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Radiology Lecture



Join this informative on-demand medical session with experienced radiology professional Zan who will walk you through a collection of highly relevant topics in radiology. Emphasizing the importance of systematic observations, Zan delves deep into the analysis of chest X-rays, including a variety of possible abnormalities and case studies. Discussion extends to the reading and understanding of abdominal X-rays too, along with a discussion of their indications and various applications. With an engaging, interactive teaching style, Zan invites questions and contributions throughout. This session is ideal for medical professionals hoping to enhance their radiology knowledge or as a refresher.
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Learning objectives

1. Understand and identify the correct methodology for reading a chest x-ray, and recognize different abnormalities that may manifest. 2. Become familiar with and able to identify signs of different chest and abdominal pathologies, including aneurysms, ischemic gland occlusions, lung collapse, and obstruction in abdominal x-rays. 3. Identify and discuss the significance of different features on an x-ray, such as the tracheal position, the volume and symmetry of the lungs, the cardiac position and size, and the presence of any foreign objects. 4. Gain knowledge on the usage and importance of various imaging techniques, including Doppler, color Doppler, and ultrasound of the screening program. 5. Develop a comprehensive understanding and ability to identify the management changes in aneurysm cases based on imaging range results.
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Computer generated transcript

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

Emery. Am I able to share it from my side? Hi, I am uh sorry, I was away for a wee second there. But um you have enough. I see you've got the presentation um open there and shared. So, what I'll do just at the end of the presentation is I'll send in the wee feedback, um form link to them so that they can fill it in and get their um slides and stuff. Yep. Sounds good. Thank you. Thanks. Hey, guys, I'm just gonna give it another few minutes before we start. I think I'm gonna get started now. So, hey, guys, I'm Zan. Uh just a bunch of radiology today. Quite a few slides. So I'll just get started. I have a few questions here and there. So if you just wanna shout out the answer or put it in the chart, either way works. OK. So this is your UK uh MLA content map and I've just highlighted what I think I'll cover today. I'll either cover it through imaging or questions in one way or the other. And just going through the presentation, uh Queens keeps uh talking about misplaced NG tube and very likely a station easy enough to get, they could ask you about indication for an NG tube. Give you a misplaced x-ray and identify that it is misplaced, easy enough osteo. Uh I'm just going to, I think uh balance is gonna cover most of your trauma stuff and fractures. So I'm not gonna do much of that and coming over the conditions. Uh This isn't an exhaustive list. Queens could very easily ask you conditions outside of this. But II do think this list covers most of what you need to know with regards to aneurysm, ischemic gland occlusions. It is mapped to different specialties. So more likely to get a question from vascular surgery than radiology. Although do know imaging for uh aneurysm know the the ultrasound of the screening program know the the age at which they start and know the uh the ranges in which management changes. And with ischemic lymph from radiology, all you really need to know is uh a bit of imaging and they use Doppler. And uh yeah, color Doppler. Uh Just a quick talk about breast cancer. I'm not gonna cover much potential cancer studies will cover most of that. And uh uh most of what I'll cover is a lot of chest physio, uh chest pathology, a bit of abdominal pathology and your neuropathology. So, if you have any questions, feel free to stop me. And so I'll just get started. Ok. So I think it's a good idea to have a decent approach to reading a chest X ray itself. Uh This is a Pneumonic IU throughout me. So on the left and yellow. So that's doctor's ABCDE. If you've done your BLS or a S, it's the same thing you see a chest xray and you have no idea what to do or what to say. Just think about your literal ABCDE. So it's your airway breathing circulation disability and others. So first when you're starting off with your uh chest X ray details, that's a, that's an easy mark. You literally just read out what you see on the film. So you talk about your name, date of birth type of film, study date. And if you see my cursor over here, any markers on the chest X ray, there's usually a side markers left over here. And in addition to that, I think it's nice to have a good opening smell spiel. So something along the lines of uh this is a chest radiograph of a 23 year old male patient who presented with blah, blah. Uh His name is this date of birth, this is a PA or an AP film. If it isn't mentioned, whether it's a PA or AP film, it's more likely PA AP films are the ones that you don't want. They're not ideal films. So APA plans not great films, you can't assess for cardiothoracic ratio in uh AP films. Uh talk about study date and time and say that you'll clinically correlate or you would compare previous images. Uh I know uh we spend a lot of time on Rala radiograph quality. So your rotation, inspiration, exposure picture, but you literally just get one mark on the queen's marking sheet. So I say don't spend more than 25 seconds at the most. Uh You can combine your soft tissues with extra at the end if not just go run through the clavicles, quickly, look at the spinus process. Uh look at the spine for compression fractures, strong verse fractures, go through all the ribs, make sure you don't miss a fracture. If you do get a fracture alongside your chest x-ray, it will be very obvious. So uh if you can't find one move on, it doesn't matter again. So go through your airway, breathing circulation and uh cardiac and diaphragms as well. Uh I think it's a very good summary slide you can use. I'm just gonna go into each of these a bit more in depth. But before I start, don't forget here, all these abnormalities on your left. You see it chest x-ray. You don't wanna be talking about uh clavicular fractures and uh aortic nerve. When you see there's a knife halfway to his chest, same thing on the right. Uh You don't wanna be drawing out shin line and talking about pelvic gram when there's clearly uh bottle up his uh a rectum. So if you see an obvious abnormality, get it out of the way and then say you will go through that systematically. You go through the rest of the xray systematically. OK. Airway fairly fair. I I'm sure you know that, but I'm just gonna run through the real quick, fairly sounded. Make sure you check the tracheal position. So all the way from the top, trace it down to the carina right about there. Look at the right and left. Main bronchi. So what you need to look at is N so I've got a checklist for you. So nice to have in mind when you're running through these X rays is a straight and midline. Any evidence of narrowing any foreign objects and is a carina wide. Now, you don't really need to worry about the angle of the carina but it, so it, it sounds like when you say it out loud, uh look out for NG tubes, look out for et tubes. Yeah, those are the main things you need to look out for in airway. And with regards to the actual lung itself, uh again, make sure both lungs are there. There might be a postsurgical patient with a lumpectomy and have no lung. So just make sure there's both lungs present, make sure there's equal volume of air in both with a lung collapse. You could have a much smaller lung compared to either side. Uh and make sure you