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Hi, my name is uh doctor M I'm I have got one of my junior colleagues with me doctor. So and uh let's just uh try to share the screen first and then we can take it from there. Just give me a second, please. Ok. So uh was the screen visible to everyone? Cause once I share it, I might not be able to come back. Uh Sorry, I'll go back. And if uh you can kindly let me know if you were able to see the screen, just don't be able to see it in the belly, but now I can't see it again. OK, I will, I will, I will do it again. Yeah, just give me a second. Yeah, I'll just hand over to my colleague. Yeah, sure. We should do now. Yeah. So, hello. Hello everyone. I'm doctor Sa. And uh uh today I am presenting a teaching on trauma of upper and lower limb with doctor MP who is at uh Radiology Register. So, the aim of our teaching is to know about the basics of the bone and the joint trauma of upper limb and the lower limb. So here are some questions which are visible on the screen. Hopefully, at the end of this teaching, you are able to answer all of these. OK. So there are some basic aim of this teaching. So to discuss and describe the fractures of the lower limb and upper limb and the joint and the joint commas. So in this session, we were gonna discuss about the anatomy of the bones and the joint and we'll discuss a lot of fractures which are common. And in the end of the discussion, we will have uh interactive session in which we will discuss all of our uh teaching. OK. So first, now we are gonna discuss the bone anatomy. So we divided the bone into the different parts like epiphyses, which is the end part of the bone. Then the metaphys is which is the trumpets shaped end of the bone and then come, we come to the diaphysis which is shaft of this bone. OK. And uh then the epiphysis, which is the this part of the bone in which the tendon and ligament joints, we can also divide the bone into the head, neck shaft and condyle or base of the bone. So after that, here are some common fractures of the bone. So there are there are different type of fractures of the bone like a transverse fracture, oblique fracture, spiral vertical and comminate. First of all this transverse fracture in this, as we can see, it is a type of a fracture which is perpendicular with a bone, long axis. Then we come to the linear ex linear fracture, which in this, the fracture is uh preic parallel to the long axis of the bone. Then the oblique fracture in this, the fracture is oblique to the long axis of the. And there's another picture of the oblique one. And here is a spiral fracture. It is a type of a fracture in which uh the fracture is a spiral or it's in which bone rotate on itself. And it presented as a staircase. Then it comes to the green stick fracture. It is a type of a fracture which is common in young Children. And it only involves that we can see only the cortex of the bone. Yeah, is as the cortex is broken. Then the comminate fracture in it is a type of a fracture in which if the bone is broken in more than two parts, then we'd uh call this a comminate fracture. So here are some uh radiological diagrams of the bone. So II will just pass it to OK. Thank you have, I'll take it from there. So now uh the next part uh involves where we have describe the fracture of the bone according to the site and the relation to the joint. So first of all, as Hafsa has rightly said that we are going to describe the fracture on the basis of the shape, spiral vertical ac comminate. The next thing we when we are describing on a radiograph, we would say that if the joint uh if the fracture is involving the site, which is intraarticular or it is extraarticular. OK. Yeah. And after that, we described the fracture on the basis of the displacement. So what is displacement is displacement means that both the parts of the bones are underlined? The alignment has been broken and it has been malaligned. So we would say, OK, this fracture is mildly displaced or like in this diagram, you can see that we would say it is a complete displacement of the femur. Then uh there is another description whereby we would describe the fracture. On the basis of the angulation. Angulation always means the mo uh how angulation is described that we would describe the location of the distal part according to the proximal fracture portion. For example, in this one, I would say that, you know, the distal part is laterally aligned according to the proximal fracture site. So going back to what we have already discussed, describe the shape site and relation to the joint, either the fracture is displaced or not displaced. And what is the angulation of the fractured fragment? OK. So we can see in this example, we would say that uh it is a commun fracture for the fact there are three portion of the disc uh sorry, proximal metatarsal. Obviously, we don't know if it's right or left. Uh and the fractured and it is an intraarticular fracture. And then the fragments are, I cannot say angulation on only this view. Uh I would like to have another laugh for you to describe the angulation for this one. In this one. Yes, I could say that you know the distal portion of there is a transverse fracture of the distal uh fifth metatarsal which and the the fracture segment is mildly displaced and the distal portion is having medial angulation or we can say volar angulation in relation to the proximal part. OK. Again, in this one, I would say