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Hi, good afternoon everyone. Uh, I'm Taha. I'm one of the, er, education leads for Ir Juniors. Uh, welcome to this talk today on radiology for Fy one. Uh, so today we're gonna have two talks. The first talk is by Anise Can who is a radiology registrar in leeds, teaching hospitals. And he's going to give er, a short talk on how to interface with radiology. So things like how to protocol and bet scans and key tips for when you're discussing things with a radiology registrar and how to rate those conversations as efficient as possible as they can be quite daunting. Um, when you're just starting by one, uh, following that we'll have a short talk by Rebecca Morris who is also a radiology registrar in these teaching hospitals. And she's going to give um, a short talk on key things not to miss on, er, x-rays. So things on like muscular SCLE x-rays and chest x-rays that um, are maybe not taught as well at medical school and, er, things that can be very important for management and, and useful to know during foundation. So, er, without further ado I'll hand it over to Anish, um, to start the first talk. Um Please feel free to put questions in the chat. Um I ish is particularly to this a no interactive sessions. So please er it would be great to have you and guys engaged and um yeah, I'll just hand it over to him. Thank you. Uh Good afternoon guys. Apologies for the slight delay. That is my fault. But as th kindly um introduced me, I will be giving a talk on how to interface with the radiology. It's I as, as he mentioned as well. I do want it to be as interactive as possible. The slides are pretty minimalist, it's mostly just a guide discussion. Um Yeah, I'll just get started. So I am one of the ST ones in leeds at the moment. Um My background is in surgery prior to starting radiology. I'm also happy to answer questions about that later if people want to, can uh give you my details as well if you want to send me an email. So I've kind of broken down into sort of er when, how and why. Um I think the key thing that I want to highlight about when is is radiology. E even in my relatively short career, I started in 2017 as a doctor and the amount of requests and the amount of scanning that we're doing now is just getting higher and higher. So, and as I've said on the slide here, almost all inpatients will interface with the radiology department at some point during their stay. So that might be for several reasons, it might be someone who's a repeat at tender and they might have loads of things that are going on and they might need imaging for one or many of those problems. And the acute side of imaging, at least as a registrar is where you get the most involved. Certainly in your junior years. So that'll be calls from A&E or deterioration of the ward patients. It's less about the outpatient reporting. However, having an idea of the outpatient reporting is important because that's what you build upon. And as you become more senior and certainly as you become a consultant, you end up doing more of the outpatient imaging. Another thing I think is really important is to talk about when not to have imaging and what ur is and basically the principles of around that. So it's difficult because I can't see any of your faces and I'm not sure if you have the ability to talk or if you have or if you can only type in the chat. But this is the sort of time where do you guys have any questions about when not to or anything on the slide? Currently, any fears about it, anything that from med school you had questions you weren't able to ask because you've got, I think you're starting next week. So anything immediately daunting, I'm keeping an eye on the chat as well. If people have questions and they're not comfortable to unmute and speak, uh, just to clarify that people generally put questions in the chart. I think it's, um, difficult for them to, I speak racially. Um, there's currently no, there's currently no questions in the chat. So, what I'll do is I'll probably share my own experiences and talk about where, where I wasn't sure. So, things have changed a lot from when I started. So when I started, it would be I'd finish Ward round and I'd take a stack of paper notes or paper requests rather round to the radiology department. And I'd speak to the relevant radiology consultant and I go through the process of vetting the scans, the majority would be rejected and we there would be like a fruitful discussion as to why. And that was useful for my learning. Unfortunately, I think that process isn't quite as 1 to 1 and it certainly isn't as personal as it used to be. It's a lot more on the phone. You tend not to know who the radiologist is, particularly in a big center like Leeds where it'll be rotating registrars of which there are lots of us. But I think the point being is for the, when you will often be asked by a senior colleague, be register our consultant, whoever for example, who's leading the ward round will say, right, this person needs imaging because they've got sepsis of unknown source or because they've got abdominal pain and recurring obstruction or whatever myriad of acute pathology there is. And I think the thing that I would really encourage you to do is speak up and ask if you're unsure as to why? Because I think the thing that's most painful now, having done it from both sides is when you speak to the person who's put in the request because obviously you put in the, the request on whatever, er, system you have and then you'll call the radiologist to vet it. And I think when you have few answers to the questions being asked and it comes across that you're not that prepared, it can make the conversation quite difficult and if it's obvious that you are prepared, it just makes it a lot easier and it means that often certainly as a radiology, I can trust what you're saying a lot more if it's a lot of, oh, sorry, let me just go and check the notes or actually, I don't know why we're doing that. Now, don't get me wrong. I'm not expecting you to have an encyclopedic knowledge or consultant, registrar level knowledge of your subspecialty and why you're doing it otherwise you wouldn't need the training program in the first place. But I think some basic stuff is quite important. So for example, if we take acute abnormal imaging as a, as an example, knowing whether or not they've had any surgery in the past is usually pretty good. Um, why they're admitted and the specifics of the surgery, it doesn't have to be perfect. But something, for example, oh, they've had a Hartman's or they've only have had a laparoscopic appendicectomy. Those kind of things are really, really useful. Um, generally speaking, I'd say abnormal imaging probably isn't the problem zone. So again, I think it would be more relevant for the people who are starting surgery but if you have some more specific questions about any type of imaging modality or anything, you're not sure about. As I said, please, please do ask. So I've alluded somewhat to this with what I'm saying. But the why of when a when any sort of imaging is requested is it can be pretty much anything. This the purpose of this list was more more just to highlight the fact that it's going back to what I was on the previous slide where almost all inpatients will interface with radiology that pretty much sums up why the why the why list is not exhaustive here cos it it can be for anything so unexplained symptoms, I've put with a reasonable differential in the brackets because unfortunately, there is, there is actually this wasn't a thing when I started, but there is now even a clinic and a pathway for nonspecific symptoms and they end up with a whole host of imaging. Now, with modern CT imaging, the doses are much lower than they used to be so and so you can justify a bit more why these scans are being done. But still, if you end up ever in this situation, I would try and have a clear question in your mind. Um, deterioration. So someone who's come in with something, but now they're deteriorated. So we're not treating them efficiently or not treating them well. And so they need to have imaging that might help explain it, postoperative, relatively self explanatory. Though. Again, what I was saying before, have some idea of what operation they've had and the common complications. And also in your own mind, it, it'll help with your own learning. It'll help with your ability to assess acutely and while patients and also when you become the senior and people come and ask you for questions. So for example, if somebody's had a bowel resection, have they got a stoma? Have they got an anastomosis? And then that will be a very important bit of information and then having an idea that when a leak typically happens. So typically three day, three to day seven, POSTOP with day five being a particular peak. And then have you ruled out all the things that don't require imaging such as wound infection, urine infection, chest infection, the basic stuff you can do and get right. And I think that will stand you in good set, not even in interface with radiology, but just in life in general. And it will, you'll be a very proactive junior that seniors will find adds a lot of value follow up. So after resections or after they've had some cancer diagnosis and they've been given a status of remission and, and follow up over some period of time staging, obviously malignancy thing and then general acutes and trauma. So trauma's something that's leads specific being the trauma center for the region, but you probably won't get involved in that. And generally speaking, trauma studies do just, just do need to be done. So how I think is incredibly important cos uh certainly for myself, I didn't really understand what, why we did certain things. So is that plain film is that Mr, is that CT, is that out? And increasingly, I'm getting a, a phone call where I'll be like, I don't think CT imaging is appropriate and they'll be like, oh, well, what imaging would you, would you suggest? Now sometimes that's asked in earnest and that is a useful discussion to, for us to have. But also the answer isn't always they need imaging. The answer can be they don't need imaging because they've had it recently, they don't need imaging for whatever other reasons, appropriateness or just we can't answer the question as an example, I had recently, I had somebody ask um us for a CT for just query ulcer and that's not query, perforated ulcer, that's not query complications. And also it was just query ulcer. And I think, rather than being critical of the person. I think exploring why that's not useful, why radiology can't be useful in that context is probably helpful in the what, what we're looking for on a CT scan is primarily an inflammatory process that as a result of a perforated ulcer, the ulcer itself won't show up as anything and it won't show up as anything on ultrasound, which is what this clinician's next question to me was is oh, can we do ultrasound for it? And I said, well, no, you need to do direct visualization. And that is an obviously an O GD done by Gastro, that's nothing to do with us. So I think that's quite important. Timing is also very important because this is, I mean, there's without going into the specifics, cos I don't think that's particularly within the scope of this talk unless again, feel free to use the chat function and ask specific questions. I'll be more than happy to answer those, but timing is around again. So when we talked about using that anastomosis as an example, bowel anastomosis as an example, if somebody is unwell six hours after their operation, having them have act and giving them rectal oral contrast depending on where the anastomosis is, isn't helpful. You won't be able to identify the leak in amongst all the postoperative changes. And also you could probably blow a fine anastomosis. So things like that are important to know in our and out of hours this is more of a, this is less for you to be aware of, but more an understanding of why someone might say no. So for example, a C TPA that can be done the next day because there's no contraindication starting anticoagulation. That is something that almost all radiologists will, will say to do the next day in hours because we also have a workload and we also have uh priorities that we need to handle and make sure that things are triaged in an appropriate way. But this, that's more just to be like why someone might not say no outright but more specifically say not right now. And for another time and the key information part, I think it's a difficult one to go through