has anybody a actually done that themselves? Yeah, but a bit more proximal on my forearm. Transverse. So anyway, so that that's a potential cause but maybe not necessarily something that we would deal with. Can anybody else think of any other causes for causes of skin pain? I mean, I think I've never seen anybody with a, a um uh what do you call it? A herpes type rash, shingles rash in that region. But I guess potentially that could cause pain there. Uh So nerve, I guess so, Wattenberg syndrome, I guess everybody has heard of that and I put in to be aware of Wartenberg sign. Now again, II can't see anybody to ask anybody if they know what Wattenberg sign is. Uh any volunteers. Uh It's the escape of, um, the little finger, um, into an abducted position when you ask a patient to, um, uh, a, up their fingers. Ok. And that occurs in association with ulnar nerve palsies. Excellent. And why is that, that, that happens because, uh, you have, um, you have an unopposed pull of the, uh, uh, em, oh, no, I don't. II ie med that your, your little finger. Yeah. So, the resting tone in that. So the eccentric, you know, uh whatever pull of that. Yeah. Excellent, good. So, um, clearly a lot of people out there who probably should be giving this talk instead of me. But no, that's very good. So, Wartenberg syndrome. So that's uh irritation or, I don't know, dysfunction of the superficial branch of the radial nerve. Yes. And so Wattenberg, uh sometimes it's nice to put a face to a name. And so this is Robert Wattenberg. Good upstanding looking fellow. Um And so he described this, uh, I think in about 19 to 30 or thereabouts. Uh And so his syndrome. So, etiology. Any thoughts on etiology for anyone? Oh, I just had it. Ok. Brave enough, turn on your cameras on so that this office can see who he's talking to. Oh, see, I don't know. So, are you able to turn on your camera so I can see you people? Oh, ok. Yeah. No, I, I've now found a list of names down the side. Sorry, I digress. So, um, uh, yeah. So I don't really know why warn bugs develop. So I don't see it that often. I doubt many of you have seen it that often, but usually a patient just presents with a sort of a, a discomfort pain to the radial side of their wrist. And they might have some sort of strange sensations, possibly numbness in the distribution of the superficial branch of the radial nerve, which is, and I would ask you if you knew what you do. So, the region of the dorsal web space region, first web space, dorsal area. Um it can be quite uh intrusive the symptoms. Uh I mentioned some people wonder whether or it's been because they've been wearing a, a uh a wrist wash or bracelet that's too tight. But I wonder if, maybe that's just um coincidental. Uh So yes, I don't really know why it develops but it does develop from time to time, as I say, I don't see it often at all. Uh People talk about in terms of treatment, people talk about um, surgery. If it doesn't settle down, I'm not really convinced that it's something that would benefit from a steroid injection, although I'm sure people do that, but I would have thought that would probably irritate the nerve and make things worse. Um So in terms of surgery, II, think I can remember of two cases in the dim and distant past that I did operate on, uh without the patient seeming to get any benefit whatsoever. I don't know if anybody else has any experience of successful superficial branch radio nerve decompression. Charlie is shaking his head. So I'll take that as a positive. Uh But anyway, so that's Wartenberg syndrome. Um So investigation as well. Ultrasound possibly, I think it's mostly it's a clinical diagnosis having said that there was a patient I saw not that long ago who in fact, did have a youngish fellow who in his early thirties, I think, and he did in fact have a neuroma uh on the superficial branch of the radial nerve. So um in terms of, I don't know if I mentioned that examination, but yes, positive to sign, possibly area of altered sensibility. Anyway. So this guy, he did have a positive 10 sign. And on ultrasound, there was a little neuroma there no obvious cause for it. And so I saw him some months ago now and I pretty much said to him, well, let's just see what happens because if we explore it and excise it, then you'll have an area of numbness which might be worse and you might have developed a neuroma which would be worse as well. So he is one who had an ultrasound scan. I think he may also have had nerve conduction studies. But as you are probably all aware, nerve conduction studies, even in significantly intrusive carpal or cubital tunnel syndrome, the the results can be reported as normal because as I tell many patients, you can have enough pressure on a nerve to cause symptoms. But without there being enough pressure on the nerve to cause changes that you can dictate by nerve conduction studies. So you might find, you know, if you find a positive ultrasound or nerve conduction study your findings, well, then you can reassure the patient that yes, you know what it is. Um, but I would recommend saying to following that up with, but we can't do anything about it apart from just wait for it to get better. Uh, if that doesn't sound unreasonable. So basically, I would recommend avoiding surgery. Um Are we all happy with Wartenberg syndrome? Anybody want to add anything? Can't really see anybody nodding their head. But