Computer generated transcript

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

Hello, everyone. Um, welcome to mind the bleeps. Radiology, Siris. If you are here and you can hear me, can you just, uh, say a little? Hello? Just shot in the chart for me doing using in the chart yet on, and we'll hear us. I think some people have said Hi. Hello. Hi, everybody. Thank you. Um, cool. So I'm just gonna give it another couple of minutes. Um, just, uh, get, uh, the last few people in who would like to join us, and then we'll jump straight in. Okay, Let's go. Brilliant. Um, so welcome to this radiology event. We, ah, being joined by June. She's going to tell us about shoulders on D. Um, elbows on what we're going to do, um, is go through some cases together. So my name is Sira. I, um the F one in the Oxford Diener E. Thank you so much for joining us this evening. So, um, we've probably seen some of you before, so thank you so much. If we haven't seen you before than welcome s over November, December in January. This radiology Siris aims to cover all the imaging modalities that doctors and healthcare professionals come across in the hospital last week, we saw Doctor joke hang on because through the knee, ankle and foot X rays and today will be continuing the M s K section of the serious with Doctor June. Now, um, she's an ST to in radiology, and she'll take us through a structured approach to the shoulder, elbow and forearm Plain films, which is some of the films that junior doctors, including me on do you hopefully often find difficult to interpret? It will go through a logical approach of how to interpret these paint. Plain films discussed, um, cases with us. Um, So I I'm very, very proud to introduce Doctor June low. That was a very comprehensive thank you very much. Cyrus. Oh, hi, everyone. My name is June, um, and as Sarah mentioned, I'm training as a radiology registrar in my interest at the moment, and we're going to go through some trauma X rays of the upper limit, nearly the shoulder and the elbow, and at the end, we will cover a little bit of the forearm is Well, so, uh, in our session, I, um, plan to cover a brief assessment structure. I know you'll have your own ways of assessing. I'm just gonna show you mine. And then once we're happy with that, we're going to go through the shoulder and the elbow or four. Now in each of these sections, After we go through the assessment, we'll have a short quiz. So that's where hoping of the interaction will come through. If you have any questions, feel free to just type in the chat box. I will have lovely Sira. Just keep an eye out on it for me. And if there's anything pertinent, she'll let me know. Um, and at the end, if you've got any sort of burning questions, we'll have time to answer those as well. All right, so we'll start off with assessment structure. Um, like I said, you'll find that many, many ways to look at trauma X rays, but I find that if I stick to one and stick to it always, then you're going to see most of your pathology. So I like to use ABC two s and I use it for almost every single trauma plain film that I see. So a stands for alignment very self explanatory. I won't bore you with it. You just want to make sure the joints are well aligned. So in here, you can see that there's a dislocation of thie. Um, third metatarsal phalangeals joints. Can you see my mouse, By the way? Go. Should I? Um uh, sorry about that. Otherwise, it's going to be very tricky. There's a liquid you can use as well, If you want to know. That's fine. I think I'm all right with this. Thank you. Um, right. Sorry. A alignment. Happy moving on to be so b stands for bones. And that is actually the bulk of your assessment. Obviously, Um, and the two ways you can look at bones first is the cortical outline. So normal cortex is crisp and sharp, and you just want to make sure that it's same the whole way through started one of the end of the bone. Go all the way around. Make sure you close your loop in the move onto the next boom. And if you do that, you and there is an abnormality. It often presents itself like a step. So here you can see there's a step in the cortex, and then when you notice a step, you can obviously scrutinize it further, and you notice that there's a transfer's fracture over here off the fourth metacarpal shaft. Now, this is a very common fracture after a punch injury. It's also known as a box. Is fracture very common, especially if you're gonna work in any and, um, people are coming in after they've punch Someone punched a wall, uh, is a common fracture to see in the 4th and 5th metacarpal, so cortical outlined. Very useful, even more crucial in Children. We all know Children's bones don't break the same because they're bit bendy, a there bit more elastic. And furthermore, Children don't tend to have very much bone or sort of ossified bone. So when you're looking at Children's cortex, really scrutinize the cortical outline at any sort of irregularity, Just draw your attention to it. So in here, if I can convince you there's a little belt, a bulge here, and this boat is known as a buckle fracture, also known, um, as a tourist fracture from time to time. Um, and this is a fracture in a child. There is a very, very, very subtle Lucent line just go across, but the most, the more obvious abnormalities, obviously, in the cortex, I said there were two ways you can look at the bones. The second way is to assess that trabecula or the texture. So bones have trabecula and they tend to grow in lines of weight distribution. So, in the for example, in the femoral neck and proximal femur, um, the lines in the direction that the weight is born, I suppose, And you just want to make sure that they're no breaks in these lines that are masking any non displaced and subtle fractures. It can be quite difficult to interrogate this properly and thoroughly. So, um, all I asked you to do here is just be aware of it and have a look at it. The next thing is texture, and when I say texture, I mean cortical texture. So when the bonus injured by anything infection, inflammation or a fracture, the sort of periosteal periosteum the King film that surrounds Thiebaud ones will wrecked. And this is called periosteal reaction. Very helpfully, Um, and it's basically when the cortex looks fuzzier, like in this picture over here. So here we have a case of a young woman who is a runner who went to a GP, said that she's got pain in the foot, did an X ray, didn't really see anything kept running on it, went back to the GP with a couple of weeks later. And then you see this over here so this some of you may already know it's a callous, and this fuzziness around the, um, cortex is can sometimes be less subtle than this and that, and that is a periosteal reaction. So this meant that that was a fracture before a hairline or very subtle nondisplaced fracture. Stress fracture, that is. Oh, that can't be diagnosed in a plain film. Um, but it's a fracture. Nonetheless, the bone reacts the same way, and it develops a callous or a period still type reaction, right? So you happy with a M B can move on to see see stands for cartilage. And where there's cartilage, there's often a joint, so joints basis is, well, that two things that you want to assess one the space. So is it narrowed, or is it widened? And secondly, what's in the joint? Um, it is narrowed. Not very concerned, you know. It tends to be chronic pence to be um, degenerative in nature. You want to be concerned when it's wide and especially in the context of trauma and sort of acute pain so he can see a narrowed joint space, Um, which is very classic position for osteoarthritis in the big toe here we can see a distal radial fracture and a widening of this joint space here. If I can convince you this. These are all relatively uniform and very narrow, and all of a sudden you've got this gap. So this is important to note because not only if you got a fracture, but you've also got a rupture of ligaments. And and that's why why didn't joint spaces in the context of trauma can be very So Was he happy with the, um, the width of the joint space? You need to think about what can be in the joint space so classically be fluid. But obviously, if there's a fleck of bone or an injury in the joint space, that's very important to know it's well. So here we've got example of the ankle, and, um, if I can show you here, this looks very different to this, isn't it? So this is what's called an osteo. Sorry, the hours just showed up. This is what's called an osteo chondroitin fracture. So within the joint, the impact of the injury has taken off thie cartilage as well as the bone under me osteo chondroitin. Now this is very important. It can be very subtle but very, very crucial to detect because it's an articular surface and it can change the management off. The patient relatively drastically can move them straight on to more invasive type management versus a conservative route. So yes, that see? Oh, not yet. There's also fluid that can appear in the joint space very