go systematically, I'll show you a few pictures but very easy to miss things. So in our finals uh on, on the PA on the hospital day, we were given an X ray at the last minute and asked to spot two obvious abnormalities. Now, the first obvious abnormality was an ICD, easy enough to spot, but there was a small pneumothorax on the left hand side and uh I nearly missed it until I went through it systematically. So make sure you go all the way from the A PC down to the diaphragm, go zone by zone to make sure you don't, you don't miss anything. So uh just going to the checklist then, so go zone by zone. Look at the lateral margins. Is it a thickened pleura? Do you think there's fluid? Could there be pleural clot from assis? Look at the costophrenic angles. Never missed that cause they, they very well could be like a a mild full effusion. And can you trace out the cardiac arteries? So if I were to just give you uh run you through the x-rays as well? So the picture on the top left normal x-ray, you're just looking at it. Are there any obvious abnormalities? Is there equal volume? Then you're checking for symmetry in figure one and you fall all the way at the bottom, you're looking at the core angles. Any blunting is usually some sort of fluid buildup of pleural effusion. Then you check for the hemidiaphragms. Is there any uh hemoperitoneum? Is it, does it look like it's paralyzed or is the position off? Then in figure two, you can go through each zone. Uh uh II suppose when you're explaining or interpreting an X ray during colonoscopy, talk about zones of the lung as opposed to lobes of the lung. Cause I feel lobes are quite difficult to figure out during an X ray. But zones are quite clearly obvious. It's 1234 or 123. figure three. The other dot lines are on the edge of the pleura. Quick look at the pleura, then you look at the cardiac borders. Any obfuscation of the cardiac border could mean ST sign or uh consolidation and uh retrocardiac area. I don't think it's very important for ICA. So with regards to uh the heart itself, just a few things, look at the cardiac position. Look at the cardiac size, you can look at the aortic arch and hilar vessels, but not particularly, I don't think we get marks for that. So again, just a quick look at the heart, make sure it's fairly central, make sure there's no major media signal shift and uh look at the cardiothoracic ratio. It should be less than 50%. This is your aortic arch pulmonary window and in between that, you have something called the AP window sounds pretty cool. When you say it, it sounds like you know what you're talking about, but you don't really need to know all that. Uh Then you look for importantly, when it comes to disability, you're looking for any major fractures and uh yeah, any other obvious findings. Sos uh like s is emphysema stab wounds, things like that. So that was your chest x-ray. Any questions so far? Cool. So I'm just gonna move on to abdominal X ray. Abdominal X rays aren't particularly high yield. I personally think, I don't think we've ever got an abdominal X ray during an OS, but we did get a few questions for our finals. And from what I've been hearing, UK ML is fairly heavy on imaging to expect at least 5 to 6 imaging. So we got, we got two abdominal images, perhaps one NG, we got about two chest x rays. We got a neck of femur fracture. I think that's all we got. So we have five x-rays for our finals. So with abdominal X rays, similarly, you have a pneumonic on the left and yellow. So, abdo X uh run through a pneumonic. Is there air where there shouldn't be air? Look at the bowel, I'm sure you've heard about the 369 rule. Look if there's any signs of obstruction, uh look at calcification, bones, any obvious dense structures. And then you look at the organs quite hard to figure out organs on abdominal X ray. But I think during exams, it will be much easier images and lastly external objects and artifacts. So just a qu uh just indication for abdominal x-ray again, is not particularly useful except for these couple of scenarios. Uh you look at, you look at x-rays for obstruction more than anything else. And pneumoperitoneum where we do an ect chest x-ray. So this on our left is a normal abdominal chest X ray with super imposition of your organs. Uh give it a look and just be able to trace out your liver, kidneys, pain, have a good idea where your intestines are small, bone more per uh centrally and uh large bowel more peripherally when it comes to bony fractures. The main things you're looking at is spine, lower ribs and hip and neck of femur. And uh it can be quite easy to get confused with normal bowel gas pattern. I think it is an obstruction. If you go to either radio pia or gine metics, I think they have a bunch of pictures of normal abdominal X ray with different gas patterns. So have a quick, quick look at that and it gives you a better idea of normal. Ok. Just going into assessing ball a bit more in depth. So three main things, can you identify the actual large and small bowels? A couple of features are mentioned here. So, excuse me. So, you know, uh the valvula convenes or the frustration. So if you find one of those, you're able to differentiate between your large and small bowel, then any dilation of the ball uh would follow the 369 rule So basically your small bowel is uh uh sorry, you see come is three small, is six and large is nine. Then uh just the location of the ball itself, uh bowel wall contour and thickening again, I don't think we need to know it as our stage, but just for completeness. So again, so you see your large bowel frustrations and these don't reverse the entire colon. So it's like small ridges in your colon. While on the other hand, your small bowel bowel even you have lines that transverse your entire colon. I think this is a key learning point. Good to know this in general, you might get an M CT as well. OK? NG tubes, uh two methods of confirming NG tube, Ph and uh chest X ray. I think gold standard is chest x-ray depends from trust to trust. But what we need to know is we need to be able to identify a misplaced NG tube on X ray. So uh this is that I suppose the five steps to identifying that your NG is in the correct place. So make sure you have good exposure. So if your x-ray cuts off about your, your abdomen, there's no point. You cannot confirm an NG, even if you see the NG dissecting your carina and going down the midline. If you cannot see the tip of the NG in your tummy, you cannot confirm uh correctly NG. So a couple of things with good exposure it needs to remain in the midline. It needs to dissect the carina and the tip of the NG should be clearly visible below the left hemidiaphragm. And they also say you need to tip approximately 10 centimeters beyond the, the G OJ. But uh that's variable. So I have two cases with me now and if you just wanna shout out the answer but say whether it's correct misplaced or uh appropriately placed, either shout out the answer or just put it in the chart. Uh So this is just a quick review of extra anatomy. Let's see your trachea, right and left main bronchus. That's the carina. So your uh and you should pass all the way split your carina, go below the diaphragm and come into where you see the gastric bubble. So that is your case one. Do you just wanna put it into the chart? Whether you think this is a correctly PN G or not? Give me a second the stuff. It is correct. Indeed. So, so as you rightly said, just trace down the ng, it goes through the midline, it bisects the carina right about the, it goes well beyond the diaphragm. You see the gastric bubble here and is well within the stomach. So it up this is case two a bit more obvious. But do you think it's correct or incorrect? Yeah, absolutely. It is a pretty incorrect I'd say. So I think this is into your left bronchus at this point and uh I think it's quite obvious that you need to take this NG out. You cannot be feeding with this