yeah, no happy, happy. We're all happy. Ok. So then blood vessel again just because it's a structure there. Very rare. But I have seen, well, at least one, maybe more patients who postoperatively have complained of radial sided wrist pain and have had a fairly prominent thrombosed vein. Uh And I think sometimes if the anesthetist um squirts in the, I don't know if it was midazolam or whatever, it was a bit too vigorously, then that can cause some irritation in that region and that can, you know, be a bit uncomfortable for a while, but it does seem to resolve spontaneously, but that's just to mention another structure, but you know, probably not really something to think about. But So then really we move on to tendons and I think, uh, tendon, uh, causes of wrist pain are probably the most common thing that we would see outside of trauma. Um, so for tendon, you probably don't know what I'm going to be talking about. First off, just cos it's probably the more common. Uh, so who's this cheerful looking fellow on the left? Does he look a little bit Swiss? Maybe. So. Could that be, could that be Fritz Devein? Ok. So he was a Swiss physician uh and over onto his right, slightly more dapper fellow looks a bit like a New Yorker maybe. Ok. So that's Harry Finkelstein. So those are the two main names that I associated that I associated with Dick Weins. So Finkelstein's test. So this is something that in my view, many people get wrong. Uh But in their views, maybe I get it wrong. But for me, I did read his paper once it was a while ago, but basically I read that for doing his test. He talked about moving the wrist sharply into ulnar deviation by pulling on the thumb. OK. So you take the thumb and you put it, I don't know if you can see me, maybe you can put it on your thumb. Many people think that Finkelstein's test is abducting the thumb and flexing into the palm and then moving the wrist into ulnar deviation. But if I do that on myself, that is painful So anyway, that is not what Finkelstein described. And I think that test, I think, I don't know if people call that like o or whatever, but it, as far as I'm concerned that has many false positives. So I tend to would stick with Finkelstein's original description. However, this condition can be really, really painful. And so I don't do Finkelstein's test. Uh And if I do, it's usually if they're not in much pain and they're happy for me to cause a bit of pain, I usually show them what I'm gonna do by performing that test on the normal painless side first to give them a bit of warning. Um I don't know, I sort of put this together fairly recently. So I was just wondering in terms of uh yes, I do get onto diagnosis and history and what have you. So, so Finkelstein's test, I guess I probably put it there just so not to forget it, but just to be aware that Finkelstein didn't necessarily describe what most people do. Um And yeah, so he described that in 1930 I think a little bit earlier. So the, so the other thing about it is to be aware that it is a stenosing vs, it is not an ITIS. Uh And so yes, we have some famous names there associated with Cambridge, Mike Clark. He's now a prof over at sort of upstate New York. So I think Harry Lyle who is currently working with us doing some sessions. Um I'm not sure who J JJ W Grant is but Mh Matheson Murray Matheson, he was my predecessor here. So they did a little study and look at histology from controls and from those who had dein's disease, they found that there was no inflammation uh and not wanting to digress too much. But you might then ask, well, if the first line treatment for veins is a steroid injection, why are we giving the steroid if there's no inflammation? And I would say, well, for the same reason that we give it in cases of trigger finger where there is no inflammation. Uh and also carpal tunnel syndrome where in the vast majority of cases there is no inflammation. So how does the steroid work? Um I don't know if anybody knows, but my view or impression is that it dehydrates the tendon and makes it shrink or tendons. So that's how I think a steroid injection works for the veins, which it does. So, so, so basically, yeah. So it's, it's an osis, not anit in the vast majority of cases. So, etiology, um why does it develop? So there was a time when it was uh it seemed to occur a lot in, in sort of young mothers or mothers of young babies. Uh and it was thought in those days, I don't know when 3040 years ago, 50 years ago that it was because of the constant wringing out of uh washable nappies. Um However, despite the advent of disposable nappies, uh it continues. So I think it's more sort of a, a stage and phase thing a bit similar to the way explanation. Same explanation would be why. Uh mm mothers, pregnant ladies, whatever develop carpal tunnel syndrome during pregnancy, you know, I think there probably is a sort of a hormonal aspect to it which would explain why there's a tendency for it to occur in young mothers. However, having said that there was, I don't know, one month when I saw it in at least two young fathers. Um so it varies a bit. But otherwise, etiology, I think is one of those things that just comes on for no obvious reason. And if somebody has been doing a lot of work with their wrist and then develops it, I think in most cases that would be coincidental. So, in terms of diagnosis. So the main thing, history, what