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Hello, everyone and welcome to me education. My name is Sue and I'm usually on the support desk here. It's really great to have you today for our talk and we are joined today by Abraham Barro, who is an orthopedic and trauma consultant. Um, he's gonna chat to us for about 45 minutes and during this time, please put your questions in the chat box on the right and hopefully we'll have about 15 minutes at the end to er, chat er, to go over those questions. I'm not medical. So I really am relying on you guys to pop some questions in for me at the end of the event, there will be a feedback form which will be emailed to you and then once completed your attendance certificate will be on your med account. Ok. Um, now I'm gonna pass you straight over to uh doctor Borini so that he can do his amazing presentation. It's over to you. Hi, good afternoon. Nice speaking to you. It's a pleasure. Uh speaking to our colleagues. Um, we've been asked to speak about upper limb trauma. Um I found upper limb trauma is quite a very big subject. Uh very difficult to cover in 4 to 5 minutes. So I choose to speak about our upper limb fractures. Um Out of these fractures, I choose to speak about this radius and clavicle fractures. So, and this um 40 minutes or so, I'm going to concentrate to speak about this radius fractures and clav fractures. OK? To start, I'm gonna speak about epidemiology of upper limb trauma. If we take 10,000 people from the population, uh six, about 67 of them will have fractures in the upper limbs. Uh This is not percent incident. So 6 to 7 fractures every 10,000 persons in the community. Um Distal radius fractures represent um about 12 sorry, 16 fractures out of 10,000. Uh uh which is where the most common fracture then hand fractures including pharynges, metacarpals represent about 12 to 8 uh fractures bear 10,000 respectively. Uh proximal humerus will represent about six bare and, and a frac fracture of clavicle uh about six Avary. Uh th to, so there is a quite variation between different fractures. Uh We'll go on details about that in a minute. OK. So um the most common fracture of all age groups and the upper extremity is this fracture. OK. Now, if we take age group 18 to uh to 34 a year old, uh met carbo and phalanges more common. So present about 16 and 12 bare 10,000 respectively. Uh If we take if we go a little bit higher in the age group is 35 to 49. Uh The phalanges fracture will be more common. Uh about 11,000, we go a little bit back. So the youngest, the more younger age group, they have more uh metacarpal fractures. Uh The reason is that they are um doing more sports, um probably fighting. So we see a of fi met carbo fractures, uh people fighting and hitting walls and things like that. Um uh When they get a little bit older, um it will be more mature. So the meal fractures will go down and still they have phalanges fractures. Ok. So this fracture is a good bi modal distribution. It either uh less than 18 years old, which is mainly the the Children with the greenstick fractures and then you have um more than 65 years old uh where osteoporosis will take off and they have this rate of fracture due to weakness of bones. Ok. Next slide. Now, um if you take males and females, the most common fracture in males is phalanges fractures present about 11 um and 10,000. If you go females, most common fracture in female is, is this the fracture? It's uh uh about 12 by 10,000. Now fracture phalanges and mears, they uh go with the social economic status. So the they go less uh and high socioeconomic status though having said that no other facts represent this variation by the socioeconomic status. Now, um up limb fractures, um nail injury associated, it is quite rare. It's point point 3% overall. This rate fracture, uh sorry distal humeral fracture within 1.5%. This is uh several uh several, several uh sorry um some fractures of the anterior to his nerve, mainly uh open fractures is about 4.7 cases most commonly in the distal, which is uh about 23%. This is from this paper with stoma. So I'm gonna speak about um fracture, clavicle, uh clavicle, the first bone to ossified and the last one to to complete ossification at the sternal end. It's about the age of 22 to 25. If you look to the um um the clavicle, uh this is the sternal end, this is the uh clavicular end, sorry, the um the um and if you look at this side, it's a circular and this side is more flat. So there's a bit of junction there between the circular and the flat. This is the inferior surface. This is the standard uh this is uh and the same, this is circular. Uh This is a bit flat. Um This area is considered as a a stress friz uh So fracture surge comes around this area. We'll speak about that in a minute. Uh Just a little bit about the fracture in Children. Um It's considered quite common fracture fracture. Some, some peoples who this is the commonest fracture in Children fracture clavicle, some other literature support saying that the this radial fracture the six is more common. Uh personally, I saw more dys radial fracture rather than a clavicular fracture. And and Children. Now how fracture happens, how we get fracture, clavicle or mechanic injury, usually by direct fall. So people fall down in, in their shoulder uh or die broke or on the on the clavicle by a stick or whatever or at least 6% on falling and re hand. Mm. So you could see this. These guys are um uh cycling and uh OK, so they fall down on their shoulder and get um a fractured clavicle. So uh skating, s uh skiing, cycling, horse riding, all this can lead to a fractured clavicle. Uh just add to do many injury. You can see if you were