that there the f there is a fracture of the um pros, I'm just trying to find out. So distal distal ulna and the fracture segment is slightly displaced and there is dorsal angulation. OK. So this is again a transverse fracture of the mi middle third of the right clavicle. I uh yeah. One thing I forgot to tell that there we also uh differentiate or divide the fractures on the basis of how much the cortex is involved. If it is only one cortical site involved, we would say the fracture is incomplete. If both of the cortices are involving, then that means that there is complete fracture. So this one, I would say this is an incomplete fracture of the middle third of the left clavicle. This one is a complete complete displaced fracture of the middle third of the right clavicle. OK. So there are a few other examples we would go through them. Uh So we can do that later now. So this is again a displaced fracture of the middle third of the right femur with some medial angulation. Again, this one displaced fracture. So this one is extraarticular, displaced fracture of the middle third of the uh fifth metatarsal and it is volar in on angulation to like towards the palm. So just uh yeah, fracture of the sorry, I had been saying sorry metatarsal. No. So it's for the hand they were metacarpals and for the foot, they were metatarsal. So this is again a very common site for the foot fracture, the fifth metatarsal. So there is one transverse fracture and the other oblique fracture. Again, there is the small transverse fracture of the fifth metatarsal. This is an intra if I would say that it is going till this portion, then I would say that it is an intraarticular fracture. It is again kind of an oblique fracture. This is complete, completely displaced fracture of the patella, again, fracture of the patella. So this uh this image is showing. So there is a fracture of the fibula and there is also a fracture along the medial mallus. So this is the kind of example for a spinal fracture whereby you can see that it is like like a staircase we are seeing. So yeah, there are some uh specific names for some fractures. Uh for example, so for ulnar fracture, whereby there is a fracture of the proximal one third of the ulnar with the dislocation. So if you see in this image, the the radial head is dislocated. So we call it at asthmonia fracture. So what it would it is it is a dual fracture where we can see that the fracture is of the ulnar, middle third of the ulnar. But there is the dislocation of the radial head. Uh we also have got another example where we say what is a glazy fracture. So basically the glazy fracture is the radial fracture. So remember Montague is ulnar fracture. And glazy fracture is the ulnar fracture, whereby distal one third of the ulna shows the fracture with also the uh uh fracture of the ulnar steroid uh sorry, not the fracture of the steroid. There is the dislocation of the radioulnar joint. So the radial ulnar joint is disrupted but there is a fracture of the radius. Ok. So then emulgent fracture aversion fracture uh occurs whereby uh there is injury to the ligament or the tendon and to to which that small fragment of the bone gets avulsed. So there are the few examples. So here's the example whereby uh the patellofemoral tendon gets disrupted and there is the agent fracture you would see along here in the tibia again with, with the digit with the fingers of it. It is quite common in real practice to visualize few of the agent fractures due to the interferential ligaments. Ok. Yeah, then uh we move forward. So there was this, this is the basis of uh the bone fracture. So again, to summarize, we would like to describe the fracture. Whenever we are reporting, we would like to describe the fracture. On the basis of how the fracture looks like, is it oblique? Is it transverse uh greenstick fracture in kids are quite common and where they are obviously uh their relation to the joint, their relation uh to the anatomical position is the fracture displaced or undisplaced. And is it angulated or not? Then the next part of my teaching involves uh the anatomy of the joints and we would go through a few of the uh joint fractures. So the joints this that we have got the fibrous joint and the cartilage and synovial joint, fibrous joints occur within the skull sutures. And the tibiofibular joint is the fibrous joint. Cartilaginous joints are basically uh they're in are intervertebral discs. And then we have got synovial joint and the synovial joints are more uh I mean, you know, the common joints we go through which are the hip, knee and shoulder. OK. So for the description of the joint uh injuries, we use a few terms whereby there is a term which is known as dislocation. So, dislocation means that the complete uh joint alignment is disrupted, there is separation of the two bones which are actually forming the joint if we see in this diagram. So you see we would see that there is complete dislocation of the proximal interphalangeal joint subluxation happens when there is partial uh separation and still some of the bone is in contact. So for example, in this, you would see that some portion is still in contact. It's just uh that if we compare both of the images, we might be able to understand better. So this image shows complete dislocation, I mean dislocation. And this I would describe at subluxation as again I previously mentioned. So again, for the description, we all and radiology is always about two