and I it would take too long to just be like for this presentation. What's the key information for this presentation? What's the key information again, if you use the chat function? I'm happy to answer specific questions. But I'd say generically, key bits of information are knowing someone's eeg fr particularly if you think that there might be contrast involved, I'll talk a bit more about contrast later. Um in the context of abdominal injury, abdominal imaging. If they've had any surgery in the past, what is it is usually helpful? We all as radiologists quite don't enjoy the phrase complex surgical history because it's meaningless. Um And it really doesn't help particularly if they've not got prior imaging that we can use or if it's from a different trust that we don't have access to. Um, yeah, I think it's hard to pull specifics of the information. But if you think it's definitely more, is more in that request box, just write everything that's useful. It's not a case of, oh, it's taking me more time to write this cos that is more likely to, to help us. And also, unfortunately, the conversation you have on the phone isn't something that's defensible. Like if it comes to any medical legal stuff later on, the only thing that we have unless we document it all ourselves is that request. So you might have written. So, and actually, often I'll have to go to the electronic health records and sometimes there's incongruity between the two as well because the purpose of the discussion with the radiologist isn't, you're trying to sell a scan or you're trying to bribe the radiolog to doing the imaging for you. You are referring to a specialty and it should be treated as such. You wouldn't, let's say you were referring to orthopedics, you wouldn't be like, oh, there's a fracture and there's no fracture, that sort of stuff. It's not helpful and it might help once, but it's important to maintain good relations, I think. And it does go both ways as well because it will help foster good relations. So I think this bit is very important. So radiology won't solve problems. Radiology just aids diagnosis. Now, unfortunately, this is a losing battle and it's not something that a single person is gonna fix on a Saturday lunchtime. But radiology is not a treatment. There is obviously interventional radiology and things that radiology can be specifically useful. But generally speaking, imaging is not a treatment. So when people want say CT K US or ureteric stones and they're saying, oh, well, my patients in pain. So that's why we need to have it done. Now, that's not true. If there are objective measures that the scan will help with such as stone burden. And uh for, if they need a nephrostomy, if their egfr is low, then yeah, there's, there's grounds for it and the scan will happen again. It's often times it's not a no, it's just getting the timing right. So if the, if it was out of hours, for example, and the person is otherwise well, having that C TK U be done then and there is not useful. Now, I must say with that particular example, people are very understanding and similarly with C TPA S, people will often call you and be like, oh, I'm vetting the scan for tomorrow or I'm vetting a scan for as an se returner or whatever equivalence you'll have in your, your trust. So I think generally speaking, I would say that's done well, but I think the understanding of what a certain imaging modality is for would be quite helpful. And I think maybe a bit unbearable me because I II certainly didn't have that understanding when I was an F one. But I think an appreciation for when ultrasound is used or when CT imaging versus Mr is used is helpful and also just a general point, Mr is almost entirely nonacute imaging, corda, quina and lumbar spine. Notwithstanding there is almost no acute Mr being done. So calling and asking about that is generally not going to be met with a positive response. So what is contrast and why do we use it? So contrast helps enhance certain parts of an image and in certain structures will take it up more certainly vascular structures because that's where IV contrast obviously runs and it's helpful. So when we use phrases like hypo enhancing or Hypoattenuating, it's useful and the contrast as the name suggests helps give that more con helps differentiate between the various shades of gray. So there's IV contrast, which is what most people will be familiar with. And that's the things that have renal implications. If people have poor eg fr s or things that A as and vascular stuff would be, would be the most commonplace that it's used, then you get things like oral contrast. So that would be used. So in fluoroscopy, which you'll get less involved with, so I'll probably stay clear of that. But again, using the leak example, you can use oral contrast to assess for upper gi leaks, esophageal small bowel, you can use rectal contrast to assess for lower gi leaks and then the type of contrast is relevant. So IV um will often be something called omni, it's not really important what it is, but then you can also use water and er, they can both be used as contrast, another thing would be phases of study. So I think an awareness of this is important. So just keeping it relatively simple, you can have a non contrast phase or non contrast study. So that's just there is no contrast being given, you can have a portal venous phase, which is where the majority of the IV contrast is in the venous system. So it's delayed from when it's administered and then you can have arterial phases. So that's when it's taken very quickly after the pictures are taken very quickly after the contrast is given the reason I'm saying that is cos it's very relevant cos you'll often have uh clinicians call and they'll ask, oh, I want a CTP for example, and a C GPA is done as an arterial face chastity and but they'll be like, oh whilst you're looking at a CT, can you also assess for XY and Z things? And unfortunately, the phase of contrast can mask certain pathology. So again, this is going all the way back to having clarity in your own mind as to why you're doing the scan and sort of a scattergun shotgun approach isn't very helpful and it's true for lots of things, but poor data in will give you poor data out. So if there's no differential, if there's no n question, there's no clarity in the question being asked, oftentimes the reports match that. So when radiologists get mocked for writing, correlate clinically or for listing a wide differential, it's often because the data is quite poor. Whereas say for example, if you're told there are a young person writing that fossa pain starting the umbe like migratory grumbling, maybe some vague gi symptoms on top of that, then that's a good history for appendicitis. Now, whilst it might not show that I would say anecdotally certainly much more efficient to picking up pathology when the clinical question is good. And I'd say that's none more. So for in CT heads, a good neurological assessment that shows pathology is often met with similar on the studies. So who cannot have contrast. So to be honest, and this isn't really, you'll have to follow whatever trust guidelines you have. And unfortunately, we're all bound by that. The reality is as more and more stuff is coming out. Contrast induced nephropathy, for example, is probably closer to myth than it is to reality. And there is often ways and means if people truly, truly need contrast to be able to delineate things, again, I would leave that to a discussion with the radiologist. If you've gotten that far, you're probably just doing a good job anyway. So I wouldn't worry too much about that. So I think this is the penultimate slide. And the reason being is I kind of budgeted about half of the talk for me talking at you, which is essentially what I'm doing. And the other half to sort of help alleviate fears and concerns. Cos certainly for me, interfacing with radiology was very nerve wracking to start with. But just before we get into that part, so for the tips, I would say, have a clear question and we talked about that previously, if you do not have a clear question, you will often not get a clear answer. Now there's plenty of opportunity where the scan just reveals the answer. And unfortunately, because of that, that's probably why there is such a predilection for just resorting to radiology. But if you don't have a clear question, it will be very clear, very, very quickly and radiologists are are often relatively senior clinicians. So and I mean, you're a registrar from the start and you also bear a lot of responsibility. So people will ask a lot of questions because the responsibility often ends up falling on the radiologist. So you are, for example, when I press justify that's me prescribing the radiation. So you, you are the person as the radiologist who said, OK, it's fine and the benefit of the study outweighs the risk that is inherent to the radiation when referring on someone's behalf, saying at the end of a request or when written or verbal saying, oh, if this was the consultant sort the consultant wants, that is not a substitute for clinical information, that is not a substitute for clinical assessment and that is not a substitute for conversation. That is that is dictation. That is you trying to be like, oh, well, you might be saying no, but actually my consultant just says this is what they want. So I'll give you an example. From this week, I had somebody uh who had a CT done of their neck. And the ct report suggested that it was um more inflammatory or inflammation rather than malignancy. And the clinician called me and said, oh, can you get a staging chest, abdomen and pelvis, please? And I said, well, ok, well, what do you want a staging for? And he said um for the neck malignancy? And I said, well, the report suggests that it probably isn't and he was, and he was organizing MRI neck as well. And what I said was, it's not a no now, but why don't you wait for the MRI neck first? And he was like, well, the professor, someone or other says that they want the staging scan. And I still said, well, it doesn't really matter the information I have is that in the first instance, whatever this is being diagnosed as is most likely to not be malignant. Now, that could be wrong and the Mr could show it to be malignant. But if the Mr is happening tomorrow, there's no need to unnecessarily irradiate that person. And whilst I'm not teaching you how to be a radiologist by any stretch, I think that is true also at your stage. So be willing to ask questions, be willing to say, oh, actually is it, does it not just make sense to wait a little bit and we can still, it's not gonna significantly delay treatment. And that's where I think having a good clinical base and building that confidence will help the next two kind of fit in together. So if you're feeling like you're having to fight or if you're feeling like you're having to convince someone or hoodwink someone or whatever you want to use, it's probably an appropriate imaging if you're having to twist somebody's arm to, to do it and it, it, it shouldn't be like that. We should be working together very much so for, for the patients. And so if you're having to fight, it's probably the case that it's not appropriate investigation. Now, there are certain things where we just cave as radiologists and maybe you shouldn't share insider secrets. I don't know. But for example, ct non contrast ct head imaging, if you've requested it, I'm betting it, it's not worth any sort of discussion. The only thing is if they're very young or if they've got, if they've had a multitude in the past, but they're few and far between and I've alluded to this already, but you are referring to a specialty. I, you are speaking to a registrar from another specialty who out of hours will be the senior decision maker for that specialty. So approach it with the same respect that you would speak to anybody in any other specialty and be similarly prepared. You'll come across this eventually. But I remember having a lot of fear before I'd or a micro consultant and I'd have like this is also revealing my age, but I'd have all of their paper notes out in front of me. So I could answer any questions. They wanted to let them know what their childhood dog was called if that was gonna help aid the diagnosis and my antimicrobial treatment. But I would say that being similarly well prepared for that discussion is helpful. So thank you all for listening to me ramble away. Um If you've got any questions, this is, this is now the time because as I said, I budgeted half of the talk to answer your specific