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Hi. Everyone thinks true coming along to our webinar this evening, sometimes being given by Doctor, you know, to next to in radiology on a on a very boring topic for all of us. It's on trauma. X rays would have any further do is gonna hand over it surgeon to take away the rest of session. Thank you very much. Um, so my name is June, and I'm currently working a PSA test you to Radiology Ridge in Manchester. Onda, Um, hopefully within the next hour will be able to go through how I look at trauma X rays. So because we only have a now our, um I had did a quick survey of some of the junior doctors that I knew, and we chose some of the images that we thought would give us the highest yield. So in the session, what I hope to do is go through a brief assessment structure. So a structure that I use for every single trauma X ray that I assess, and then we'll use that structure to go through each of these in turn. So this is cycle spine, the shoulder and the ankle. So that's what I have planned. But obviously, depending on what kind of time we have, we'll see how much we can do and for the interest of time. If you have any questions, I'm obviously more than happy to answer them. But if you could drop them down for now and then ask them at the end, that would kind of make sure that we have the time to go through what we need. An answer. The questions later. All right, so let's start off with our assessment structure now. I am, um, hammering this whole months again in radiology. We have to make sure that our films are adequate. So that's the first and most important step. It's like checking for danger in BLS. Um, you want to make sure that you have enough use to assess the joint or the injury. You want to make sure they're actually the entirety of what you want to assess is included. There's no point having, you know, missing the end of the finger. If you want to make sure that the entire fingers not fractured and then finally make sure you check for previous imaging because something might be chronic and you're worried nothing so what you happy with adequacy? Then you can move on to your approach on and in. Radiology would love a B. C's. So this is the same. You've got ABC to s to look at Troma X rays. So a sensor alignment be for bones, see for cartilage. In, of course, where there's cartilage is often the joint space and then two s stands for soft tissues and special review areas. So for each of the X rays were going to look through, There are certain special review areas that we will touch upon. So start today. You've got alignment, and it's quite self explanatory. You want to make sure that all your bones are well aligned. Make sure that that is the case, no matter how many joints you have. Basically, and here you can see the third metacarpal felon. What metatarsal file. And your joint is not well aligned. Um, and it's been desiccated. Then you want to be so be is bones. And that sort of the majority of what we're going to be looking at at in a trauma X ray and their two ways you can assess the bones first is by tracing the cortical outline. It's very simple. You take finger a pen, whatever you have and just trace the outline of each and every boom and it should be nice and shop. And if it's not all you noticed, like a little bit of a step poor and irregularity that interrogate that region further, And in this case, you can see in the fourth metacarpal there is a fracture. Um, this is also a very common fracture that you see, especially if people coming with history off punching something a person or wall that's also ironically known as a box is fracture. Not raising the cortical outline is even more important when you want to think about pediatric X rays. So here you've got a pa at wrist and you can see the Fyssas hasn't fused yet. The couple bones or tiny because they haven't fully else if I'd now a lot. People are quite scared to help you the actual X rays because they look a bit odd. But if you just remember that pediatric bones soft elastic, they don't break like adult bones. Uh, I think and you trace the court of the outline, you're going to squat most of the abnormalities. So if we traced this outline here, you can see all that. Looks like there's a little bump. Maybe I mind if I that this line here shows what I'm looking at. And this is known as a buckle fracture also. Ah, tourist fracture. If I can convince you, the trabecular pattern here has been disrupted. A swell. Which brings me on to the next way we look at bones, which will which is to look at the trabecular on the texture. So we've got all these tiny, tiny the lines of stress along most bones and all bones. And while you're tracing the court a season, make sure you just look at the bones and make sure that they're These lines are all running in the right directions there No abnormal bricks along them as well. Know when I talk about texture. Obviously, um, I'm referring to cortical texture. So if you look at this foot here, um, which is belonging to a young lady who was a runner coming with foot pain, Um, and the first X ray doesn't show anything. Nice. Smooth quarter sees she goes home, keeps running on that foot, and three weeks later, she comes back because the pain is not better and you can see an irregularity on the So I met a couple, but metatarsal. Sorry. Commit to toss that here. And this is a callous. And if if you want to see this, increase your life, the texture is very fuzzy on this is actually what a stress fracture would look like. Really small MicroStrategy fractures that you can't see initially, but you can see the reaction off. So the reason why the bone gets fuzzy and former callous is due to the periosteum. So the periosteum is a little cleaning film that goes all over every bone, and it responds to an injury and infection or inflammation, so sometimes you'll get X rays, or you request X rays to look for osteomyelitis or for inflammatory arthritis. And this is what you're looking for. The texture of the cortex. So we're happy with a A and B. Then we can move on to see. So we're looking at our joint spaces, and I'll see sense for cartilage book. Just remember, it's it's, uh, the joint space so the joint space can be narrowed or candy right. And now, in the context of trauma, a narrow joint spaces less concerning because it tends to occur more chronically. Um And I'm sure you see many all still arthritic joints in your work. And they often appear with no narrow joint spaces, bit increased density or subchondral sclerosis. And you may be sometimes you even see some osteo five formation. So this, if someone comes in, complains of Toprol and you see this, the joint spaces have a narrowed, you