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Hi, everyone. Uh We'll just start in a couple of minutes. We'll just wait until a few more people come and then we can get cracking if I can just have someone in the chat, just say if they can see and hear everything. All right, that would be great. Ah, great. That's great. Thanks guys. We'll start in just a couple more minutes um, and just a few um, points before we start. Um, we'll be putting out the um, advertising for the next event coming up very soon. So the next one will be about um CTS and also we have one on interventional radiology. So make sure you keep, um, look out for those and those will be happening soon. So same time every Tuesday 6 30 we'll just wait until a couple more people join and back in. Ok. I think we'll start with the introductions and then hopefully as more people start to come, um, we can start with the actual content. So, hi guys, my name is AA and I'm one of the, um Preclinical leads for B A this year. And so as I said, we've got a lot of lecture series coming up this year and starting with radiology, we've got two more sessions left. Um, and then after that, we'll be starting with the Preclinical Series, um, going all the way from Neuro to Gastro. So make sure you keep a look out for those and sign up as soon as you can for those. So today we've got a radio radiology lecture, um, deve, uh, delivered by Edward Limb who is an fy currently in Edinburgh. Edinburgh. Yeah, in Edinburgh. Um, right now in general surgery with a big interest in radiology. And, uh, joining him today is Mr Chuckler who is a consultant orthopedic surgeon in ring. Um, so both of them will deliver some limb x-rays for you guys today. Just a few um, housekeeping things. So if you guys have any questions, feel free to put them in the chat and I'll keep a look out for them. Um, and, uh, let the speakers know that you've got a question as well as that guys. Make sure you fill in the feedback at the end that's vital for um our attendance. But also so that you guys can get your certificate. Once you guys have done your feedback, you'll get your certificate to say that you've attended straight away. So make sure you do that. Um Right. So I will hand over to Edward then. Cool. Thanks for watching. Um, hi, everyone. Uh, my name is, um, the, uh F two is currently doing my general surgery. Rotation in uh Edinburgh. Um And today I'll be doing a limb x-ray interpretation as part of the BMA Radiology crash course um lecture series. I'll be doing this today with uh Mister Chlo, who's an orthopedic surgeon and he'll be sir. And well, the both of us will be giving you this lecture today and any questions, you know, feel free to just pop them in the chat and we'll just answer them as we go along. Ok. So a brief introduction on what we're gonna go through today. Uh Just quick introduction on when and why you would consider getting limb x-rays in clinical practice, the different types of limb x-rays that you can get. We'll go through a brief overview um on the anatomy that you expect to see in limb x-rays. Quick, look on what to expect in x-ray reports and what you can do with them. After that, we'll go into a structured approach in terms of how we can interpret our x-ray imaging. And after that, I'll have uh a quick run through on the common fractures. The, you know, the different types of fractures that you can get different classifications. Um mainly just going through the ones that are a bit more common in like finals exams in medical school. And then after that, um we'll go through some clinical cases surrounding various pathologies we can see on um limb x-rays and then just to end it all off, we'll have the usual uh, single best answer questions at the end and a Q and A session, uh, for either me or Mr Cha as well. Um, I, so when, why, and you know, what, when would you consider getting like a limb x-ray? What are these sort of indications for limb x-rays? So, the most common ones would be when you have a trauma. So that would include your falls, your road, traffic accidents, your, um, you know, if, uh if you have any like pup bites or any assaults, usually around in the middle of the night and they often come through A&E apart from that, you can also use x-rays for to look at certain types of infections, mainly your joint infections and your bone infections with your osteomyelitis. Apart from that, you can also have a look at your arthritis in your joint and sometimes you can use the x-ray to tell the difference between your inflammatory versus your noninflammatory arthritis as well. Um apart from that, you can also look at foreign bodies. So if there's any sort of inanimate objects that are not meant to be there. But yeah, um, next is the types of limb x-rays. So with the limb x-rays, you can kind of separate them through where your upper and your lower limb, you have your upper limbs, which consists of your sho shoulder girdle, which includes your shoulder joint, your clavicle and your scapula. You have your humerus for your upper arm, you have your elbow joint, you have your radius and your ulnar bones in your forearms, you have your wrist and then of course, you have your hands as well. And in the lower limbs, you have your pelvic girdle which covers your hip x-rays. You can have a look at the head of the femur, looking at the femur shaft, your knee joint, your tibia, your fibula, your ankle as well as your foot. And with any in like all of these x-rays, you can always get different views of them. So you can have an anterior posterior view, which is just basically a view from the front or the back, your lateral view. And sometimes you can even get an oblique view as well. Ok. Right. So just briefly going through the anatomy in a limb x-ray. So let's start off with the bone, which is often the densest and the brightest thing that you can see on limb x-rays. So with the bone on an x-ray, you can assess for the bone density, the alignment of the bone as well as the joint. Um and looking for any lesions or fractures around sort of within and even around the bone with. And then after that, you can look at the soft tissues which are a bit less dense and these typically come up as sort of grayish um kind of a color on these x-rays. And here you can usually look at the muscles, your tendons as well as your ligaments and sometimes you can even see some calcification around these structures. Um a an example of this would be something like a calcific tendonitis where you basically have a chronically inflamed, either tendon or a joint which eventually lead to some calcium deposits within the um injury sites of these structures. And then finally, you can even look at the joints um on x-rays. So these ones are the least dense and they usually come up as dark gray or even black at times depending on what's there. So here you can assess for the joint space, whether there's any narrowing of the joint space, um any alignment issues or looking at any effusions or any fluid pouches uh around the soft tissues um as well. Thanks. Yeah. All right. So briefly going through x-ray reports. So with almost with most radiological imaging, if not all radiological imaging, all of these should be reviewed by and reported by a radiologist in a timely manner. However, in actual practice, this do this doesn't always happen just because of the shear workload and like the sheer amount of images that radiologists get requested for. So they typically have to prioritize their workload and they try to focus on the more urgent and more complex cases. For example, if there's any major trauma cases that come through A&E or if there are any sort of surgical emergencies that they have to rule out, for example, like an ischemic bowel, therefore, as a junior doctor, I find it very important to be able to at least have a rough or a basic understanding on how to interpret and like approach um x-ray imaging, whether it's your chest x-ray, abdo x-ray or even like your limb x-rays to have a basic understanding on how to interpret these in a structured approach and make sure that you can at least be able to identify any obvious abnormalities or uh pathologies that are there. So here we have um so an x-ray report, you would typically find these sort of key informations on them. So you'd have your patient information, the date and time the imaging was