questions, cos I at least assumed you'd have some. Now you all could well be significantly better prepared than me going into foundation training. And that is fair enough. But this is very much an opportunity to ask questions and get things out of the way before it becomes a lot higher stakes if um just to just to uh clarify as well, like if you have any specific questions of everything you've seen on placements or during medical school. So if you don't understand why particular scans are requested, so, like why sometimes I request an ultrasound for cholecystitis or sometimes why they would request a CT for certain things. Er, this would also be a good time to ask those questions if you have any specific ones. Um, uh, please just put them in the chart. I'm sure Arnie will be very happy to answer them. Um, and if not, what we can do is, uh, we can just move on to the next talk and if any questions do come up, um, in your mind or anything that you've remembered, just put it in the chat at some point and then we'll be able to answer them. Um, but, uh, it looks like there are probably no questions at the moment. So, uh, we'll just move on to the next talk in the first instance. Um, so I'll just, er, introduce, er, Becky, er, Rebecca Morris, who's a radio in Leeds and, er, she's just going to move on to the next talk, which is, um, going to hopefully provide some key tip on, uh, x-rays that are very relevant for foundation training that might come up. Um, so without further ado I'll hand it over to her. Well, thanks, Jo, I'll just try, uh, er, playing films with you kind of what areas that are less reviewed during medical school and things that you don't want to miss, um particularly when you're working in A&E, I would say on the wards, um, it doesn't tend to be left to you as much. But in A&E sometimes, uh you know, if you are looking after the patients, um as like the, the main doctor, you'd be requesting these X rays reviewing them and then making decisions about them all kind of in one go. Whereas on the wards it tends to be a bit of a slower process and more people get involved. So, um I'm sure a lot of you have A&E jobs and you're probably very terrified to do the A&E jobs. I know I was. Um so hopefully this will help you feel a bit more confident. So like I say, just we want to make you feel more confident, kind of add some review areas to you. You will already have a way of looking at chest x rays and abdo x-rays cos you'll have to do that for your exams, but it's just adding kind of fluffing that out uh and making it less exam um kind of reviews and just more real life things that common things are common, what not to miss type of uh pathologies. Um and also just some top tips as we go through, uh particularly as I've learned through this first year of doing radiology training, things that I wish I knew, known in foundation training. Why did no one tell us that that would have been really useful to know. So, um, a lot of people say this, a lot of the registrars say this, that they hate plain films and plain, I think the biggest thing is if you're really worried about having to interpret plain films, you're not on your own, they're really difficult. And there's a reason for that. So if you take a hand, which is a, one of the more simple x-rays to interpret, um, your X rays are going through your hand. There's not that many structures in your hand, there's soft tissue, a few muscles tendons. Um you know, and then your bones and there's not much else really going on. So you get quite a nice picture where you can differentiate bone compared to everything else. Now, when we scan people's heads, uh this is kind of like the most dreaded x-ray possible is if you have like a facial bones x-ray, if you think about the kind of structures that the X rays are having to go to and all those 3d structures are being squished onto a two D picture, suddenly it makes you realize, oh actually this is why this is so hard. Everything's so busy. There's so many other lines, structures and trying to separate that in your head is really difficult. So I think the first thing to acknowledge is plain films are difficult. So don't feel that just because it's a more basic kind of radiology that you need to be able to do it and be, you know, competent at, you know, reporting your own x-rays. That's not the case. They're really, really tricky. So you have to kind of give them the respect they deserve and also ask for, he ask for help if you're not sure. So first of all, if we just start out with some top tips, so lines are your friends with x rays. So generally interruptions to lines is a bad sign. So when you're looking for fractures, obviously, if you get an interruption to bone cortex, that's not usually a sign of a fracture, but generally everywhere else in in chest x rays, abdo x-rays, anything else, you should have natural lines that continue and fall into something if it suddenly stops or there's a jump in a line that's normally means there's something gone wrong nature doesn't make triangles either. So in the body, if you spot, for example, you see a chest X ray and there's a triangular, a pacification in the lung, there shouldn't be triangles in the lungs. So that probably is some kind of like lumbar collapse or something. So if you see something you think, oh God, that looks like a triangle or some like weird lines that aren't normally there, just make you have a think about what actually is there. And also when you're tracing the lines, if you're following, er for example, if you're tracing around the edge of a bone, if you trace it all the way round and you keep following that line, it often makes your eye follow to an area that you wouldn't normally look at if you just kind of like, look blankly at the, you know, just straight at the film and not looking at anywhere in particular. So if you pick a line trace it all the way round, you're gonna be doing a more thorough review. So I was just say, try and follow all the different lines around bones and around different structures. Windowing makes a big difference. So we're really lucky in radiology, we have really fancy screens, we have dark rooms, um a lot less interruptions than you when you're on the ward and busy ward rounds and things like that. So what I would say is when you're, when you're busy, when you're being pressured to make decisions about X rays, you need to create time and space for yourself. Cos that's, you know, that you need to give yourself a bit of grace to have a bit of time thinking time to figure out what's going on and also using your technology to your advantage. So we have really the fancy the screens and stuff like that. So, you know, Mos we were lucky on the wards, you normally have a really rubbishy portable laptop that's on wheels. The screen might be like smudged with loads of fingerprints and it's just not ideal. But if you can find a computer that's in a proper office, even if it's like, at the nurses' station, that's just like a bigger screen. That's less like grim, you know, turn the lights down. If you, if you're really looking at something in particular, just try and give yourself the best chance you can at interpreting the films. It's difficult, but don't, don't be pressured to make decisions on really rubbish screens. It's, it's not optimal and, and you, you know, you don't want to be looking at it the next day and thinking, oh my gosh, how did I miss that? When? Actually it was because there was a massive fingerprint over where you were trying to look, er, the next tip is always look at the images before you report in daily practice. So this is really where my interest for radio. So I never thought I wanted to do radiology but I think doing this made me realize how much I enjoyed it. So this is uh my introduction to radiology really is I used to be on the wards and every time the patient's er, report would come back, I would look at the images first, so not read the report. Look at the images, see if I could spot anything and looking back, I probably never picked up anything but that doesn't matter. Um looking at CT S like, I don't even know what organ that is. But anyway, trying to stop peas, things like that and then have a look at the report and kind of check your working. So it's testing yourself on a, in a low level, kind of like low pressure environment. Just to see if you can, you, you can see what we can see. The more you see, the radiology is just kind of pattern recognition and the more you see, the better you get, there's no real magic behind it. It's just, you know, once you've seen something you're aware of it, then you might pick it up next time. If you've never seen something before, you're never gonna get it in the first place. So just um if you are particularly interested in radiology, I would definitely encourage this. But also if, even if you're not better clinicians, look at the, er, that I've worked with w look at the images themselves. Um I find it really frustrating when you get a consultant that doesn't even bother looking at the chest X ray, they look straight at the report. I think it's, you know, you're a doctor, everyone's a doctor, everyone's trained to look at plain films and you can have a look at CT S, it's not like they're, you know, unaccessible. So try and look at your images as well. And also if you, if you, if you read something in the report, you try and look at the images and try and see where it is and you can't see it if you are interested, you know, we are more than happy for you to ring up and ask and say, would you mind or bobbing down to the radiology department and say hi. You know, I'm interested in radiology or, you know, I'm involved with this patient. I'd be interested if you could show me, I, I'd be very surprised if any radiologist turned you away from that and, you know, was funny with you. I think that's a really showing interest. It's your learning, you know, foundation training is a, a really good time to, to get that in. So, um it, we're more than happy to help you improve your radiological skills. Um This er, is again another kind of really useful thing to be aware of is patient positioning makes all the difference. So, um particularly with chest x rays, chest X rays are notoriously difficult and the patients who often who are the most unwell, make the worst chest x-rays because they're normally very frail. Um you know, they're unwell, they're in pain, they're short of breath or, and, you know, for lots of different reasons making them very unwell. So their positioning is often really poor, that makes interpretation of the chest X ray really difficult. So if you can um before you send your patients off to get uh the plain films done or any s any um radiological in er investigation, try and get them as comfortable as possible. Um So if you've got a patient who's got, you know, a shoulder injury try and load them up with analgesia before they go for that shoulder. X-ray cos it means that they're gonna be able to get them in the optimal position to take the best views. And then when you get that film back, first of all, if you're interpret, interpreting it yourself, it'll make your life easier. But also when the radiologist or the radio reporting, radiographer looking at it, you'll get a much better report, you won't get that annoying line of nondiagnostic or limited interpretation, which is, you know, no one likes writing it, no one likes reading it. So if you can make your patients really comfortable, you're going to get better pictures. So they're kind of my top tips and I'm just gonna go through now in different parts of the body in plain films. And I obviously, I can't teach you everything, but I've just picked out some key things which I think would be useful for a foundation. So, um first of all in the chest, uh like I said, chest x- is are really difficult. Um I think the big thing to kind of try and get your head around with chest X rays is a lot, a lot of the time the terminology makes a big difference. So for example, if I said there is a patchy area of increased opacification in the left lower zone of the lung immediately, hopefully, you guys are thinking that sounds like consolidation, most likely thing of consolidation is infection. So the patient's probably got a pneumonia if I say there is a well demarcated wedge shaped opacity in the left lower zone that hopefully will make you think more of like a lobar collapse. And then think, ok, why has that patient got a lobar collapse? I don't know if they got a history of weight loss, night sweats. Have they got a malignancy? So you can see how even without even showing