do patients complain of while they complain of pain to the radial side of their wrist? They can usually point with a finger to where the pain is just over the region of the radial styloid. Uh And classically, it's painful with certain move maneuvers such as twisting a door handle. People might say they're reaching back to do their bra if they uh that sort of thing. Um But so it can be painful with certain maneuvers. Uh and it can be very painful. Now, as with many of these things, it can get better of its own accord. So there are probably many more cases out there that we never see. Those that we see are clearly those that are persisting and, or deteriorating. Uh, patients are often sent off, you know, with the M SK they're sent off for physio and no end of different things. And in many cases, those cases might get better purely through the passage of time. But by the time we see them, yes, they've had persisting pain which is nasty and you can usually pick up the diagnosis on the history, moving on from the history in terms of confirming your thoughts. Well, then examination and classically, yes, they are tender over the region of the radial styloid. But yes, you look first and often you might see a little swelling in that region. So the the region of the radial styloid often looks a little bit more swollen when compared with the other side is usually tender specifically over the radio styloid over the tendons of the first dorsal compartment. Uh And uh the tendons themselves might be a little bit tender just distal to the first dorsal compartment. So I mentioned about the uh Finkelstein's test. So what I usually do is I would just gently move their wrist into armor deviation to see if that precipitates the pain, which it might do. The other thing I do is extend the thumb, ask them to extend the thumb and apply, I apply pressure, so resisted extension and then I palpate the tendons of the first compartment and see if that exacerbates that pain. The other thing that um I often do before honing in on the tendons of the first compartment is just to check, for example, E pl is the tendon that over there or over F cr. So I sort of check around to see where they might be most tender before homing in on the radio starter. And if they say yes, that's the most tender spot, then I'm gonna be more confident that uh the information I've gained from the history fits with my examination findings. Anybody want to add anything to that so far? Ok. So investigations, I mean, I tend not to do investigations for this because usually, uh, history and examination findings are pretty classic, but yes, if you're not sure, then yes, you could do examinations. Uh, well, that's a test first, isn't it? So I think maybe I didn't list uh examinations, but in terms of examinations, the most obvious thing to do probably would be a, an ultrasound scan. Uh and potentially an MRI. So reasons for doing those might be if you're not sure about the diagnosis or if I don't know there might be some underlying medical legal aspects to the, to the problem. Uh And in that situation, it might be appropriate to either do the ultrasound scan or get an MRI scan. Before you inject because otherwise, of course, the injection is going to show up some abnormalities, probably so, examine investigations rarely needed, uh, in my clinics, but something to consider if you're not too sure. So then treatment. So, yes, a local anesthetic and steroid injection is the first line treatment has been shown to be beneficial in the majority of cases. Uh, we used to use, uh, hydrocortisone acetate, but I don't think anybody can get that anymore these days. So what I tend to use is a mixture of, so I draw up a mill of 1% lidocaine. I inject that into the one ml of 40 mg per mill of methylprednisolone for little vials. And we give out a good shape and then I draw off one ml of that and draw up another mill of 1% lidocaine. So the methylprednisolone is diluted down a bit just because I have some anxieties about giving them too big a dose, but maybe I should be using more, but it seems to work well enough with that percentage. Um So things that you might warn a patient about before you inject them. First of all, uh you might warn them, but it's not gonna work. You might also warn them that it might work, but the benefits might only be temporary. Uh The other thing that it is worth warning them about which you probably some of you out there will be saying, yes, you've got to check on this or make sure the patient is aware, it can cause the steroid can cause an area of localized skin discoloration. So just warn patients about that, particularly in patients who have darker skin because otherwise they might not like that. Um But my understanding is that in the vast majority of cases when that does occur, it does get better with time. So skin discolouration is something to warn them about. So this slide here is just for demonstration purposes. It's not actually the technique I use, I usually use, I draw up using a green needle on a tumor syringe. But when it comes to injecting, I actually use an orange needle a long one, it needs to be a longish one. And then I palpate for where the tendons are. I try not to stick it into the vein that's there. And then I run it along the side of the tendon palpating the tendon. So you get into the mouth of the tunnel distally and then having put a bend on