views. So the dislocation or subluxation would be better understood in the lateral views for the hand. So yeah, again, yeah, you can describe it. So if it uh it is something like this, the image you need to report. So you would say there is fracture uh or dislocation of the proximal interferential joint. So uh shoulder joints um if someone is specifically uh covering a and knee, so it is quite common presentation uh the dislocation of the shoulder joint whereby anterior dislocation is very common, about 95% there is an interior dislocation and uh only 3% is posterior and 1 to 2% inferior. Uh patellar dislocation usually occurs laterally whereby patella is dislocated. Then we have got the dislocation of the elbow joint and within the elbow, mostly we see the poster dislocation in the wrist. We can see the dislocation of the lunate and the pad lunate. Then, obviously, as we have already discussed the dislocation of the interphalangeal and the uh met metacarpophalangeal joints. And again, with the hips, most common is the posterior, but anti dislocation can also happen. So this image shows the normal anatomy of the shoulder whereby the humeral head is congruent with the glenoid cavity within the scapula. So there would be this clavicle and for the shoulder joint, you would do an AP and then this Y view. So uh again, obviously for the diagnosis of dislocation, you would require the Y view too. So we are looking at now how an anterior dislocation is going to appear. So you see as in this one, I said that this is the normal anatomy where we can see the humeral head is aligned within the glenoid cavity. So in this one, you could see that the glenoid cavity is not aligned with the humeral head, humeral head is like further uh apart and the glenoid cavity is empty. Yeah. So this is the view as I mentioned. So if you again go back to the previous Y view. Yeah. So here we, we have got it aligned and now moving to this one again, you see that it is not. So this is the glenoid cavity and the humeral head is not in the glenoid cavity. It is dislocated anteriorly. Yeah. And this is how it would appear in the axial view. So as I said that you have to go through all of the views to understand. So this image shows the patella, you see the patella is not well placed centrally, it is dislocated laterally towards the fibula if we can appreciate. So this is tibia, this is fibula and the femur patella is dislocated. So this is the normal elbow joint. So we have got the radial head, we have got the ulnar head and the humerus well aligned. And this is how obviously we would see that the alignment of the joint is disrupted. So this would be the lateral view and this is the ap view. You can see that, you know, the bones are not congruent and obviously, you can see small fracture, fracture fragments. So looking for that again, I'm just trying to go through the normal basic anatomy for the fact that we can only and there's always more detail to it, but the basic should involve like knowing the normal anatomy. So if you can memorize a normal one, then obviously, we can compare it with the abnormal one. So hip joint. So this is the acetabulum, the femoral head is well congruent within the acetabular cavity of the pelvis. So now, obviously, we can see that the acetable is empty and the femoral head is not within the acetabular cavity as we said that, oh you know, we talk about the metatarsophalangeal joints. So this is the normal and this is when the metac um sorry. Yeah. And this is when the metatarsal. So these are the metatarsals, these are the phalanx. So, so there is disruption of the metatarsophalangeal joint of the big toe because the distal portion of the metatarsal is dislocated. This is a very classical example of the uh patient with rheumatoid arthritis. So the uh people with rheumatoid arthritis obviously have got the deviation of their um phalangeal joints uh in comparison with the met uh metacarpals. So this this is showing the widespread uh deviation and the dislocation of the uh phalanx uh of someone who is suffering from rheumatoid hands. Then within the joint, uh we have to see that if there is any evidence of effusion, what it wouldn't involve is that we would look for any fluid uh uh density within the joint, which would uh give us an indication that there is joint effusion. So, obviously, we have to uh correlate it with the clinical picture if we are questioning someone who is having uh sepsis or you know, some joint is hot tender. Obviously, our diagnosis would go towards septic uh joint if someone has got gout. So any inflamed joint and the radiographic features, we would uh correlate to uh look for gout effusion or if there is hemarthrosis, hemarthrosis means that blood within the joint or lipohemarthrosis to uh rule out traumatic effusion. So, within the uh knee, we really have to look for hemarthrosis and sometimes the fracture and the uh knee radiograph might not be clear, but there could be evidence of hemarthrosis, which would mean the patient has got an an impacted fracture or a tiny fracture, which we are not able to see uh within the radiograph. So, if uh we go back to the previous normal knee anatomy and try to find it, I don't remember if I did have the uh did I have that? I guess I just had the APM to normal. Oh, yeah, not the, not the lateral one. So uh high beam, lateral view we normally do for uh the uh to, to see the joint effusions. So if you see in this one, and obviously, we