NG and Yeah. Right, right, right around the corner. Good stuff. So I think it will be quite obvious when you do have anything in the exams. So don't worry like you're not gonna ex you're not gonna be expected to know much. So just basics will be fine. Uh Just another slide on this place in GT which you can look at in your own time. So I'm just gonna run through a few chest pathologies. Uh We can do this either way I can just run through them really quick or I can give you a second to look at the image and guess what it is. So again, feel free to shout it out or just put it into the chart. So what do we think this is, I'll take descriptive words or diagnosis or anything really? The quality isn't the best. So I do apologize. But uh Yep. So this is pneumonia indeed. So on my left, you have a right middle lobe pneumonia and on the right, you have atypical pneumonia might be lesion. I'm not, I'm not entirely sure, but we did have a patient in third year with pneumonia and we had to talk to the X ray, the os you causative organism, they ask you what the curve score. So it is a common enough and the way you describe pneumonia is if you describe what you see, so you see a bit of haziness here. So it is opaque. So you can either mention that there is a region of opacity on the right lower zone of the right lung or you can mention, for example, on the left one, you say this patchy consolidation bilaterally. So quite literally explain what you say and consolidation. Uh pneumonia aren't interchangeable terms. Uh consolidation just means there is an area of infection, fluid pus or whatever in the lung. And it's just uh so it doesn't necessarily mean it is pneumonia 10 out of 10 times. But you will get a history of saying the patient was coughing up up green phlegm and they short of breath. So clinically correlated at most consolidation is pneumonia. So just a key point about the terminology and for pneumonia, in particular, the signs you see are bronchogram to add bronchogram are basically just your alveoli, which is air, uh which is filled with pus of fluid on a background of an airless lung. So you see you see those streaks and that's what we call air bronchogram. That's more specific for your uh pneumonia as a uh just just to be clear between consolidation and pneumonia and pacification. Uh you can use the term consolidation or pacification fairly interchange of art to you and that should be fine. Oh, yeah, I guess you've seen. So this is a spontaneous pneumothorax. I think queens particularly love pneumothorax. So you will potentially get them as an osteo. We got that as an osteo station in our fourth year oscopy. So it was a patient who fell secondary. So, pneumothorax secondary to trauma. And the key learning point from that OSK was to either identify whether it was a spontaneous pneumothorax or a tension pneumothorax. Uh In that station, we also got a question with the head ct. So two imaging in one radiology station. Uh uh I think pneumothorax are easy enough to miss a couple of things you need to look out for are there will be zero lung marking. So, on, on the right hand side, you see some sort of pulmonary vasculature, some sort of veins or arteries pre branching. You will not see that on the left hand side, it is pure block. And if you look all throughout the lung, there is no lung marking at all. And you might also see the collapse. You might see the, the visceral pleural edge I which I believe is if I might be wrong. So that is how you identify a pneumothorax. And uh how do you differentiate between a spontaneous pneumothorax or tension pneumothorax? That would be a tracheal position. So, if there is tensioning, so a lot of pressure from the right hand side, which causes mass effect, that'll push the trachea to the other side. And this is opposed to a lung collapse where your entire lung has collapsed And since it's dead space on your right or left, the trachea is pulled towards that area. So tension pneumothorax is push away the trachea and lung collapses pull in the trachea and in a tent in, in a spontaneous pneumothorax, fairly, fairly central, no real change in tracheal position. Uh I have enough of that. OK. OK. This one, can anyone tell me what this is? Just put it in the chart? Uh So this is attention pneumothorax. So I appreciate the images on the best and the slight rotation. But if you look at the one on my right hand side, there is some obvious tracheal deviation and you can see the plural edge quite clearly. That is a tension pneumothorax. So you look at the lung, no lung markings, p perhaps the vet edge and then you look at the trachea, there is clear deviation towards your right. That is the tension uh the one on the left, not the best image quality, but I hope you can appreciate the trachea being pushed into the left. So just a few points, this is a CT image. Now, you're not expected to notice it, but just to give you an idea of uh the amount of air that is pushing the trachea into the other lung, you might also get some media sign of shift of your entire heart and all the vessels around the heart being shifted due to the pressure from the other side. OK. Uh Yeah. II don't think it's particularly high yield for radiology but it just again for completeness, mistake, all you need, all you really need to know is a sign, ring sign. So that's a sign you see on x-ray, I'm sorry, on CT, you might even see it on x-ray, but more likely to see it on CT. I feel like I've done a few questions and the signet ring signs come up. So that's why you need to know and got a bunch of notes there if you want to read it later on. Uh Yeah, for x rays, what is high yield is a crown tract sign? So it might, you might also see a a fluid level and uh these are the crown Lantus is just a rep representation of tr tracts and your uh dilated bronchi and bronchiectasis. So, not a whole lot you need to know, but just be able to recognize the X ray itself. Ok. Can anyone tell me what this is not for this? I'd be impressed. So this is not a pneumothorax. I know the exposure is a bit weird. Does anybody wanna give it a go? Perfect, right. So it is indeed bilateral hilar lymphadenopathy, which would mean it is most likely sarcoidosis again. Um They're not gonna give you this in a because I think it's particularly hard, but I think it is fair question for MCQ S. So just be a, this is the high limb. I didn't know about the longest time. So this is a high limb and this increased density in the high limb is as almost calcification like that is your increased uh that is your lymphadenopathy. So just be aware of that again, high, high, that's all you really need to know. This is the next image we had this in our third or fourth year exam. So if I'm not wrong as an MC two, so what do you think? This is, what do you think the diagnosis is? Uh I I've really given it away but sure, uh is wanna come in with the cha Perfect. So it is a pe indeed, this is a saddle embolism if you do get any ct of a slice of the lung. My bet is that it is a pe even if you have no idea what you're looking at, even if you cannot identify the sad embolism. If they've given you, what sounds like a pe and given you a ct chances are that the answer is had embolism. So just have a quick look at it. You don't even be able to interpret it or present a ct a few things like this is good to know. Ok, heart failure. Uh I think important x-ray, they can easily give that to you on your hospital oscopy day exams or even your oscopies. Uh, just a bit behind the pathology. So most of the signs you see are due to increased heart size pulmonary edema, leaky vessels and uh redistribution of the fluid itself. Uh Just a, just a bit, a bit of a note if you wanna read later on. But again, another ABCD, I know there's a ton of ABCD ES. But uh it's particularly useful for heart failure picture. So you classically see your baling opacities and I think that's what you will get in. Either your M CQ or an