classically, um three. Or trained to look effusions. So here's an example of a knee fusion. Just that So a B C then we've got to s is so the first stands for soft tissue, and that's just a reminder for me to look at the soft tissue around the bones. Is there anything in it any foreign bodies and Lucent sees that can tell me that this air on open wound is it swollen? Is it symmetrical, etcetera, etcetera. So and here you can see that this increase of true swelling along the lateral malleolus and in the absence of a fracture that can be quite useful because it tells you that some other process is going on. Ligamentous or tenderness damage? Um, another way soft tissue can be more important to can be crucial is in Children when the when the fractures are more subtle. If you've got significant soft tissue swelling in mix, it's almost like a like a beacon. And it tells you to look hard to make sure you can't see a fracture before you send that kid home. Um, the second s stands for special review areas. Um, and each X ray has got they've got different anatomy. So there are a couple of review areas that are become more pertinent. For example, in a C spine X ray, this little soft tissue region in front of the spine is one of the special review areas. And then there are special things we need to look out for in the shoulder and elbow X rays, which I will go through with you in a moment. Come off it. That's ABC into s. Does anyone have any questions before we move on? Take that as a no. Okay, so move on to the shoulder. So what I'll do in each section is we'll go through that and that to me, radiological anatomy of each one. And then we'll use our assessment structure to look at those films. And then we often will then move onto the quiz. Um, but just before we do that, I'll touch on some shoulder dislocations quite quickly just cause they're exciting and you can see him quite often in the department. Okay, so when you ask for a shoulder X ray, you can get sometimes you get three. But more often than not, you get two out of these three films you get a PV you you always get a PV. You and you could either get one of these views, which is known as an axial view and a y view. So an axial view is interesting because you have to abduct the shoulder and then take the X ray down like this. So the patient needs to have a decent range of movement basically, and the Y view is taken with the scapular end on, so it's it's taken in this direction. So when you see your scapula like this, so Brittany run through some of the Not to me. We've got your humor ahead here. You call a night you got your scapula. Then on the Humira head, you've got your greater and lesser tuberosity. You often can see the great unless as much obviously smaller. But also it's more interior. So it's not so obvious. Then you've got all the other normally bits you're acromion clavicle and your coracoid process that sort of points full woods in the shoulder. Now, these are your, um, other two views the active. You used to confuse me a lot until I saw this graphic. So these two views the Axiron wife use airbase ically to determine thie alignment of your colon. Oh, humeral joint. And if you imagine the humeral head is the golf ball on a T like this here, as long as your golf balls that nicely on your tea, that's a, uh, located joint. And if you imagine your chromium and coracoid like your pincer grips you, you're usually in a good X ray. Your pincer grips should be holding the golf ball basically like like in this case, Um and although in this view, the most important joint issue, Plano Humeral joint. You can see you acromioclavicular joint. Swell. So make sure you have a good look at that. So you're not missing anything. This is your wife you aptly named because it looks like a why. So in this case, you've got your rib cage. So you know, this is anterior. And then you've got your coracoid pointing forward your chrome and kind of coming from the back to join your clavicle on this end. So you know that this is anterior and this is posterior, and this is the blade of your scapula. So in this view, what you want to make sure is that your humeral head, whichever direction your humor shaft is pointing in, it doesn't matter. But your humeral head is intersecting with this. Why? Like this. And if that is the case, then it's enjoy. Right? So we're happy with all of us know we can move on to trying to assess. I'll show you to join, so we'll start with a eza like mint. We've got two joints. We want to make sure they're lined. You've got your glenohumeral joint going to make sure it's that it's got that nice overlap. Like the middle of the vendor Gram, Um, And then you put your acromioclavicular joint as well, the way you make sure it's enjoying. First of all, it looks in joint, then it probably is. But if you really want to sippy specific, then you could draw a line from the inferior border of the clavicle to the inferior border of theochron me in. And if it forms a a relatively smooth line, then it's enjoying. And again, these are the two views T. O. R. Joint alignment as well Golf ball on your T and your humor head is in the middle of your wife. Yes, So once you're happy, you can move on to be self explanatory. Make sure you look at all the bones. You've got your humerus glenoid your clavicle or you're not normally bits your coracoid acromion. But don't forget your scapula, so people often ignore it because it looks like it's behind something else. But you can actually see the entirety of the scapula on, uh, on a good shoulder views and make sure you just look at it, make sure they're not gross abnormalities, not fractured. Think so. Once you're done, you can then move on to see joint spaces. So those two joints and they're going to be two joint spaces. Um, the chronic allergic allergic rhinitis in the same alignment. So you just wanna make sure this is not too wide. There are very specific measurements, but no one uses them because every everyone is different as long as it doesn't look too wide. Not, you know, I'm concerned now in the glenohumeral joint. The joint spacing it to look at is actually here. So it's underneath the acromion aptly named the's sub acromial space. Because because the overlap of the actual glenohumeral joint, you can't really tell joint distention. Based on this alignment, you want to be looking at this alignment. So if there's joint distention, then this space will increase. And sometimes you can even see the humeral head being pushed down as a result of that, and then we can move on to our two s. Is so soft tissue not just this soft tissue outside the bone, but remember, you've got soft tissue. Here is well between your arm and your rib cage. And here it's often where you'd see the first signs of surgical for Seema in the cases off further injury. Um, and on the shoulder, it's quite easy. You're gonna get one special review area, which is to make sure you look at all of the x ray. Um, and by that I mean, make sure you look at this bit of the x ray as well. So your chest, it's almost half of the x ray. But often time we forget often times you forget to look at it. Um, so make sure that in the bits of long that you can see, you can't see any gross lesions on the ribs that you can see make sure they're not displaced. And a very common thing to miss is a pneumothorax where someone's got the full on their shoulder. Um, and you think they're, um, technique because of the pain. But really, there shouldn't be having a pneumothorax. And the only image you've got, it's a shoulder X ray. So it's worth looking out for, Right? So that's how you look at a shoulder before I move on to the quiz. I said I was gonna talk about shoulder dislocation so really quickly get the of interaction from the crowd. I want you to tell me what you think is more common anterior dislocation or a positive identification. And if so, can you tell on an AP film just waiting for a couple more people to answer It looks like you guys got the gist. Yeah, that's right. So anterior is more common and a bit of a trick question, but yes, you can tell on a PPI fill. Um, so and here is more common because there's less muscle anteriorly. Um And if you think if you just feel your own shoulder the back, you've got all your back muscles and then you've got your rotator cuff muscles and your deltoid and things like that there preventing sort of backward movement. Basically. So unti is more common, and I will show you how you can tell in an AP film. So, um, someone's mentioned a light bulb sign, which is great, because that will tell us, um, that can tell us which kind of direction? A ah, shortest occasion this bar. Get to that in a bit. So anterior shoulder dislocation. So you can see here the glenohumeral joint is no longer ah, well aligned. You've not got that nice pen diagram. In fact, it looks like the Humeral head is kind of overlying the glenoid now, um, and if you think about I know it's a two d image. But think about it. It's now kind of underneath the coracoid. And where's your