a picture of a chest X ray, just the words you use can paint a picture of what is the diagnosis. And when you're first of all, when you're in the writing in the patient's notes, so you've reviewed a chest x-ray and you need to document what your interpretation of the chest X ray is. It's important to be using the proper terminology. And also if you're not sure about something and you need to discuss with your seniors or a different specialty. If you're using the correct words, if they can't see the images, they'll be able to help you a lot better. Um location is of, you know, a lot of these words are actually just relating to the location of where pathology might be. So you can, you know, in lungs, you can say like upper, mid, lower zones, apical hilar mediastinal. So remember to locate where you are, I think um if we were in person, I'd probably get you to sit back to back. One person describe a chest X ray and one person write it down. Unfortunately, we can't do this online. But actually, that's a really good way to kind of think about when you're, when you're writing down your interpretation or you speak to someone on the phone, you need to describe it to a level where the person on the other end of the phone can draw what, what you're explaining to them. And if they can draw what you're saying, then you're doing a really good um explanation and interpretation of that film. If you're just saying, oh, well, there's just a bit of whiteness over on the right. You know, it just looks a bit weird. That's not helpful. So if you say there's, you know, increased density patchy, you know, or rounded lesions, there's multiple lesions, at least five lesions, you know, try, try and describe it the way you would want someone to explain it to you. So another thing about chest X rays is there was a lot going on in a chest X ray. So just like I was saying about that facial bones x-ray where the 3d structures are all squished onto a two D plate. It's chest x-rays is a similar uh kind of um situation. So as you can see this film here, first of all, the, the first thing I noticed is that the patient is quite large. So you can see that we've got quite a zoomed out image. There's lots of soft tissues which straight away is making this, uh, chest X ray quite difficult to interpret. And it can often, you can often get a, a bit bogged down and thinking, ok, you know, these patients come in, I'm worried about a pneumothorax. They're a bit short of breath. Um, you know, panic stations, look at the lungs. Oh, God, they look a bit weird. Oh, I think there might be, you know, an infection and move on and it's very, you know, very easy when you, when you're faced with stuff like this. So, but the, the important thing is don't forget your structure. So I presume a lot of, you know, the A to E of chest X rays is everyone aware of that if you could give me. Yes. No, in the comments is that if you have no idea what I'm talking about, I can quickly run through it. A to e meaning like A for airway, B for breathing C circulation, D for diaphragm and chest X rays. Yeah. So we've got a yes from Amelia. Thank you. So, um I'm not gonna go through that and that cos no one's said that they have no idea what I'm on about. Oh, so we've got to know. OK, that's absolutely fine. Um I'll just quickly run through an A to have a chest X ray. It's just basically a simple structure of review areas. So on this chest X ray A is airway. So you're looking at the trick here. Is it central as it deviated? Can you see the um the carina be breathing? So that's how your lung feels. You're assessing your lung feels and your pleural spaces. So, checking lung markings are going all the way to the edge. Is there a pneumothorax? Have you got any um you know, fluid down in the bottom, any kind of weird masses or anything? So, b just looking at the lungs, see um circulation. So looking at the heart, cardiac contours and media sinum o you know, included in there. So you just checking, you can see your heart borders, there's nothing obscuring. It is the heart large is the me media sinum widened, shifted, shifted, that kind of thing. D for diaphragms. So can you see the diaphragms? There's one raised. Is there any air underneath the diaphragm? Can you see a gastric bubble blunt again, blunting of the angles if there's any fluid there and then e is a bit of a cough out but it's everything else. Er, and that would just be your bones and your soft tissues. So if you hadn't done the system here, so A is fine. Bi haven't taken a deep breath in so it looks a little bit, it was a bit more interstitial but grossly are kind of fine. C looks. Ok. D is fine. E if you have given up before e you would have missed the pathology on this chest X ray. So has anyone spotted what's going on with this chest X ray? So it, it's in, it's in soft tissues or bones. No one spot anything. No, that's OK. Um Looking at the bones here, can you see the shoulders? So you get a partial shoulder X ray free in your chest, X rays. Can everyone see this here? So when we were saying following lines, so for example, if we, if we wanted to see if there's a clavicle fracture following this line out, nice and smooth, doesn't get interrupted all the way around. Oh OK. We can see your mouth. Oh Can you not? No, no. Is there a way to do that? Um I don't know if there's a way to get a point on here. I think it might be. Oh Yeah. There we go. Yeah. Oh Do you see that? Oh, sorry. It was on my screen. Here we go. So here you can see. Thank you. Uh You can see the contour of the clavicle nice and smooth, no interruptions. You can follow it all the way around. You keep on following all these lines round, nice and smooth. You can see the scapular lovely moving on to the humerus. You've got an interruption here and an interruption here. So this is a fracture of the right humeral neck and then also on the other side. So there's no breaking lines. But can you see this humerus here is articulating nicely with the glenoid this one here is moved anteriorly. So this patient's actually got two. He's got bilateral shoulder injuries. Now, if you'd have not followed your um structure, if you'd have just, you know, panicked and looked at the film and said, oh, it looks kind of ok, you'd have missed this. So this patient needs dedicated shoulder views um and referral to orthopedics and relocation of the shoulder joint. Um So remember to look at the whole film. Um It's easy as well. Satisfaction of search is really, um you know, you can found this shoulder X ray. It showed this humoral fraction. Oh, my gosh, I'm a genius. I've, I've picked up the shoulder fracture on the chest X ray can be really proud of myself and you can cos that's brilliant. But don't let, don't let this one trip you up. Ok. So once you found one thing, don't give up, keep looking. Ok. So another thing which is uh quite difficult on chest x-rays people worry about um is spotting pneumoperitoneum. So we've got four chest X rays here. There's only one pneumoperitoneum. Can anyone spot the pneumoperitoneum? So you can go like upper, left, upper, right, lower, left, lower, right. If you think you can spot the pneumoperitoneum. Don't worry if you get it, there's no, you know, I've picked tricky stuff. So don't worry if you, if you get it wrong, it's absolutely fine. No. OK. We'll, we'll go through one by one. So this one um, it's not the, again, this is our unwell patient. So we've got, there's a lot going on here. Um, you might look at this bit of black this gas here and think, oh my gosh. Is that massive pneumopar? Now, the thing that this is not the pneumoperitoneum, the reason why it isn't, can you see these white lines here? So these are the hatra folds of your large bowel. So this is just a big loop of large barrel. Now, if I sold this, I wouldn't think it was, you know, it's not pneumoperitoneum, but I might think. Oh, actually that bowel looks a little bit big. The patient's unwell. Not quite sure what's going on. Maybe we need an Abdo, you know, I definitely want to be feeling their abdomen. And do we need a, a quick Abdo film just to make sure there's nothing crazy going on here. Um, so I'll review them in place of that, but I'm not worried about pneumoperitoneum. Yeah. So, I mean, possibly think up a right. So this one's, again, this is another, I've picked really tricky ones. Er, er, cos easy is boring. So this one again, really, you know, you might be really worried about this. Now it does here. I agree. It looks like a pneumoperitoneum but it doesn't hear and it doesn't hear. So this is so this is a normal gastric bubble and I can see why you, you, you think that what that might be a pneumo protein in because this looks like a really thin diaphragm. And you're right. It, it, it i that if that was all the way across it would be a pneumoperitoneum. But this is just a stomach bubble and you can get cos you, you, you get fluid in your stomach. So you do get kind of a fluid air level. So that's just a normal appearance. No. Yes. So, Amelia just spotted. Yes, you've spotted um the pneumoperitoneum. So the pneumo protein is this one in the lower left. So, really well done. Now, um normally we look for pneum protein on the left. Diaphragm cos that's where air goes to cos the liver sits on the right and often, you know, we, we look for the pneumo, you know, the pneumoperitoneum here. But yes, this is the thin line of the diaphragm here. So, yeah, brilliant. That's right above the liver. Um And actually you can see wriggler sign here. So you can see the full width of the bowel wall. So here we've got pneum and air outside the bowel here and then this one down on the right, this is the patient has got dextrocardia. So the heart's on the, on the opposite side of the chest and they've actually got sinus inversus. So the liver sat here, the stomach's here. So that's why that one looks a bit weird. So you're all done. Now, we're just gonna go through some normal and abnormal chest X rays. So I wonder I might try and do a pole. Let's see if we can do a pole. Get fancy now so we can get so normal. Bye. So hopefully you can see the palm. Although if you can't use that, I think a little bit annoyingly the question comes up and covers the screen. I do that. Ok. Ok. We've got one for normal. Ok. Well, that two people normal. Yeah, you're smashing it guys. That is a normal chest X ray. Brilliant. Next one, I'll, I'll, I won't make a poll. You just type normal or abnormal. You don't have to know why. If you do know why it's normal or abnormal, then you know, if you, if you still think it's abnormal and you know why that's great and ounces on this one to 5050 no one's gonna remember what you said. Don't worry. Um, no one's sure. Ok. It is a weird one. So this one's abnormal and you might be looking at this and you know, thinking, oh, it looks weird but I don't quite know why. So again, if we were doing our A to e so our A for airway that was kind of ok, which would be a central B looked a little bit weird, but I can't really put my finger on it. That's fine. But generally the lungs are clear. See, heart media standing looked normal. Dear ones have got a bit cut off. But again, nothing dramatic going on there. And we're into our e again, bones, you go through all the lines. Yeah, there's no lines and then we go on to soft tissues. Now this is where the, the problem is on this film. Um, they've got lots of black areas throughout all of their soft tissues all the way around, mainly over here. So if you look here, so if you look at er, this area here, this is normal. So you get kind of like a smooth whitish appearance of, you can just see the skin folds compared it over to this size. Suddenly, actually, what we can see is kind of like muscle fibers almost coming through. Does anyone know what this is? If I said to you the patient's been in a car accident or, or yeah, we'll go with that. I don't know what that is. So black is air on a chest X ray. So air outside, the patient is black. So there shouldn't be air, you know, this is kind of black air is in the soft tissue. So this is surgical emphysema. So lots of different causes for that esophageal rupture, you know, if you've got trauma to the chest. Um Yeah, emphysema, brilliant guys. Um I think you have time to type and that's fine. But yeah, absolutely. So, emphysema um so trauma, if you've got a big, you know, if you've got a connection between the outside and chest, um air can leak out into your soft tissues. Well, this one normal or abnormal again, you don't need to know what it is. If you think it's abnormal, you think it's normal? That's fine. Abnormal. Yeah. Amelia smashing