the needle, I don't know if I mentioned that a bend on the needle. So you can slide it along power with a tendon inside the sheath. Uh and then inject and usually if it's running down the tunnel, you'll see a little sort of swelling up here or you might palpate a swelling appearing approximately to the little tunnel. Uh And I think so far, I haven't yet mentioned the tendons that are affected. Uh I've assumed that most of, you know, about the six compartments on the back of the wrist. Maybe I shouldn't. Uh But anyway, there are six we won't go through them all now for the sake of time and I would be very happy for somebody to tell me at some point if I had one and if I had five minutes to go, is that ok? Maybe I'll just get the nod from Charlie and say, hey, speed up. Um So yeah, so injection, yeah, it does work um in a, a significant proportion of cases, it is worth trying first. And the other thing about injections just in passing is I do tend to always get patients to lie down on the couch before I inject them because hands are sensitive and patients are liable to keel over and it's a lot less embarrassing if they're already lying on the couch. So, yeah, so injection for s uh is worthwhile and just take it gently and it's not too painful. So then surgery. So yeah, I do this under local anesthetic. Uh And I use local anesthetic that has some adrenaline in it so that you don't need a tourniquet in terms of incision. It is generally advised by most people who have advised me and apo less of the he on transverse uh that to, to do a use a transverse incision. So the structures are running longitudinally. So it would make a lot more sense and be a lot easier to make a longitudinal incision. But the reason for doing a transverse one is not purely because we want to make things more difficult, but because it is suggested that the scar resulting in a transverse incision is less obvious than one from a longitudinal incision. So that's the reason for transverse incision mostly on the dorsum of the wrist. Whereas on the palm aspect of the wrist, we tend to do longitudinal. And I was told that the reason for a longitudinal incision for surgery on the palmar aspect of the wrist is because transverse incisions, there might look as though the patients had to gert themselves, uh uh had a go at themselves themselves as in deliberate self harm. Um So we, yeah, so a transverse incision, I often sort of squeeze up the skin a bit to see where there might be a bit of a cruise. And often the incision in fact, is very slightly oblique. You might see from palmar to dorsal proximal to distal, a little oblique. There's a cruise, usually go through that. The key thing to watch out for. Yes, is the superficial branch of the radial nerve. Again, in the consent, you might warn them about the risk of nerve injury and therefore, neuroma tender scar. Um So look out for the superficial branch of the radial nerve. Once you've gone through the skin, there's usually a layer of fat and then a sort of a very subtle sort of uh layer and then another layer of fat and the the nerve is usually in that second layer, deeper layer of fat. So once I've gone through the skin, well enough, I usually use uh Tenno as blunt dissector to open out to expose the tendon sheath. Uh and you can often see the nerve if it's going to be there. But if, even if you can't actually see the nerve, if you've swept all other tissues away from the uh tendon sheath, extensor retin act, so that you can see that clearly and divide that without dividing anything else, you should be safe. Uh What I tend to do is identify the tendons going into the sheath distally at its opening so that I can make the, the incision in the, in the uh root and act. And from there approximately, usually using scissors. Um And usually if you do a bit of blood dissection underneath, you can lift up the retract and you get a good view of the sheath pretty much all the way down. So I've put on their release all sub compartments. So as again, many of you may be aware when you open up the um first compartment, you often see far more tendons than you are imagining. Usually because the abductor policies, Longus has multiple tendon slips. So did I say Longus abductor, sorry, the the abductor policies, Longus um usually has multiple tendon slips and the PB um I think less so, but certainly the abductor um can have multiple tendon slips. Um and there can also be septa within the compartment. So there might be more than one compartment within the compartment. So the key thing for success is to make sure that you do check to see if there's more than one compartment and to release those as and if necessary and sometimes they can be quite hard to spot. So it is worth taking a little bit of time just checking distally where the tendons are emerging to then follow them, proximately check that you have released them all clearly. Um So that's the surgery for that. And I tend to close with a uh a subdermal um for vide and then uh a put a gel on that small meatball, some go be bending crepe and then pretty much tell them to get on with it thereafter. Um And I tend not to follow these patients up these days unless there's a problem, any questions on that so far. Uh I was just to see if there's any chat. No, that was people anyway. So uh so that is the, I think you probably have enough of that. Oh And so this was just a fact I found