core record? Your core record is anterior, isn't it? So for your shoulder to move forward has to move underneath the coracoid because it can't smash through it. So and anterior shoulder dislocation tends to be infero medial. So it kind of moves down. And in this way, um, and you can see that on this wife. You hear your humeral head is no longer in the middle of the Y, and it's actually underneath the coracoid, which would prove it's an anterior dislocation. And this is a positive identification. So, very helpfully, it's showing that sign that your colleagues mentioned the light bulb shined so it looks like a light bulb as opposed to a walking stick. Um, however, I don't know if you've ever seen shoulder X rays where the shoulder is internally rotated. It can also look like a light bulb, so it's not terribly specific or sensitive show, we say, Um, but what's more important here is Oh, it looks. It looks like it's actually still enjoy it. But it's not because look how posteriorly positioned it is. It's now under the acromion. It's under the acromion, and a posterior dislocation doesn't have the the the impeachment of the coracoid, so it tends to move back and upwards as well. And it's shown here again, you can see the humeral head is no longer in the middle of the Y, and it's moved upwards and right underneath the acromion. So this is a posterior shoulder dislocation quickly summarize on an AP view for anterior dislocation. It tends to move down and in words and posterior doesn't have the coracoid in its way, so it just moves up and up on a why, or axial view. The anterior dislocation moves towards the coracoid, and your posterior moves backwards towards your criminal, and that's it. So once you've identified a dislocation, though you would relocate in any you know. You give us have patent back, you save the patient, and then you send them for a post dislocation X ray, obviously to check whether or not the shoulder is in joint. But what is also important to determine if there any post dislocation related fractures? So you're definitely gonna pick up the clavicle fracture? Humeral fracture. But what about fractures from the dislocation? Just really quickly. Um, I will show you what these injuries are. Does anyone know what these are? Cold thereupon, Um, it's which is not very helpful. But if you do, just drop it in the trump box. So these are called Hill Sachs and bank heart lesions. So you get Hill Sachs lesions. What? Both Both of these you get from anterior dislocations. So Hill Sachs lesions happen and you got your glenoid You've got your humor ahead. The force of the desiccation pushes the head forward. But you still got all your muscles. And you know you're not on all your ligaments intact. So what happens is that reverse force, um, pushes the posterior superior bit of the glenoid again. Sorry, the humeral head against the glenoid. And then you get this notch type fracture over here. Um, and this is called a Hell Hill Sachs lesion, and it's just important because of patients have further pain. Um, that ah related to the, um, dislocation. It can be because they've got fracture. Basically. Now, the reason why I said bank card and bones are made a difference between bank on Boniva and car lesions because a bank heart lesion is a tear in the anterior glenoid labrum, which you obviously can't see on a plain film. But if that forces so great that, you know, only tear the glenoid. But you also shatter the front bit of your, uh, bony glenoid, not just the labrum. Then you get what's called a bony bankcard lesion of these are more important to pick up straight away because it's an articular surface. You wanna, um and you want to make sure that, um, the Ortho Pause or the patient is aware that this has happened so that management can be tailored towards this specific fracture, and that's it. So we've talked about short of desiccation, how to tell a poster shoulder dislocation type injuries. And we've also gone through our assessment system for shoulders. A quick recap. So I'm going to show you how I look at the shoulder X ray, and then we can move on to the quiz and you guys can do all the assessments. So a alignment glenohumeral joint nice pen diagram impression and your A C joint is nice. Smooth line. So is enjoying a swell. You're making sure that you've got your golf all on your t and you'll hear my head is in the y. Fine. And then you can sort of don't discard them. But these are less important. You can focus on your refill. Be Look at all the bones and the make sure you look at your scapula trace all the way. See, looking at my joint spaces and my cartilage So this joint space is fine. This joint space is fine. And then my two s myself tissues looking at the soft tissues outside, checking for any swellings foreign bodies. Okay, so to come see me over here, over here and then my special review area, making sure I look at the rest of the film. So the chest, a swell looking at all my ribs and then making sure this long looks relatively unremarkable. No lesions or no pneumothorax. See, So the lung markings go all the way to the top, and that's a A B. C two s. Obviously, I'd spend a lot more time on it, but But that is a good way to tell quickly whether not you've got pathology, right? So we can we want our cases. I have 11 cases, and depending on how interactive you guys are, it may or may not take, um, more than sort of 15, 20 minutes. Um, and we should get started. Right? So if you type in the chat box what you think these are, um, Mohammed Got enough answers? I will reveal the answer. Now, don't be afraid to put the, uh, to put a wrong answer. And because it's as important to know why something isn't a fracture. Um, as is to know what the correct diagnosis is if you know. I mean, it sounds like most people have, um, gotten it right. And this is a a si joint, this location or disruption, so to speak. So you can see here very nicely. You've got you don't have a fracture, but you're a si joint is no longer aligned. We say the glenohumeral joint is fine, because here you can see that nice little vin diagram type impression. Um, and the appearance of the humeral head still has that walking stick type appearance. Great. We can move on to our next one. What is this? Most of these films have one abnormality. If they have more than one, I will tell you. And then, you know, you guys are aware nowhere know to stop looking. So most people have said anterior dislocation, and that is correct. So here you can see the humeral head is underneath the coracoid process. And this is a wives. You You're wise here, and your humeral head is here underneath the coracoid. So this is the anterior dislocation? Um, yeah, there we go. Next. So again, there's only one happen. Um Alatini, this one. So someone mentioned posterior dislocation. And that's, um, I I wonder if that if it's the light bulbs time like pulp sign that makes you think that. But if you look here, it's still got that nice overlap between the two. So this is stolen. Ah, and enjoying shoulder basically. But that's why I mean, as in, if you internally rotate the shoulder, it looks like a light bulb. But it doesn't always mean that it's positively desiccated. Yep. Okay, so people have seen it. Now it's a fracture. Scapular. Look at that. This here. It's a combination fracture of your scapula. Look how badly is fractured, but if you don't look at it, it's not. It doesn't come through straight at you. So why is it important? None of the question for you guys was important to identify a fractured scapula. And how is it different from any other sort of fractured bone? We go, yes, someone's said the right answer, which is the mechanism of injury. Exactly. Is, um well, it it tells you this is a very large or strong mechanism of injury. If you think about it, the scapula is very flat bone, and usually when we injure long bones, you get four script, comes up and travels. But to fracture your scapula is very unlikely. You're going to hit one of the edges, isn't it? It's a force that's come this way. And to shatter it, you've been on legal. Have to pass through all this back muscle, your traps in your lats, everything else that's there. But it's also got to be a large enough sort of area of force to shatter it, so that implies that they're going to be other injuries. Potential internal injuries, a swell. So if you see a fractured scapula In any case, however subtle you need to consider more either Cross sectional imaging. Almost lower imaging off the rest of the region. Well done. Oh, someone mentioned a rib fracture. So are you looking at this here? I don't know. I can't count to 1234, 5678 years. So that, unfortunately, is just long marking. But good. Shout on looking at the ribs and making sure you're not missing out Rib fracture as well. Next. You guys doing very well. You've been listening. Okay, What's this grand? You guys have picked it up. So this is the posterior dislocation. See? Again, You've got nicely here. You've got light bulb shined. But most importantly, there's