it. So then we'll know if, if you don't know exactly what it is. Is it in the ABCD or E bit, that's wrong. There's a lot going on in this one. So why you're having a think is this line here? So this is a et tube. So endotracheal tube, they have like an opaque strip on so that you can see where they are and see if they're correctly sighed. Got a central line here, got a AG leads coming off as well. So you can tell already this patient's really unwell. OK. So this is actually COVID um which to be fair, you guys um might not have seen loads of um you know, if you just flash back a few years, loads of patients like this. Um But now, luckily, COVID'S not as much of a thing, people don't really recognize it as much anymore. So yeah, that's COVID. So I was a patient in ICU COS of COVID this one normal or abnormal. Again, there's kind of a few extra bits on here. So we've got some steno wires. Um I've got this as well, which is a cardiac monitoring device that just sits in the subcutaneous tissues and monitors the heart a bit like the I imagine it's like those, you know, those diabetes monitors that get under the skin. Like now we just like a monitoring device. Anything alarming you, anything jumping out, no one's no one's shouting at me in the chat box to say it's abnormal and actually, often, so this one is normal and sometimes that's the hardest actually, er, to say if something is a, is normal. You know, that, that last one. Yeah, I mean, brilliant. Er, so that last one, you know, you can say, oh gosh. Yeah. No, there's definitely something wrong. That's easy to say. That's actually harder to say. Um, so normals often take a little bit longer to review sometimes cos you're thinking, I don't want to miss something. But yeah, that one's normal. This one no more abnormal if you're saying abnormal, if you can stick a letter to it. ABCD. E I don't expect you to get the diagnosis with this, but the food. Yeah. So it's in C absolutely. Does anyone know what it is or concerned or what would you do next? So merely you're absolutely spot on. It's abnormal in C, what would you do next? You're in A&E patients come in, they've got chest pain. So you get a chest X ray and this is what you pull up on the screen. Yeah, absolutely. So, Amelia's worried about aortic dissection. That's absolutely fine. So, um, does everyone know? So, yeah, so worried about aortic dissection? Brilliant. If you notice the mediastinum is absolutely massive. So if we go back to this here, so that we've got a lovely kind of narrow mediastinum heart shadow comparing it to this. So normal heart shadow. That's not. But up here we've got massive ballooning here. So this is, you know, possibly if you, if you looked at loads of old films, it could be that it's just an unfolded aorta and you'd be less worried about this one, especially with chest pain, you know, worrying about aortic um pathology here. So you'd, you'd want to get act for this patient. So we we did and this is what it showed. So here, so if we just start off with this, so axial, so this is sliced through the patient's tummy. So the slide or slice through the chest, sorry slice through that way you're looking at from the patient's feet. So this is the back of the patient vertebral body, front of the patient. Um and scapula coming off here, black bits of lungs and this is the aorta here. So normally the aorta is this wide. So it's got this massive an aneurysm here. We can't tell to that section because there's not contrast on this study. But yeah, it's a massive aneurysm here. And then so again, normal aorta is coming up here. So it's a sagittal putting through this way, spine is going down here in front of the patient back of the patient. So aorta is going down the back of the chest. But you can see there's a massive ballooning here. So yeah, patients are very unwell. So a good spot and then this one, so this one's a bit the sneaky one sleep again. So it could be argued both ways on this one. So say normal, you got it right. But if you want brownie points, can you got something, give you some clues. So it's a lady, he's quite young and she has had an operation in the past and you can see evidence of the operation on this X ray. It's not anything to do with a cos that's fine. It's not anything to do with B or you could argue that this lung looks a bit whiter than this lung. This lung looks a bit if you just compare directly across, not necessarily up here, but more down here, this has just looked a bit whiter than this bit, but I can tell you for free, she hasn't had any surgery to her lungs. So that's just a bit weird, but it is related. C Justin is fine. Knuckles. Ok. Cardiac shadows. Ok. Ok. The diaphragm is ok. So possibly bowel obstruction. So I'm gonna show you a couple. Uh, I haven't got much Abdo cos we don't really do much Abdo, but, um, this is normal, but I like you thinking you're looking outside the box. It's not bile obstruction, that's just normal bile gas. So nothing to do with the bones. Anyone else soft tissues. She had an operation. This bit looks whiter than this bit. I'm not sure. So, this patient's had a mastectomy so you can see brush shadow here and there's no brush shadow here. So it's a bit of a sneaky one. It is a normal film, but there is like evidence of previous surgery. So that's just another thing which a lot of people are often like, oh, my gosh, how did I not notice that? Cos once you spot it, you're like, oh my God, you know, it's quite clear, but that's why going through your system, if you'd have gone through ABCD E looking at your, your different lines, you would have maybe picked that up and even in your B section looking at the lungs comparing left to right, saying this looks white, I'm not sure why this just looks a bit blacker. Um It might make you pick it up well, so technically normal, but there is a bit of history there. So ABDO X rays. Um So first of all, what are abdominal x-rays used for? The answer is actually very little. We do very few abdominal xrays compared to everything else. Um And the reason for that is because first of all, they're awful to interpret and they don't really give you much information, but also the radiation you get from an abdominal X ray is really not a lot of the time, not worth it. So one chest X ray um is equivalent to 10 abdominal x rays. So that's quite shocking. I think that, you know, for something which, you know, you don't think is that, you know, it's not that far apart is that it's not different, massively different, you know, it just doesn't lower down on the body, but it's 10 times more radiation to penetrate through all those organs and structures. So, a lot of the time rather than wasting time, um, and just delaying the inevitable. A lot of patients do just tend to go for CT straight away. There are a couple of things where it can be um useful. So for, you know, bowel obstruction, if you, I think if you're really worried about bowel obstruction, you'll be getting act. The only times I've kind of done it is if I've been on and on the walls of a patient, it looks, looks quite well, but they've got distended tummy. You know, you just know there's something not quite right or you just want to kind of quickly reassure yourself, but also be aware that you can't get portable abdominal X rays. So they're gonna have to go down to product department anyway. So I don't know, there's very few occasions where that's, that's suitable. Um If you're worried about perforation, um you need a right chest X ray. So you, you do the abdomen as well, but you need that. That's to look for the pneumoperitoneum. You want to do your right chest X ray. Uh Sometimes we use them for following up, following up renal stones. So if you have a patient who's been confirmed to have a renal calculi um before the E CT is taken, we do a scout, which is kind of like a, it's just an X ray to position the patient and make sure we've got everything on the field of view. And if you can see the stone on that, then you'll be able to sit on an X ray. So rather than E CT in the patient loads and loads of times to follow up the renal calculi, we can just do ABDO films if it's able to be seen on the scout. So that it should say that on the reports and kind of a toxic, which I wish I knew as well or well, I learned when I was on my oncology job is if you have a patient who's neutropenic, um it's, you know, we don't normally do pr examinations cos there's a, a theoretical risk that you can introduce bacteria by doing the pr examination. So if you worry about constipation, you could do a, an Abdo x-ray about that. I would just check with your department that they, you know, that's what's done. It was what wasn't in leeds when I was there a couple of years ago. So that's a way to get out of the pr probably the only time you can get out of it. So there's different. Again, there isn't a nice at e structure of abdominal films. Um, there are different approaches. I'm sure you'll all have your own or, you know, you'll, you'll find your way. One which I quite like. It just cos it rhymes a little bit is gas has masses, bones and stones. So if you work through the gasses of the bowel, free air, um, you know, gas pattern masses being all your organs. Um, bones cos obviously you get essentially a free pelvic x-ray. Um, and stones are looking for renal calculi gallstones, things like that. The other thing as well to add on as well is always look at the le lines and tubes. So if the patient's got an NG tube, make sure it's not going into the lung. Um, you know, if they've got a drain in something like that. So here we have patient who's come in with abdominal pain and distension, vomiting bowels haven't open for three days and they've had a previous append appendectomy. So query bowel obstruction. So there's no one saying normal, abnormal on this one going with abnormal any other takers. No. So this one's actually normal. So abdominal films, I think the best way to think about abdominal films is the bowel should have gas in it and it should have poo in it. So all of this kind of fluffiness, all of these black areas where you can see kind of the inside of the bowel, you know, gas down here, that's all normal because that's what the bowel does, isn't it? It's transiting food and poo essentially and getting rid of it and there's gas with it. So that is normal G bow gas pattern in comparison. There's this one. So, first of all, on this one, we've got colon here. So it's a fully transverse colon here. That's about the right size, so quick tip on, know where the bowel is dilated. If you look at the vertebra, it's kind of a, there's a 369 rule, so, three centimeters for, er, small bowel, six centimeters diameter for large bowel or, um, nine centimeters for the sein or kind of rough guide is your small bowel shouldn't be any bigger than the height of one vertebral body. Your large bowel shouldn't be any wider than the width of a vertebral body. And then you see, it can just allow a little bit more. So if it's a bit bigger down here, that's fine. So here you can see the width of this bowel is about the width of this, uh, this little bit of small bowel here probably isn't any bigger than the height of it. So we're not, we're not too fussed about that in comparison here. So, um, we've got lots of loops here. First of all, that's, um, and lots of it looks quite different to this. So we've not got a la lot down here, but we've got a lot of bowel here and can you see all these lines going across? It can seem quite right here. Lots and lots of lines going across. So these are the valvulae kind of enters, there's lines that go across the small bowel. So that's how, you know, it's small bowel. Another reason is it's all quite central. So where on this one, you've got the large bowel, kind of remember the large bowel is a bit like the picture frame around the outside of the abdomen. So we're happy that that's large bowel here. This is more central where your small bowel sits and this. So if we take, take this width here, from here to here is a lot bigger than the height of this vertebral body. So we know that there's bowel dilatation here. So this is small bowel obstruction and that's generally the on the main thing I'd want you to be able to do going into foundation year is to pick up something like that. So this one, if you're worried about this, you know, you'll probably, I remember the foundation. Yeah, I was worried about a lot of normals and that's OK, cos you're being safe. I just want you to be alarmed by this. Ok. So if you see this, we think, oh gosh, that looks wide. It's wider than that. I'm worried the patient needs