know, too concerned, especially if there's no fractures. But in the cases of this, so here you found you you've correctly identified the distal radio fracture. Um, but if you're not looking at the joint spaces, then you know you might miss You might miss something like this if I can convince you. This joint space here is much wider than this joint space here on do this is obviously most more concerning because joint stays widening. It's often caused by rupturing ligaments. Um, and in this case, yes, there's a rupture of ligament between these two. Culpable. Okay, so what? You're happy with the size of your joint space? You need to think about what can be in your joint space so there should be nothing. Basically, they should just a calculation, A little bit of lubricating fluid. But in an injury, if you see, um, little flecks of bone like this inside your joint space, then you need to be concerned that there's no fracture somewhere in the flank of bone has come off. So in this case here, you've got an AP view of an uncle and this little bone fleck here, um, is now within the joint space because it's come off your talus, the Taylor don't. Now, this is just a little anatomical, uh, illustration that speaking off joints basis with the other most common thing. We confined in this in the context of trauma myself see an effusion. So I I found it quite difficult to identify fusions up until very recently. Um, so if you just think about it's all about densities. So it's important to know where the fusion is. Chemical, for example, in the knee, You know, that kind of happened in and around here. Perhaps if they're big down here underneath, ask of inferior to the patella. But you have to understand density. So if we look up here, it's black. Black is a run, an X ray, slightly less black, so that tends to be fat. Then you've got soft tissue. So you got all your tendons here. That's kind of Ah, a medium. Great. Then you got a bone and off. See, the most dancing on an X ray is going to be metal. Um, So if if this if you are looking in the region where you expect an effusion to be and it looks the same density a soft tissue, then you can be quite confident. This is an infusion. All right, so we have done a B's and C's on. Then we can move on to two s. So the first s is soft tissue. When you get an X ray, obviously you're paying attention to the bones. But don't forget you've got soft tissue on there. You have to be able to look at, uh, in some cases, you interrogate the bone, uterus. Everything recorded. You can't find anything doesn't mean that isn't an injury. It just means you can see on this X ray. In the case of soft tissue swelling, that's a good indication that something else is injured on the very rare cases where um, you see a little nick in the bone or a line that you think is a fracture, but there's no soft tissue swelling next to it. Then it's then it you can feel safe. They're saying it's probably something more chronic or something more benign and not an acute fracture. It's a soft tissue is very important. I will include this here because in the context of a C spine, soft tissue doesn't only mean external soft tissue, but it also means internal soft tissue. This region here called the prevertebral soft tissue space, and with regards to special review areas, we will touch on those as we go along, assessing each of these X rays, and that's it. So that is the ABC two s that I use to look at most of the trauma X rays so we can begin by actually looking at some bones and some X rays. Now we'll start off with us a cycle spine, and with each of these sections, what I'll do is I'll go through a recap of the anatomy and then we'll start using the assessment structure to go through our X ray, and then finally they will be some good cases for you guys to interact with. So I'm hoping that in the case of section you guys Kentucky ounces in the comment box and we can have a bit of a discussion, Right? So in a cycle spine, um, X ray you get to use you get your natural view and your AP view, and I have to say most of the assessment of the trauma is often done on the lateral view. Although I receive you've got something to see you you should look at it. So a brief, um, a brief recount the anatomy. So looking at a lateral view, you've got your vertebral bodies I often find See two is the most, um, it's the easiest but not identify. And then you can come down with an adequate C spine. X ray should allow you to visualize the top of t one. You've got your facet joints, so these give your C spine the movement. Then you've got a port in called the past interarticularis past and for bridge. And really, it's just a connection between your superior and you're inferior, articulating, fasten. You got the lamina. And so that's the little roof here around the spinal canal and then your spine is process kind of comes off the tip of that roof, um, and can see it very nicely. Highlights it here on your AP view, you can see slightly less, but you can still see some things you can see about your body's. Obviously, um just like how See to was easier to see on the electoral view on an AP view. I find it easy to find C seven t one first, and the way I do that is by finding this horizontal diamond sign, um, you'll find that C seven transverse processes point down and then t one points up. So if you find this diamond, you know, you see 71 you can of woods just very mind that some of the upper cervical body's might be hidden behind gyn. And that's very by how off how high or low you patients head is tilted. You can see pedicle. So these are little round things over here. You can see these are the pedicles of your vertebra. And of course you can see Sinus processes. Okay, so now that we're happy with our anatomy, we can start actually assessing this. C spine X ray. We'll start off with eight. And a is, um, your alignment. Now in a C spine, there are four lines that you need to know. And if you can remember these four lines, you're going to see most if not all, of the C spine fractures or dislocations and transactions. So these are what they are. You've got your anterior vertebral line, your posterior that relying. So it's the front in the back of your vertebral bodies. You've got your spinal laminal I, and what that is is remove the roof and the spine coming up the top. So it's that line where they all join, kind of like the Mercedes Benz. But from that's that line there. And then you've got your posterior spinal line, and that's just the line from all the little spinous processes. The leader, the tips of them. Now I know these lines aren't straight, so you're not looking to make sure they're straight. What you're looking to make sure is that they can continue