no overlap between the humeral head and the gleno, the glenoid. And then in your wife, you, um you can see the humor head is now not in the middle of the Y, and it's underneath the acromion. You'll notice that you often get wivb use with true shoulder dislocations. Because to get axial view, need to abduct the shoulder. So if you suspect the shoulder dislocation and it comes back with an axial view, you don't need, you know It's not desiccated because they can't abduct the arm if it's truly the seat. All right, take that. Okay, well done. Next. Um, what is wrong with this one again? There's only one abnormality on this film. Yep. Yep, exactly. The most people have picked up that you've got something wrong with your humerus and very aptly. So this here, this is your lucent line. And this. Like I said, you can often see the grace of greater tuberosity less. The tuberosity is much smaller enough often overlaps with the rest of the bone. So this is a minimally displaced on on displaced greater tuberosity fracture. Well done often happens in older people when they fall in their shoulder. That's the first. But that the fracture along with the clavicle as well. Next. So there's two abnormalities, um, in this still within the same region. But, um, try and see if you can pick it up. I will accept this. Looks weird. Is there's an answer as well, because that's your gut feeling and got feelings. A very important we were looking at X rays. Okay. Got quite a few answers, and they're all slightly different, which is very exciting. they're all not wrong. By the way, There correct is actually great. So Okay, so this is a human head fracture off human neck fracture. More like so here can see the humeral head over here. And then it kind of stops, and all of a sudden you've got the neck. So you know that it's been fractured an impact. It almost angulated. So this is a fracture. And, um, some of you have picked up this space is much wider and it looks like it's dislocated, Which I will give you that because we can't tell if it's dislocated or just sub locks. But coming back to this space on this view, this is a modified axial view. What do you think this is? What is this? You can see the humor neck fracture bit better, you know. So most men should fluid level. Yes, it is a fluid level fluid. What level is it is It's less dense. It's not quite extensive. The sorry, it's not quite as loosen as this outside. But what what else could this be? It essentially is a hematoma. But what is this this lighter bit up here? Anyone know? Like a specific name we give to these kind of joint effusions. So someone mentioned hemarthrosis. Very close that something in front of it. Something in front of hemarthrosis. Likely Mother, is this? There we go. Well done. So, like a hemothorax, it stands for fat and blood. So this joint effusion this dense fluid here is blood. And remember, you've got marrow in your bones, right? So if you've got a big joint fracture that marrow, that fatty marrow can then come out off the joint and go into the joint space. So when you see a flat line in a joint effusion, it's a lipo. Hemochromatosis. It's a fracture until proven otherwise. Um, you can see the fracture here, but in more subtle things, like knee, uh, tibial plateau fracture. Sometimes you can only see a lipo. Haemophilus is so it's important to I remember it well done. There we go. Fracture of the humeral neck with subacromial lipo, hemochromatosis and the case I got this from said it was pseudo subluxations or not true dislocation. But in reality, you can't really tell unless you got the patient to move their arm, which they probably can't, or you've got another better view so well done. For those of you who said it was an anterior dislocation as well next. So this one has one abnormality. Um, and I will say it's in your view area. Someone's mentioned a C joint disruption. It looks like it doesn't it. But if you draw a line from the underside of the clavicle to the underside of the Acromion, it's still relatively intact. And that's why I mean most. Most people are different, and as long as it's relatively intact, it's acceptable and it doesn't look too dislocated like the first case that we saw. So that is acceptable. But good thinking. It does look about. I agree. Fab, there's a really egalite and you've been listening. So this is eight pneumothorax, so I'm just gonna illustrate the line here is this is a pneumothorax. After a shoulder injury, there is no rib fracture to be seen here. But can I convince you that above this line you can't see any lung markings, and here you can see the same as well. So this is all your fuzzy fuzzy lung markings, and that's not really that same lineage quality there. Um, and then someone mentioned sternal clavicular joint dislocation. Now, uh, we can actually tell on this X ray. Good to think about it. We can't tell because of the direction that the clavicle comes, and it kind of comes towards you. Know what? All towards the screen. Um, and then you up stone, um, is so like this. Basically, if you want to see the stomach aviculare joint, you need to do in a clavicle view, which often means that we angle the beam upwards and make sure we get the whole of the clavicle. And then it's attachments as well, but it's good to think about it. You guys are doing the right thing, right? So this is a normal shoulder, but the apical pneumothorax well done. We're coming towards the end now. This is where it gets a little bit more interesting and there are two. I will say that two abnormalities Typical yes, or some. A lot of you guys have, um, noticed the first abnormality, which is your distal clavicular fractures. You go. It looks a bit odd because it's not that classic Lucent line. But if you think about it, it's just like the fracture has occurred in the same plane. This your X ray. So this is what you're seeing and you can see this lucency through it like that. Well done. I agree. This part, the glenoid looks odd, but it's, um, it's basically just a general change. Good on whoever who picked it up. So that's great. And with regards to open, whether it's an open, a closed fracture, unless they're surgical emphysema and a a soft tissue defects, it's very difficult for us to tell. Obviously, that's where clinical colleagues are very important. You can see whether or not there's a wound associated with the injury, and it looks like some people have seen, um, the second injury. But I will hold off a little bit just to give you guys, um ah, bit more time and again, it's in your review area. Like I mentioned this, this abnormality is a bit more subtle, and it's in in our in our review areas. You think some people have started starting to see the rib fractures now, so it's in this region here. And if I pointed out to you, so here you've got your first rib, and then when you trace your second rib, you've got a little step there. You've got a second rib fracture. Then you go on third rib, and then this is even more subtle. But you've got a full for a fracture as well here. So this this is the fourth rib fracture. It's very subtle. On off on your computers and workstations office you consume in a window will be a lot easier. But here, on this way that you can also see your second room fracture a little bit more displaced in this and in the fourth rib fractures. Well, here, this is not a buckle fracture. This is a fully grown adult, obviously, but it just looks that way because it's off the projection and the way it's only just minimally displaced. Well, then you saw it, though. So you've got a district logical fracture with 2nd and 4th rib fractures. Review areas. Very important. Oftentimes on. Um we find that, um ah, real practice and missed. So you're focused on the pneumothorax, not manual thorax. The pneumonia that you often forget. Have a look at the ribs. So I am. I'm proud of you guys. Well done. Just in the interest of time, I will point out some of these to you. So this is left upper lobe lesion. So there, that's just the appearance of a degenerative shoulder. And here you have a left upper lobe lesion here. Of course, you can't really compare it with previous, but the first thing you should do is, um, noted. And if it's not there, then you know it's a new finding and needs for the investigation. Um, this case also has a subtle undisplaced fracture of the you chromium. But to be honest, I wouldn't expect you to see it on your screens. I don't I expect you to maybe pick it up on a more high definition screen. And this one is a classic appearance of the Hill Sachs lesion. So here you can see in the superior portion off the humeral head. You've got a little different, and this is what that looks like. This almost looks like someone's taken them by over out of Annapolis. It's definitely abnormal. You should have a nice, rounded, humeral head like that. And this last one I will let you guys give ago. So this is the last one, and it's It's more subtle. Um, them before, but I think it be a nice case to end on. So you think? Okay, it