taken. Um And sometimes you can get the date and time for when the report was given as well. The radiographic views of the images, the findings of the imaging as well as a conclusion and an impression of what is the main finding of um set imaging. So the example report here is actually for the um two x-ray images that we have here, the knee x-ray, the uh sorry, the left knee x-ray. So here we've got the patient information. So the patient's name is Mickey Mouse. He is born on the 18th of November 1928 and it looks like we have an anterior posterior as well as a lateral view of the left knee. And it looks like the image was taken around about four hours ago. So the findings wise, it looks like there's no fracture is seen. There is a normal alignment of the bone and architecture, joint spaces and articular margins are intact, soft tissues are normal. In conclusion, there is no significant abnormality that is seen. So that's just a brief example of what a normal report would look like. Um And sometimes if you have an abnormal finding within the sort of conclusion and impression section, they would usually um give you a recommendation as well as to whether or not you should speak to a different specialty regarding a certain finding, right? So next, let's go into how to interpret our own images. So with almost anything in medicine, whether it's assessing um a sick patient that you've never met before, or if you're being asked to interpret an x-ray imaging of which you have no idea what's going on, always just go back to your Ab CS. So a in this context would stand for alignment and joint space. So what you want to do is you want to look at the imaging and you just want to make sure that there is a sort of smooth contour and lines between um well off the joint, you try to draw a straight line or a smooth line and make sure that there's no sort of misalignment of uh these structures. Um Any sort of changes in alignment can usually suggest a fracture or subluxation or even a dislocation. And then after that, you would want to look at the joint space really quickly. Here, you try to care carefully, look at it just to see if you can see any sort of narrowing of the joint space. Usually due to like cartilage loss. Sometimes there's some car cartilage calcification, some chondrocalcinosis or sometimes you can get some new bony formation in the form of osteophytes. The example x-ray on the left here is essentially a normal knee and the x-ray on the right is actually an abnormal knee, um with um, osteoarthritis. So a mnemonic that is commonly tossed around in um medicine well, in medical school and even as an F one on osteoarthritis is um loss. So here you actually have four of the mics. So l for your loss of joint space and then o for your osteophytes. Um I'm not sure if you'd be able to appreciate on your screens if it's big enough, but you would be able to see sort of small bits that kind of pop out at the side of the bone. And those are the new bone formation um of osteophytes and then your subchondral sclerosis. So you can see there's a bit of a thickening uh on the sort of subchondral region and those are your scleroses. And then after that, the subchondral cysts typically come up as less dense material as usually they're a bit more hollow in these structures and you can kind of make up them, um just around here with these sort of more less dense um blacker dots uh on the imaging right. And then next is B for bone texture. So with the bone texture, you just want to make sure that there is good density uh within the bone. And it has got a normal trabecula. And these are basically the fine white lines that you can see within the internal matrix of the bone. You can see that these images here, they're um quite regular in terms of um the trabecula, uh the image of the on the left side is got really good bone density. Uh everything seems to be quite fine and regular. The image on the right has also got decent bone density. However, he is missing a second left toe, likely due to a previous amputation um of, you know, his second digit potentially due to an osteomyelitis or a previous um ulcerative infection, right, and then see what stand for your cortices. So with here, you would again want to trace out the outline of the bone of the cortex and make sure to see if there's any abnormal steps. Um And if you do see any abnormal steps, these can indicate again if there is any fracture or infection or sometimes even a malignancy. So this imaging here is actually an image of an osteosarcoma of a 12 year old. So without me telling you that um the way that you can tell that this is an x-ray of a, you know a developing person um is that you can still see that the growth plate is very visible on the x-ray with this line over here. And apart from that, you can also see that there is some periosteal reaction in response to the osteosarcoma. A periosteal reaction is basically just some new bone formation that happens in response to any bone injury or inflammation around the um sort of periosteum uh of the bone. Sometimes you can see it in more benign conditions, for example, a healing uh fracture or even a mild Osteomyelitis. And then finally, you have your s for soft tissues. Um I appreciate that, you know, soft tissues and fluid isn't exactly the easiest things to make out on, on um plain fields and x-rays. Um but they are very helpful as uh an initial investigation to try to rule out some other more sinister things. Um But the good thing here is that the x-ray on the left, the pleural effusion, sorry, not pleural effusion, just the knee joint effusion is actually nicely well outlined for us. So if you can see this image, uh uh this part here, it's actually slightly darker compared to the soft tissue structures that surround it. And then the image on the right side here is um you can appreciate that there's a bit of a lump within the calf muscle here. And again, just with this x-ray alone, it's very difficult to tell exactly what it is and sometimes you would require other imaging uh modalities, whether it's an MRI scan, an ultrasound or even sometimes a CT scan. In the case of this imaging, um This is actually an intramuscular hem angioma, which is essentially a soft tissue swelling that is benign and it, most of the time it wouldn't really cause any major issues. Um Oh, also, I forgot to mention that um along these uh slides as we go through them, you'll notice that there's some um blurred out gray bars here. These bars are just um the sources for where I got these images from. They're just the references. The reason why I blurred them out is because sometimes within the l it, it directly tells you what the images, uh what the pathology is of the imaging. And I've used these for some of the clinical cases and the um single best answer questions. So that's that. Next, let's talk a bit about fractures. So with fractures, you have um ma different ways that you can, you know categorize your different fractures. But for the purposes of this lecture, we can mainly split them into complete fractures and incomplete fractures. So with your complete fractures, you are. So any complete fracture is basically a fracture that goes all the way through the bone and any incomplete fracture, the cortex is usually not fully broken. A transverse fracture is basically a fracture that goes straight across the bone. An oblique fracture is a fracture that goes sort of diagonally across the bone or in an oblique fashion, you have a spiral fractures, which if you imagine a corkscrew, it kind of goes in that sort of a pattern, a spiral pattern down the bone. And then you have your coated fractures, which is essentially a fracture. Well, any fracture that's, that gets broken down into more than two different parts. And then after that, you have your incomplete fractures. So with the incomplete fractures, these are more common in Children and developing um young adults, mainly because their bones are still developing and they're often more malleable or softer than adult bone, but adult bones are stronger. However, they're a bit more brittle compared to kids bones. So also if you notice with any bone in your body, there's not a single bone that is completely as straight as a ruler, most of the bones, they have a slight bend into them and these play it and these kind of play a big part into