down unbroken. If you start following down one and you notice that there's a step, then that's an indication that you shouldn't interrogate that region. Further once you have, you feel I meant you. Then I can move onto boats. So that means we use that tracing around the boat will body bones. But we also need to bear in mind that the virtual body should be off the same height. Now is very uncommon to get a compression fracture in the C spine because the lack of axial load in. But if you keeping your mind that you just have to look at the heights, then you're going to notice any other traumatic fractures that can happen. There is a little then we look at the cartilage of the joint spaces. So there are two main joint spaces in your C spine. You've got your disk spaces in between your vertebral bodies, but you also have your facet joints a swell. So you want to make sure that these are all of the similar height, and if they're narrowed, not not too concerned. It's quite common to get cervical spondyloarthropathy. We get older, but if they are widened on, someone has sustains the deflection or extension injury than that is concerning. Because that could mean that you, um, almost tourney your disk from your vertebra and that's going on Stable injury. Same goes for faster drugs. They should all be the same height, and then we can move on to two s. So, um, I briefly mentioned soft tissue spaces in the C spine, and this, I think, is, um ah, really known point. But it's it's good to remember your prevertebral soft tissue space limits. So from C 12 C three, your prevertebral soft tissue space of this region between the front of your vertebra and the trachea should be about a third off the vertebral body with helpfully see want to see 31 of the three is a good and then from see ford onwards, it can be up to a whole vertebral body with so here where the stars are, it can be up to, ah, the whole width of the vertebral body. If it's less than that, not concerning. If it's more than that, then you need to consider why, in the context of infection or raising phlegm, Jemarcus is is an abscess in your rectal pharynx or in the context of trauma that the ligaments have ruptured and you've got a hematoma in that region. Yeah, Of course, you've got electoral view and you've done a lot of the assessment on that. But you've also got a PT, so you need to look at it and make sure that it looks all right as well. Where you can assess in an APB, you is your spinal alignment. So you still got lines you control your spine is processes reformer line transfers, processes should as well you can. It says vertebral body heights. But very mind if he looks like he squished, it could depend on the flexion and extension of someone's neck. On and off course, you can assess disc spaces so you've done a B. C and one s. The last s is a special review area, and that has to do with the top joint over here between C one and C two. So this here like to call the little coffee bean? It's the anterior sort of arch off your, um C one that's like a ring. Now there's a specific, um, amount of space that should be between the dense or the auto on trade Pegasi to and see one, if it's narrowed, can happen in osteoarthritis. Uh, if it's widen, then you need to think about whether or not this subluxation or loosening or rupture off the ligament that holds them together. Because if you think about it, you've got a peg. You've got a ring, and if it's not articulating properly, your head is not going to be stable on the joint. So it's quite important once you happy with everything else. Make sure you look at this area and you're happy with that articulation. There's an example of the pre dental space, and that's it. So that is how you look at a C spine with the ABC two s method. Now what I'm hoping to do is go on to some cases. So what I'll do is I'll show you the pictures. And then, um, if you could kindly type, you'll, uh, once is in the question box, then we can go through them. Someone said, uh, this location at C four. Um, and then someone said, There is no anterior posterior linemen. That's great. So, um, so ignore the fancy name, but you're exactly right. So you've got some sort of dislocation between C three and four facet joints. A widened. There's anterior and posterior line. Um, disruption. And if you look here, there's if, while the BC four vertebras not intact anymore, basically. So you got a fracture and this is a fracture. The can see in whiplash injuries when you have severe hae bricks and then followed by severe and high force hyperflexion. And that it's almost like this bit of C three has gone straight into C four and fractured it. Well, well done. You using the lines properly? We can move on to our next case. So somebody said, um, see, three fracture close. It's it is a fracture. I think this is what you're looking at, isn't it? But it's not. C three. Have another girl. Um, somebody said compression fracture at C 23 posterial. I know. Align. It's see three more lemon are linemen. Okay, so that's good. Um, that you're trying to muscles articulate it, using the alignment. So here's your fracture from this is C too. So this is your dens here. You've got the biggest Sinus process is also off. See, too. So you've got a flexion again. Another sort of hyperflexion fracture of C too on D your posterial I meant is still maintained. Your spinal am in a line is here, and it's tricky to look at it here. I will appreciate that, but it's there's no step. So here I would still say it's maintained. And And if you look at your spinal, I'm in a line that sorry, the Spinous Process nine here. That's not gonna step in either, So as long as he can draw some, this is a very strict of Michael spine. Usually you'd get some sort of lordosis, but in this case, if we can draw a line through it without disruptions, I would still say it's a well aligned. So this is a C to factor in teardrop fracture well done for giving it a golden guys. Um, and here is just an example on CT, we can see it more. Um, I will skip this one because again very similar as our previous images, where you when you draw the anterior line, you notice that there's a step here. So there's a flexion, um, fracture again on this line, the posterior line is still maintained and your spinal arm in a line, which is this. It's still maintained. There's no step on it. It looks sort of really degenerative with osteophytes and things like that. And that's just how sort of all next look. And here your spine, it's Process nine is also well maintained. Okay, how about this one? Um, somebody said C seven spinous process fracture, see to dislocation. So, um, it is a spinal process fracture, and that is highlighted here. So this is your