Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

my microphone stops working any point, just let me know I couldn't repeat something or we can go back over anything. And if anyone's got questions, any point, just pop them in the chap and I'll try and respond as quickly as I can. So this is gonna be a a talk about muscular skeletal imaging and trauma. My name is Jonathan on one of the radiology registrars working in Leicester. Work specifically the last general hospital I'm currently my STD five year on, but I'm specializing in muscular, skeletal radiology. Yeah, okay, so the talk is primarily going to be around X rays because they remain the first line investigation for the majority of suspected fractures on almost anyone that comes through the emergency department. You had a ninja re will ultimately get an X ray, so I think it's useful for everyone at most positions to be able to review them on spot any fractures. That's important both the patients, because Ms fractures can have long term consequences if they're not picked up in time, and also that Ms Tractors immediate the number one source of litigation. If they are missed, then patients likely to seek compensation so we want to try and avoid that. If possible. CT is also widely used, especially if we have INDETERMINANT findings on the plane fell on. The patient has persistent injury assistant symptoms or they have discordant symptoms. Cities first line in polytrauma when we suspect that might be official injuries and maybe abdominal organs or lungs, heart major vessels. Something like that on often we try and provide three D reconstructions for the surgeons. Which Canadian? They're surgical planning. So if you were, if you're able to view those on your system, it's always useful. We give you a good idea. On overall picture of the fracture, MRI is less frequently used in the acute setting, except when we're looking for suspected quarter acquire syndrome, in which case is the first line investigation. But it's, um, use more widely in the outpatient setting to image soft tissue structures like ligaments menace Guy. Things like that because I read a graphs are by far in a way that most common, that's the thing that I'm gonna cover most on this talk. This is just an example of a mist rupture in a 20 year old patient. There's an injury to the list. Frank Ligament, which is points out by the green Arrow. This is, um, 10 weeks down the line. After being missed, you can see that the bones are generally office, you Penick slightly darker. And this is the results of the patients not using her leg on d losing all the bone mineral density as a result of that. So these the kind of things we want to avoid I know the example is this which can results be the result of missing skateboard fracture, Which is why we're very concerned about not missing those. And patients will be invited back to have a second repeat radiograph in 7 to 10 days. Just to make sure that we're not messing these kinds of injuries. This is on advanced collapse of the scale focally night articulation with advanced degenerative change. And at this point, uh, the only surgical options are likely to be removing some of the proximal carpal bones, confusing the wrist. So this is quite a severe case of a mist fracture, but something that we definitely want to avoid. So the general principles which could be applied to already a grafts is that you must check the patient details. First and foremost, if you're working on a workstation other people have been working on, they may have opened or the radiographs. So you want to make sure that you're looking at your patients. Film. Make sure you look a lot of use. Many Siris have more than two views, particularly skateboard, that I just mentioned. They could be five or six radiographs to look at, so make sure you interrogating all. Compare with the opposite site if it's available. Often, if patients are having that hands X rays, you'll get both sides also applicable to the pelvis, where you often get both proximal femoral, so have looked at them. Both review the patient's old images. Um, a lot of the patients coming through the department will be elderly, have multiple previous images, so compare with those. Make sure the images a decent quality is less of a problem now with the digital systems books. Um, make sure that it's proper on. Do that. You can interrogate it if the patients got rings on, particularly if it's in the region. Where you're interested is always appropriate to ask the radio. Refer to repeat the plain film If you think that might be something obscuring the region that you're interested in. One of the most important things is satisfaction of search. If you spots of fracture, you must continue with your system. Review the rest of the image. Make sure that there's not a second or third fracture that you've missed because you've found the first one on. Be familiar with the common ossicles, particularly around the ankle, had lots of different oscal's that you could potentially confuse with. And I've also fracture or something else like that. So there's a few that I'm gonna bring up. I'm going talk to really shortly so everyone's different. But the most important thing is to create your own systematic