would like to look for the irregularity. So this seems like quite thickened. Uh So this means that there is something happening there and there is evidence of this, I would say is blood and this is uh the fluid signal and the signal for the uh fat. So that's why this bit is all given as hemarthrosis in context of a trauma. And then obviously this very tiny tiny fracture which we can see in the next slide. So this is again, uh an indication of the lipohemarthrosis. We can see that there is patella fracture and there is uh this blood and then lipid. So as I said, lipohemarthrosis is a very important thing to pick up in a knee radiograph where there is a history of trauma. So uh these are the few slides which I added because um you know, the carpal pos we tend to forget their names to it is scaphoid lunate tri trapezium trapezoid capitate and Hamate. And then this fracture uh sorry. In this image, we can also see a fracture. So there is this fracture of the distal part of the radius. And again, this is a very common presentation with a clinical history when someone falls on out of a on a stretched hand. So there would be fracture of the distal radius and there is sorry, I missed that there is also a fracture of the ulnar styloid. This I have already discussed. So this is this tiny uh agent fracture along with the subluxation of the distal phalanx of the index finger. This one is obviously because it is a compound fracture involving the two bones. And also if we can see that the anatomy uh and the syndesmosis of the ankle joint is disrupted. There's this spinal fracture of the distal fibula along with the fracture of the medial malleus with the talar shift. So the basic thing uh as I said, we always have to check two views to understand the whole pathology of the fracture. Then we would describe the fracture based on shape site displacement and angulation. We would tell that if it is a complete fracture, if it is an incomplete fracture, if it is a completely uh dislocated fracture, there is sub subluxation. Yeah. And obviously, if you see any uh, lipomatosis. A, any compound fracture. You have to get the specialist, um, opinion. Yeah. So that was it? Um, any questions or do you want me to go through something again? Uh, sorry, I can't hear you are muted, is it? Yeah. Uh, maybe now. Hello? II can't, sorry, I can't hear you. I don't know why, uh, rejoin. So it says me that I have to rejoin the call. Uh, II, II can't hear you. Should I rejoin? Yeah. Hello? But you are muted again, I guess. Uh II, you can't, you can't hear me. OK. OK. Uh I ca I can't actually hear anyone. Yeah, I can't hear her too madeleine. You are muted. Yeah, because on me it says the sign is muted. Oh, so you're trying to ask me like the differentiation based on uh if it is uh uh traumatic effusion, if it is septic effusion or due to some other. So that's what I said that uh it, it uh would require a clinical history. So obviously with the septic joint. Mhm. So you can't hear me now? OK. OK. OK. So I was saying that um so jot jot joint effusion, uh if you're asking me if you can clarify that, what actually you're asking you. But if you are asking me that if the joint effusion is septic, if it is traumatic, then obviously someone with the history of trauma and if you are saying is seeing effusion, that would be most, probably because of the trauma and for septic uh joint, a obviously the joint is supposed to be hard. There would be edema patient would come with pain, but that wouldn't come like all of a sudden that that would be like, you know, for weeks or so. And that is why whenever there is joint effusion, we try to aspirate it, we take the fluid from the joint and we send it for cytology. Uh Does that answer your question? Uh Male, whatever you are saying, we can't hear you. No, we can't hear you. So II actually rejoined, maybe you need to rejoin because it, it's showing that you need to, we, we can't, I can just see you saying something. Uh Anything else? Uh Maybe I was uh quite fast. Uh So if uh I can repeat anything, if you guys want, I didn't go into many details of many of the pictures because uh I mean, uh they were quite light uh you know, very specific. So I just thought to get the overview first and then, and as I was doing the mistakes, uh like obviously you have to say the right name of the bone. So in the start of the session, I was saying metatarsals instead of metatarpal. OK. We still can't hear you. Yeah. OK. You can, you can type, I guess we would have your messages but can't hear you. Thank you guys for your time. OK. And yeah. Yeah. I can share the slides and uh more. Do you want me? I mean, uh do you want me to go through all of them again? Or I II can send uh the powerpoint to Madeline and then she can share, I guess. Uh Yeah. Yes. Uh sorry. Uh like do you want me to go through the uh or I can send the uh powerpoint hair I to actually, so if you guys, OK, So yeah, II will send you the powerpoint and uh that, yeah. OK. Thank you so much. Is that it then? And uh please also give some feedback from my colleague, Doctor sa uh she uh she was actually observing me for um my radiology training and she's aspiring to become a radiologist. So um then obviously as a part of her portfolio, she also required to do some teaching. So if you can have some feedback for her, so if she needs improvement or something or if she did something good that would, would be really helpful. OK. Thank you so much. Take care. Bye.