C 234567 Yet seven spinous process fracture. So if you draw your lines, this anterior line, I'm happy. He's relatively smooth. Posterior line smooth again. Spinal. Um, in the line. I'm happy with that spine is process mine. Oh. Where's the last one here, Um, see to dislocation? Um, yeah, I think perhaps this region here it was just a bit confusing This What you've got here is the aura Ferrex go soft tissue of your tongue. Here. This is the edge of your mandible. Just there. Um, and as long as you can draw, we can identify your see two vertebral, and you can draw a line, and it seems like it's in in, um, in alignment with the rest of the vertebra. Um, I would say it's not desiccated. Right? So this is another CT there that got done afterwards. And you can see actually a lot more spinous processes of fractured with the lock. Soft tissue swelling in a demon. A swell. Okay, um, now, this one, I would just give you a hint and say pay attention to electoral and, um, yeah, pay attention to the anterior posterior lines on the facet joints, and then tell me what you think. Um, so people, except chronic osteoarthritis degeneration, no spondylitis. Tyson's of C seven 67. Yeah, it's It's a list, DCIS. Yeah, but, um, the generation of drying things, um, into alignment disrupted at C four narrowed. This space is at C five C six. Yeah, great. So everyone's pointing all the chronic changes, which is fantastic. But mainly if you draw your anterior posterior line here, you can see at the level of C six is disrupted. Here's your C seven vertebral body. So this is spondylolisthesis More specifically, anterior also anterior and Trulicity sis off C six on C seven. Um, and if you look at your facet joints is well, you go. Yeah, I suppose this is this is congruent, congruent, congruent. Then you come to see six facet joint. It's not easy to see, but you can't see that same sort of alignment. C seven. And basically, what's happened is that to get this degree off anterolisthesis of one vertebra moving on top of another, you need to have a facet joint dislocations. And this is exactly what's happened here. So both of the facet joints come dislocated. It's allowed the vertebral body to anti. Really, Um, and basically causal off problems with narrowing of the spinal canal, but well done for picking them all the degenerative change. I'm impressed. Um, right. Last one, uh, I want you to tell me. No, we're happy with the alignment. We're happy with the bones. You know, We, um happy with the joint spaces. I want you to tell me what looks odd. And then what did these two neck X rays have in common? So someone's just said soft tissue swelling. Uh, privates. Bro's based is widen. Yeah, well, don't. So what do you think this is? So that's exactly you've got soft tissue swelling, So here in the front, you can see that this is at least at least half. If not almost 100% of the total body with and he obviously it's very, very swollen. You can see the trachea. It's pushed forward. What density do you think this is compared to the things around it? What do you think? It's similar density too. And once you figure that out, what do you think is going on? Uh, people mentioned area. Uh huh. Someone said Metro Torrential abscess. Yes, well down bending dame. So when you see aerosol tissue, unless you know that said injury and you and it's surgical emphysema. If someone is presenting like an infection or we raise inflammatory markers and you see gas in a soft tissue, you need to think about abscess and gas forming pathogens. Basically. So these are both examples of pre vegetable soft tissue swelling in this case, a retroverted you abscess. And in this case, is just there in July, tissue swelling of the pharynx that's causing thickening on a Dema of the tissues. Anterior to the vertebra. Well done. And I think that should be all our cases for the C spine. So, um, there was in many cases, but if you just remember alignment like I said, you alignment and soft tissue those are the two sort of things I think are quite different in a C spine X ray. If you can remember those two things I think you will see and pick up most of the C spine injuries. I think it's wonderful that you guys all saw the degenerative changes as well, because you'll see that by the truckloads. Um, but hopefully you feel a little bit more confident next time your face with the C spine X ray. So looking at a time, I think we've got enough time to least go through the shoulder. And then we after we finish that we can decide if we want to continue. Or I'm happy to send out the last bit of my presentation a slight so that you can go through them in new one time. Right? So back to try, like a different joint, we're going to keep the same structure will go through the anatomy of it, go through the assessment together and then look at some cases. So in a shoulder X ray, you can get up to three views, most commonly at least two views. So you get a PV you so front on you get an axial view on that for you is taken like this. You lift your shoulder up and the views kind of the X rays taken from underneath. It's almost like an armpit view. But obviously that means that the patient needs to be able to up abduct their shoulder. So it tells you a lot of someone can have you taken. And then the last one you get is a is A Y view or lateral view. So you're basically seeing the scapula on its side and you're wanting, um, to make sure that the glenohumeral joint is congruent basically. Oops, sorry, right. So really basic. And that to me, you got your humor ahead. You're glenoid you acromion clavicle. And then don't forget you've got coracoid processes. Well, this will nothing here that points forward. Um, in your joint. I used to find this view very challenging because I didn't know what I was looking at until I saw this. So you can break it up into two separate items. Ah, pincer view. So if your index finger and your thumb and then obviously a golf ball on a T. So the golf ball is your humeral head, the tea is your, uh, really noid. And then your pincer grips is gonna be your a chromium. I'll come in is much bigger. And your stomach's, you know, been basically so acromion is your index finger here and your thumb is the core record. And like I said, this is your why you you're seeing a scapula on its side. You're going to have you a crewman coming through like this. Your coracoid in the front so across mean it's always posterior coracoid is anterior and then they all kind of come to a mid point where the green Oh, it is. And you basically want to make sure that your humeral head is bang or in the middle of the Y, and that's so not Okay, so we're going to start using a PC two s again with eight. Um, we're checking for