approach. Have your own one for each of the common joints on D. Most importantly, replicate that each time you review that radiograph go through the same system, repetition will cause you to be to make less mistakes. Um, so repetition on a systematic approach is the key. This is my particular method. First of all, we'll look at the bone on joint alignment, make sure of things aligned, how it should be, Then look a spacing between the individual bones of the joint trace the individual cortices looking for small fractures. This could be particularly laborious when you're looking at radiographs of the hand on foot, but the one time that you don't trace around all the bones will probably that one time that you missed school fracturing the fifth metatarsal or something like that. So that's important. Look, the texture of the bone, like the the wrist that the ankles that I showed you the beginning diffuse osteopenia could be a sign of chronic misuse. And that may be an underlying reason for that. Such a mystery, actually On Leslie. Review Soft Tissues It has been a recent trauma that might be diffuse soft tissue swelling, and that could be a clue to an underlying fracture. So starting up with the pelvis proximal from fractures, probably the most common thing you see coming through the emergency department is a fractured neck. FEMA, the femoral neck, the weakest part. And so that's part of the reason why they're so common. Uh huh. The two main categories a shins are intracapsular on extra capture, intracapsular other most common, but unfortunately they carry the highest risk off a vascular necrosis. We further subdivide them into capital subcapital on Trans Cervical. I'll show you examples of all of these shortly. Extracapsular can be further delineated into into a truck and Eric and some truck and Eric General findings on X ray or disruption of the pelvic lines, which I'll show you in a second. Prominent, less a truck trocanter do text on rotation asymmetry. That's why it's important to look at the contralateral femoral head on. Def. We're dealing with a more chronic fracture. You might get reactive sclerosis of the fracture line. Okay, this is just a pictorial representation off. What? I just talked about intracapsular and actually capture that are most important things to remember. It's not as important. Remember all the various different subcategories, A shins. So these airlines that I was talking about this is the pelvic brim on the operator for a minute. Make sure you trace those out. If you see a break in one is highly likely, there's gonna be a second break is the pelvis often fractures at two separate locations, so trace those out. Make sure there's no abnormality. The sacroiliac drinks on the cubic simple cyst again must be interrogated. Now this looks a bit more complicated, but is important to have an idea of which lines were looking at the this line here is the Eylea bacterial line on then the Eylea issue line. This is the acetabular roof on then Medially we have the anterior acetabuloplasty on Posterially. We have the lateral acetabuloplasty again. Make sure they're intact and then this is probably the most commonly disrupted line. This is referred to a Shenton is line on any a naked femur fracture is likely to cause a disruption here. So make sure you trace it all the way around on on the other side if you have that available. Okay, so this is the first really rough. If any point, Anyone wants to make a comment as to what they think the type of fracture is, just pop it in the chat. If not, I'll just run through it briefly because I want to go through many cases. I can in the hour that we've got that I have have. Everyone's okay with that. So, you know, we've got both sides, so we look at both sides. Femoral neck is what we're talking about on on the left, you can see there's this irregular, sclerotic line on a slight bulge on the lateral aspect. So this is an impacted subcapital fracture on D. It's got a degree of chronicity to it because this sclerosis starting to set in another naked femur fracture, this time on the right, you can see Shenton is line on the left is normal on the right, completely disrupted because of this angulated trans cervical fracture. This is an example of an inch of truck and Terek fracture. You can see the greater trochanter here unless it's a counter itself is actually avulsed. Immediately on the fracture line is clear between the two, so this is an example off on extra capsule. A fracture with a reduced risk of a vascular greatest was still important spot. This is another example off a transcervically fracture you can see Shenson line again. Disrupted is a good example of the media of the proximal migration of the femur itself, which gives rise to the short and limb, which you're probably familiar with seeing clinically one of the most important things to look for when you're examining patient degenerative joint disease, less commonly an acute presentation, but something that you'll see very commonly is an incidental finding so important to know how to diagnose it on to recognize that it could be contributing to your patients symptoms if they're presenting with pain. Very common in the knee and the hip risk factors include increasing age