how these incomplete fractures actually happen. So if you have a child who has gotten an injury, whether if they've fallen down, they've hit their hand or they've had an injury of some sort, you can get a greenstick fracture, which is essentially a fracture on the convex curve of the surface of the bone, you have a focal fracture which happens on the concave surface of the bone and then you have bowing of the bones of the long bones, which I guess some might say that it's not exactly a fracture because you don't have a sort of classical fracture line that goes through it. But a bowing make basically means that the long bone is being bent as a result of uh injury Edward. Yes. Can I just chip in a little bit at this point? Yeah. So just to add some clinical aspect into why do we want to understand the nature of the fracture when you are describing the fracture as a transverse oblique spiral or or communicate uh or in an incomplete fracture. So Edward has already mentioned that just a little bit more uh explanation, any classification anywhere in the body, whether it's a lung, abdomen or bones, there is a reason why they are classified in a certain manner. So this particular classification tells us about the the force or the nature of injury because that is what is going to decide the line of treatment when it comes to as an orthopedic surgeon or as a clinician or you are in accident and emergency department, you are the first one to see this patient. So starting with the first one, which is a transverse fracture. So transverse fracture more or less tells us that it's a relatively low velocity type of a trauma. And there is almost like a buckle type of an injury. So there is a direct or indirect but like a buckling type of an injury which can lead to single axis fracture. So it could be a, a transverse or a sometimes a slightly oblique fracture, oblique and spiral fractures are also commonly associated with a rotational movements. So, footballers uh contact sports, all these kind of injuries or somebody thrown out uh of a bike or something like that. So there is a combination of a direct impact but a twisting injury on the top of that. Uh and finally, the communi communi is the most severe nature of injury which tells us that there is a significant force involved in sustaining this trauma. Combination means there are more than two fragments. So when you break a bone, obviously, you have two from 21, it becomes two sec segments or fragments. But then when you have more than two, which could be a butterfly fragment or really com fracture or multiple fragments, it tells us that there is a significant force of injury involved. Why? Why is that important? Because we are only looking at the x-rays, do not forget the soft tissue, which Edward Al already has described that you are looking at the soft tissue injuries. As you learn more about the x-rays and fractures, you will be able to understand that there can be a soft, soft tissue break, what we call an open fractures. Ok. Some of them are closed fractures, some of them are open fracture. We should not forget the nature of soft tissue injuries that can be a muscular injuries, a vascular injury, neurological injuries. So all this classification tells us about the nature of injury, what has caused this fracture and the severity of the trauma on the top of it. Um Yeah. Ok. Thanks Mister Ler. Yeah, I think it's very important to remember as well. Um I appreciate that sometimes when you look at um x-ray images, it can very, it can be very easy to just hone in on the obvious fracture that's there, that's the bone and that's usually the easiest thing that you would see on x-rays. And sometimes you forget to think like, oh that these bone fragments, they can actually cause um damage towards the surrounding structures which are the soft tissues and muscle um tissues that Mister Ler was talking about there. But yes, that's very good. Um Sort of information that we should uh add, add into as well, not just for like exams but for clinical practice as well. Um Right. So, next, actually, um it's good that Mister Ler has briefly mentioned about uh you know, open and closed fractures cause next, we're gonna go into how we can describe different types of fractures. Well, describing um a fracture that you can see on the x-ray image. So um how when you're being asked to interpret, well, describe a fracture, you can always ask yourself these few questions. So you can ask yourself where is the fracture? What type of a fracture is it whether it's open or closed fracture and the displacement of the fracture. So just briefly going to displacement, um a displacement basically just means any abnormal alignment of the bone. But you have a few different ways that you can describe displacement. Uh So you have your angulation which can tell you how much, how much of an angle and how much of the distal bone is pointing towards one way or the other, whether it's me laterally anteriorly or even more posteriorly. Um If there's any rotation like the rotational injuries that um Mister Trippler mentioned earlier. Uh However, I appreciate that it's very difficult to see them on just the plain x-ray film and sometimes with just a single x-ray film film, it's even more difficult. That's why when looking at x-ray imaging of the limbs ideally nine times out of 10, you should be getting uh more than one type of i imaging in terms of more than one view, I mean, so you should have at least like an anterior posterior and a lateral view as well or even an oblique view just to make sure that you know, you're not missing um any hidden mechanisms of injury that you can't see from just the anterior posterior view. Um And then translation is basically just a description of how far the two portions of the fracture are far apart from each other. And we'll have a look into that just now. So if we were to try to use those bits, those um questions to try to describe this x-ray here. Where's the fracture? So we can see that it is a, this is an x-ray the. So you have um what looks to be a transverse, sorry, not transverse, an oblique fracture of the midshaft of the left femur. This is likely to be a closed fracture just because there is, doesn't look like there's any sort of breakage around the skin or the soft tissue. Um And displacement wise, you can say that this is laterally displaced and any displacement that we describe. It's always in relation to the distal portion of the fracture rather than the proximal portion. So you can say that there is a lateral displacement of the midshaft left femur fracture. You can see that it's medially angulated as you can see, it's slightly the sort of distal bit of the femur is pointing slightly towards more medially. Um And then translation wise, if you were to try to use translation to describe something like this here, you can say that there is an lateral translation of the fracture about 50% of the width of the bone, right? Um Edward, can I just interrupt you one more time if we can just go one more time on the last slide? Yes, just one quick reminder. So you have already mentioned about the um classification and, and you very nicely you describe that it's a midshaft fracture which is very important. So whenever you are describing certainly as a medical student, as well as as a trainee, you we also need to understand the location of the fracture. So do not forget the the three basic parts of any long bones. Uh I'm I'm using the word long bone, short bones may not have that many differentiations but certainly in a long bone efi meta and difficile, right? So I I'm sure you all understand that but epi meta and difficile part. So this is a midshaft, which is a difficile fracture, epi facial fracture, which is usually intraarticular or closer to the articular surfaces in most of the time meal is the weakest part of the bone. Again, those things will be having a great implication when it comes to the management. So either you can describe as a midshaft fracture or a difficile fracture, you can be over a little bit over Smartt and say that it's a middle part of the femur or middle third, lower third junction. You know, you can have a different variations of uh description but certainly do not forget epiphysis, diaphysis metaphysis. Those those descriptions are also equally important. Thanks. Thanks, Mister Ler. Um So yeah, I