OS will be quite clear. You might also cla you also classically get per B signs. Then you look at your cardiothoracic region. You, you tend to have some cardiomegaly, dilated upper lobe vessels, hard to identify it. I wouldn't worry about that. Uh You can also get a pleural effusion to look at your costophrenic A. Uh This is an X ray showing you heart failure. I know it, it doesn't particularly look like back wings, but sure use your imagination. So just this uh patchy area of patchy consolidation in the media lung. That's what we call uh ba ba air, air, air space, shadowing, just fluid leakage. And you look at the costophrenic angle, there's bilateral blunting. So there is a small eus as well. Uh this post surgery. So you have some sternotomy wire, uh look up for wires, clips and surgical uh surgical clips. So we had a question. And so yeah, I think it was a, I don't know what it was perhaps post uh uh post breast cancer surgery. And there were clips on the breast and how you figure out the answer. So look at the whole picture and these are your septal curly bee lines hard to appreciate, but just look at the lateral aspects of the chest structure and you may you may be able to find the curly bee lines. OK. Uh Quick M CQ break. Does anyone wanna put it into the shot or give me a shot? This image uh I appreciate not the best image, but that is correct. That is indeed free air in the abdomen. So you see your pneumoperitoneum bilaterally and that is your major finding on this x-ray. Uh If you have no idea what you're looking at, uh try excluding things. So is there ane on the left? There isn't hemi diph looks quite fine although you might be mistaken that it might be raised. Uh Again, I can appreciate what you would think is consolidation but no real pneumonia. There might be, but it is a single best answer after all and no fractures as well. OK. So moving on to abdominal pathology then uh just get used to looking at images of small bowel obstruction, large b obstruction. So this is classically your small bowel obstruction, quite central, quite dilated. You have your posture, which you can see these are a few of the features, sorry, valvulate, counter, not yours. So these are a few of the features of a small bowel obstruction. And uh these are a few other features of a large wall obstruction. So you see ho administrations instead of your valve, even that would be your key giveaway and it will usually be more peripheral than central. We had a question on Volvulus this year in IMC Q. And I suppose the only thing we really need to know is the difference between a sigmoid, volvulus and a cecal volvulus. So position is a good giveaway. It's usually the left lower quadrant of sigmoid. If you look at you think about the position of the sigmoid itself. So it is gonna mimic that in the X ray. And and other thing is with sigmoid volvulus is you have your uh coffee bean sign. So we had a classic coffee bean picture. I'm pretty sure it was the first picture. If you Google search sigmoid valvular, that's the first picture you see on Google images is what we got in our exams. So do you wanna tell me which one is which? So let's start the with the one on the left. What do you think that is, that is indeed a sigmoid. So quite obvious picture. So in your exams, it will be fairly obvious but easy to get confused between a sigmoid and sequel. That's how you do your mark. But yeah, that's the coffee bean and another sign you need to know for your exams. Hm, not particularly high but good to know in ulcerative colitis, you get a lead pipe colon that is your bar and enema uh that's a few X rays. So you see this uh a pattern looking quite like a lead pipe would uh would make you think of you see and other X ray now, sorry and other MCQ. So this is a barium swallow study. There is a classical sign associated with this condition and that's what I'm trying to represent in this barium swallow. What do you think it is? That is Crohn's. So that is cancer string sign? Perfect. It is indeed cancer string sign. And yeah, it it is more than more often than not as just a spot diagnosis. But if you have no clue, look at the history, the history is quite Crohns as well. So uh look at the history correlate with the imaging and you should get the M CT. OK. I know I haven't gone through a ton of op pa, but I thought those were important. You might, you very well might get other things, but just moving on for a time. So with uh neuropathology, they've given us uh head CT S in fourth year. We also got a station with a subarach in fifth year. And the question there was the type of imaging we'd use so broadly. If you look at radiology for you get MS in three ways or other two ways, they can ask you a question, they'll give you an image and ask you what no, three ways they're gonna give you an image and ask you for obvious abnormalities or they're gonna give you a short history and some sort of image and ask you for diagnosis. And the third type of way they're gonna ask you a question is they're gonna describe a condition and ask you what the next best imaging is. And II think that should cover most of your radiology or imaging questions. So with neuropathology, key points for neuro uh new neuroimaging is your extradural versus subdural. And you, you guarantee a question on this either then to cure all case. So there is a, a very classical history for your extra D where they have a lucid interval and it is either it's classically, your young patient who's had head head injury gets up, goes back home is completely fine and then they have a severe headache or they lose consciousness or they get confused. On the other hand, your subdural hematomas, you usually have a steady decline of consciousness. So that is how you differentiated on um history alone. Uh Another common question is they might give you an image or they might give you a history and ask you what the injured uh vessel is. So, Ed H is your middle meningeal artery, subdural uh usually tearing of the subdural uh bridging veins. Uh This is a quick picture of an Ed H and a subdural. I found the lamin and banana. Uh uh Yeah, II found the ba lemon and banana thing to be very, very helpful. So, extradural looks like a lemon and subdural is more banana crescent shaped fish. That's all you need to know. So that's few of the radiograph features. So if it's all you get off this in and I think all they want you to do is a squat diagnosis. But if you mention, oh, there is a lentiform shaped uh hypodensity on the right hand side makes you look pretty slick. That's about all you need to know and just your treatment as well. I think we got treatment in our fine again, just uh the MRI it, the CTA itself and just a representation of the crossing of the suture lines versus no crossing of the suture line. So that gives you an idea of why this is crescent shape and why this isn't crescent shaped and why you haven't used an interval and why you don't because the mass effect uh I'm talking a lot, but all you need to know is this image and nothing else and you should be fine. Uh A sub is uh more of a MCQ for neurology, but you could very well get an image. I'm sorry. And finally, your osteo subarach hemorrhage, not uh not your DH and uh subur so that is your subarach hemorrhage. Just be familiar with the picture. That's all you need to do. Uh I don't think this is particularly common, but I've seen this on uh a post med, so be able to identify a Vestar scleroma. So if a patient presents with the tinnitus and your ent symptoms and show an MRI like is it is a vessel stoma? We did get a question about a patient with a vestibular stoma sounding history. And the question is, what imaging would you do? So, always remember it is an MRI and not a CT. So it is MRI of the cerebral called pontine angle is your investigation of choice. That could be an NQ question. Potentially queens do repeat a lot of questions. So uh just be aware of that. And