act. Yeah. Any questions about that. If there's any questions all the way through, just do shout. Um Yeah, hopefully you can just see the difference by like having one and then the other, you can see how that's quite different. Lovely. So that's chest and Abdo. And like I say, this is very much like a, a whistle stop tour of just like key points. Um But we're gonna go through plain films. Now, if there's any questions just, I'll keep an eye on the chat. So M sk so the one thing which I didn't really appreciate um at medical school was the different ways. Again, terminology of how to describe fractures. Um It's not, it's not essential that you know these words, but it is quite nice if you can stick them in when you're interpreting or on the phone to orthopedics. So transverse fractures are straight across the bone. So they're just like straight through linear your heart. I don't really see linear fractures. But if you, if you do see one going vertically along the bone, that's a linear fracture. Most common ones you see is kind of a um oblique. So this is non displaced, oblique, I'll, I'll come onto a displacement of things on the next slide. So it's a again oblique cos it's like diagonally across the bone. If the fracture line seems to be wrapping around the shaft of the bone, that's a spiral fracture. Green stick fractures happen in Pedes because uh kids bones are bendy. So they often just break one side. Uh So in adults, we have really hard bones that are quite, you know, brittle and strong. So if, if they break, they break all the way through, there's no give there impedes the kids bones, their kids are crazy. Their bones can bend and come back on all sorts. And so sometimes they just break one side and that's a green stick. You can also get buckle, um, fractures or torus fractures, which is kind of like the edges, kind of buckle out a bit like, um you know, you see those trees with like the bits of bubs on them, it looks like that you call it a Yeah, trying to think of other. Yeah, there's just like straight bubble at both sides, straight and comminuted fractures is where it's kind of just smashed. So there's lots of different pieces. It's not just broken in one place and there's two separate bits of the bone, it's just all smashed. There's lots of different pieces the other way to describe fracture. So once you've described kind of the direction of the fracture line, you can then describe whether it's displaced angulated or rotated and a lot of the time it doesn't really matter where. So it matters where the fracture line goes from two if it's intraarticular or whether it's just like through a sh the shaft of the bone. Um But it also matters how those two fracture lines are in respect to each other because if you think about it, if, if you've got a fracture like this, it's, it's never gonna heal because these two edges of the bone aren't touching. So it's not gonna heal or if it or if, say like this one, if it heals like that, it's always gonna be have a deformity to it. So this is the bit where orthopedics, you know, need to come in and fix it or we, you need to manipulate it. So to describe it. So you're displaced is basically how far apart are the two fracture edges? So are they touching each other? Are they touching each other a little bit or are they miles apart? So are they non displaced, mentally displaced, severely displaced? You know, we can talk about degrees of it, but basically, are they touching angulation? So this is where, so these fracture lines aren't displaced really cos they're touching each other, but this bone's heading in this direction and this bone's heading in this direction. So that means it's really angulated. So there's still quite a significant deformity there and there will be some, um it's not ideal for that fracture to er fix itself in that place. And the other thing that can happen is rotation. So um here if you look at this X ray, this knee joint is pretty straight head on. So you, you, the knee is very front to back. Whereas if you look at the ankle, we're looking at it from a side on view. So this is kind of looking at the patella would be here. So that's ap so like anterior, posterior, this is very much lateral. This is the calcaneum on the side. So this is very, this is ro rotated 90 degrees. Um and a lot of the time you'll see that clinically. Um or, but sometimes it might not be that obvious, but you can see it in radiologically. So they're the different words to use for that. So hopefully, you know that we can appreciate the difference between displacement angulation and rotation. So when you're describing a fracture, if you can include all of these different bits and also whereabouts it is, then you've done a really good deer deer description. And so for example, this one, if we said so there is a severely displaced transverse fracture through the, you haven't got the whole thing. But if we said the distal shaft of the radius and ulnar, um, then, you know, you've described that really beautifully brill. So classic histories give classic X rays and you'll see this in A&E. So if you have a patient who's had a fall, so see fa fall onto outstretched hand, they're most likely to have a collie's fracture. If they've come over a bike, I find, I find this quite strange that Smith fractures are a bit less common. Co people fall on the back of their hands or no, normally they come off the handlebars when they're riding on a bike, you'll get a Smith fracture. Um, cos most people normally put their hands out in front of them and they fall, not like that. Which would be weird. Um, el, if so, if you've got an elderly, um, er, patient who's had a fall, unable to straight leg, raise their legs shortened and externally rotated, you worried about enough. You've had a, a rugby player come in after they've had a tackle, most likely a posterior shoulder dislocation has been pushed back, fall from a height onto your feet. You're worried about Liss Frank inversion injury of the ankle, worried about your fracture, the lateral malleolus. So this does ring true for clinical practice. Um And if you think about it, it's just mechanics. So if you think about what muscle attaches or what tendon attaches, where if you've moved it in an abnormal way, what bone is under pressure, which way is it gonna go? And so you can, you can figure it out if, if you get a good history from the patient, normally, you know what you're looking for, just a quick note on management as well. So as an fy one, your, your kind of role particularly in A&E is to check the neurovascular status, prescribe the analgesia and refer to orthopedics if you think the patient's gonna need surgery. So you see the X ray and you think, oh, that looks like a right mess. Um They're gonna need to fix it, then you can start getting things prepped for the surgery. So get the patient, an E CG, get some blood group and save all that kind of thing so that you're, they're ready to go to the theater orthopedics will love you for that. Um, and actually this is a really good area to get experience a lot of the time. Um, foundation year can be a little bit frustrating. You feel a bit like a, you know, you know, jobs monkey that just does tt like, er, discharge letters and, and you know, just on ward round, typing ward round notes. But actually if you've got a patient who's, you know, particularly in A&E um you can actually get really hands on, learn some new skills by, by like pulling joints, relocating joints, things like that if you ask people are keen to show you. So if someone comes in with a shoulder X ray, don't uh you know, shoulder dislocation, don't just, you know, hang in the background and say, oh can I help you relocate? Oh, can you teach me how to do that? Um And if you do make a note of it and write it on your portfolio cos that's showing, you know, interest and being proactive. So it's actually, you know, the good bits of the foundation. Ok. So that's just a quick, you know, general talk, then I'm just going to talk about specifics of different areas of the um some different areas. So, teeth, I've just thought I'd cover because I don't know, I've never got taught any of this really in, in medical school. Um, and then suddenly you're in A&E, someone's comes in with a punched jaw or, you know, mouth pain and, you know, and you know, pain at tooth, a toothache, wondering why they haven't gone to the dentist but they are, they're sat in front of you so you're stuck with them and then you, you order one of these and you think, oh my God, what the hell's going on? So I just thought I'd talk you through, first of all, how to numb teeth. So that when you inevitably have to call max fax and ask for help, you can describe what you're talking about and also just AAA few things just to not miss. So first of all, when you're trying to numb teeth, so if you spot an abnormality, um, near the teeth, it's important to be able to number them. So you split the mouth up into quadrants. So you've got the upper left, upper, right, lower, left, lower, right. You have your incisors, er, your 1st and 2nd incisors, your canine, so your big pointy ones, premolars and then molars. So, um, your, the difference between your premolars and your molars is that your premolars have like one root, whereas your molars have two. That's it. I, I'm not a dentist. This is very low level knowledge. Hopefully not of you have done dentistry before and uh you know, wincing here. But anyway, so that's, you know how to name the teeth. And then if you wanted to describe, say this tooth, so you could say the upper left canine that would be fine or you could say upper left third and you can abbreviate that to UL three. So if you're on the phone and say, how do I say down here, you see an abscess down here, which I'll show you what that looks like in a second. So you say, oh gosh, it's an abscess here. You can say you can be on the phone to max for who I need to discuss to and say, as you can see a periapical lucency in LR to lower right, 12345 and six are missing, but we still count them. Otherwise it gets too confusing seven. So LR seven per usually around LR seven and that is well above what you need to know. Ok. So if it's got anything, use the system and ask for help. Now, things not to miss is obviously, if someone comes in a lot of, you know, the typical thing, someone's been been in a fight, punched the jaw, got swelling over the jaw fine. We want to know if there's a fracture. So again, we're following our lines all the way round. Nice and smooth lines, line, line, line, line, line interruption here and we see a loosen fracture line going through here. So that's fine. We've got fractal line. Now, this one, if you can see is it, it is interacting with the root of this tooth. So that's technically an open fracture as well. So I would say open fracture of the left hemi mandible that interacts with R so I think it was right. We got this is the middle teeth. So middle teeth here. So l so this is left, so ll one um I can't remember 123. Yeah, so that's an open fracture. The other thing I was saying about dental abscesses. So you can see here normal tooth roots, normal bone. So it's just kind of like really dense bit of the tooth and then normal kind of bone appearance we move on to here. Can you see this black, there's like a black kind of halo around this um tooth root. So that is a, is a apical lucency, which is, which is an abscess. So that's a dental abscess here. You can see the patient's er got retained roots. So they've lost the crown of the tooth here. So these are just like bits of roots sticking in that they haven't come out yet. I mean, again, we've got this lucency, here's this kind of halo here and so there we go. So we've got some dental abscesses. That's what uh now you're seeing them, you know what they are. And the other thing to check as well is um checking the dislocation. So, again, we're following our lines round and you can see this is a normal articulation here of the condyle, er mandibular condyle and see here we're following it round. And actually there's another line crossing here which isn't here. So this line here shouldn't be touching this line here. And over here it's overlapping. So this is actually an anterior dislocation of the left mandibular condyle. This is post reduction. So you can see before and after it should be like this, it's just articulating nicely with this joint here. This one's overlapping. So that's another thing. So they're the kind of three things, three main things you'd be looking for. So you want to see if there's a fracture. Is it, is it touching the teeth? If