agree with Mister Ler. Um Always remember, remember your anatomy. Um and sometimes you can get a bit too into trying to describe exactly what the type of fracture is and getting, you know, into the intricate details of the mechanism of injury. However, sometimes in, in clinical practice, um these tiny tiny details might not matter um every time and it's sort of the bigger picture that we have to look at and the clin co correlation that we have to consider as well. So next up is push fractures. Um I find that these type of uh eponymous fractures, they get pass a lot in uh medical school, especially like um in exams during the final year. Um So foot stands for, fallen on outstretched hand and these type of fractures. Um There are many different mechanisms of injury for them, but I'll just be focusing on the main ones that typically come up for exams. So you have your Colles versus your Smith's fracture and these fractures are typically sorry. No, what I meant to say was. So your colo fracture is basically a fracture of your distal radius when you fall in on an outstretched hand while your wrist is in extension. And then this would usually cause a posterior or a dorsal displacement fracture. And then your Smith's fracture is a fracture of the distal radius when you fall on to an outstretched hand with your wrist in flexed position. And this would typically cause an anterior or a ventral dislocation um type of a fracture. So a way that you can try to use to remember which goes to which, which fracture is that if you try to extend your wrist, um you can kind of see that your hand makes a bit of ac shape here. And hopefully, you can remember like, you know, extension makes kind of ac C for a Coley's fracture and for a Smith's fracture falling on an outstretched hand when your um wrist is flexed, when your wrist is flexed, this looks a bit like the first half or even the bottom half of an s. So an s for Smith's Fracture, hopefully that's useful for exams. And then after that, we have the Monia and the gal fractures. So again, I think this is another one that really um confused me and like I always got this wrong in medical school. Um But hopefully with the today's clarification, uh I hope that you guys will remember this a bit better than I did. So, a Monte fracture is a fracture of the ulnar bone with an associated proximal dis um proximal radial head dislocation. And then a gai fracture is a radial fracture with a dis with an associated distal radial ulnar joint dislocation. So whether you like football or not, um I hope that this will be useful in helping you remember. So for the Monia fractures, you can use Mu or Manchester United. So you can remember Mu Monia ulnar fracture, mu Monia ulnar fracture. And then for the galli assi fracture, you can remember the classical rangers gr so G for gals and then R for radial. So gal radial fracture, Gr gal radial fracture. And that's basically it for the push fractures. Um Before I move on, um MLA, do you have anything else to add on to, um you know, falling out to, onto outstretched hand, um type fractures? Have you come across anything interesting in your clinical? And I think, I think, I think you have already covered that. Uh All, all I would like to add is when obviously we are talking about x-rays, but clinically when you come across a situation where somebody presents to us with a history on a fall on outstretched hand. Uh Do not forget the force has gone from the wrist all the way up to the upper part of the arm, which is the shoulder. So um obviously, clinical examination evaluation is equally important and we should never forget that, you know, always, always go joint above joint below. Make sure that you know, clinically, you evaluate the patient very, very well. You will be surprised many a times that how often we miss fractures in a situation like this patient comes with a very obvious distal radius fracture. Everybody forgets that he also had a dislocated shoulder on the same side, right? So it's not uncommon. So yeah, that that's the only thing I would suggest that clinical evaluation equally important. Uh As far as the Mont and G are concerned, these are very special classifications, name classifications. There are so many of them, Montag and G are one of the commonest one. They have subclass informations. And all those things. I think again, the importance of this is uh somebody just uh ask a question about the description of the displacement now, which Edward will cover that later on. But uh important part is that when you are seeing the nature of force where one bone is broken completely off, displaced angulation, significant shortening, another bone has a dislocation. This kind of injuries are extremely commonly associated with neurovascular injuries, right? So that that is the clinical aspect, we should not forget that. So just from the x-ray, it tells us that this person is not just has fallen while walking, there is a significant force, significant trauma and that has linked to this nature of injury and displacement. So just from the x-ray, you can anticipate, you know, quite a lot of things happening. Ed work showed the femur fracture with a midshaft displaced dial fracture. You can in fact see the soft tissue swelling of that. A femur fracture will bleed almost a liter, liter and a half. Ok. A closed fracture. You can imagine the amount of blood loss contained within the thigh or within the leg compartment syndrome, neurovascular injuries. So many things just the x-rays can tell us as well. So x-rays not only just look at the bones, but even in these two x-rays, you can see the amount of soft tissue damage it's already showing us. Um Thanks Edward, no problem. Um So yeah, I agree, Mister. Always remember falling onto an outstretched hand means like your entire arm is full, um sort of stretched out. So any of the mechanisms of injury can happen from your hands, your wrists to your forearm, to your elbow, as well as up towards um your upper arm and your shoulder joint as well. Ok. So just because a question comes up as um, oh, a person has fallen, uh sustained an injury, fallen on an re hand. Don't just focus on the forearm. Don't forget to think about the entire arm as well, right? So next part here is something that I believe mister, well, a lot of orthopedic surgeons uh deal with on a daily basis which are hip fractures. Um So with the hip fractures, uh we can classify them into, well, we can group them into different parts depending on where the fracture is. So the most common one is your neck or femur fractures. Uh And these fractures, they're often displaced. They're more common in older adults and they're usually a result of an low trauma impacts. These type of fractures usually have a low stability and often they need some sort of an in surgical intervention. Um And with trying to decide what type of surgical intervention, um some of you may have come across the gardens classification of neck of femur fractures before some of you might have not. Um But basically the gardens classification goes from 1 to 4, depending on the severity of the hip fracture four being the worst one being the, you know, least displaced if you will. So there is a phrase that um has been tossed around here and there. Um It's called, it goes like 12, give it a screw, 34 on the floor. So that basically just means if it's a gardens classification of one and two, you would give a most of the time, at least you would use a dynamic hip screw to uh fix the fracture. Cause gardens classification of one and two. They're typically an undisplaced type of a fracture. And then Gardens class three and four, you would consider a hip replacement, whether that's a hemiarthroplasty or even a total hip replacement. It all depends on the um you know, the individual cases and what the baseline functionality of the patient is. Um And then next up, you have your intertrochanteric fractures, um which is basically a fracture that goes between the greater trochanter all the way down towards the lesser trochanter of your femur. These fractures are typically the result of high impact trauma. They're more stable than neck of femur fractures. However, they still require surgery most of the time. Um I believe they use an uh intramedullary nail for these types. Um But mister can add on to that later on. Um So subtrochanteric