walking and have 40 of time or diet or, or, or, or they go to the shoulders. Oh, so uh sorry, this, the paper here is not very clear. Um um most of or majority of um fracture cla are closed. So 98.2% are closed injuries. OK. They are present roughly about 3% of all orthopedic fractures. So, papers saying about six on some people but less. So that's about 3% of all auto fractures, which is quite, quite a lot and they 44% of all shoulder GG injuries um who could have more uh uh concomitant injury. With the fracture, pla like fractured ribs, knee more hemo to right. Um So 75 of poly trama with club injury, they have thoracic injuries. Uh 65 they have closed head injuries and 35%. They have cervical or risk spine injuries. So, if you take a injuries affect one, um, one in 10,000 people per year and it's called bi modal distribution, um, younger age group over 25 due to sport injuries and when we're getting older, more than 55. So, osteoporosis will kick and have another um clavicular fractures. Um is 2.5 times common in males than females. If you look at the graph there, the blue is male. So um uh the age group here uh uh tend to, so 20 to 29 is quite high compared to the females which is much less there. Uh We go so males are more males are more, but we go quite elderly people who have osteoporosis kicking. So the females start to take off from about 70 plus age. So about 2.55 common common in male than females. So what we can have with have with the fracture play, we could could have breakup back injuries, confusions been tracing injury, I have muscular in ju uh fracture, ribs, fracture, scapula, knee, thorax, hemothorax. So all these can be associated the fracture. So putting in mind when we arrive to er uh uh examination should include all these. So we need to check the c spine, the chest um vascularity and your vascular status. Ok. So just back to the um um anatomy again. So this is the ster in uh or medial side of the clavicle. This is the lateral side, as I said earlier, this is the circular, this is the flat. So there is a weak point at the junction between the middle and out of there, majority of fracture clavicle appear in the midshaft or near the junction between medium, middle and out of the. Uh it is a thinni and narrows. Um It's a transition between curvature and cross section area. The anatomy, sorry. Uh This area is not supported with ligaments and muscles. Uh really there is, it's a sign of new artery, so it makes it more weaker. So this is where most of the fractures happen is about 80% of the fracture happens in this side. So what x-rays uh uh we take uh according uh according to the clinical uh examination and history, um um we could uh just take x-ray A P uh with uh we call zinc cap uh use uh shooting um upwards about more than 10 degrees, up to 45 degrees. Um We could take more x-rays if needed like XC, spine and chest uh on my leg. Yeah. Now, uh most of the uh F fla it will be diagnosed by some x-rays. Uh CT scan has been mentioned uh in the literature. To be honest, I never ordered AC T scan myself for a fracture clavicle, a list to diagnose Ma Union or Ma Union. But ac T scan as um uh first line of uh examination I think is needed um at least from my experience. So classification of fracture clavicle. Um the blending classification, there's near classification. There is a o classification, all man classification and Robin classification. I cannot speak about all of them. So choosing to speak about all man classification uh or classification. So divide it to type one, type two and type three. Type one is a middle tier which is represent about 80% of fractures. Type two, distal end or distal tea represent about 15% of the fractures. And type three which the medial side uh should be 5%. Um C 0 5%. But I didn't see to be honest a lot in my career. Um It's quite rare. I see the suici of uh uh stay in the clavicular joint uh mainly anterior. I seen very few post location fractures in this area, seen really few. Um But they say it's 5%. So the bulk here have the, the middle tier which is called type one. I'm type two distal tea and we'll speak about types. Then we be, we're gonna um define a type two to the group uh according to near uh classification. So um that's uh clavicle fracture. I'm seeing uh the displacement. If you look uh to the uh medial or proximal fragment, where sta mastoid is attached, it will uh distract or displace the mean the fragment proximally and the material to the back. Now, we have uh the uh pectoris and lets the measure of this. So they will bring the distal fragment down and an interior. So that's why this is the muscles acting on the fracture side, dis displacing the fractures. Then we have the weight of the arm and the deltoid um trying to pull the fragment, the distal fragment down. Now most uh fracture clavicle treated no operatively uh majority. Um There, there are two times how to treat it. There is a figure of eight which is not very popular in the UK. Uh uh though I saw patient mainly coming from abroad with this. Um but mainly I we treat them and brother thing. So the figure of a um the advantage of eight is ba patient can move, still use his hands. Uh By far, it's quite difficult um to have uh this to the body, especially um for hygiene. Um The riches, there is no different than the um union rate outcomes more or less the same. OK. Treating uh uh fracture clavicles, nonsurgically. Um uh Most of neighbors will go, go back to work about six weeks for light lifting, a full duty at 12 weeks, at least as well. Take them about 12 weeks to go back to contact sports. Uh, so, um, operative intervention, whom we can, whom he needs surgery. As I said earlier, most