if you do get bilateral vs normal, I think of your uh N FTS and stuff like that. And other important spot diagnosis is your hyperdense MCA sign. We might have potentially got this on one of our MCTs. But again, all you need to know is if it's a stroke sounding history and you get a head CT, it's most likely a stroke or if the osteopor the sign, it is a hyperdense MCA sign. It's just this bit where the red arrow points. That's your hyperdense MCA that usually represents some sort of occlusion or some sort of stroke. I'm just gonna run through a few things real quick. Uh Breast cancer, all you need to know is triple assessment, what triple assessment entails and just know that mammograms aren't particularly useful in young women of giving you a little bit about the breastfeeding program. Itself. Uh There's multiple views when you're doing uh breast cancer, you have your RM, you have your head, uh your cc you need to know all that. This is just showing you a mammogram or what a mammogram looks like and what uh a nodule or potentially malignant nodule looks like in breast cancer. But you actually do not need to notice. Again, this is a random possible question I got. So I just put it in giant. So tumor known as the soap bubble sign. I don't think it's particularly high yield. Again, I don't think this is particularly high yield as well, but this was a possible question, potentially. So Robert J spine seen in hypothyroid, a hypothyroid. Uh This is a CT scan of a patient with autosomal polycystic kidney disease. So just be able to identify this on um CT or ultrasound. Again, I don't think it's a particularly high yield uh gallstone. This is high yield. Two things you really need to know with G gallstones are your acoustic shadowing and your twinkling artifact. So if you just follow my cur here, this is this. So we here is a E block chamber is your gallbladder. These are your stones and right behind the stones you follow with pressure is acoustic shadow. So when the sound waves are coming in, uh the stones are opaque radiopaque, so they block, they block the radio waves and that you get a shadow. That is your acoustic shadowing. And if you use a color Doppler so that you see the vessel flow, you might get a twinkling artifact. Know when they use ultrasound for gallstone, know when you use a CT for a gallstone and generally know management of gallstones quite well uh regardless of radiology or not because those are common questions in the U Kla, this is a Polycystic Ovary. Just it can be able to identify the ultrasound because I think when we did, they met, they had a bunch of images and this was one of them. Again, I don't think you particularly high yield, but it's good to know. This is the sto uh snow storm appearance of a complete high form mole. This is the ring of fire sign which you see in an ectopic pregnancy. And the the the imaging of choice in an ectopic pregnancy is your transvaginal ultrasound scan. I think for most things in gyne, if you have no clue what the imaging is, it's likely a transvaginal ultrasound scan. So that is your adult pregnancy that ring off fire. Uh just a few points of rheumatoid arthritis. So just not dissolved by your heart. They are very well might ask you that as a question, your uh count strength sign, which we covered uh double bubble sign, the the no atresia pediatrics. Good to know. OK. Uh a few rapid fire questions. I'll give you about 10 seconds for a question. Just put it into the chart. The first thing that comes to your mind. So common lesion on the lungs. So this is the lesion itself. What comes to your head? What are you most worried about? Uh either shot it out or just put it a shot, popping out? Saliva? Perfect. It is cancer. I mean, not confirmed but most likely cancer. And other lung cancer thing I should talk about is uh we got a picture with cannon ball Mets in your lung. Uh The question was, what is the most likely primary? I know we mostly expect it to be renal carcinomas, but that wasn't one of the options. So just be aware of that. And next part, I'll, I'll give it away but olive shaped mass, I don't think they're likely to give you imaging but olive shaped mass, you think about P stenosis. OK. Target sign on ultrasound scans. Again, this is more likely seen in pediatrics. Yep, that's right. So that is your interception, your treatment is your air enema, air uh in inflation. So it's basically a ball telescoping into each other and hence to get the target sign. OK. I think this is the last question. This is a barium swallow. So what do you think? This is perfect. That is indeed uh a few of the resources I use radio pia is great in general for all things radiology. There's good summaries, there's good pneumonics, there's good pathology as well and very good to see a lot of images with pathology, muscle radiology. I did their entire course. So they have, they have courses on trauma reporting, chest x rays, spine x-rays, blah, blah, blah. Very, very good. I did that before my o and I felt like that was all I needed. Then the third one is an official guide to radio. That is a book that you might be able to get it off. Um the Queens library. But uh good bunch of stuff for Os practice and I think top tip for Ay themselves are just uh pull up geeky medics and have a go at presenting different x-rays to your mates. It seems harder for us, but you'll get the hang of it and that is all I have for you today. Thank you so much for your time and if you have any questions, either pop me an email or just pass away. Thank you. Great. Thank you. Um I'm just gonna put the feedback on into the chat here and then um if you have any questions, you can pop them in as well and then Allen is going to do her fracture xray eyes now. All right. Thank you, Mary. Bye bye. Thank you. Do you want me to go ahead and share now, Marie or do I give you a sec? Yeah. Yeah. Work way they can fill in that form. Maria. Can you see my slides? Yeah, that's perfect. Yeah. Yeah, great. Um OK, I'll just get started. Um I'll try not to keep you too long. I'm sure you guys are all tired as well. Um Fourth year is tough. You've got your finals as well. Your final paper. Um So I think I just kind of went with the bar basics here trying to make you not overwhelmed um, fractures as well. I think a lot of people freak out about fractures, uh especially with xray identification. Um My advice is you only get like two days in your fractures placement. Uh I did in Belfast anyway, so it's, you know, it's quite a small topic in the wild context of things and the rest of fourth year. So don't be panicking and hopefully this helps. Um You can put questions in the chat box as well. Um So yeah, I'm going to chat a bit about kind of history and exam a bit on xray interpretation. Although X has already covered that for us. Um Just some common fractures, some common fracture management and then some special types of fractures and some complications. Um There's some extra slides at the end which are low yield, but if you want to read them, you can um and I'll see how far I get through the, the slideshow anyway. Um So in terms of the history and examination fractures, history has never come up and II don't think it will to be honest. Um but just kind of for your knowledge anyway, um the important questions would be the mechanism of injury. So, what I mean by that is, was it high or low impact? Was it maybe a fall from a height? If so you need to quantify the height? It's really important. Um, if it was a vehicle, fast or slow speed, kind of in what position was the joint, um, when it happened. So kind of if you're hit like that, that's obviously going to push the bones in a different way than if you're hit like that. Um And yeah, kind of thinking about the legs, a virus or a valgus force being applied as well. Um, occupation and hobbies is particularly important with orthopedic patients. Um Obviously, if they're doing very manual jobs or