today. Um Yes, I found it on the internet and so I would like to establish the authors. I did check and there was no fee payable for sharing that with you So I have done all this by the book, although I didn't log in or sign in register for, for an actual account, but because they said it was, I wasn't going to pay me, I didn't think I needed to. So here they talk about triggering of the abductal policy longest. And on that slide, hopefully you can see there's a bit of localized swelling on the tendon just as you get with a trigger finger. Um and sometimes patients will describe a clicking of their wrist um as they move it so clearly, you can sometimes get triggering. But that's just I ju just thought that was quite a nice intraoperative photo apart from the fact that it looks like you've used a long incision but will let them off um of the two tendons. They're looking there quite a bit bigger than they were. But also it does look as though they're running through two separate compartments pretty clearly. Um So that's just something to be aware of. Um So then another cause of radial sided wrist pain, peritendinitis, crepitans or Intersection syndrome or radial bursitis, uh which is inflammation of the bursa between the tendons of the first dorsal compartment, which we just talked about and the underlying tendons of the second dorsal compartment which comprise the B CRL and B. Um Now we hardly ever see this because it usually gets better within a week or two. So it's gonna get better long before we're gonna see the patients. But it might be that when you're in the doctor's mess or teaching students or something like that, one of them might come up to you and say, hey, look, I've got this really painful wrist. It's a bit swollen and I got this strange creaking feeling when I move my thumb around and I, and I've been doing a lot of rowing lately and I just, you know, wonder what's going on. And so, yes, they've got peritendinitis Crepitans and you just reassure them that it'll get better without any problem and, but it's nice to be able to tell them what's going on. So I don't know many of, many of you have experienced that or seen in a particular thing around Cambridge and Oxford where you're gonna have a greater number of, I don't know if they want to call them oarsmen or rowers or whatever. Um, anybody seen a case of this? Maybe not, maybe not anyway. Um In fact, I did experience it once myself. Um I probably shouldn't admit how or why, but having said that I probably should explain. But basically, I, I decided with a friend a while ago that we should go powder skiing, heavy skiing before we were 40. Anyway, after I was 50 we finally did go. And, uh I think with the, with the powder skiing because if the powder is quite deep, your ski poles are relatively too long. And I think it was lifting the ski pole higher than I did need. Usually that then brought, it was just on one wrist. Uh, I got classic Tendonitis Crepitans. I know, I just sort of, I don't know if I took some power but basically I ignored it and carried on. Uh, and within about a week or so it did get better. I did take some photos, but I can't find those unfortunately. But anyway, so it is something that does happen. It's quite dramatic. So, etiology, unaccustomed, repetitive wrist movement such as ro canoe kayakers and yeah, skiers, it is described as well. So I didn't manage to write up a case report because it was already out there. Um Unaccustomed use, you get local aching pain and crepitus. There's usually a bit of a swelling. So this swelling is just proximal to the radial styloid by a few centimeters. And it's yes, it's where those tendons cross over. It can be a bit tender, but the thing is the crepitus is really well, like in my case, it was really pretty dramatic, you could almost hear it and it was particularly with certain movements of the thumb that you really heard it and it was quite painful as well. Gripping a pen was quite sore for a time. Um So treatment well, symptomatic really until it gets better. I don't think you really need to do anything at all. Just reassure the patient, tell them it will get better. And I have never seen a chronic case that has needed surgery. I don't know if anybody ever has, but it is described, but I've never seen it. So, and I think in clinic I'm not sure I've ever seen a case but it's just something that's useful to know about. Um, so then, so we're getting there, we're getting there. I haven't had the five minute. No yet, I don't think. But we'll, we'll wrap up very soon. So other things, bone uh fractures. Well, you know, following trauma, people might have a fracture of the radial or scaphoid. And the other thing to be aware is it's not unusual for a patient to pitch up in the fracture clinic with radial sided wrist pain, having had a fall and they don't have a fracture. But in fact, they do have de Coin's disease and it may be that in the fall they've sort of had this incipient swelling of their tendons and things have got a bit stiff without them noticing. And then they fall on it, sprain their wrist, pull the tendons through the tunnel, but they're not used to being pulled through because it's all stiffened up a bit and then the Dequervain's disease presents. So, so that's just something to be aware of. But now I say fractures, yes, usually it's obvious it's following trauma, you'll probably see um