weight, particularly if the patient has a high B M I. R likely to develop degenerative joint disease much earlier, so patients may present in the thirties or forties with degenerative disease and knees. A previous trauma or insult the articular surface of the knee can predispose them to degenerative disease, and again they might present more early. So the typical findings on X ray classically, there's four findings. Joint space narrowing is the first usually a symmetric onda, located in the medial compartment of the knee, where most of the load is transferred. Any measurement less than three millimeters is considered to be absolute joy space narrowing and would be classified as severe degenerative disease. Yeah, sclerosis, as mentioned before, is a chronic finding and is a reactive reaction of the bone and that's present immediately in a sub control location. The subchondral refers to the regional bone immediately adjacent to the articular surface. Osteophytes OSIs is where you get outgrowths of bone as a reaction to they degenerative. Change on do some control. Cystic change is also a reaction to the degenerative joint disease. Spiking of the tibial spines has been regarded as one of the earliest findings and may well be the only finding so important to assess for that this is an example off severe bilateral degenerative disease of the knees. We can see both medial compartments. There's complete joint space loss. You can't see any of the joint whatsoever. There's slightly more dense bone, which represents the sclerotic change on these outgrowths of bone. All the osteophyte The tibial spines aren't very well demonstrated. But on the left, you can see there spiked in comparison to a nice, rounded appearance. That would be normal. This is another example of severe degenerative disease on the lateral radiograph. You can see that these structures here are abnormal on there are intraarticular loose bodies. They result from fragments of cartilage which has been tourney away from the articular surface. They might great through the joint capsule on develop their own blood supply, Onda. Eventually they can grow into these large ossified fragments, which is important to note, because they're going to reduce the patient's range of motion on potentially cause paying for the patient on the third view, which we often see when assessing for degenerative diseases, the patella view this is refer reverts specifically to is the skyline view. As you can see, the joint space is normal all the way along here, but at the edge we've got narrowing on, we've got small osteophytes again. We've got sclerotic change. So all things that we've seen on the frontal and lateral projection of the knee. But it's important when you're reviewing the radiograph. Just make sure that they, whether they've done one of the views or not, these are also really handy. When looking for a teleprompter on the AP view, the patella is hidden behind the distal femur, but here you get a really good idea of whether it's a patella fracture or not to always check that view. Moving on to a foot on Duncan fractures the represent 10% of all fractures in trauma on, uh, second most common to fractured lack of femur. When looking at a level in fractures, there's a fine motor presentation, which is often the case we often see them in young men on older females. All the families tend to become osteopenia juice, uh, hormone imbalance earlier than, uh, older gentleman. So the the most at risk category on like I mentioned at the beginning, a mist rash. We can result in severe function impairment. So is absolutely important to interrogate the radiograph and to not dismiss any symptoms that the patient might have, even when you think the radiograph is normal. So this is the weather classifications of ankle fractures. This is a normal representation of the ankle joint. Now the lateral malleolus, which is essentially the distal fibula medial malleolus, which is the distal tibia. We have that syndesmosis, which joins the two the lateral stabilizing ligaments here, which include the Anterior Taylor fibula ligament on the posterior talofibular ligaments and medial stabilizer here. Often referred to as the deltoid ligament complex, which are all vulnerable to damage in an ankle fracture, Type A is a fracture that Lodosyn is Moses. Time be is a fracture at the level of the syndesmosis, which is often associated with the medial malleolus fracture on Type C is at superior early to the symptoms. Most is on disease, the most unstable type of fracture. There's also the posterior malleolus, which you'll be able to see on a lateral film, which is essentially the posterior aspect off the distal tibia, which, when we have a try compartmentalize fracture, will last referred to us when you have fracture of the lateral, the medial on the posterior malleolus. So here we have example of their ankle fracture, you can clearly see there's a horizontal fracture line through the lateral malleolus is inferior to the level of the syndesmosis on D. In these rashes, the deltoid ligaments likely to be intact, and it's rarely associated with the medial malleolus structure. This is a good example of why we always look at both views on the lateral. It's quite difficult