looks like most people have seen it. Well done. You guys are scapular experts now, so this is a scapula fracture. Um, here you can see the loose in line going through the glenoid. So it's likely that there's been impact this way to cause a fracture to propagate the other way. Um, and you can kind of see propagating throughout the ah, rest of the scapula and on your wife you very helpfully. You can see that there's a disruption of the nice, smooth blade of the scapula. Now, again, a C joints. They're tricky on there. But if we draw a line from the bottom of the acromion, which is here to the bottom of the clavicle, it's nice and smooth, so it's not disrupted. And yep. Anything else, Teo? Yeah. No, I I agree with wife said it looks like it could be a posterior dislocation. Um, but that's only because the glenoid is not sort of is a little bit on fast, so you can't see this way, But just trust me that this is enjoying your humeral head is on the glenoid, so it's not a positive identification. And here you can tell. Actually, here's your wife view. Your humeral head is here. So it's It's intersecting the Y. And if anything, it's heading more towards the coracoid. Probably because it's been rotated internally like that. Well done. So that is all of our shoulder cases. I hope you guys enjoy that. It is almost nine o'clock, and I still have the elbow and shoulder. Sorry forearm to do. Um, So I was wondering if you guys wanted a break really quickly have a cup of tea, or he wanted me to just quickly run through it so we could hopefully finish in half now for 40 minutes. So once they keep going, in any case, I'm just going to run through the anatomy. So feel free to put me on speaker and then grab yourself a couple ti. Okay, Good. Move on to elbow and four. So we ah, going to start with the elbow and then kind of continue down towards the forearm and it's the same format we go through. And that to me we used the assessment structure and then we'll go through the quit again. with an elbow X ray, you'll get two views, a lateral view and a PV and in an adult elbow, this is You're not to me. Well, it doesn't change in a pediatric callable. To be honest, you just can't see as many bones. Um, you've got your, uh, all now here your radius and important articular surfaces are your radial head, your coronoidectomy process. Then you're electron process as well. Then on your humeral side, you've got your trochlea that ah articulates with the ulnar. You've got your capital, um, or capitulum that ah, article. It's with the radius. Then you've got humeral condyles, which are these bits sort of underneath the trochlea in under the capital. Um, and you've got the epicondyle of the teeny tiny ones on either side On a lateral view, you can see a lot of the same things so you can see a radial head here, this little round ball, the often see um, that's kind of coming off. This little teardrop shape is actually your capitulum because he can see it articulates with your Radiohead just behind it. It's a slightly larger bulge. So this over here, that's your Oh, no, I've got it wrong. Sorry. This is your capitulum causes articulating with your Radiohead's are. And this rumble is your Tracleer because it's a ball, and then your core in yours. Are you all now, um, articulates with it like that. You've got your, um, core cornered fossa. You got you elected on four So behind. And then obviously you've got all these are the big radio neck electron on cora annoyed process cetera. Now, the important thing on the lateral view, which I hope you guys will learn how to look at it after. This is, um, fat pad so you can see your anterior and posterior fat pad. Well, you've got to fat pads, and you can commonly see your anterior posterior often sits within the electron foster. So, um, on a normal elbow, you don't see it, and these are relevant because it can denote a joint effusion. As you can see here, there's not a lot of fat not have the knee where you've got fat pads that shows that can show you fluid, a lot of the elbows just quite dense. So these fat pads and knowing what's normal and what's abnormal could be very useful in trying to detect a fracture. Now, before we move on to trying to do the assessment, I want to introduce the pediatric elbow to you guys. So if you already know this greater just the revision. But if you don't, this is what pediatric elbow looks like. Um, and like we said before, um, pediatric joints have a lot of cartilage, and they're very little bones, depending on when you image thumb. Um, there is a very useful pneumonic called cry tall, which tells you the chronology of ossification off the different bits of the elbow. So C stands for the cap cap. It, um capitellum, which is this. This has been labeled wrong. Sorry. The capital. Um, with the radium radius, um, Aasif eyes first. Then you've got your Radiohead, then your internal epicondyle. So, medial epicondyle, um then the trochlea, which is here that articulates with you all know than the electron process, and then finally last your lateral epicondyle. Oh, Now, the reason why is useful to identify these ossification centers and the chronology of us a vacation is first of all to not be surprised when you look at pediatrics elbow and there's no bones in the joint. But second of all, um, if there is an avulsion off, any one of these epiphanies sees knowing the chronology in which it also fires can be very useful. For example, if there appears to be a lateral epicondyle before the internal epicondyle has also fide, then you know that that's probably not the lateral epicondyle. It's probably a fleck of bowling from somewhere else, etcetera, etcetera. Right. So we will be going through some pediatric cases at the end, so hopefully that will give you a chance to practice. The cry told criteria. This is another illustration of appearances of the pediatric elbow as they grow. So first you get your capitulum than the read your head. Then you know, Internet condyle Tracleer electrode on often appear the same time or at the same stages. And then finally, as you hit sort of 10, 11, 12 years old, you tend to have all the epiphany season. The prophecies now we can start assessing are elbows. So I like to start the lateral because, like I said, you can tell, um, if there are fractures based on whether or not there's a joint effusion. But also it's very useful with alignment. So again, in the elbow we've got we've got one main joint. But I got three bones, don't we? So we need to check that all of these are aligned. And they're two very useful lines in the elbow called the radiocapitellar line, which is drawn from the radio neck all the way back. And it's to intersect the capital, Um, right in the middle. And then you've also got your anterior humeral line. So if you draw a line from the interior border of the humerus all the way down, it needs to intersect at least the third of the capital. Um, sick. It can be within the middle third of the capital. And this is useful because I read a capital. A line tells you whether not the radius is enjoined or if it's dislocated and anterior humeral, I will basically tell you if there's been a fracture. If you're super condo, uh, process super condo the region here, then once you're happy with your alignment, you can move on to bones once again go three bonds. So just trace them really well and make sure you can see a nice thin cortex. One of the things I do want to draw your attention to is this little cup here. So this articular surface of the radial head, it's almost like a little saucer. And sometimes, um, you can you can only see a little lucency or little step in this cup, and you can't see any sort of cortical irregularities on the side. So if you just pay attention to this region here, you can pick up some more subtle, um, fractures. So here again, region. Okay. And then want you happy with a A and B you can move on to see so c refers to joints. So we're looking mainly in this, in this case for joint effusion. So, like I mentioned, fat pads play a huge role in the elbow X rays and this swi elbow X rays. Um, one of my favorite so anterior fat pad is quite normal. So if I can convince you, all this dense, dense tissue is muscle ligament, skin fat, subcutaneous fat story, and just in front here, off the humerus is your anterior fat pad. Now, if you can see it, it can be normal because it should kind of gradually flow from the top of your huge, very distal humerus all the way down, disappearing into the joint. It should be obvious. It'll so that that's an illustration. It almost looks like, um, a sale, but like a closed down sale. So it's not open and in the wind. Um, but when it's raised, that's when it has, um or, um, right angle triangle type appearance. So this is more of closed Triangle, Um, and I will show you examples for them. Now. I've talked about the anterior fat pad, so the posterior fat pad, like I said, lives in the electrode on fossil, so you should really never see there's so much born overlying it, um, it's not really