fractures are any sort of femur fractures, well, any fractures that happen below the level of the lesser trochanter. Again, this is uh this is a result of a high impact trauma. Still again, they're very stable for the most part and they might not require surgery if there are, they are relatively stable. And last but not least you have your pathological fractures. So with pathological fractures, these are often reserved for any fractures that happen with an underlying diagnosis, uh sort of underlying uh malignancy diagnoses, for example, bony uh metastases and this can result in really, really weak and brittle bones and they can end up with uh fractures even from sort of minimal impact trauma, right. So, before I move on to uh ankle fractures, mister Ler, I feel like you would have a decent amount to say about a hip fracture. Uh This is bread and butter off uh orthopedic surgeons as well as the trainees. Um This is what we will see day in day off. So just uh I'll, I'll elaborate just for a minute. So type of fractures, basic 23 types as Edward has mentioned, one is a neck of femur, what we call it neck of femur, trochanter and subtrochanteric fractures which constitutes uh the in, in general, if we have to say we call it a proximal femur fracture. Proximal femur means upper part of the femur, right. So just we will apply the same classification which we have applied before. So one is the anatomical classification, epiphysis, metaphysis diaphysis. So let's apply that epi facial fracture. They are also known as a intracapsular fracture, intracapsular, as the name says inside the capsule of the hip joint, uh which you, you call it a e either a subcapital fracture or a transcervical fracture. Um As you learn more about that, you will understand more and more. So what you call it in this classification neck or femur, I would call that as a intracapsular fracture, which is a fracture of the efi part of the hip joint. What is important now what happens in the epiphysis? Number one, it's a growth part. So in a young person, child, uh before the fees has fused, uh it will have a significant impact on their growth potential, almost like a 25% of the growth potential can be affected. So it's important. Number two, it has a very poor blood supply. So this part has a extremely poor blood supply, which is why avascular necrosis or a nonunion or both of them are extremely common in what we call a intracapsular fracture. Neck of femur, right? Which is why they fall into very special category. Uh As Edward has mentioned, if they are incomplete fracture, which we call it a garden one or complete but completely undisplaced fracture, which is a garden two, they are intracapsular but less likely to have any interruption to the blood supply or the growth plate. So those kind of fractures can be treated with in situ internal fixation, which is a screw fixation. We will not go into detail of that, but it's basically they are fixable fractures when they are displaced. So again, the nature of injury is telling us Garden three, Garden four, there is a significant nature of injury. There is a disruption of the trabecular pattern. There is disruption of the blood supply, those kind of fracture, neck of femur or intracapsular. Please remember the word intracapsular fracture. They are less likely to survive very high incidence of avascular necrosis or a nonunion, which is why you end up with a replacement. So classification and the degree of displacement is also telling you the treatment, right. That's the key part here. It's already telling you what you are going to or how are you going to treat this patient? Then comes the extracapsular. Now you have come out of the capsule that means you do not have to worry about the blood supply to the growing part or the fees or or the head of the femur. Um And remember the metaphysis metaphysis, what is the characteristic if you look at the anatomy again? Uh metaphysis is a cancerous bone cancel. This bone has the the bones are a little bit more porous. They are like that. They are not very densely packed. If it is diaphysis, they are packed like this very, very dense bone metaphyseal bone will always collapse. So go back, distal radius fracture fracture will always collapse. There is a loss of height, intertrochanteric fracture or per trochanteric fracture, there is always a shortening of that fracture. But the good news about them when they collapse, they heal faster. So there is a very low risk of a nonunion in this kind of a fracture, which is why you fix them, you are fixing them rather than replacing them. And the final part, subtrochanteric fracture almost always, if you see a sub subtrochanteric fracture in a relatively older age group in their sixties, seventies, eighties, always, always think about a pathological fracture. Pathologic can be anything, it could be even osteoporosis tumor, whatever. OK. Carcinoma of prostate. Very common, getting a um uh bone uh metastasis in the proximal femur. So subtrochanteric fracture, always think about pathological fracture. Thanks. Thank you, Mister Ler. Uh You've already briefly mentioned on some of the things I'll be covering later on. Um I'm a bit wary of the, the time cause we have quite a few clinical cases to go through. So I'll try to um go through the rest of the sort of teaching bit of the slides. Um And we'll try to get through them as quick as possible. OK. Uh So next up is your Weber's classification of your ankle fractures. So with your Weber's fractures, you have your types A B and type C, those, those are sort of the main um classification ones. You might have your type um B one and B two and so on. But for the per purposes of like today and like, especially for medical finals, we'll just stick to A B and C. So A Wevers, a fracture is basically any fracture that happens below the syndesmosis. So the syndesmosis is your joint that connects your distal tibia and your distal fibula together. And these fractures are usually very uh have, they typically have a very good prognosis and most of these are just conservatively managed with some analgesia. You put them in a moon boot and often you might, they might need a bit of uh physiotherapy help. But for the most part, they're uh they don't really require any surgical intervention. Your Webber c fracture is any fracture that happens above the syndesmosis. And these ones usually, they would need surgical intervention, usually an open reduction, internal fixation or an aura. And then you have your type B what? Sorry, your type B Weber Weber fractures, which is at the level of the syndesmosis and these fractures, uh the treatment of it depends on the extent of the injury and whether or not the patient is able to weight bear. So you can have them conservatively managed or they have to go to theater for uh an open uh an oral procedure. It all depends on um individual case by case basis. And then after this, we have the Salterharris classification of growth plate fractures. So these are growth plate fractures. So growth plate fractures, they can only happen in Children cause by the time you're an adult your growth plates have been fed and it's very, very unlikely that you be ge getting any of these other types of fractures. So, uh like Mr mentioned earlier, the growth plate itself, which is within the meta metaphysis, which is represented by these blue regions here um is the most important structure followed by the epiphysis in terms of bone development in a growing uh person. So with your type, going from your type one to your type five or your sulfa Harris classification, it goes from the least uh well, the least severe to the most severe and your type one and type two, the proliferative zones of the growth plate, they are typically intact. So they usually have a very good prognosis and then your types oops, not that. And then your type three and your type five, they usually have worse prognosis as the proliferative zone is more damaged. Um And then you have, of course, your type five having the worst prognosis because although there's no displacement on this type of a fracture, it has a direct crushing type injury to the growth plates. So all of the growth plate is directly damaged by the compression. So there is a way to remember the mechanism of or the um description of the uh salter Harris fractures by using the min salter without