to make out a fracture off the lateral malleolus, but much more clear on the AP to make sure you're checking both projections. Often you'll see a red dot that's where the radio over for his thought that they've spotted abnormality, and it's just a highlight to anyone reduce reviewing the plain film. But there's likely to be, um, pathology on that. So when you see this, just pay extra attention Unfortunately, there's no system that I'm aware of off the radiograph. It actually highlight what they think the abnormality is. But it just make sure if you see that, too patty close attention. So here we've got an example of a weather type B, so that's at the level of the singers. Most this. These are usually as opposed to Type A, which are horizontal. These are usually spiral or oblique type fractures. Syndesmosis is usually still intact, but the media malleolus may also be fractured. Stability of these type of fractures is variable on. They may need fixation, so always refer these onto the orthopedic team, uh, promptly. Finally, a Type C fracture, which is super syndesmotic. These are often associated with disruption of the syndesmosis on the medium Elio structure on the deltoids, or medial stabilizing ligaments are often injured. These are unstable. Fractures on often require open reduction on internal fixation as opposed to the other two. It's quite obvious also on the lateral projection that there's a fracture, but I always check into, so we're moving on some of morphine, eponymous named fractures. This is one specific example the Maisonneuve fracture, which is ah, combination of a proximal fibula fracture within months. Stable ankle injury. They're often associate with ligamentous injury or a fracture of the medial malleolus. So the most important takeaway message is when you spot on ankle fracture, such as one of the ones we've seen just now. Always request further imaging of the fibula, particularly if you're patient has some proximal tenderness just in fairly to the knee. They may have stuff it this type of fracture pattern on. We often see medial malleolus fracture, but they could be associated with a more proximal fracture on if you haven't. If you looked at this and simply dismissed it, you've noted the fracture, but not thought about the more proximal aspect of the limb. You may miss the fibula fracture. The patient might go on to suffer prolong symptoms if that's not fixed appropriately. So always image the proximal joint. If you suspect there might be that type of fracture pattern moving more distantly, looking at a foot, we're going to focus on the fifth metatarsal because that's one of the more commonly injured. Okay, let me just go back. Okay, so these are difficult to identify Clinically, you wouldn't necessarily diagnosed it purely on the injury pattern, but you always must remain suspicious when you see a medial malleolus fracture. You may not examine the patient around the knee, but this will be a parent if you do palpate around the knee around the fibula head. So if you see this fracture and make sure you go back to your patient, examine a bit more approximately. If this pain in this region get a knee X ray just to make sure you're not missing a fracture here, yeah, so the fifth metatarsal commonly injured on the various different patterns, which are all seen the base of the fifth metatarsal stress fractures, Jones Fractures of ocean fractures on This is one of the more important accessories articles off Peroni Um, so it's an accessory obstacle that lies within the Prolia's longest tendon, Um, us. On subsequent radiographs. You may occasionally, uh, Ms or over call that as an avulsion fracture. So that's important, too, to recognize the accessory ossicle on to dismiss it if necessary. So this is the aspirin in. As you can see, it lies a Jason to the key void little bit more distantly, a little bit more approximately. Sorry than you would expect for an avulsion fracture. The base of the fifth metatarsal is complete, so it's unlikely that divorced fragment would be pulled all the way approximately down here. But make note of that, so that is no later described as a fracture. So here we've clearly got a fracture at the base of the fifth metatarsal. It's very much more proximal. Then you would expect for a stress fracture or the Jones fracture. And also you can see that it's angulated, almost like it's been pulled away from the bone. So this is an example of an abortion fracture. Yeah, you can see the front line is quite clear, but it's more distantly almost into the matter. Diaphyseal Junction. Uh, so this is an example of a Jones fracture, which is important to differentiate because this type of fracture also involves the articulation between the 4th and 5th metatarsal. So missing this fracture can have implications for not only the fifth toe, but also the fourth. My advice would be when you spot something like this would be to describe the fracture pattern itself rather than just trying to think of the economist name. If you describe the metadata facil fracture of the fifth metatarsal bone as much more useful toe one reading the report into just state that you think it's a Jones fracture. Um, particularly if you get the economist name wrong. I would always