alignment mainly, and I'm off joints in the shoulder. There's only really two joints got you glenohumeral joint, and you've got your acromioclavicular joint with the glenohumeral joint. You want to make sure you can see this kind of overlap like the middle of then diagram. Um, and as long as you have this overlap, you can be quite happy with its congruence. With the acromioclavicular joint, you want to make sure that the bottom of the acromion here is in line with the bottom of the clavicle. If that's the case, it's in line. Hunky dorey. Move on. Um, when you're looking at alignment with these views, you're mainly looking at the glenohumeral joint alignment because acromioclavicular joint alignment will be more obvious on the HPV. So this just highlights how your ball is on your tee and how this humeral head is right in the middle. The y like. So then we can we want to look at the bones again, your tracing the cortex. You're looking at the trabecular pattern. Um, and that's quite self explanatory. Just make sure you trace every single bone. Make sure you're happy with the cortex, But don't forget the scapula. So the scapular is a huge area of bone, and half of it, if not most of it, sits behind your thorax. So make sure you just look at it. You can't blame for missing really subtle fractures. But if there's something quite obvious and you've not looked for it, then maybe a shame then once you're happy with You can move on to see And you're looking at the same joints us before, but assessing their joint spaces. So it's really this space here between your acromioclavicular joint A song was in line in the spaces to widened. Then you'd be happy There are specific numbers, but I wouldn't bother memorizing those. I would just look them up if you are ever concerned and then with the glenohumeral joint. So you're not really looking at this joint space here? You actually looking at this space here which is known as the sub acromial space? Now that this space is narrowed very common. You get people with the British cuff tendon opera the on you can see in all people. This humeral head just rises up towards the equipment. If it is widened, you need to think about what's filling it. In this case, is it an infusion? Is it that you tomar Is it like a hemarthrosis that whole things that you need to be concerned about this joint space widening? And finally we get back, we come back to the two s is so soft tissue. There's so much soft tissue around the shoulder. I'm sure you can appreciate that already. But as before, we don't only want to focus on the external soft tissue. But we want to look at this region here. So this. I mean, it's not internal. It's your chest wall. So it's this region here, and this can be the first instance of surgical emphysema in the case of chest injury, rib fracture, things like that. And speaking of rib fractures, you've also got a whole other section of your shoulder X ray that's included. So make sure you look at your thorax. You just make sure you just look and make sure you're not missing any displaced rib fractures, not missing any huge honking lung tumors or onion with Rx. And that's the main review areas of a shoulder X ray. And this is just a little fun fact with shoulder dislocations that I just like to put in there, because I, um, found it very useful on an AP radiograph. They're always you can tell whether or not a shoulder is dislocated, anteriorly or posteriorly. Um, and just having the comments, Which one do you think happens more frequently? Anterior and posterior or posterior? And if the posterior and yeah, anterior posterior. Um, so basically, if you think about your shoulder and anterior dislocation, can't has to come forward, but because you've got this coracoid in the way, it has to come underneath it. So if you'll show this humeral head is dislocated and in theory to your coracoid than it has to mean that it's come anteriorly. And I can prove this by looking at the wife, you're an axial view, uh, mostly alive. You and you can see that your Humalog head is displaced anteriorly under the core record and away from the acromion. Similarly, with a posterior shoulder dislocation, um, you'll find that it will be more superior Lee, whereas before this was more underneath the coracoid. And this is kind of know any other coracoid, and they also has classic shape, which is doesn't always happen. But when it does, it's quite nice to see. And it's called a light bulb uh, humerus. Or he will had light bulb shake. Okay. And when you do why, I've you you can see the humeral head is displaced posteriorly towards the chromium. So posterior dislocation buses, anterior dislocation, and that's it. So that's a B C. to us of the shoulder. I'm gonna, um So I'll leave this here for a bit. So if you wanted to just refresh your mind before you go into some cases, right? Okay. So let's, uh, go with the first one. What do you think is going on? And I will give you a hint by saying it has to do with alignment. Um, so someone's mentioned a c disruption? Oh, a c looks Asian. Um, scapula dislocation. Yeah. So, um, the first few answers, but what I was looking for so you can see here your A C joint is disrupted or dislocated this year. So you've got a C joint desiccation, um, with the scapular. I think it's actually okay. Difficult to dislocate your scapula, if you know, I mean, because it's very much attached to, uh, the muscles on your back, it's more likely that you're going to dislocate something that's joining onto the scapula, for example, the humerus or the joint itself. Sometimes you can have disruptions of tenderness, attachment to the core record as well. But most of the time I think the scapula does stay in place. It's held down by a lot of lot of muscle, but good. Good girl. Right next. Now this one has to do with our bones. Yeah. People's mentioned humor's head fracture. Humor had a fracture. That's D What else? Um, someone said anterior shoulder dislocation. Greater typical fracture. The majority of them said humor's had fracture. Great. So we're all right. It is a fracture of the proximal humerus, so to speak. But humeral head really just means here, you know, the articular surface, the smooth bit. This is the greater tuberosity gibberish. City S O. Whoever said greater tuberosity fracture. Well done. So here you have you trace the quarter, actually not to stairs. A bit of a Well, not so much a step in this case, but definitely lucent line. And you can see the fracture here. So this isn't a dislocation, but good girl, because you can see you've got that nice overlap between the glenoid and your humeral head. And if you look at this natural view, which is the wife, you your humeral head is right in the middle