it is, it's open and they'll need antibiotic cover dental abscesses looking for these LCEC and dislocations, just check your um your joints, 12 wrist. Um So going back to those classic histories just to remind you of cos these, you'll see loads. So Collie's fracture. So this is where a patient has fallen onto their hand. So if you think about the, the mechanics of this, that all their body weight is being pressed through their hand as it hits the floor and so their hand gets displaced backwards. So you get a fracture through here and then this bit gets angulated. So it's dorsal angulation because it's all the pressure weights going through the hand. So the front, it might not look particularly er displaced there, you can see a fracture line through here, but once you get the lateral, you can see it's dorsally angulated there and you'll normally see some kind of visual deformity. This is the kind of a weird one normally like going over handlebars kind of history. So, again, looks very similar on the um on like the front view, but when you look on the lateral, you can see that it's gone the other way essentially. And this is like the dinner fork. So if you think of the little fork, it's like Benz, that's a deformity. So that's your Smiths carpal bones. So when you're looking at these ones, remember you, you do, you've got your carpal bone. So although you've spotted this, you need to review all your carpal bones. Now, realistically, you're not gonna remember all the carpal bones names. I don't expect that, but the one you cannot forget is your scaphoid. So this is your scaphoid here. So everyone worries about that because there's a lot of litigation cases to do with um Ekho fractures. And normally there's some kind of um process that, that if you're suspecting one, they need follow up even if you can't see an injury on the first x-ray. Um, but one thing to help you is be aware that you can actually get dedicated scaphoid views. So if you're worried about a scaphoid fracture request, scaphoid views because you get these really nice zoomed in um x rays. And actually what the radiographer will do is get them to kind of um deviate their hand more like ulnar like towards the ulnar and it just opens up that joint space. So that when the X rows go through, you see a lot more of the scaphoid. So one thing I would say is if you worry about a scaphoid fracture or uh you know, ask for scaphoid for use and then it'll make cos this, it's the same patient that fracture is, I know you can see it there, but it looks so much more obvious on the scho you. So make your life easy, older escape fight, shoulder, um, shoulders are, are tricky. Um The anatomy is quite complex, quite um a complex joint. Um just because of the mobility. So not many joint, you know, it, it's the most mobile joint that you have cos it's, it's not really, um there's not much contact between the humerus and the glenoid. It's all through these um the shoulder joint capsule and all these ligaments that may mean that it can be so mobile. So it's quite complex. Um Just a reminder of, of your anatomy which helps you when you're looking at the x rays, you've got your clavicle coming across, which makes you acromion, your glenoid is what your um humeral head sits in. So that's what, so this kind of like shallow articulation here is what you're looking for. Got your scapul behind and obviously your humeral shaft coming down lots of different ligaments. I wouldn't worry too much about knowing all the different ligaments, but the key one is this one here. So that's your ac um ligament. So your premier clavicular ligament and the reason why we worry about this is because of this injury. So hopefully you can all appreciate um that you're clavicle normally. So as we see on our normal anatomy, clavicles should come across and be in line with your acromion. And here it's or straight away, we can see it's flying really high and it's nowhere near our acromion. Now, the way to kind of um on the shoulder X rays is you need the, the, the inferior border of your scapul of sorry of your clavicle to be in line with the inferior border of your acromion. If there's any um interruption to that, you need to worry about an ac joint disruption. Ok. So that's one thing just to be aware of always would be, you know, you're reviewing your bones, there's no fracture here, there's no actual bony injury, but there's a ligament, serious ligament injury here. So you need to be aware of that. The other thing as well is you do get a kind of a, a quarter of a, a chest X ray. I've got a bit more on this one, but you do get a bit of a chest X ray. Um and you can pick it's quite common actually to pick up lung pathology on shoulder films. So if someone's had trauma to the shoulder, they could well have rib fractures. So you can pick up rib fractures. But also if you've got rib fractures, there are a potential risk of pneumothorax. So don't miss a pneumothorax on your shoulders. Always review, remember, review the joint review, you know, different lines in the um and you know your soft tissues, whatever. But also do look at that lung, check your ribs, make sure there's no sneaky pneumothorax that you're missing. So this one, I've been a bit naughty here actually, cos we've only given you one view. Um but hopefully can appreciate that this, your glenoid and your humerus are not touching each other. So you'd want a second view to confirm this. But um here this is the articulating sur of the g uh of the humeral head and that should be over here. So that's um a dislocation probably anterior. Um This one again, it just looks a bit weird and hopefully you guys have heard of the light bulb sign. So you can see here that it's, I know it's dislocated, but your humeral head is like a bit like a walking stick. So this is like the handle of the walking stick and it's the shaft going down here. It's not like a walking stick at all. It's like a light bulb. So that's your posterior um dislocation much less much less common. And these are the ones you see cos your shoulders, uh it it's less resistance anteriorly, but particularly with this history, you would be worried about um some kind of seizure. So it's inviting, you know, urine incontinence, that kind of thing, you have to have a seizure and that's or electrocution is the other one as well where you have really strong forces pushing your shoulder, pushing your shoulder backwards. So we go, that's the light bulb. Sometimes you do actually get this kind of like the glass bit of the light bulb effect, um which we haven't got as much on that one, but there you go. But you, if you got given these X rays, the first thing would be, where's my second view? And then the, the, you know, they need a an orthopedic review, the knee reduction. Well, this one's gonna want to have a stab at this one. So 18 year old fell onto his arm while playing football. What can you spot? So see if you can use those words, I was describing earlier, just fires some buzzwords at me. What would you say on the phone to orthopedics or what would you say to your registrar or what would you write in the notes? Brilliant. So immediately it's gone transverse humeral fracture. Is there anything else you could add to that? So agree. It is a transverse fracture, transverse humeral fracture. But if I was gonna draw it, what else do I need? So, is it angulated, displaced, rotated? You might not be able to answer those display. Yeah, absolutely displaced. I like that. And the last thing I want to know is whereabouts? Anatomical neck? Yeah. Brilliant. Fantastic. I can draw that now. Fantastic. You guys have been listening. Yeah. Proximal shaft look fine. Or um on top of the neck. Yeah, that's fine. Brill. You guys are listening. That's good. So, elbow, we're nearly there. Uh elbow fr elbow radiographs. Um The key thing which I want you to take away from the elbow section is the fat pads. So if you haven't heard of this before, uh this is kind of like the biggest tip you can get for when looking at elbows. So normally, so you have two fat pads in your elbow one anteriorly one posteriorly. Now, then if you think about when you bend your arm, this bit of, so this is your ulnar here and this is your radius here, this bit of your ulnar when it gets bent. So this bit comes up here, this bit will go into this fossa here and you have a little bit of fat that just kind of cushions that process. You also have one at the back for your electron on here. So when you straighten your arm, this bone comes around here and you have a little fat pad here that cushions your Lecrone. So normally this this bit of um this fossa cos this bit of bone is much smaller than this bit of bone, this fat, this er fossa, the coronary fossa is quite shallow. So this fat pad kind of peaks out a little bit. Sometimes it's, it's nice and smooth. It kind of goes in the line with the bone a little bit. But you can see this little fat um black triangle here. Now, the posterior one you can never see because if you see the size of your um the bone here when that straightens out, it's got a lot of areas here. So the fat is always hidden in a normal elbow. So you never see a posterior fat pad in a normal elbow as soon as you see a black sliver. So that fat pad sneaking out in the back of your humerus, you need to worry about a fracture, ok? You might not see a fracture line. That might be the only thing you see. But as soon as you see that there is a fracture in the elbow, ok? And that is because there'll be a big ef effusion something's fractured and the fat fat is um goes on top of the, the blood. So you get like a like a lipoma arthritis. So fat goes to the top a bit like, you know, if you have oil in a pan of water, it goes to the top, the same thing. So you get fat around the back. So this, this one look first of all, it does look a little bit bulgy compared to this one, but the fact that you can see the back one, you've got an effusion you'd be worried about and a called fracture. So treat it as a fracture. Ok. So that's pleased to take that away. The other thing to be aware of is pediatrics. So peds, radiology super hard and particularly in the elbow. You might look at this elbow and think, oh my gosh, massive like, you know, there's loads of fracture lines, loads of bits of bone fragments. This is actually a normal pediatric elbow. They are an absolute nightmare and there's just lots of different ossification centers. So as your bones growing different bits grow at different rates, bits ossify at different points and um growth plate plates fuse at different times. So as a child gets becomes mat um skeletally mature, different lines appear different lines disappear, different blobs appear different blobs disappear and you just when you're on foundation, you just need to be aware that there sometimes are funny lines that are normal. So here this is normal, there's all just different different ossification centers and there's no actually no fracture here. I would just be super wary about saying there's, you know, no fracture in here when you've got lines that you're not usually looking at. Um OK, so just yeah, pea is tricky. I would just say always ask for advice with that to describe different fractures in different parts of um bone. So if you've got an adult bone, it's quite nice and easy. You've got the shaft or the diaphysis and you've got the kind of bit at the end, which is the metaphysis in pedes, you have different areas. So, because you, we've added an extra bit in of a growth plate, you have the diaphysis metaphysis. The fines is, which is the growth plate and then the epiphysis. So there's just different, these are different words. I don't think you really need to know this. But if you might, you just, so you've kind of heard these words before and if you see them in a report, you can know what it's referring to. So the er defy is the shaft metaphysis is kind of the widening bit, that's the growing bit. The pis of the growth plate, epiphysis contributes to the joint. And then if you hear of apophysis, that's the second ossification center where a ligament attaches. Don't worry about that too much. Just so you've heard those words before. Um what you might have heard of those, the Salta Harris and that's kind of what this is relating to. So particularly when we think of the the growth plate, salta Harris fracture. So depending on where the fracture is in relation to the growth plate, you can call it different salta Harris um types. Again, this is more of like a thing for finals in real life. You will hear it if you do know it great, but it's not gonna kill the patient if you