visible when it's normal. When is abnormal a lot of the fluid from the joint effusion Kingdom travel into the election and force and push that out. So if you ever see so this looks like there is a lucency here, but this is what we call a Mac effect away. When you've got something really bright next to something less bright, you your brain makes you think there's a darker line in between. But if there is like a triangular or a a bulky, a darker line behind your humerus than that is a positive fat pad. And it's always pathological. They always means the eyes of fracture. Okay, so I'll give you examples. These are examples of joint effusions. So before highlight them. This here, this is your raised until you're fat part and this very different from that Mac climb we saw. This is more bulgy. It's more Lucent. This is a posterior fat pad. Same here and here. A fat pad, almost like pushed up. That way. If you imagine your triangle's this has been pushed up like that, it's more sort of right angle e. And this is your post your fat pad here and there is highlighted for you. So if you're like I said before, this is a raised anterior fat pad and this is poster. There we go. If you see this, that's almost always a fracture, and here you can see the fracture and the radio on that, and then I believe this one is in the radial head. There we go now. The interesting thing. So the reason why I showed you adopted Children's elbows is festival. Those Children's Children fall in the elbow, so it's good to know how to look at them when you're working any d. Um, but also there is, um, a difference between the most common fractures in Children's and adults. So in an adult, the most common cause for an elbow effusion post traumatic is a Radiohead fracture. Redone neck Aredia head fractures. So if you can't see any fractures but there is a joint effusion, you can see anterior fat pads about Syria fat pads. It's most likely going to be a Radiohead fracture in Children. However, um, it tends to be a super condo, a fracture. So a fracture up here or a lateral condyle fracture. So, um, the lateral condo would be where the, um, like just before the capitulum Aasif eyes, Um, and that bit of bone can get fractured. I'll show you, in example, eight. Um, right, So that's how we assess joint effusions, um, in an elbow. And then once we're happy to say we can't see anything or were happy what we're seeing, we need to then move on to our two s. So you've got soft tissue on a special review area, so soft tissue is really simple you got so much sufficient. Make sure you look at it. And basically, I want to remind you that they're loads and loads of muscles that that, um, insert into the elbow. So if you have any sort of for selection for type injury, then muscle can pull bones a bit of bone off like here. So you can before to think that this is an A prosthesis or in a you know, And the purpose is, But this is a fully grown adult. They fused all the If I sees and in the context of, um, direct trauma or fall into the elbow while it's been flexed. Then this isn't This isn't avulsion product fracture until proven otherwise. Okay, now, the special review area, you can see I said polo ring concept. So that refers to the polo ring below the elbow. And I want to use this Segway into, um, before basically, So this is this is our polar. Okay, assessing your forearm. It's much, much simpler than elbows and joints. Um, oftentimes this When? When you get asked for a forum X ray, this is what you get. You get bit of the elbow, we get rid of the wrist in it. Um, but your main concern is looking at the owner and the radius. Uh, I'm not going to patronizing you. If there's a fracture there through the through the ulnar or the radius, you will see. And I don't need to tell you how to look for it. What? I do want to, um, tell you about things that are less common. Behalf bigger consequences. So we still use ABC two s for the forearm. A is, ah. Refers to alignment of your joints. Like I said, you can see your joints above and below the forearm, so just look at them, make sure they're not grossly desiccated. Be again cortex. You contracts it, you'll experts by now, um, and see, Well, that's because there's no true joint in the forearm. I kind of skipped this bit, but I suppose you could consider the distances between your distal radio on a joint and your proximal radio. No joint, because you've got syndesmosis is there. So you have a look at those as well. Make sure they're not, uh, largely distracted. But, um, I can move very quickly on to, um, two s in the forearm. basically so soft tissue, same concepts. Make sure there's no irregularity to show, to denote laceration. Surgical. Ever see a month or for a body? Um, and then want you happy with that? You Your special review area is this polo ring, So I'm sure you've heard it to death. A polar in doesn't just break in one spot. If you've got sufficient energy to break one side, it often causes another injury on the other side as well. So this is where I introduce you to the montage and Galatsi fracture dislocation syndromes. Often it's relatively high impact injuries. But it is important to know because sometimes your fractures ah, higher up or your dislocations are higher up and you've not. If you're not aware, then you won't think to image the rest of the forearm. Catch the other bit of the injury, so to speak. Okay, um, again, I hate upon this names, but there is a way to remember this. So, um, the way to remember which is, which is by this may not pneumonic called mugger, like someone who steals stuff from you. Eso emu sense for Mantega and the U is thie. It describes which bonus fractured, so it's really silly, but this is how I remember it. Among go comes, injures you, so injures you in fracture something. So that's the ulnar. And then they take away you all it so while it's small and so the dislocation of the opposite um, bone is at the smaller footprint. So you get a fracture of your honor and a dislocation of the Radiohead. Because if you compare the radio, this still radio footprint to the radial head really heard of smaller. So that's how I remember it might be basically so amantadine A fracture dislocation. You get a fracture of your ulnar with a radial head dislocation so you can see here. If you've just gotten your elbow, you might miss this, uh, owner fracture, so it's important to be aware of it and make sure you get the rest of forum moving on. A galaxy steep exact opposite G four g l e s e r for radial fracture. And the dislocation is of the owner where it's smaller. So the distal on here compared to you know, the big electron, um, process On the other end to this issue is your galley at the fracture message. That's your elbow. And four, um, quickly recap our look at the elbow, and then we can move on. Um sorry. Evelyn form, and then we can go into our cases. I hope you guys are still with me. So, a alignment. We want to check our and to humeral line our radiocapitellar line. Um ah. And then be for bones. So make sure we're checking every surface we can see, including with radial head surface. Make sure we're looking up in the super condo region as well. Then we can look at C, which is joints. So we're looking at this and this anterior region making sure there's no sort of big sale like that posterior region making sure there's no big sort of bulgy Lucent region. That would be our posterior fat pad. So happy no joint effusions and then two s so soft tissues I can't see any looking at are soft tissues and tendon insertions. I can't see any of oceans, a country for, um, bodies. No surgery on Fetzima and the special review areas would be our portal ring. So there's no fracture here and nothing to make me suspicious that there's a distal injury quickly. Same thing again with the elbow. Sorry. The forearm. Um, you're looking for alignment. This looks line that looks well aligned, Bones making sure you trace the shaft. Well, especially in Children. Because this is where you can get the distal buckle Fractures or green stick fractures are more subtle type of injuries. Um, See, uh, supposed look at your radio, all the joints and then two s or soft tissue and the special review area. Make sure this pulling is nice and intact. Me go. So we've got 12 for, um uh, and elbow cases, Um, and we'll see how we get on. And then we may or may not, uh, just quickly go through the last few if we run out of time. Yep. Okay. So let's give this a go again. There's one abnormality here. Yeah. Looks like a couple who will have spotted it. It is, uh, an electron fracture. So this is the main thing here. You've got lucent line through your electric on. Yep. Vertical fracture. Fantastic. And it's also slightly common. You did? If I can convince you here, there's one piece here in one piece here. World. Um and that is a little bit soft swelling around the elbow. If you think about your own elbow, it's quite thin over here, isn't it? So any sort of swelling in this region should point towards true soft tissue swelling. Unless