stick with describing the fresh pattern rather than the name. Okay, this is just another example off that same fracture, but with less displacement, you potentially could miss that on this projection. But on the on the other one is quite clear. So just to reinforce, check both projections. So this is not the fifth metatarsal, but it's the best example have off stress fracture. Um, so you might not necessarily see a distinct fracture line going across the shaft off the matter tarsal. But what is distinct is this abnormal finding in some tissues around the shaft. This is what we refer to is periosteal reaction. Periosteum is that very outer margin of the cortex on This is an inflammatory reported response on Just see wants. The fracture is fully healed. No fracture line visit a little, except for a slight bulging of the cortex. Um, so important to note either this acute finding, Yeah, note that there's been previously a stress fracture, but it looks like it's probably healed. We don't have any more of that periosteal reaction. They're moving back to the upper limb. These are the important bony landmarks off the proximal humerus. We have the anatomical neck on the surgical night. Surgical neck is much more commonly fractured, but it's not technically where the neck allies. Which is why there's a discrepancy between the two descriptions. The greatest typical on the less achy vehicle also noticed the greater unless a tube truck cancer running through there is a long head of biceps tendon. So there's quite a complex classifications, proximal humeral fractures, but I think I'm just gonna go over it briefly. The most important thing is, if you spots Humeral had fracture is to try and identify which of the four parts, which I just detailed. The fracture line extends into so the humeral head, the Greater Tuberosity last Djerassi on Humeral front shaft. The classification also takes into a part into account the degree of displacement between the fragments on in the classifications they describe. Displacement is either being a separation between the fragments of more than one centimeter, or more than 45 degrees of angulations see classification is increasing or decreasing the common, so the more simple fractures are more common fractures on D. They're the ones that are treated conservatively, 80% off. The French is, uh, described as one part fracture on now, usually treated without surgical intervention. So here the fracture lines of quite obvious. We've got a fracture line at the Greater Tuberosity on also a fracture line about the surgical neck. So there are two parts. But importantly, because there's less than one centimeter between the fragments on, there's no significant ambulation. This would be referred to as a one part fracture on would likely be treated conservatively. Also important. You're reviewing shoulder X rays. Have a quick look at the acromioclavicular joint, which often be a sites off degenerative change, which, of course, symptoms. And also look for any evidence off dislocation off the shoulder joint, which is quite common. Presentation into the emergency department on a lot of the time. A small portion off the rib cage and thorax is included in the radiograph. It's important to review this. Just think of it as a snapshot of a chest X ray. The patient's likely undergone trauma, so make sure there isn't a small pneumothorax hiding within this partially image. Bit of the chest. This is an example of a two part proximal humerus fracture. There's only one fracture line at the surgical neck, but there's significant displacement of the Humeral head is for more than one centimeters, one centimeter displaced from the humeral shaft and also massively, abnormally angulated doesn't match it with the clean I'd whatsoever. And you know, you can also see a humeral shaft has migrated cranially. So this is a two part fracture on D. Likely to, um, necessitates surgical fixation Parts three part fracture on day four part fracture A relatively uncommon, so I wouldn't get through those in any detail. But if you do see a fracture of the proximal humerus, which with many fragments in there all displaced from each other then like to be a three or four part fracture, so moving down the arm on to the elbow this light is just to detail how complex the elbow is. Um, important. Understanding off the anatomy is very useful, but more important is to identify any fracture line on. Describe it as I'm gonna try and I'll give you examples off now. Most common humeral fracture in Children is what's referred to as a supracondylar fracture, which is a book the level of the medial on D lateral epicondyle. So in this region here, that's actually the weakest part off the, um, the distal humerus impatient. So that's the reason for it being the most common fracture site typically seen in younger Children with a peak of 5 to 7 years and usually due to accidental trauma on obvious fractures not always seen, which is why we always mess. Look for indirect evidence of a fracture, the anterior fat part sign also referred to as a sale sign. If there's Ah, Colt fracture, it's usually accompanied by a joint Effusion, which pushes the fat part forward on, gives you the appearance of a sales sale. The same thing