if the job could, either if their injury could affect their job or the job, maybe precipitated the injury, um, similar to your ps histories, hand dominance is really important in M SK as well. Um If you've got a trauma patient, any injuries or pain elsewhere, you know, they, they can have a bone sticking out of their leg and you could focus on that and miss something that's gonna kill them sooner. Um So was there a witness when this happened? Could it be as a result of a medical problem? Could they have maybe had a fit and then broken a bone on the way down or something like that? Um Social history again, really important for fractures. Um So smoking impairs bone healing So a lot of orthopedic doctors like to focus in on that. Um, and I always kind of forgot this when you're thinking about like obs and Gyny Peds fractures histories where you've got extra bits. Sometimes you forget about your standard history, you get focused on that. So don't forget your past medical history, like drug history, Socrates and all that as well. Um Yeah, and then just always remember to examine the joint above and below the one affected, obviously not in an ay, but you would turn around and say I do need to complete my exam. I would and then get your extra mark. Um and always examine the neurovascular status. So you want to see if there's been any injuries to the surrounding um blood vessels or nerves. Ok. So fractures on an x-ray signs covered a bit of this. Um So in your ay, remember one view is one view, two view. Ok. So they will have the two views if you're getting an X ray of a fracture, but they may not give the other one to you. So, and that could be the one as I say there with the most obvious view of the fracture. So always say, I think there might be a fracture here or analyzer x-ray. But ideally, I would also like to see a lateral view, something like that and then they'll probably hand it to you. Um If you're looking at it and you're panicking and you really can't see an obvious fracture trace around the cortex. I don't know if you can see my mouth but kind of just go around the bone and trace around the cortex looking for any steps, any breaks. Um And then you can sometimes see some surrounding soft tissue damage like a kind of periosteal hematoma or something like that. Um I got this from osk stop sod thought it was pretty good. So when you're describing it, talk about the site, so which bone say the femur um is the break intra or extra articular, which is particularly important if you've got a neck of femur fracture um and then position uh so proximal middle or kind of distal third of the bone. So break it up into thirds um obliquity. So, is it a complete or an incomplete, does it go all the way through the bone or not uh direction which you can see in the wee image there, skin penetration. Um You can sometimes see you can see this on an X ray if it's really obvious. Um But we'll talk more about open fractures later. Um And then the condition of the bone and then you're gonna talk a bit about displacement. So, translation, angulation, rotation and if there's any kind of uh lengths, discrepancies as well. OK. Um So moving on then to like common hand and wrist, so scaphoid is extremely high yield. So definitely learn your scaphoid fractures. Um So patients with those fractures. It's your typical your fish fall on an outstretched hand. Um And the wrist will, will usually be hyperextended as they fall onto the outstretched hand as well. Um So these patients will have pain in the anatomical snuffbox um and they'll have pain with you, telescope their thumb as well. They may help poor kind of grip strength as well. Um So you can see there in that image, there's a sca waist fracture. Um and I've included, so I can just see myself over this image. There it goes um kind of the issue with the scaphoid. So there's a risk of avascular necrosis because it's got a retrograde blood supply, it kind of goes back on itself. Um And if the fracture is way down at the bottom, down at the scaphoid pole, there's a really high risk that it's not going to, you know, fix itself and you're going to need to surgically intervene. Um I thought that wee image was nice to explain that uh sometimes as well. Skateboard fractures can be quite tricky to see on an X ray. And if you can't see a scape boid fracture on an X ray, but the fall on an outstretched hand got pain in the snuffbox, the pain when you telescope their thumb, it's looking like a scape fracture. You would call that a clinical scape and you would immobilize their hand anyway, and then seek further imaging like an MRI to definitively confirm that. OK. Um Z has much better memory than me about what's come up in the past. But I think we definitely did get a Bennett's fracture on M CQ in fourth year. Um So that's the first metacarpal base fracture. It is intraarticular. I think that was the question actually. Is it intraarticular or not? Um And that's a push when the thumb is abducted or extended. Um Just as well if maybe people don't have their own little way to remember this. I were abducted and AUC I think ad ducted, the double D is like middle. So you're moving towards the midline that helps. Um Yeah, and then Boxers is just a fracture of the fifth metacarpal base there. And again, common in Boxers, I think it's like, is it maybe per um like punching technique? I don't, I don't know what it's supposed to be but yeah, that's your common hand and wrist. Oh dear. Some there uh fracture management. So try not to get too worried about this. I think the table that they give you can be a little bit overwhelming but just keep it very simple. So if it's undisplaced, if the two ends of the bone on either side of the break are completely perfectly aligned, um You obviously don't need to reduce that. You just want to maintain it in position until it heals itself. So you can put them in a cast or a brace depending on where it is. Um, you might have seen if you've done your fractures placement. They like, uh, doing like a molded cast where they'll kind of put pressure on the plaster while it's still wet. So there's a little indent and it'll just help keep everything in the right position. Um, if it is displaced then, so you'll need to do a closed reduction or an open reduction. Um, a closed reduction can be done with sedation with um your Entonox or your penthrox. Uh just the gas that you inhale or you can use a general anesthetic as well. Um And for reductions, you can then use fixation. So you just use kind of like K wires which are in the image up here, uh or gamma nails or a dynamic hip screw or anything of the sort just to keep it in place and then you would cast it obviously, um if it's unreducible, if it's just beyond help, then you would just replace the joint. So hopefully that's ok. Um So forearm fractures then, so a fracture of the humeral shaft, um which is usually quite obvious to see as it is there, it just carries the risk of radial nerve damage, um which I thought was pretty high yield. Um And it's interesting because if it's in a younger patient, it's usually due to like a major trauma, but older people can, you know, just have a, a very simple fall and this can happen to them Um So in these, you're gonna be checking your radial nerve function. So I have a slide at the end about how you check the function of the, I think I just did the upper limb nerves. But hopefully that helps. Anyway. Um A Barton's then is a distal radius fracture and then associated radiocarpal dislocation. So which is a little bit hard to appreciate, but that's the dislocation there and you've got your fracture here. Ok. So this is really high yield as well. Collies and Smith's Collie's fracture on an X ray came up in 1/4 year os in like 2017, I think off the top of my head. Um I come up with this as well, like cook dinner, C for Collies and D for your dorsal slash dinner for deformity if that helps you remember. So these