it's a child, they got chubby arms. But this, we know, isn't ELISA Skeletally mature person. The raised anterior fat pad is a bit more subtle. Uh, and I will put a handle and say that. So that's this here. So this slight lucency that, But I don't blame me if you didn't see it, but, well, I'm not picking up the fracture. There we go fracture. And this this year this is your fat pad. Just made it a little bit more contrast. Next Fab. Looks like you guys are right on it, so we've got a radial head fracture while done. So this is it. Here, loosen. Lying through your radial head can't really see on the electoral. But what you can see on the lateral is this beautiful anterior fat pad. So it's That's it there. There's no posterior fat pad, which is quite normal because it's, um, it's a it's a nondisplaced fracture. So maybe the infusion isn't that great? But there we go. That shouldn't be there, so your fat patch just seamlessly flow into the joints would speak well, then next. Actually, I like what you guys are doing telling me whether or not that's a fat pad and then with it, where the fracture is. Um, that's great. That's exactly how you should be thinking. I'm very proud. You guys all picking up the fat pads. That's great. So you're right. There's an anterior and posterior fat pad. Here it is now. Nice, right angle lucency here and then this. A bulge e bit of the back. Lucent posterior fat pad. So you know there's a joint effusion in the context of trauma. Where's, Ah, fracture? That's the question. So I think some people mention with another dislocations. That's my fault. This is not a true a P view. It's almost like an oblique view, so that's where things can look a bit odd. So the electorate on itself is fine. The peers to be, Ah, it looks like there's a loose in line, but there really isn't. It's just sort of the the irregularity of the bone on the way, the uh, X ray is projected. Um, and I think you're looking at the right region here. So this is where the fracture is. This is where the fracture is. Can anyone? It's very subtle. It's not the Radiohead. It's It's the Radius. Its proximal radius. Absolutely. But it's, um, something else. There we go neck. Yes, it's the radio neck. It's here. So the the articular surface in the head itself is fine because you can get fractures through it like we saw before. But this is a real neck fracture. No context really doesn't change that much, but it just means that it's not through an articular surface. And that has consequences to the patient in mind. I'll have consequences to the actual management. That's all right. Okay, so well done. So this one isn't dislocated because you enter humoral minus nice and straight. It goes through your cap. It Tellem, which is this bigger bit? Not the small one. The small one is your Tracleer on. Then you're really ahead. Is enjoying a swell because slight angulated like I said, but it articulates well. And the Linus it passes through the capital. Um, let me go. Next again apologies for this oblique. Few of the off the radius of the elbow. Sorry. Okay, So most most people have gotten it. So it's a reason to your fat pad. Look at you. Taking out those fat pads. That's great. This is your fat pad here. And in this film, I will just say no. There's no obvious fractures, and there's no distinct fracture. But in a patient that looks like this, what do we think? The most likely fractures? Oh, yeah, The lateral epicondyle. This is the lateral epicondyle. Oh, here. Um yeah, it just it looks odd because of the the way it's been rotated. What you're seeing here is just the It's where the ah, it's the common extends attendants. Yes, they attached. So that's what that little divot with the the tendons attach. But usually you're right. You don't see this appearance a medial here again, it's just the way it's been rotated. It looks more biology, but in reality isn't This is more just to illustrate the that the old in joint and the nicest move. There we go. Yes. Sorry. The, um yes. In a patient that skeletally mature. Um, the most common fracture is a Radiohead or the radio neck fracture. A proximal radius. So if you see this, treat the patient as a fracture. Immobilized, Um, referred him to a virtual fracture clinic because something's going on over again. That's just illustrate the And here, if I had uh huh. Okay. What is this? Yeah. Yes. Okay, so this is clearly a fracture and a dislocation. And then the trick is reality could just google this, but let's pretend we can't Google. Um, it's a figure out what part of his name it's called. So we can all see that there's a nice displaced mid on a fracture with a dislocation here, Right? The Radiohead is definitely not enjoying it with the capital. Um, anymore. So this is you've got a owner fracture. So it's a you and then mom goes m u g also is, um, wanted your fracture with a proximal radio dislocation. The smaller footprint of the two? Yes. And what about this? Yes, exactly. So it's a galaxy fracture or very aptly put a radio shack fracture with a distant on the dislocation. You can also do that, but it's known as a galley, etc. Fracture. So your fracture is of the radius S O r. So mugger g r and then the ulnar is dislocated and dislocated where it's smaller. So it's the distal, um, almost over here. Right. So we're moving on to some pediatric elbows now. Um, the concept of assessment, it's still exactly the same. So I just want you guys to give this a go and see whether he can pick up the abnormalities just trying to deem it's stiff. I the pediatric elbow you have done. You have done very well so far. And while we're at it, if anyone wants to a hazard, I guess as to how well this patient is to give it a go Oh, yes. I was asked me how old a child is. Um so the ossification centers a normal. So I want to say that they are 5 to 6 years old approximately so I've got some good answers already. I never don't know if it'll help. If I just tell you that this is your capitulum because in criteria C comes first. So C is ossified. Is the first ossified? So that's you capitulum there. That's your radial head up. If assists, this is your internal epicondyle. Yeah. Okay, so a week someone has mentioned the correct answer, which is, um, radio head dislocation. And here, if I draw the anterior humeral line, you can see yes, it by 60. Okay, Capitellum or capitulum. So there's no super condo. The fracture, in any case, is not really a good going fat pad. But if I draw the radiocapitellar line, it's not is nowhere near the capital. Um, it's kind of intersecting the notch here. Um, and this view looks a bit odd, doesn't it? Looks like the radius is sort of closer to the humerus, and that's because it's sort of dislocated out. So this is a Radiohead dislocation. So you've got disrupted radiocapitellar line. Um, now the electron looks a bit odd, but it's probably because the ossification center hasn't come up yet, so it looks shortened. So I understand why you think it looks a bit irregular. Could see r i t o l. It's called the fifth ones. The 4th and 5th ones to Aasif I, and this patient is when you got three. So it's still got a lot of growing to do before you see an electron offices. Okay, What about this one? So tell me where the fracture is and how you So what other features that are there? Nice. So both everyone seen it. It's this fracture here, and it's tricky when you're trying to figure out always this epicondyle condyle Um so it's actually So this is your condyles your capitulum You trochlea hasn't ossified yet. This. Like I said, behind is your condyle and then the Z epicondyles this little pointy bits. So it's above thumb. So this is Super condo a fracture. And, um exactly. Someone's mentioned that the anterior humeral line doesn't intersect property. So if you draw a straight line down like I said, it should intersect the middle third of thie capitulum curriculum all capital. Um, and it kind of just skims the anterior, the anterior border of it. So that means it's probably because there's a fracture, and the bottom bit of that humorous has moved backwards and very rightly so you'll have seen this lovely and two go. And if I can convince you here, look straight line through the radius intersex the capital. Um, so this radio capital line is intact, so let's see, Anterior fat pad. I can't see it that well today. I have to be honest. I saw it when I prepared this case, but definitely the one. I want you to recognize his people. Cereal. Fat pad. Next. Okay, so it looks like go a couple of answers in and I'm very impressed. So the anterior fat pad is raised while done. There it is. So we've got a fracture going on It. Is this over here? So it looks like it be in the right position for the electron up offices. But this patient only has a cap patella up if assist at the moment. So C r I T. Oh, L Where's the other three? The Radiohead doesn't look terribly ossified. In which case, the internal, if you can't see very well, he's still got I so internal at the condo. Can't see there. Tea is definitely no