happens posterially on. Often you'll get both signs appearing at the same time. The anterior humeral line is also important. The normal I mints of the until your Humira line is taken us the anterior border off the distal humerus as it into sex. The capital. Um, the capital, um, is the first part off the pediatric elbow to us. If I So this bone should be visible from between 1 to 2 years. The line should pass through the anterior one third so that if the line doesn't, it's often the only evidence of an occult pediatric elbow fracture. So always look at the alignment of the capital. Um, with respect to the humerus here, the anterior humeral line is positioned correctly on the only evidence we have of a super condo. A fracture. Is this small cortical breach here? This is obviously, um, a lot more stark, but this is an effort on example of a complete super condo, the fracture. So we've got fractures off the medial on the lateral aspect of the distal humerus on posterior displacement. So this would require surgical fixation or, with the child risks, long term disability of that arm. This is a good example of why the anterior humeral line is important. If we traced the anterior, you know, line it barely into sex with the capital in so we can tell them is displaced, there's likely to be an associate it super condo. The fracture. There's this small, bony fragments likely to be associated with that fracture pattern so dislocation are often described in terms off the distal bone relatives the proximal bone so that everyone knows what you're talking about. Civilization is a subcategory of dislocation and refers to only a partial dislocation on. If the disc desiccation is a traumatic injury, make sure to check for, um, associate it fracture or burning fragments like we saw in that previous pediatric elbow. Grade A graph. And of course, the manipulation of the joint is another form of trauma, so make sure repeat radiograph has taken on. Do you then interrogate that for further postman it Relation Fracture, which conveys a a side effect of the joint being reset. Elbow dislocation is the second most common large joint dislocation. Shoulder joint dislocation is the most common. The to subcontract is available. Dislocation of simple, complex with simple. We have no associative fracture, but with complex, we have either a fracture of the radial head. Well, the car and I process the third category is refer to is the terrible Try out where we have posterior a dislocation with both radial head on Currently process fractures. It's a high energy injury on often has poor outcomes in the medium to long term. So we look at we can clearly see the elbow is dislocated. The humerus is the proximal bone. And so the radius and all the old dislocated posterially In respect to humorous, we can clearly see the coronoid process on the radial head. Oh, in touch. So this would be a simple dislocation. Um, you would want to confirm that on a P projection. Here we have again a posterior dislocation. But the radial head could be seen to be fractured on displaced. So this is a complex fracture pattern in a similar vein again, posterior dislocation. The radio had this time is intact, but the coronoid process is significantly displaced from the older, uh, on the electron. You can also say that this fragmentation within the joint So this is okay in a complex injury pattern. Finally, we've got all three injury patterns. The coronal prices process again is displaced. The radio head is not clearly seen. So this is being example of the terrible. Try it with a poor long term outcome. A fracture dislocation. Two more economists names, which are the more common fresh patterns that you'll see montage on daily, etc. Was, um acronym that you might have heard in order to help you try and remember this fracture pattern. But I think that's less important than actually just describing the fracture or the dislocation or the combination of injuries. So the first one, it's a fracture of the owner shaft with a radial head dislocation. Second one is a fracture of the distal radius with allergic with a dislocation off the radio on a joint. This is a picture or representation off that I didn't find that particularly helpful because I think just describing fracture pattern is the best way. But if you're that way inclined, then I think that could be helpful. So this is an example of the first rash us and I was talking about. We've got a displaced fracture of the middle on the shaft in combination with a radial head dislocation. The radio had normally articulates with the capital. Um, here and you can see it's quite considerably displaced. The anterior humeral line also potentially doesn't intersect with the capital, and so there may be an associate it super condo. The fracture. You can see that the the bones of the carpus haven't all fully ossified, so This is a child so perfectly reasonable for them to have an associated Super condo a fracture as well. The second injury possum is sorry is the radius moderately displaced Radio Shack truck with a dislocation at the distal radio. All the joint, which is confirmed on the lateral projection. Here we have unfortunate patient, which is undertaken trauma and suffered a combination of both. Those