of the glenoid. So this is your humor. It needs to be very much displaced before you call it a dislocation. Yeah. Next this one again, Bones. And I'll be impressed if, um And if you get this, it means you You paid attention. Basically, someone said fracture the scapula fracture of the border of the scapula. Yeah, um, actually, the body of the scapula all very, very good answers. So that's exactly right. What you've got here is a fracture that appears to extend from supposedly annoyed through the body. And you can see it here on the Y view. And this is a perfect example of how a joint is in it. The, uh, the glenohumeral joint is not dislocated because you can still see. Um, the Y is here, the center of the Y's here in the glenohumeral joint, or the head is still in the middle of the y. So this is not dislocated, uh, shoulder. But there is a fracture through the body of the scapula. And, um, feel free to type in the boxes. Well, why you need to pick up scapula fractures. Why are they so concerning and and why the important? Okay, well, we think about the next case. So people mentioning anterior shoulder dislocation. Yeah. Great. Which means we all get it now. It's definitely not incongruent, so we know it's a dislocation. And then now we have to figure out if it's anterior posterior, Um, and it's underneath the coracoid, which means is until you and he had this proves that you can see your why of the scapula Here, this is the middle of the Y and Humeral head is all the way over here underneath the coracoid. Well, that and your shoulder dislocation. Now, what about this one? Posterior dislocation. Someone said, like, help sign. Yeah, exactly. So that's this is, ah, another example of dislocations. And, um, the more I don't know of anyone mentioned, but the more common form of escapism. Anterior dislocation. It's very, very difficult to push against all the back muscle that you've got on your shoulder and desiccated posteriorly. The only instances where you see this and you commonly hear people say, is if someone has a seizure and all that, all the muscles are tensing up. That's on one of the UK one of the occasions were positive. A dislocation can occur because of the power of the muscles gripping intense in a pool at once calls, um that otherwise it's always an anterior dislocation. It's almost over. Right? So what about this? So that's two findings you. I will say that one has to do with the bones, and one has to do with our seen of our assessment. The joint space. Um, so someone said fracture off the head of the humerus, um, into a dislocation. Uh huh. Ruptured And anatomy, not atomical neck of the, um humorous. Yep, that's great. So you're right. That's a fracture of the ahead of humorous anatomical neck. It looks like a dislocation. I will give you that. It kind of is. It is subluxed. So when it's not completely dislocated, we call it subluxed. What do you think of this? This region here. So people mention blood swelling's swelling of the soft tissue. And yeah, it could be a that level. So it does look like a because it's definitely less dense than soft tissue is in it. But this'll in this case, it isn't it. This is fat. So this is a, um, Leipold. Hemarthrosis is when you've got fracture of the bone and all the fatty marrow that sits in your bone. It sleeps out, I suppose, And as the blood leaks on the fat leaks out. It forms a a definite sort of f no fat fluid level, so to speak. And even if this wasn't fractured, you see a sign like this. You know, something's happened and they need for the imaging so well done. It's increased joint space due to a traumatic effusion increase. So I increased red spaces. Sorry. Um, let's see how many more we have. I think this might be one of the last ones, so I'm just going to start by telling you that a, A and B are Okay, So what do you focus on the latter bit of your assessment? So someone said a C joint rupture thumb who steer this location So looks a C? Yep. So there is a sub locks Stacy. It's not fully ruptured, but it's, um it's I will give you that. It does looks of blocks. No, it's not. It's not that there's not. That's the main thing. Someone who's is it clavicular fractures. Oh, you here. Yeah, that, unfortunately is, is it's the irregular surface of the underneath. The third, the clavicle. I know that's not very helpful, but that's not fractured. Keep you. You're getting warmer though. You're looking here. They're looking here. You get it again. Warmer. Keep going. Someone said sternal clavicular dislocation some more clothes. Factors coming in. Uh huh. It's the last one. So it's always gonna be a bit trickier. Important on the less someone said, If it click, click the clavicles and the wrong location. Sorry. A chromium fracture. Bring her. So if you're talking about this here, that's just the irregular shape of the across. Sorry. No. What do you think about the chest? Someone said rib. Okay. Someone said no more Durex. Yeah, exactly. Well done. Um, I realized this might be slightly delayed, but well done. This is any math oryx. Um, and I've drawn that blue line over there to show you you've got lung markings down here, but a distinct lack of lung markings here. So what you can get sometimes is Oh, someone falling over in the shoulder kind of hurts, but they've also got sort of chest pain. Um, and they might have a rib fracture that you've not seen, but you can most definitely see a new Earth or X. So this is a month or Axio a shoulder X ray and that is more common than you think. So I always make sure you're properly looking at the thigh, or it's not just giving it a glance is, Well, when you happy with the rest of the shoulder and that is the end of our shoulder cases, Uh, thank you very much for participating. I realized that it is almost nine o'clock. Now. I do have another section, but I think because of the delay, we've, um, obviously know her as much time as we'd like. So I'm happy to keep going, But obviously, I'm appreciate that this is your evening. So if people want, I can also, um, condense everything down and make sure that you get a, like a like a brief, slight copy of the ankle bit as well. Um, I'm not sure how we can get a consensus. Well, I spoke to you. Yeah, I will hand it back to Wendy and the team, um, to see what we should do. I just stopped sharing for a moment. I think people that happens continue. Um, this general consensus on the check box of people happy to keep continuing. Okay, right. Thanks. Thanks, everyone, for sticking with me There's only one section left. And if you found a useful, then great. I working, going Let me make some amendment so that we can make the quiz be a little bit faster. Um, So what I'll do is I'll try and show you each