ossification of the truck. Clear something we've got a lecture on. That is odd. So that points towards it being a probable of altering fracture as opposed to and apophysis. Even though it looks well rounded, it looks well corticated in an adult. You Satan. That's an oscal. It's not fractured, but because of criteria we can be, be a bit more confident and because of the fat pinas well. And someone mentioned whether or not there was a observe fracture around three gyn that is also a radial neck fracture. So it's not obvious on the lateral view. But when you look on this AP view here, you can see a line of the of the neck going up and the head. It's not continuous, probably because it's being compressed down that way. Um, in this case, I don't think there's a true positive fat pad. What you're probably seeing is that Mac lines or M a C H look it up. It's an obstacle illusion where when you see something really bright next to something less bright, you perceive a dark line, Um, between the two, that's it's not there, it's just your brain. So once you understand that, then uh, you can try and think that posterior fat pad has to be more obvious. And if and if this Lucent language all the way up it can be a fat pad is probably an optical illusion, that part should just be in and around the electorate on Force Up Next has done very well. Pediatrics elbows are difficult, but, um, if you're picking up the right tools, Yeah, looks like most people have seen what I intended for them to see. This one is easier because you've seen it before already. It's in a slightly different form. This is a, um, a radio neck fracture here. Very nicely illustrated. The whole radius is kind of angulated downwards, so probably it's slightly dislocated. Um, because that articular surface no longer congruent. Um, And you also have a lovely little anterior fat pad here, so raising to refer part with a radio neck fracture and look on this lateral view. So this is a modified A PV you. In fact, um, the on this lateral view or you get it's a slight bulging that isn't normal, your coordination. Like I said before, nice and smooth as it travels across. So this is not normal to have a like a bump, especially in a kid. Any bump, any slight, widening need to be. You need to be thinking about traumatic fracture, but well done. One of our last, uh, I think so. I actually wanted to, uh, take you guys through this one, so This is a more subtle fracture. Um, and actually this fat pad here, I don't think it looks particularly raised. If you think back to all your other factors that will probably raise, it's more, Um, it was small sale, like, so to speak. This looks like it flows quite nicely into the joint. And if anyone can remember, I mentioned that there were two common fractures in Children's when the Super Candler fractured. The other one is a lateral condyle fracture now, and the only happened when you'll, uh, I suppose, if I sees have infused yet. So in this child, you can see they've got a capital capitulum. There's a very faint, tiny bit of Radiohead, and then you've got your internal epicondyle. So they may be about 46 years old and they have a fracture and it's here. So it's It's very, very faint line at the lateral condyle Happy condos. I hear not not, um, calcified. Yet this is a non displaced lateral condyle fracture, and, um, I realize one house doing sort of training that we don't pay enough emphasis on this, and it's as common as a super condo. A fracture in Children um So there you go. That's a little tight. Lateral condyle. Fractures and super condo. The fractures in a child's elbow. His reasoning here fat. But I I don't think it's that raised, actually. Okay. Um, see? Yeah. Here we go. Just highlighting that lateral condyle fracture. All right. And this last one. So this last one, I will tell you straight away has to do with Ah, lovely. Cry tall and try and see if you can figure out what's going on here. Think is one of our last cases as well. So well done. Everyone okay? Give you a bit more time to work through that. Cry tall. Oh, good. A few answers. So that's good. Can always work through them. Yeah. Okay. Um right. So let's work through quite a lot, then. See capital. Um, so that's this here, our radio hit. I can see that Capitellum Radiohead. So cr I internal epicondyle internals. Medial. So it's on this side. It's not They're fine. Um t trochlea so trochlea we should be next to the capitellum. And I suppose this is it. It's a bit small, but that's normal. That is one of the last few, too also if I, um And then you've got l lateral epicondyle c r I t o l electron. Sorry. Electron on here and then l So it's all that we don't have our c r i internal epicondyle. Um so then we need to look and figure out where it is. So if I can give it to you this here, it's strange it What is it? You don't have a coronal? I'd ossification center. This is your truck? Clear. So the chocolate should be far away from it. So the pain physician be too far away from the lateral condyle. Um, you've got your all and ah, your l here. So on l a here. Which means the only explanation is that this must be an evolved bit of the medial epicondyle or the internal become now. So there is a very faint raised fat pad which is seen better on, um ah, sort of dycom screens with wind doing, and then this is actually an avulsed a segment of thie internal epicondyle. So if you think about it, your internal epicondyle is where are your flex? The muscles are, and that's quite strong. So the common insertion of flex the muscles, so it's a common. It's one of the most common, uh, also vacation centers to be a vote in an injury and commonly would evolves, and that can lie somewhere in the joint. So for those of you who said Internet, the condyle mediate the condo. Well, don't you correct, um, with regards to whether it's a fracture, so it's probably Well, this is a fracture, but everything else this is all normal faces. Um, and in this case, there's no mention electron fracture. So in the previous case, where there was only see our and I and a little bit and aflac there behind the electron on that was probably a fracture because, um, you're the trochlea. Hadn't Aasif? I'd yet Or maybe the internal epicondyle had an ossified yet, so that didn't make didn't make sense for you to have an electron, A prosthesis for the oh, bit, I suppose, Um and in the case of trauma is more likely to be an evolved from fracture. Where is in this case where you can actually go see our i t o l with, you know, bear in mind that that was missing then. This is likely to be an ossification center as opposed to a true fracture. But, yeah, that's the abnormality. So it needs. It needs to sit here. The reason why is bigger than the lateral one is well is because it also five earlier. So it's got more time to for more bone compared to the lateral line. So that's why that one looks a bit smaller and it's been evolved by the muscle and it now lies in the joint. And that's it. You've survived. Um, going through the shoulder, the elbow and the forearm world on everyone. Um ah. Recap of the ABC two s of the elbow and forearm is can be red. Here. In the meantime, if you guys have any questions at all or you have any feedback, I would agree Cleopatra's she ate that. I hope you enjoyed the the quizzes and quit run through of how to look at the shoulder, elbow and the forearm we have massively overrun. I do apologize on my part, but oh, it was useful. Um, let's see. There we go. Thank you for listening. I think Sira has very helpfully put a link in the chat box for the feedback. Um, And if you have any further questions, this is my personal email. I'm more than happy to answer. No, uh, no question is stupid basically. But thank you very much for being patient on day for bearing with me, Frankie. So much Doctor Low. That was fantastic. I learned a lot. I I stuck with it the whole time. I really enjoyed the cases. It was actually really fun to do, so thank you so much. I know. Wrapped up here, it's freezing in my house. Um, so, yeah, I just bought some links in the chat. So the top link is to fill in our feedback form. So you will get your certificate of attendance once you feel in your feet, but form, um, to join. Our next event is thesis and link. So you click on that, Um, and that will, um, be for, um, the there with me for the CT ap weapon. All, um, which will be on the fifth of January at eight. PM with Doctor Henry double on. It will be about the basic structured approach in common cases and fit pitfalls of ct, abdomen and pelvis interpretation. So the third link is to sign up to any of the other weapon or serious that mind the bleep offer. So any medicine, surgery? Finance? Pediatrics on ophthalmology. Click with EarthLink. Um, And if you have any questions, please do contact up to allow. I can't say enough that that was actually fantastic. I did really, really enjoy that. So thank you so much. Um, Andi, Brilliant. If that's nothing else than Merry Christmas on to you Very, very soon. I know. Thank you.