don't know it. Um But just uh if orthopedics talk to you about that, that's fine. Ok, Pelvis again, lines is probably your biggest friend in Pelvises. So this um picture it is actually really, really useful. So these are the different lines you want to, to check. So check obviously all your iliac bones and your sacroiliac joints, don't forget the lumbar spine in the middle. You might see a ver a vertebral fracture or something like that. And then when you come in, when you're particularly worried about your neck of femur fractures, you want to check the acetabulum here, is that not as smooth, there's no crazy fracture through there. You want to trace the pelvic ring. So there should be a line all the way round and no interruptions to that. Again, with your obturator foramen, when you think about pubic rami fractures, this should be all really nice and smooth and able to trace shen's line. So if you follow the line of the femur going upwards, it should make a really nice continuation with the, the neck of the femur and into the obturator. So that's a really, that's a really important line. And again, one which isn't on here is this line here as well. So I would do the same on the outside of this neck going into the femoral head should be really nice and straight. So pelvic, pelvic x rays, it's just a game of lines, just keep on following them all the way around. So, this one, if we're following it round, so we could start over at the spine here. We've got, you know, first four bodies quite tricky to see. Got sacroiliac joints here. No problem with them. Iliac bones. Fine. No kind of avulsion fractures around here following all the lines around line of the pelvis going all the way around. Absolutely fine. No, look noticing bowel gas and things like that. Normal following. She's line going up and around, no problems on this side, but here they're all going up. Well, there's something going on here and it's not following the same way around. It's a bit like awkward to follow. And again, if we've compared from this side, nicest new line, this side, it's completely not over. So this is the left uh me feur fracture. Ok. So it's just getting blind again. Don't worry about the classifications too much. More of a final thing. Um The main thing that the orthopedics will want to know is if it's intracapsular or extracapsular. So anything to do with the neck, um, if you draw a line kind of across from your Tantus, anything higher than that is intracapsular. Um, anything past that is extracapsular. Um And that's, this is the reason for the, the difference is it changes management. You don't have to worry about that too much but they, that will is just the kind of the main thing to know different ways to fix hips. So, we've got a total arthroplasty hemi arthroplasty. Got an iron nail dynamic. Hit screw again. Don't worry too much about, you know, that's not your job, that's orthopedics job to know what they're gonna do and to do it. The thing you need to worry about is if you get a patient coming in who's had one like this, just check and be really cautious saying, oh, I've had a hip replacement. Oh, it's metal, you know, surely nothing can go wrong with that. You can get some really nasty peri prosthetic fractures and these are really, really nasty um orthopedics, they definitely want to be want to know about this soon. Um Cos they'll need like revision, really complex surgery to fix these. Um It can be quite tricky. So for example, if I go back to this one, you can see the fracture line from, you know, the initial injury. And if that patient comes in again, you know, say they've fallen again and they've got hip pain on that side and you look at that and you think, oh my God, is that a fracture or is that the original fracture always just compared to the original? So hopefully with the patient hasn't been, you know, gallivanting across the country and you'll have access to the old images. So if you're in A&E bring up the old film, look at what the old frac the original fracture was like and then compare it to this. If it looks the same, it's probably ok. But if obviously if it's like this very wrong or even like if it's changed a bit, so always compared to the previous for these ones, cos they can be, can be quite difficult, just be aware of that. Well, the ankle, ankles are um quite tricky. My top tips for ankles is actually always review the base of the fifth metatarsal. So you might be worried about kind of malleolar issues, but the base of the fifth, it's actually a really common site of fracture. Um So ha add that to your review area, have a look at them, the tailor bone, I'll demonstrate that in a second and always be aware that you might need to image the proximal joint. So if you've got say you've got knee pain or you've got ankle pain, remember, pain can be referred and a lot of the time someone will have knee pain, but the problem is actually at the hip. So don't ignore um more proximal um joints particularly and distal joints. If you've got an issue at one joint, don't be blinded and and you might need to X ray. So for higher up. So this is what I was talking about the talar bone. So here we go, this is normal anatomy. You've got your tibia coming down fibula and you've got your talus here, which is kind of what it sits on this. Can you see this black line here? This is what I was talking about. So this the width between your talus and your tibia should be consistent all the way across and between your fibula and your talus. So it should be a nice even track all the way round as soon as you get an interruption to this bit, worried about all the ligamentous injury, ok? And this is your lateral as well. So for example, here, we've got kind of relatively consistent width here, but you see there's a massive gap here and compared to here, so straight away without ignoring all the fractures, it suddenly, I'm seriously worried about this joint. This is an unstable joint because we've got talar shift, ok? Um This X ray is really nasty. So we've got unstable joint straight off the back cos of this, but also we've got lateral malleolus, me, medial malleolus, posterior malle. This is a trimalleolar fracture. So this is probably like the one of the worst um injuries you can get apart from it being completely smashed. Um So that's just to be aware of and then lastly foot again, feet are tricky. It's, it, it's just following lines. It's a bit of a pain because there's so many different bones, it just takes a while to kind of go through each of the bones. Um But the thing which you can't miss or you just need to be really wary of is that history of a fall from a great height onto feet and you list Franks. So this is the way you basically, it's a um midfoot injury and the way to spot these is compared to normal. So we've got a love. This is quite nice. We've got a normal foot on the right, got a list for injury on the left. Can you see here again going back to kind of that talar um shift picture if we, if you have, if you just think of like bathroom tiles. So you've got tiles and you've got grouting in the middle and that grouting should be nice and even all the way around. Ok. It doesn't even matter if you've got a fancy pattern of tiles. The grouting should always be the same thickness throughout your joint spaces is the grout. Ok. So here got nice, lovely even grout all the way all the way through here. We've got nice even grout, we're happy with what, what's been going on, but suddenly you've got too much brow. Ok. So this is much wider than it should be. Ok. So you can be fancy and say, oh, you know, the 1st and 2nd metal base um should line up with the medial and intermediate uniforms. But essentially we've got a gap where we shouldn't. And like here we've got a normal line through here, normal kind of paving picture. Suddenly here we haven't and this is the area you want to look for. Ok. So this is, it can be really, really subtle but just really key in on those joint spaces and compare it to the others. Is this line straight down here or is there a gap as soon as there's a gap concerned for Liss Frank injury? This is kind of a buzzword. Um you know, say this phrase to your seniors and then they'll get looked at and reviewed. Very unstable. Can have really bad um long term kind of complications due to this like disability. So just tune into that when you're looking at your feet, particularly with a history of a fall from a height. Ok. We're, we're very much near the end you'll be pleased to hear. Um So general tips for when speaking to. Also, we've talked about the vocabulary, we've talked about kind of key areas, but just when you're speaking to on the phone, um these are the things we want to know. So first of all, is it opened or closed? So, remember particularly with teeth, that's a sneaky one, cos it's technically got coming to like a skin surface. But if it's, if it's interrupting with the tooth, it's open, is it displaced or undisplaced? Remember it's never gonna heal if those two fracture lines are miles apart, native or prosthetic, like we were showing you those um x-rays where you've got that really nasty per periprosthetic fracture, they're much you know, more keen to go in and fix things. Um, when it's prosthetic, um, if you're dealing with um, upper limb injuries is the patient left or right handed? The neurovascular status? That's kind of the big one. never ring orthopedics. Um, without knowing the neurovascular status, it should be part of your assessment and always document that as well. Er, so checking, you know, do doing your nerve exams, checking capillary refills, making sure pulses all of that mark. That is like you cannot miss that functional status. So if you've got, you know, June, who's 99 she's come, you know, she's come from a care home, she's hoisted. Yeah, she's, you know, got cancer, you know, she's not, she can barely hold a cup of tea. She is not going to be a great surgical candidate. Ok. So that is really useful when going on the phone. Whereas if you've got, you know, Tom, who's a rugby player who's, you know, just had an injury that's very clearly that he'll be fine for um, surgery. But those are two, you know, they could have the same injury but be very different. So, having a functional status, what is the patient's baseline? You, you're not making the decision of whether they can go to theater but you're helping them make that decision. Allergies. Um, again, basic things, but a lot of time people forget medications in particular are the anticoagulated cos that'll affect the theater. Um, and if you are doing manipulation, make sure you get before and after x-rays, um a lot of the time, if some, if a joint is out of place, be aware that once you put it back into place, fractures can often uh um not new causing fractures, but sometimes fractures can be hidden by the bone being in a funny position. So always get uh before and after x-rays check that it's manipulated back properly. Is it aligned? And also have you, can you see any new fractures that weren't visible before Brill? So fab sorry, I spoke, I, I'm glad I need to finish because I've massively gone over, but hopefully we've got a bit of time for questions if anyone has any questions. Um I can see that there's a feedback link in the, in the chart. If you could fill that out, that would be really appreciated. Um Yeah, but if there's any questions, not just about the session, if you have any questions about radiology or starting F one or anything. Thanks so much for the talk. Um It's, I can imagine it was very useful when er, well, I would have loved to have listened to the talk against F one. I def definitely didn't know anything about this frank injuries or a and very relevant for um, well, can have very significant consequences. Um If people could fill out the feedback form, it would be really useful for Becky and, and a and put in a lot of time and effort into, er, into making these presentations. Uh, and it would be really useful just for their ACP purposes as well. Um, if you do have any questions, obviously, please just put them in the chat. Um, but otherwise thank you so much for attending. Um, I'll, there will be a recording as well. Er, which, er, I'll just check with Becky and that they're happy to have it. But, um, yeah, cool. Um, so we can also put out a recording if you wanna go over anything at any point. Um, anything that you were a bit confused about or anything you want to spend a bit more time on. But otherwise, er, thank you guys very much for attending. Er, please do fill out the feedback form again and I hope you have a good weekend. Thank you guys.