film for about 30 to 40 seconds and then move on and you can write down your You can obviously keep commenting in the comment box. And Sorry, Wendy, you've got the tough job, then reading it out accordingly. All right, Just give me two seconds. I'm almost done. All right. And back. Let me just share my screen again. Can see this. Yeah, Okay, it's up. Right. Thanks, everyone. Um, let's go through this last bit and then we can everyone go home and enjoy the evening. So, ankle, let's go through that. Not to me. Um, so you only get two of use of the ankle, you get a PV you an electoral view on there? I would say that equally important in this case. So with regards to anatomy, you only really have one joint in the ankle. Yes, you've got syndesmosis here, which can rupture. But I would say that's more of a cartilaginous dryness supposed to this joint here. So you've got your fibula tibia and your tailless, also known as the lateral malleolus medium. You on this, um, and this is your main joint space on the lateral view. But then you can see your ankle joint space here and your media and lateral mail your like kind of overlapping each other. So the shorter one is your medium early on this on the longer when you can see in the back is your lateral malleolus very in mind? This is a perfect, like drove an ankle. Sometimes if you buy and pay, you can't get this perfect natural. We always have to think about that. When when you're looking for email, you lie. So sorry. Um, one of the other slightly trigger things with the ankle is obviously there's a lot off normal variance, and they come in the form of little bones that just like to sit in places and mimic fractures. So this here is a very common place. Call the Australian. Um, you can get little bones underneath your fibula underneath the tibia here is well, so if you ever see fractures in this region, or you see little bones in this region, I would suggest you just Google up quick common accessory ossicles for the ankle and then cross reference thumb. Um, I would say if something looks very round and has good borders very well, corticated, then it's likely to be something chronic. It could have been fractured a long time ago. It's just which is just then, you know, rounded itself off, but it's no acute. Um, right, So you can tell I've skipped a in our assessment because there's only one joint, and if that joint is malaligned, you would know about it. So we're gonna move straight on to be. And like we talked about, we've got a few million nine. You've got your media in your natural, but you've also got a posterior Mallya or less in the system thing. This is the man you like, Manulis that you can only assess on your electro you and one of the things I will highlight is that you've got a, um, another bone that's often commonly seen in the ankle. So you when you do electoral you of the ankle, like in In this case, you can sometimes see your base of fifth here. So when people have ankle injuries when they invert, the ankle is a very common thing to fracture at the same time. So the ankle might look fine, but you might have a fractured base of fifth metatarsal. And your posture, um, Ali, a list of highlight that it's this posterior bit. It's not as pointy, but if you see a fleck of bone in this region and someone's had injury to it, then you have to be suspicious for posterior Mallya of the fracture, often better seen on CT. So any little fleck of bone be suspicious and sort of order more investigations. Um, and if you can't see anything on being you're gonna move on to see. And like I said before, you only have one really joint in the ankle, and it's the ankle mortis. This here, this lovely, dark line is your ankles, right? Was none of the ankle mortis. Now it's very uncommon to get narrowing of your ankle joint because it's a very uncommon site. Have osteoarthritis. So this in this case, if you have, um, narrowing of one side and widening of another than no see, that's quite concerning you want to make sure it's nice and clean, so you can only see what? Sometimes you can see some of the the distal tibia through it. But if you look at this line here, this is the anterior joint, the entry joint line. The wits of the joint space is equal to roll on. If that's the case, you can't see any flecks of bone in it. Then hunky dorey moving on, um, which means we can move on to soft tissue swelling and in special review areas. So these are some examples of the ligamentous complexes that follow. I'm sorry. The heart in your ankle, You got one here, which is this in this most of staff mentioned before you've got a natural complex and the medial complex, often times when people have inversion Iverson injuries and they don't have a fracture. It's because these ligaments have gone the ligaments. The reason why you have a fracture. Sometimes the ligaments have held on to that piece of bone. You've stressed it and that one is fractured off. But if the bone doesn't go on, something else has to go something the ligaments will rupture or 10. And this is the case where you can see so quite severe soft tissue swelling to give you an indication of that. Now, a special review area in the ankle isn't actually in the film itself. It's more the concert, the polar in concert. Now I'm sure you've all been told this medical school or in in a unique a polar it doesn't break in one place only it often bricks in two places and you're tibia and Sibylla are connected at the distal tibia, fibular joint and the proximal tibiofibular joint. Kind of like a ring a really elongated room. So if you're if you have a really severe injury below, you have to have a high suspicion that something is going to be disrupted up here. So if you see a really severe unstable injury, multiple fracture, multiple fractures involving your ankle, it is always a good practice to get a view of the proximal to be a fibula and up to the knee is well, and this is an example of, um, often upon, um, a structure called the Mason. No fracture where you've got an unstable um, Taylor. Sorry. Distal tibia. Fibular fracture is not very well visualized. in this image, often with so Taylor dorm shift or widening of your eight ankle mortise accompanied by with a, um, proximal fibula neck fracture. Yeah, the way if you can't remember this, but it's just highlight that you know something horrible down here. Make sure you check up there is well, and that's it. So it's a much easier the ankle. And now that we're happy with the ABC two s method, what we're going to, um, do is run through a lot spectral cases. So I am going to start time and then show you the first case. So leave this on for a while and look at our next case. Eso people mentioned medium ago this