fracture pattern is that I've described so the radius and ulna, both of complex fractures, dislocation the distant radio on all the joints on down here. The radial head is dislocated from the capital, which we would normally articulate with probably the most common fracture of the upper limb, which presents to the emotions department, would be a distal radius fracture or some type of desperation. Is fracture similar by motile age distribution that we talked about before? Young man on old females traumas usually the cause. Um, there's various upon, um, it's names I touched on this before. But if you're uncertain, which upon, um, this fracture pattern you're dealing with, just stick with a description call. This fracture is probably the most common. This is an extra articular fracture of the distal radius with dorsal angulations. Conversely, to that is a Smith structure which has Palmer angulations a Barton fracture extends intraarticularly but doesn't involve the volar surface on the show. First fracture is an intraarticular fracture of the radial styloid. There are lots of other eponymous fractures of the distal radius, but these are the four most common on death. Ink probably would cover 90% of fractures that you're going to see presenting to the emergency department. So this is an example of the colors fracture fracture line through the distal radius on the lateral aspect, we can see that the fracture fragment is and elated towards daughter last checked, which is the back of the hand. Yeah, we have the Smith fracture. We've got a fracture through the distal radius again. This time fragment is out and elated towards the Palmer or Volar aspect off the hand. This is example of the Smith fracture. We've got intraarticular extension off the distal radius fracture, but we can see on the lateral. It doesn't extend towards the volar aspect of the distal radius. Just the dorsal aspect. And lastly, I show first fracture where we have an intraarticular fracture of the radial styloid. These aren't fact fractures of the distal radius, but also you might commonly see an isolated fracture off the ulna styloid. Oh, more approximately, a fracture of the owner just approximately to the style of you can see here, the distal fragment has migrated slightly. Approximately. This is referred to as negative on a variance on. It could have long term destabilizing effect on the wrist. As the lead. The lunate no longer articulates correctly the the owner aspect of the rest. Incidentally, this patient also has severe degenerative disease of the first carbo mass. A couple joints. Here, you can see the trapezium, the joint space between that on the first metacarpals, almost non existent. There's an osteophyte here on overall, the bone mineral density is much reduced compared Teo. On average patient. The box of fracture is a fracture of the fifth metacarpal head most commonly seen to occur traumatically in young adult males who have punched either a wall or someone else. Unfortunately, that minimally displaced, there's not usually much fragmentation, but they can be often missed if the angulations minimal. They're also one of the most often missed fractures which leads to litigation, so If you're unsure if you think you might have missed one request the second view or even a third, slightly more oblique view if you think the patient is clinically tender in that region, but you can't see a fracture on the radiograph, here's an example. Off a boxer fracture. We've got a minimalist displaced fracture. The fifth metacarpal head were able to calculate the angle of displacement when tracing a lime along the shaft and then through the femoral. The the head of the fifth metacarpal up to 40 degrees can be acceptable, but any more than that would require surgical fixation. If the fracture is more proximal onda part way along the shaft, the degree of angulations is less acceptable, and so only 20 degrees before surgical fixation would be required just to avoid any long term disability or pain associated with that injury. Here we've got the same. We've got fifth metacarpal injury. This time there's a fracture of the base. This is this results from the same injury pattern as the boxes fracture. But is the base rather than the head. That's fractures. So if you don't see a head fracture, always check the base. They can often be seen in conjunction with forth mess couple injuries as well, so checking both couple more fracture patterns that we've seen with Children are green. Stick on the buckle fracture, so these first least the greenstick fracture is an incomplete fracture, Um, with a course called Preach on only one Side. Usually it's seen in a long bone, such as the radius or tibia, or even humorous the afternoon curry temp in tandem with angulations. And that's the important finding to look for, and it's important to differentiate them from the more common buckle fracture pattern. Here's an example of a greenstick fracture off the mid fibula. Just a highlight. Why it's given the name Rene's stick. When you try and snap a young branch, you have to not only get through one side of the cortex that remains intact on the other side. That's what we're seeing here. We've got cortical breach here, but on the other