are both distal radius fractures and then the difference is the way they're angulated. So Collie's has the dorsal angulation and the hand will be kind of um malformed in this direction. Smith's is your volar angulation and apparently it looks like a garden spade, which sometimes I can find a little bit hard to appreciate. But yeah, that's, I would say that's all you kind of need to know for that. And obviously, if it's widely displaced, you know, that you're gonna start thinking about fixation. Um They could ask you that in an ac, as I think they've asked in previous years for you to prescribe an X ray and then talk about some basic management. So just think displaced undisplaced. Keep it simple. Um I think it was the last of the forearm ones. So you've got your Montas and Gallii. So Montia is proximal third of the ulnar fracture with radial head dislocation. Uh Gallii is the distal third of the radius um with a distal R UJ dislocation. And this, we image really helped me the mugger. So Mu Montes Ulna Galz radial. Um Yeah, I don't think they would come up in an ay, they're pretty tough. Um Colleagues could but I don't think they would. Um And I always kind of say be careful as well of just kind of looking at a fracture and going on in summary, I think there is the gala fracture. Uh I don't think you wouldn't get the mark for just naming it. You would get the mark for describing it. So don't worry about remembering the names of them in an AY, just know how to describe it for an M CQ, maybe know the names but Missus G. Um OK. So the ankle, there's actually quite a lot here, apologies. So thinking first about fibular fractures, so the Weber classification is high yield. So um Weber a just at the bottom there, that's a stable fracture we or c if there was a fracture up towards that direction that would be unstable and it would, you would need to go straight for an orif open reduction and internal fixation um as well. If you had a Weber B, that was particularly bad, you would also think about an orif as well. Um The I talk about this in MC Qs, make sure all angle fractures are reduced as soon as possible. Uh And they would do this in for you because the skin there is quite thin and increased pressure can really quickly lead to necrosis of the skin. So we don't want that obviously. Um Me, no fractures. It is low yield, but it does come up occasionally on past med. Um I don't think it's ever kind of come up with queens. It's certainly not coming up in a oscopy. So, don't worry. Um It's a combination of a proximal fibular fracture as well as an unstable ankle injury. So it's a fibular fracture like a lot higher up and then, which is affecting here. Ok. But don't worry about that. And then an ankle x-ray is only required if all of these criteria are satisfied according to the Ottawa ankle rules and there's also Ottawa knee rules, but I will need to check that. Um So it's basically if they can't walk four steps without it being very sore or they're tender on either side of their ankle. So basically everyone like then ends up getting an X ray, but that's what we say is used. Ok? Um This, of course, I'm sure everybody knows this by now this little diagram um this is helpful and it does come up, it came up in our fourth year, MC Qs. It came up in our final year, MC Qs. Um Yeah, it comes up all the time. It's unfortunately one of those things you're just gonna have to learn. Um But yeah, yeah, unfortunately, just learn that off by heart. It is a very important slide um fragility fractures. So these are kind of a fracture. Um That kind of the elderly people would get. Um So again, the highest of yields is a neck of femur fracture. It's really, really important to know all about that. So you're going to have your externally rotated, shortened limb, which you can see quite clearly there actually. Um And then they're gonna be taken straight to surgery really. And what I thought was surprising in orthopedics is even if somebody is kind of like in their nineties, they will still operate and give them a hip replacement. Um And they actually they can get, they get them up walking kind of immediately POSTOP, which is cool as well. Um Yeah, know your garden classification. So it's for your neck of femurs type 1 to 4 there obviously type one that's an incomplete, it's not going all the way through the bone. Type four is the worst that's completely kind of translated across. Um And you can kind of logically think about what the management would be for. Type 1 to 4 there. Um Thinking more about fragility, you've got your osteoporotic wedge compression. So anybody with osteoporosis in their spine, get these wedge compressions, which you can kind of see just with the third lumbar vertebrae down there and just remember that any thoracic pain is a red flag. So lumbar pain would be quite common. Like a lot of people have lower back pain. Um cervical pain you're worried about, especially after like a car accident, you want to stabilize the spine which you remember from poem. Um but thoracic is a bit rogue. So it's worrying um thing about spinal kind of met something like that. Um And also with the osteoporotic wedge compressions, elderly patients can with these have a sudden loss of height um and acute shortness of breath as well. Ok, I'm not going too fast, apologies. Um So some spinal fractures as well. Um The fractures that I've included in this slideshow, by the way, are generally all the ones I think you need to know. So I don't quote me on that. But um so the spinal ones I think you need to know is the Jefferson fracture. So it's of C one um for this to be able to properly diagnose it, you need an odontoid x-ray view which is through an open mouth, which is quite interesting, I suppose. Um you can get that um from diving in a shallow pool which sounds horrendous. Um And I remember that with Jeffer one for C one, which is maybe a little bit silly but, and then odontoid fractures, uh is your C two. so elderly people would get that or maybe just people who have hyperextended their c spine and they may need this kind of halo brace here. Um And now you've got a hangman's fracture which can happen from, I'm sure you can infer and then again, it's C two, but they would need this halo vest, which is where you've got a kind of pin that's going into the skull as well. Um And I think in your fourth year exams, Cathy Colin was saying that for the acies, there's maybe gonna be like overlap stations like there was for us. So this could be kind of combined with poem. So remember your Canadian C spine rules, um know how to put on the collar and that Asia chart as well for spinal injuries. That would be a little bit mean if they gave you that, but just be aware of it, it might, you know, it would show your examiner that, you know what the crack is. Um compartment syndrome. So this was our fourth year fracture station and the patient, you walked into the room and the patient actually had a full cast on the leg and I kind of panicked because II thought, can I take this off? I sure they're not going to reassemble this between every student. Um And they did So you were supposed to take the cast off, it was already split, which I didn't see. Um but I got there in the end. Uh So compartment syndrome is just usually with kind of a, a long bone, maybe like a tibial shaft or supracondylar fracture. And it's just where the pressure builds up in the compartments in the leg. So you've got your six ps paresthesia, paresis or paralysis. Um pink color, yeah, pulse sometimes. So it's usually pulselessness is what you remember for the six ps. But the presence of a pulse does not rule out compartment syndrome, which I think is important. Um and there's gonna be pain particularly on passive stretch. So in our station, I think the patient just said, oh thank God you're here doctor. I'm in a lot of pain. Oh yes, I got this leg fixed yesterday. Here's my X ray and I think some people maybe