version of the medium of the oldest them to go fracture. I think that's right. But I can't see right now, So we'll go through all the answers at the end if that's okay with you. When I when I saw you, just That's all right. It's good that people are putting down says through, Um and that was the next one. I will say this one is very subtle. And think about your special review areas. Um, sorry. Um, not better review Your is the the extra bones you can see in an ankle and then the next case again. This on this quite a subtle, um, fracture, but very important to pick up. Make sure you're looking at you. And joint space is very carefully. And then this one. So this one, they're about three things that's going on. That's it. That's the end of the ankle cases. So, um, I'm not sure how she do this. I'm happy to just present the answers, or if, um um, if if when he can see anything in any interesting answers coming through than, um, feel free to let me know we'll pipe in. I can't explain why something is. And when something isn't, that's the case. Okay, But we can go through the first one. So this, um, first, this may not have been the first one, but there's just been the second one. Apologies. I think the first one so I mentioned was eight medial malleolus fracture Weeks is correct. Let me just we just find it again. This one, This one here? Yeah. So this is a medium al you of the fracture. Well, well done. Good pick up. So here you can see a little fleck of bone and you know, it's a fracture. Well, probably come with a bit of history. This a lot soft tissue swelling in this region. And this doesn't look like a well rounded, chronic piece of bone. Basically, angulated, you can see there's a fuzzy border from where it just came off. So makes you think this is a fracture. Um, and that's right. So this is the, uh, this is the second fracture, which I've got enough answer section, which is a lateral malleolus fracture. It's a spiral fracture. Matter of you can tell it's kind of coming around like a spiral. And this is a very common method of fracturing your fibula distal fibula. I mean, you can see it extends all the way above the ankle joint and above the syndesmosis. Well, when he was interested, this is called a Web. A C type fracture and a Web classifications is for ankle fractures, depending on where they are. It tells you how stable are unstable of the fracture is the next one that we have is quite subtle on apologies. I didn't find about a film for this But this is where it's important to assess the other bones that you can see not just your fibula and tibia. This is a base of fifth metatarsal fracture, and he had tried to zoom it up. Onda, Um, this Lucent line you can see here is a fracture of the base of fifth metatarsal. Um, I think if you ever see something I send your suspicious for a fracture. It would be fine to request a foot view because the foot view will have oblique views that allows you to assess that bone much better. And if it's normal, it's normally if you happy consent the patient home. But until you do that, it's very difficult to be 100% sure. Um, this is our next case. So again, this is a very subtle, um, fracture. But if you picked up well done, and that's what I'm trying to illustrate about, um, sorry with regards to looking at the joint space. So if you're looking through this ankle mortise, you notice. Hold on. What is this? What is this little fleck here? And this is actually a hostilo chondral fracture. So, really, what happened is the top of the cartilage surface has been fractured off since osteochondral. Um, and it's a very important factor not to miss, because someone can have quite debilitating degenerative change in the ankle. If this is allowed to just float about, cause inflammation and obviously you're losing a bit of cartilage there, which is going to impact the articulation and, um, sort of axial loading off that joint you can actually also see on the lateral view. But and zooming up here and that little flake is that, Yeah, it is a bit more difficult to assess it. That's why it's important that you really look at books your ankle mortise views, so it's very difficult to be 100% sure based on this one. But here you can tell there's definitely fractured next one. Um, so I said there were three things you can mention. One of the two of them is gonna be the fractures. You've got a displaced, a spiral fracture of you to still fibula. You've got an avulsion of your, um, medium Al Euless, and this is a good example of the case with the ligaments seem to have stayed intact relatively well, but because they're so strong. They've pulled off a piece of bone, and that's called an avulsion fracture. The other thing that we have to notice in this case is that the ankle mortise is disrupted so very difficult to judge whether or not the joint spaces now road here. But you can definitely tell it's widened over here. So that lovely little, even joint space that you can see here he's gone. Yeah, this is a very, very unstable fracture. The often put this, uh, very quickly in a cast and then we'll fix it. INTRAOPERATIVE. Lee. Um, so it be very impressive if you could diagnose all these three things. Three things on day on the call to your offer wrench so they know exactly what's happened and exactly what they need to do. And that's it. That's the end of the ankle. Uh, from that section, it's much easier. Um, and I think the two things on me to take away is ankle mortise and base of fifth mess Tarsal. Make sure you remember to look at those two things. Um, yeah. So I think that's the end of the thought talk. Thank you very much for staying still have passed Yeah, almost half past night. If you have any questions, I'll be happy to answer them either on the email or if you want to drop them in a chapter. Books Now, I'm sure. When do you want my reading them out? But in the meantime, if you enjoyed yourself, thank you very much for staying and listening. We would really appreciate if you could scan a QR code and fill in a feedback form. Good and bad feedback is already appreciated. Um, for us. So thank you very much. I will stay on here for a while longer in case there are any questions otherwise enjoy. Evening. It's no question sofa, um, slots, people thanking you for the great lecture. And And I think people want more teaching as well in the future. More CT scans as well. That's good to know. Um, with thank you for bearing with me. You know, we had a few technical issues, but I really do appreciate it. Um, yeah, that's great. Um, if people are keen, I could we could always work through, um, very specific regions or specific CT scans. Things that you need to You can assess by yourself. Um, in clinical practice