the E and then your type one would be a fracture. Um So s stands for a slip. So you would have the um you have basically just uh your two ends of the bones rubbing against each other. And then your type two would be a fracture through the growth plate and then it goes up and above the growth plate. And then your l for your type three, it goes again through the growth plate and then it goes lower down towards the distal region of the bone, towards the epiphysis. And then you have your type four which goes through all three layers of the bone, you so your um diaphysis, uh your metastasis and your epiphysis as well. And then I've mentioned earlier uh R for ramp for your type five. So you have a ramp or a crushing injury which has the worst prognosis and can significantly affect your uh growth spurt. Um asthma sur mentioned earlier and yes, Edward from the exam point of view, just a quick tip. You it's impossible almost to diagnose type one and type five fractures on x-rays. So if you are presented with an x-ray of a child and a question is asked about, you know, whether what is the head is classification? Um if there is a fracture. So obviously, whether it's normal or not, that's the first thing to decide. Never said type one, never said type five because you are unlikely to be able to diagnose that you cannot see anything. So you are left with three answers, type two, type three, type four, right? So always remember what word has just mentioned a fracture going away from the joint, type two fracture, going towards the joint, whether it's a type three or four. Ok. That's all you need to remember. So, just from the x-rays, you will be very smartly able to answer that question, whether it's a type 23 or four, that's all you need to worry about. Thank you, Mister. Um Right. So that's sort of um well, uh the half of the lecture, uh I'll try to speed up the rest of uh the clinical cases um that we have here. So, clinical case one. So we have Bob who is a 65 year old gentleman who has presented the orthopedic clinic with worsening bilateral knee joint pain and stiffness. He reports that these symptoms have been present and worsened over the last few years, gradually reducing his ability to engage in his favorite activities like gardening and hiking on examination. He noted a mild varus deformity of both knees joint Cres as well as a limited range of motion in both flexion and extension bilaterally. You decide to order. Um oops, I forgot to change, that's meant to be bilateral. Uh But yeah, both knees x-rays. Um So that's the imaging that you get there. Um um But just for the sake of time, uh I'll just briefly describe on the type of things that you'd expect this, that you can see on this imaging. So you can see that there is an obvious varus deformity, uh, of both of the legs, um, with some narrowing of the joint spaces there, um, on the knees. And then this is basically, uh, osteoarthritis of the knees. So, again, like I mentioned earlier, you can use the mnemonic for, um, loss to try to identify whether it's osteoarthritis or a different type of, uh, condition altogether. I appreciate it's difficult to see, uh, the subchondral S cysts, uh surrounding the well not surrounding but like that's within the um, knee joints. Uh But sometimes in clinical practice, you might not be able to see every single criteria that marks towards a specific differential clinical case. Number two, we have Annie who is a 64 year old lady who presents with sudden onset pain around her right knee and her walking is limited because of this on examination. You noted that her joint is warm, erythematous and tender to palpation. You decide to order an x-ray and then this is what you see. Um Just because this is an interesting one. I was wondering if can someone uh it, well, the can anyone tell me what they see on this x-ray or whether it's, you know, a um spot diagnosis or if you can just quickly describe uh what you can see on the x-ray, I'll just give it like maybe 10, 15, 20 seconds. Good, good Prince UCAR uh has got it right. Uh Spot on that is uh this is actually pseudogout with uh chondrocalcinosis in the uh joint space there. Um So you can see that there's a visible layer within the joint space. Um some sort of calcified layers. So that can is usually a sign of uh chondrocalcinosis or like calcium pyrophosphate depositions that you hear so much about in pseudogout. And for further diagnosis, you can do a knee joint aspiration and send it off for um further microscopy and having a look and see what's inside. And then next is your uh third clinical case you have Andre who is a 36 year old gentleman who had a two day history of left knee pain and some pyrexia, he presents to your a and as he has never had any knee pain before, denies any recent trauma to the knee and is concerned about uh sorry, he's concerned that his mobility is affected. On examination, the knee joint is red hot and tender to touch. You also note that his inflammatory markers are raised, you then decide to order an x-ray of this knee. And as I bring out these images, feel free to just pop in the chat uh whatever you can see or if you from the history and the uh imaging, you know what is going on with. Um you know, with this case here, I'll just give it another like five seconds. Ok? So this is basically, it's an it is a normal knee x-ray um and just given the knee, his uh the clinical history that we've given there, the most likely diagnosis or differential diagnosis for this case would be something like aseptic arthritis just because of the raised inflammatory markers as well as uh the short um clinical history. Uh and most of the time septic arthritis, you wouldn't expect to see much on uh an x-ray of the joint itself. Sometimes you might be able to see some uh soft tissue swelling and some uh effusions. But most of the time it's, it will probably just be a normal x-ray case. Number four, we have Derek who is a 53 year old gentleman who works in a steel manufacturing factory and he was involved in an industrial accident while operating a ma machinery. A metal sharp broken component was forcefully, forcefully propelled into his left upper arm. His colleagues had removed 2.5 centimeters off the chart and has bandaged the injury as best as they could just from first aid and sent him straight to the hospital on examination. You see that the bandage is intact with no strike through which just means there's no leakage of the bleeding. Um He is still in quite a bit of pain, especially on mobilizing his left arm. Uh You see that it's quite difficult to tell the extent of the damage and you decide to order an x-ray of his left humerus. So, can anyone see what's wrong with this x-ray? So for the most part. Um This is uh an x-ray of where the bones are quite unremarkable. There's no obvious signs of a fracture there. If you follow the lines through, they're all nice and smooth. However, you can see that there's a bit of a dense white speck here, which is basically a remnant of the metal chart that has been um lodged into his uh soft tissues, uh and his muscles. So sometimes foreign body. Uh you can see that it's, yeah, again, it's just visible natural to the uh humerus. It's likely within the wound within the soft tissues. Um And he would likely need some sort of intervention to go in and like dig out the um small bits and pieces in there. Yup, that's right. Soft tissue injury, some soft tissue injury and basically just that spec there, right. So case number five, we have Margaret who is 76 with a known background of osteoporosis presents with some difficulty weight bearing and pain and some hip pain on the right side following a fall while she tripped on the carpet while mobilizing to her kitchen from her bathroom. On examination, the right hip is tender to palpation and you noted that the right lower limb appears shorter and externally rotated than the other. So I'm gonna bring up the imaging here. And if anybody can just tell me a spot diagnosis of what's going on. Yup, that's right. So we've got a neck of femur fracture um on this x-ray here and given the history as well. So if you're ever presented with a patient who has a shortened and externally rotated, lower leg, well, lower limb, that's usually the most um classic description of um a displaced neck or femur fracture. And yup, there's just uh some, yeah. So