evidence on plain x ray images, either a style or scaphoid. And then I think moving on really to joint. Ok. Joint causes, so, radios, O oa potentially S TT and thumb base arthritis, which will have been covered, I think last week. So I'm not gonna talk about those but, and, or they've had a wrist that hasn't been moving much and then they fall and it, that makes it move more than it's been used to moving, which precipitates the pain. So they might report pain, which has been going on for some months. Uh Usually when you examine them, there's often you see a bit of loss of the concavity of the anatomical snuffbox when you compare the two risks. Uh sometimes in more advanced cases, there will be more obvious deformity, um possibly with sort of protrusion of the proximal pole of the scaphoid, that sort of thing which I have seen from time to time. Uh They will be tender sort of in that region between the distal radius and the carpus. So specifically tender there and yes, pain and stiffness with movements of their wrist. So just as an example, a patient I just saw. And so in fact, I saw him for the follow up uh with his MRI scan just recently. He was a young man. He's only about 44 thereabouts. And uh he had a, a sort of a fall and had pain since which was persisting uh and examination history and examination all fit with uh with uh an underlying osteoarthritis, but he was a bit young for it at 44. And if you see these xray views, you might look at those and think, well, you know, nothing really, particularly exciting going on there. But they did do the Scaphoid series, as you'll see, we just got the, the pa A under sort of an, I've left the others for now. So then when you look at these, on the lateral view, you can see those little excuse the drawing on the lateral views, you can see some little osteophytes. Uh And on the pa view there, you can see very significant loss of joint space between the proximal pole of SK and radius. And in fact, I think just to because of his age, so to so as to try and exclude anything else that was going on, possibly an underlying inflammatory condition and that we did get an MRI scan, probably not really necessary, but we did. But it's quite nice in a way to see it because I think on that t one image, you can see where there's something going on between the proxim pole of the scaphoid and the destroys. And on the T two image, the one in the middle, you can see sort of reaction you can't see so clearly the high signal in the proximal pole of the scaphoid. But there is, there is some there so sort of, you know, kissing type lesion uh as you might get with radios with whatever radio ulnar lunate abutment, excuse me. Um So you can see something going on in there. And also on the right hand picture, you can see some high signal towards the distal posca. So that images more palmar as you can see by it because of the flexor tendons. And so there's a bit of abutment between the distal posca and the radial styloid. And the other thing that I think that's useful about the MRI, I haven't put all the pictures up, but you can see there's a bit of involvement between lunate and capitate as well. So anyway, so yeah, I weigh of the risk much more, you know, obviously you see it more often in older patients, but I just happened to have seen this patient recently. I thought it would be sort of interesting to share the images from that. So, um basically I've sort of talked through uh waffle through, I don't know whatever. However you want to look at it. Um potential causes of radial sided wrist pain. I think when people talk about radial sided wrist pain or side wrist pain, people often think, you know, there's something magical out there that nobody knows about that is going to be revealed to them. But I don't think that's really the case unless somebody has something out there that they would like to um chip in and tell me about that I don't know about or that I've just something I've missed. Not really. So, so is that? Ok. I think that was my last and final slide. Are we OK with that? Yeah, that's great. Great. Thank you. Ok. Did you wanna add, add anything in that I might have missed or no, I think that was fairly conclusive actually. Um And I think that's a nice way to break it up because that's, that's what the presentations will be um for the patients that people see in clinic or they get for the examination, it'll be that radial or ulnar side of wrist pain and how to differentiate between them. And certainly one of my questions on the Fr CS was the curves. OK. So all these things. Sure. And one other thing just to bear in mind if I just go back briefly to that uh description, I think I put it in them um for the veins. Did II did have a look at that paper very recently. Uh Finkelstein. Yeah. So in Finkelstein's bit here, the, the bit in bold is just to be aware of uh it says, but any of the tendon sheaths on the flexor or extensor, ses of the wrist may be affected. So just to be aware, yes, we're talking about radial sided wrist pain today. But just to be aware, you can get a similar sort of condition affecting the ec U tendon on the ulnar side of the wrist. So that's, you know, it's much less common for just where you can get a similar thing to the cos but on the Ulnar side. Oh, no. Thanks for listening and um enjoy the rest of your afternoon. Thank you. Thank you very much. Thanks. Ok, bye. See you.