got a bit confused. Like do I look at the X ray? What I do? Um But what they wanted you to do was kind of conduct a little mini examination of compartment syndrome. So kind of passively stretch. Her foot was obviously out of the cast stretch that see if it's sore, feel the pulses, see if she can wiggle her toes, stuff like that. Um So the management yeah, split the cast if they have a cast on immediately and they will need an urgent fasciotomy. Um You can actually measure the pressure of the compartment using needle manometry. So that's the machine there, there's a needle going in. I've never seen one of these in real life. Um A reading of above 20 is abnormal and above 40 is definitively diagnostic of compartment syndrome. Um But don't worry too much about that because it is usually a clinical diagnosis anyway, if you think uh somebody's got compartment syndrome, so they've got pain way out of keeping of what they kind of should have. Um You're not gonna mess about trying to find a needle manometer and do all that. You're gonna, you know, tell your seniors and get this fasciotomy sorted, fat embolism. Um sometimes comes up on MC QS. Obviously, you're not gonna get anything of the sort palsy. Uh again with long bone fractures and you can also get cement emboli from joint replacements, the cement can get into the blood system. So they'll have a tachycardia tachy dyspnea. Um A bit of pyrexia, the key thing kind of the key phrase in the M CQ will be this in the subconjunctival and oral um mucosis, they'll be confused and agitated. Um And then you can also have kind of retinal hemorrhages and findings on fundoscopy, but don't worry about that too much just to be aware, open fractures then. So this is what I find interesting a wound on the same limb as the fracture is treated as an open fracture. So it may not be as obvious as you think, do a really thorough trauma survey, which I'm sure Doctor Aoife Byrne has been talking to you about maybe an emergency medicine. Um So it may not be like just so obvious that there's just a bone sticking out of your leg. Um It could just be that there, there is another wound maybe at the top of the leg, but the breaks at the bottom that's still treated as an open fracture. Ok? Um They use the Gus Tulo and Anderson classification and if it's kind of type three in that classification, type three, ci think, um then they'll use this score. Um mangled extremity scoring system, I think uh to see whether they need to actually just go ahead and amputate the limb. So it's all quite dramatic. Um Ortho will then kind of leave the wound open. They'll use an external fixator. So they're not gonna go in and kind of operate and put plates in and screws in because there's a risk high risk of infection. Um And they'll use generally, the guidelines are 6 L of a saline debridement. But your job in the not so distant future is just to do a thorough ABCD E assessment, escalate to your seniors really, really early on, obviously, um and just help them to stabilize the patient. Ok? Pediatric fractures. I, so I didn't go into a lot of detail here because I think that Oren or Nicole will cover this for you in a lot of detail. So I didn't want to burden you with information. Um The Salter Harris classification is for any fractures um around the growth plate in Children. And this is just the handiest pneumonic ever. So type one then is your separated growth plate. Then you've got a fracture above the growth plate below through and then just uh a crush like an erasure of the growth plate, you'll not be able to see it, they'll be joined. Um Questions do come up kind of talking about the metaphysis, the fiser, et cetera and the epiphysis know where they are as well. I think that is helpful um because that can trick a lot of people um obviously impedes are always in the back of your head thinking, could this be an na I non accidental injury? So things that would indicate that could be a metaphyseal coronary fracture, which is indicated by the arrow here, which is very hard to appreciate. Um But if you kind of use the eye faith, you can see it there. Um multiple fractures of different ages. So you can see kind of, oh this one fully healed a few weeks ago or this one is still healing, et cetera. Any form of rib fractures generally uh in a child are quite worrying um spiral fractures as well because it indicates that there is a twisting motion on the limb and remember if they can't cruise, they can't bruise. Ok. Um And then just thinking more about the types of fractures. So complete we've discussed, it's where it goes completely through the bone. A toddler's fracture is an oblique tibial fracture specifically in infants. Um Don't worry about the plastic deformity. Green stick fractures do come up. So it's where it's just an incomplete kind of fracture in a child and then a buckle fracture is where there's just kind of, oh yeah, just at the rest of the bottom there. That would be a buckle fracture. So it's an incomplete cortical disruption. And you've got this periosteal hematoma just like a little bump in the bone. Um And then just to the right, you've got your green stick. So it's only going kind of halfway through the bone and it's because I think children's bones, there's more cancellous bone there. So they're nice, good quality. Um So it's just kind of giving it a little bit. Uh The limping child is something where you could have a joint pains and fractures Ocu station as well. And I think I have done that before, but again, I'm hoping that Oren and Nicole will cover this, you know, a bit more with you. So this wee table is lovely. I think so. From the ages of 0 to 3, think about transient sinusitis D DH. Um As your main kind of diagnoses 4 to 10, you're gonna think more about Perthes or HSP and 11 to 16. You're thinking about your sufis or your kind of juvenile idiopathic arthritis. But in all cases, in all ages, you're gonna always suspect septic arthritis, a tumor trauma. Sorry, that should be or N A. Um And then just an M CQ tip. So even if a question is really kind of giving obvious transient sinusitis, any child with hip pain and even a mild fever needs to have a same day hospital assessment. Ok. Um So this little baby is in a spica cast, uh which is what they use for ad DH. So they'll fix the hips. They'll usually do both for you and then they'll keep it in this um A B duction just for a while and they leave a wee space for the nappy. It's all quite cute. Um Pathological fractures. Uh So these are just fractures which occur in abnormal bone. Uh and they shouldn't really. So it's due to an insignificant injury. So this could be due to like uh a metastatic cancer in the bone Paget's disease, osteogenesis, osteosarcomas, osteoporosis, um chronic Osteomyelitis, stuff like that. So it could be a really insignificant injury and it'll result in a break which you would just not expect. So that is me, my top tips. Um don't panic about fractures. I think a really good skill to learn is knowing what's high yield and what's low yield and trying not to be overburdened with information and overwhelmed with kind of resources because there's so many um this radiology masterclass which that I was talking about. I think it's amazing where you can kind of hover over it and it colors things in for you. Um, that really helped me. Um, Ortho Bullets is a really good orthopedics website, but just be wary because it obviously has a lot of information. It's more directed towards Ortho trainees. Um, and then you stop, pass med and zero to finals as always and that is me. So I'm happy for any questions whatsoever and I wish you all the best of luck. Thank you very much. That's great. Thank you very much. Um Yes. So I put the uh feedback form into group out there. So there's two different um feedback forms for each of the fractures on the radiology. And then as usual if you fill them and you'll be able to access the um slide and yes, thank you.