you can see that the um neck of femur fracture, it's a bit displaced, it's angulated sort of medially and this will definitely definitely require a surgical intervention, whether it's a total hip replacement or even a hemiarthroplasty. So the second last case here, we've got Brian who is 55 he's gone to a and with worsening really bad wrist pain on his right side. After he fell, he was walking his dog, he tripped and basically, he had um significant sharp pain straight to his wrist and he noted that his uh arm was deformed on examination. You noticed some tenderness around the right distal radius, his right wrist is swollen and the dorsum of the wrist is not well, notably displaced dorsally, right? Um I'll, I think this one is uh quite straightforward. You've got your anterior posterior view here and the lateral view here, you can see that the wrist is displaced dorsally from the distal part of the fracture. So, remember what I said earlier. So with wrist extension and with like dorsal displacement of well dorsal displacement fracture, you have a Coley's fracture, it's a foot injury. Um And Yeah. With just one imaging, you might not have known that it's a cause if you've just given, if you were just given an anterior posterior view, it's quite difficult to tell which way the uh fracture is going. And then the final case we have Sarah who's 27 comes in A&E reports intense left shoulder pain with an obvious deformity of her left upper arm. She was playing football and she fell kind of awkwardly on her arm outstretched after attempting to catch the football on examination. You noted that she's unable to mobilize her left arm without any pain. Her arm looks significantly deformed with a boxy or a square like appearance on her shoulder. This is the imaging here and in 5, 10 seconds, if can anybody tell me what they see here? Yes, perfect. It is. Uh Yeah, that's right. So we actually have a humeral hip, uh dislocation, particularly an anterior dislocation um of the humerus and the shoulder joint. Um You also have a hill sax lesion, which is basically um a lesion that happens when you have your humerus, the head of the humerus, um slipping out anteriorly of the shoulder socket and this grinding motion of it um causes um an injury that they typically call a heal sacs lesion. It's a bit tough to see, but you might be able to see this sort of slightly more dense, more flat region um of the x-ray. Great. So we've got through most of that now, uh we're almost done. I promise you. Um we'll just quickly go through the uh common like pitfalls and the common errors when it comes to looking at uh imaging, especially limb imaging as well. So try to not forget to, well, try to remember to always consider looking at the soft tissues as well. Uh I've mentioned earlier, look at the bones, look at the tissues. If you always stick to a structured approach, stick your A CS, it's quite difficult to go wrong and like miss the obvious things that happen. Um But sometimes, you know, things do happen. Uh and we still miss um things that we shouldn't miss. But then again, we are only human. So we the next is stress fractures or hairline fractures. So these are basically just really, really small cracks that don't really cause any significant dislocation. Um and they typically heal quite well. Uh But, and they can be quite difficult to see on an x-ray because of how minimal the injury is. But then again, it's something just to be aware of as well with looking at any x-rays, whether it's limb x-rays or any, well, any imaging in general, always check and see if the patient has had any previous imaging. So even if you don't know what's going on in the current imaging, it's always useful to have a previous imaging and then you can compare one and the other. So from there even if you can't tell what's going on, you can at least, you know, spot the difference uh and say like something doesn't look right here. Compared to the old one, there might be something going on there. Try not to get tunnel vision when you look at uh x-ray imaging and always, always correlate the images you see back to the clinical history cause it's really easy to look at an image and say um oh there's um there's a particular problem with the the bone when there's actually this patient has come in with uh a different pathology and then the bony injury is just a sort of incidental finding. So always try to step back when you look at images and always look at the picture as a whole rather than just focusing in on um a particular pathology, right? Uh So yes, mister uh just uh quickly. So just to add to that whenever you are describing or looking at the fracture, uh please do not forget the anatomical location. I imagine that you are the first one to see those x-rays and you are conveying that message to somebody else who is at the other end of the phone uh in the accident and emergency department. So you have to describe the location. So, epiphysis, metaphysis, diaphysis or anatomical location. Uh And second is the nature of displacement uh OK. Says uh transverse oblique spiral orated or incomplete fracture. OK. So that will give a exactly if I'm sitting 100 miles away, I will be able to visualize what is the nature of injury? What is the force of injury? What is the possible line of treatment and, and just the last point on the pitfalls and uh what Edward has already covered um uh clinical correlation, uh very, very crucial um do not accept one view, full stop. Never ever accept if you, if you send somebody for the x-rays um or if somebody asked you to see the x-rays, you always ask for a second view. Never a never comment on a P view or just a lateral view. You have to have a ap, lateral or a P oblique, ideally a P lateral and oblique in most of the uh limb areas that will give a full clinical picture to you. Thanks. Thanks M triple. I completely agree. Right? Just to end things off. Uh We're going into the single best answer questions now. Um and just feel free to put the, your answers in the chat. So number one, we have, you're an fy two working in A&E, you have a 27 year old gentleman who is presented following a fall off his bike and 20 miles per hour in an attempt to break his fall. He extended his right arm out and he landed onto the pavement. His right arm appears to be deformed and he tells you that he thinks he's broken it. What fracture does he have? So, this is the image that you have and these are your options. Is it a, a Smith's Fracture again? Uh Just feel free to put your answers through the chat whenever. Um I'll just be reading through these at, at my own leisure. Uh Is it a, a Smith's Fracture? Is it B A Coley's fracture? Is it C A gal fracture? D A Monia fracture or E A Barton's fracture? Mhm. Yup. It's D A monia fracture. Um So remember what I said earlier is you can use the M un gr to exactly get M un gr Monia ulnar fracture. You can see that there is an ulnar fracture there uh as well as some dislocation of the proximal radial head, right? So, number two, let's go. You are an sorry, you're a doctor working in orthopedics. You've been asked by Amy to review a 36 year old gentleman um with a fracture of his ankle, how would you rate his fracture uh under the Wevers classification. So that's the ankle fracture there. And then with the options, is it a abb a verse ec A Wes ad oc or E A Wever D? Yup. That's right. It's uh option D A Weber C fracture. So you can see that there's the syndesmosis there and the site of the fracture is obviously above the level of the syndesmosis and this would likely require some sort of surgical fixation. Good question. Number three, you're working on the vascular wart, you a 56 year old gentleman with uh type two diabetes and a previous amputation of his left second toe. He presents now with an ulcer of his Hallet which you know the pus coming from it, an x-ray of the foot is ordered. What is the likely diagnosis? So that's the imaging there. You can see that the uh toe is missing and he has some pain and sort of an ulcer around the hallux. So what is the answer? Is it a, does he have gout? Is it B does he likely have osteomyelitis? Is it C osteoarthritis? D septic arthritis or e it's a normal foot. Yep, that's right. It's osteomyelitis. Um So while at least it's likely to be osteomyelitis, radiologists will always tell you you can never confirm a