side, cortex is intact and there's a distinct abnormal angulations, so that's usually the give away. But there's underlying greenstick fracture. Here we have the same fracture pattern, but this is the mid all the shaft again. The angulations is the key. We've only got a cortical breach on one side. Important not to miss. These is the child needs to be in a cast on bone needs to be realigned. Finally, an example in the radius again with even more significant angulations. And yet still one of the court to seize remains intact. Important not to miss these. Finally, the buckle fracture much more common than the Greenstick fracture. Again, it's an incomplete fracture of the shaft of the long bone, but usually results from trabecular compression rather than a lateral force. As we saw in the green stick, they frequently involve the distal radio metaphysis, characterized by a bulging cortex. These areas in mawr commonly mist because there's no distinct fracture line seen of give a couple of examples. So this is a buckle fracture of the matter. Diverse all region of the distal radius on this is the only abnormality. A slight bulging of the cortex is there and give away. But there's been a compression trabecular compression fracture. Most likely, the child had a fall put their hand out on the force was transmitted through into the distal radius on. We just have a small fracture on that outer aspect, the same fracture pattern but seen in the proximal humerus. A little bit more obvious. We can see a sclerotic line, and then laterally we have the same cortical bulge, which is key to recognizing a buckle fracture. So those are all the examples that I wanted to go through. I'm sorry if if it seems like it was a bit rushed, but for the priority should be going through a smelly films as I could rather than spending too long on each one. Um, hum happy to take any questions. If anyone has any, I don't just have some practical points for you to take away. UM, essentially radiographs or extremely common. Almost everyone coming through the D will have one. But don't use that as an excuse to rush your of you develop your own system. Be methodical on review every joint in the same way as you have been previously. That will reduce the risk of you missing a fracture. Satisfaction of searches key If you see a fracture. Two boxes fracture typically is the fifth metacarpal, but it can also be referred to when it's a similar fracture of the fourth metacarpal head as well. So forth and fifth, but fifth is probably 80 or 90% of the presentations, but technically, 1/4 metacarpal head can be referred to as a box of fracture as well. If your insurance your patient has discordant symptoms, consider cross sectional imaging. If your hospital has the facility, always give the radio that you register our ring. We'll discuss it with you. If if there's uncertainty, it's becoming more and more common to just do a limited exposure CT off the area just to make sure that we're not missing. And fracture is increasingly common with neck of femur fractures because they can be difficult to spot. Basically, of the patients got extensive degenerative disease. They're not very mobile, but they still have pain. Um, we're definitely consider doing a limited exposure CT for those patients, right? So if there's no further questions, thank you, everyone for joining would really appreciate your feedback, particularly with regards to the amount of cases and how quickly I went through them. If you prefer me to do fewer cases but more in depth review or you just want more cases, spot the fracture and move on. Be particular interested in knowing which of those approaches would be preferable. So thank you, everyone for listening on down. Please fill out the feedback if you get chance. So after you, any D. So I think it can be overwhelming, particularly when you presented with multiple radiographs on a shift. You don't want to miss anything on. You feel that you don't have basically the experience for it. I think the most important thing is develop. Develop your own system for each big joints. If it's a fracture of a joint that you're unfamiliar with, I would always seek, uh, senior review. Um, essentially, it's practice. And don't be afraid to discuss with your colleague discuss with the radiology register all. I think the most important thing is to never discharge any patient. If you're uncertain about their radiograph, because is much better to be certain than to potentially send them home with the Ms Rupture, which could have any of those long term consequences. Okay, I think that's the end off the questions. Thank you everyone for attending on. But, um, if you have any questions that you haven't thought off, feel free to get in touch with George and he can pass them along. And I can always send you an email. If you've got anything more than you want to discuss that we don't have time to discuss the evening white. Happy for you to send questions across. Okay. Thank you, everybody. Thank you. Um, I will email address in the, um, chatter. If you have any questions, please just drop them. They're on what? Your emails? Because we will be sending, uh, the catch up content on a recording of the lecture. A link for that To you. Thank you.