diagnosis of Osteomyelitis just from x-ray imaging. But indication for uh what points towards a diagnosis of Osteomyelitis is if you look at the hallux, can you appreciate that the tip of the hallux is actually less dense compared to the rest of it. That usually indicates some bone degradation, which is uh typically a sign of Osteomyelitis number four. So you have a 10 year old girl who's come in with right-sided hip pain and a limp. Her parents tell you that she has been in good health until about a week ago when she had a mild uh respiratory well, upper respiratory symptoms and a low grade fever noted that the pain started a few days after the respiratory illness. She appears clinically well to date but she still has the limp. What's the most uh likely diagnosis? So that's the x-ray of her hips there. So, is it a, a slip, upper femoral epiphysis? Is it B Perthes disease? C transient synovitis, d septic arthritis or e growing pains? Yep, that's right. This is essentially a normal x-ray. So the answer is c transient sno Vitis. So remember to correlate the images that you see that you see with um the images that you see with the clinical history. Um She's had a recent uh illness uh and having a unilateral lymph and hip pain, all kind of points towards a more unilateral type of pathology which can be transient synovitis um A for a slip for AC P. Yeah, I can, I can kind of see what you mean by it might be uh some slip, upper femoral epiphysis, but just because of the clinical history, this is uh less likely to be that diagnosis. Uh but that's a very good uh spot as well on the x-ray imaging, right? So the last question, we have a 46 year old construction worker who fell off a ladder, he landed on his left arm outstretched. He noted a sharp pain around his left upper arm and he noted that it is deformed. So there is an x-ray imaging and it shows a fracture. How would you describe this fracture? Um um hm fine, I'll read, I'll read it out. Is it a, an incomplete undisplaced spiral fracture of the humerus? Is it b an incomplete undisplaced transverse fracture of the humerus? Is it c complete transverse, medially angulated displacement of the humerus? D complete spiral laterally angulated displacement of the humerus or d complete calmed spiral medially angulated displacement of the humerus. That's right spot on. Uh So it's c A complete, so complete fracture all the way through transverse. I appreciate it's a bit difficult to see uh on the x-rays. Ideally, we'd want another view as well, but you can see that it is definitely medially angulated displacement of the midshaft of the hume humerus. Right? So um thanks very much for your time and thanks very much for listening to this lecture. I appreciate that it took a bit longer than an hour. Um But thank you so much for your patience. And have you got any questions for either me or Mis Chlo? I think uh Edward, somebody wanted you to describe the displacements again. Hm. Um Right. So that question uh one second, that question I believe was for the, yeah, from Taesa mentor. Yeah, I think that might have been from an earlier. Where is that fracture? I believe that was this fracture? I think, I think, yeah, I think the, the whole idea was probably for you to describe about in relation to the distal fragment and the um you know which we de Auld. Yeah, exactly. Um Yeah. Yeah, good. I please miss that. Um Anita, is this lecture recorded by any chance? Yes. Yeah, I have replied to that. It is gonna be recorded guys. Um So once you fill out the feedback form at the end of this lecture, you'll get access to the lecture slides and the recordings within a couple of days. And there was a, there was one question about how do you differentiate type one to type five? And there is only one way which is by a CT scan or MRI scan. Uh x-rays will not be able to Yeah. Also something about the slide. Um don't neglect the soft tissue if we could just go back to that one. If possible, I would uh-huh of course, one second. Yep. Here we go. Yeah. So this slide here. Um Basically the is it? Yeah, I'll just briefly go through it. So these are kind of the common things that people um miss to do or like they get so caught up in everything else that's going on the board that they typically forget to look at these things when looking at the limb x-rays. So don't neglect the soft tissues. So for example, if you have an obvious fracture on the on an x-ray imaging, sometimes you can see that there's some soft tissue injury as well, which can indicate a more severe um mechanism of injury and might need more prompt management compared to a simple undisplaced and uncomplicated uh fracture and then stress fractures. The only reason that why I included it there is because um I don't have an example of that in the slides. Um But there are some fractures that you can get that just come up as a really, really thin line. And apart from that, you don't really get any displacement and sometimes you can just miss these fractures and then always look at previous imaging. Um just basically have the new imaging there, the old imaging and basically, it's just spot the difference. Even if you don't know what's going on in the the imaging, you can still just spot the difference. Don't tunnel vision in, don't tunnel vision into a particular uh pathology. If there's an obvious pathology, there don't forget to just step back and have a look at the image as a whole, look at your soft tissues. Um your joint spaces make sure that you're definitely not missing anything else that might be going on in the imaging and a lack of clinical correlation. Always, always with any imaging, always relate that image back to how this applies to your um patient. And the particular case that you're um you're trying to treat. That's basically it, that's great. Um Anything else I think there is one more question um from uh Taha about the displacement still. So what I am gonna suggest is just in terms of timing and for everyone else Thank you so much for coming and we really hope you enjoyed the lecture. They thank you to Edward and to Mr Ler as well um for presenting today and please don't forget to do the feedback for us. This is how you guys will get access to um the electro slides and to the record and also it's how you'll get access to your certificate. Um Next Tuesday at seven, sorry, at 6:30 p.m. there will be a lecture on interventional radiology as well as the pathways to actually going into radiology if you're interested in that. So please do come along to that. So for everyone else, thank you so much for coming and Tanesha and anyone else who would like to go through um this uh displacement then uh Edward if you don't mind just sticking around. Mhm Yeah, sure. I don't mind sticking around. Thank you so much, everyone. Thanks so good for it when you're ready. Sorry, what was the question again? It is, please go back um to the displacement. It's I think she's a little bit unclear about that. Yeah. So the displacement or this one. So basically with the displacement, all of these things. So you can think of displacement as basically how much um away from the natural anatomy of the bone has been moved from. In terms of in general, you can just describe any displacement as just displacement like medially laterally, anterior, posteriorly depending on what the finding is um and within displacement, angular angulation, rotation and translation, all of them are sort of subtypes of displacement. So all of them come under displacement and you can even just use the word displacement in general to describe um where the bone has moved in, in relation to the fracture. Does that make sense? Uh We'll just wait for a reply. Yeah. OK. Brilliant. OK. Good. Um I hope, I hope that's kind of what you're, you're um pointing towards. But if it's something more specific about um what you don't understand, I'm very, more than, well, you're very, more than welcome to ask. And I'm more than happy to like just answer it. I think she says it's, it makes sense now. Um So that's great. Thank you. So Edward as well. That was a brilliant, brilliant um lecture. Um So, yeah, guys, you're all free to head off and if you could just fill out the feedback form at your earliest convenience, that'd be great. All right. Thank you guys. Have a good evening. Thank you very much. All right. Have a good evening guys. Bye.