of them they don't need surgery but some, they need surgery. Mm. Um, patient home har or vascular injuries, sub artery or vein, um, associated, uh severe, uh chest injuries. Of course, open fractures and group two. Um, type two. We'll explain that in a minute. Uh, cosmetic regions. Some females, they don't like this bump there or, or no union. Oh The fracture is tenting under the skin um which would be ty and uh enduring and ender in the skin. Ok. So there's absolute indications which all I mentioned fractures. This space fracture with skin tenting, subclavian artery or vein injury, floating shoulder clavicle and scapula neck fracture, uh displaced media ical fractures would just, you know, structure at risk. Oh, I'm talking here about the medial side which is the 5% fractures mainly if there is uh posterial displacement, displacement or dislocation of the joint post, which can affect the me meal structures. Um A relative uh or controversial indications this face more than two centimeters now, muscle and muscle uh let you support if more than two centimeters, we should operate. Uh If you have bilateral space fracture clavicles, if you have brachial plexus injuries. Um A patient with bone uh bone trauma, um uh fractured ribs. If patient have fractured ribs, they usually have difficulty in breathing. Uh If you fix their clavicle they start to use extra um thoracic care, uh respiratory muscles like si so helping them uh to breathe, to use uh them as muscle for breathing. So that's one of the indication for fracture clavicle. Now, if you have complete flesh on the face of the mid shaft, OK, they have 15% of nonunion if they treat it. No, if you look at the x-ray here, you have this fragment. Uh um this place super, this is inferiorly and you said there's some rotation here as well. You could OK. There's a gap, there's shorting of more than two centimeters. So these fractures usually, usually they donte, they have about 15% chance of um nonunion. Um OK. So if we fix them, so if we operate on them, they have a higher. So the 94% of them, they will unite. But if you don't operate on them, uh they take longer time to heal. So um the union rate over the time 16 weeks and not over the uh group, they take 28 weeks now. Uh uh the um the one who displaced and shortened, they might heal, as I said, but they, they heal would uh shorten the clavicle that will lead to um Detroit shortly around. I mean, the Detroit um function uh more, more forceful, the de to work and that will affect uh patient, having pain, uh discomfort uh around the shoulders. So, uh nonunion, um nonunion when x-ray didn't show any uh signs of healing after 4 to 6 months. Um clinically, um uh you could feel moving um uh fragments um who was going get my union. Uh The, the one who have com and the sign uh significant displacement or shortening uh type two, we'll speak about that in a minute and dis the clavicle, uh female and six advanced age, uh shorting mud. More than two centimeters. The smoking as well is uh very common uh cause of nonunion. So, if we take the union for a rate for all mid chemical fractions, um it's, it's about 6% is 50% for displaced midclavicular fractures. So all fractures, sorry, o all uh all m fracture was 6% and no over the group, but they are 15% if they are displaced, I'm talking about the function. Now, if three the normal too, the symptoms of nonunion can be pain, uh motion and or movement and the fracture side uh loss of function. Uh having said that many, no, you are completely asymptomatic and you don't need any treatment. Uh There's a paper by Mary and reported that smoking was the greatest greatest risk factor for Men Union among patients treated. No. So we need to counsel our patient by smoking. Now, operating with this patient, we need to involve uh police from general or, or thoracic stations um and the vascular sas of suspected subclavian vein or artery involved. Now, how we treat over there is a different way how to treat it. But with intermed fixation uh in modification, come to the fracture site, uh open a small wound to try not to uh remove a lot of periosteum. Um And you, it's like any intermit and when you do some reaming in both sides and insert the, the, the uh the pain in the or the most common way to do it uh is uh plating. Now, there's different type of plates uh coming in the market. Hello, contact, please. Um contour plates, um shaped, shaped plates uh in the market you could choose, you know, um I did the pa with them from uh sub uh superior to inferior uh sorry, sorry, superior surface uh though having said that uh while draining uh you could go down to the lung or the pleura. Uh So some people uh a me that with the material, so it'd be safe. Oh, thanks. That's so far. I never had any problem uh rupture uh taking place for the uh 20. Now, just back to the uh group two fractures. Uh group two, which is the lateral one. They will present 15% of fractures. Let me um the incidence of the union in here is quite high. Uh It's got about 50% of all non unions. OK. This age group, the distal fail 15%. Now knee specified. Uh then to type one, I type 2 a.m. B OK. Type one. the clavicle ligament is intact and that usually may be displaced ablation. Usually take that no. Uh type two, we have two types, type two A and type two B. Uh This is type two A. So the and trapezoid uh the median one is the cono the lateral one is the trapezoid ligaments, cor uh clavicular ligaments. Um So type two A is medium uh to the uh of course, it be immediate triple zo as well. So both the cono and trip zo are intact. OK. Type two B. Uh They, you have significant displacement. Um Here, the is uh ruptured and intact. Uh Here is the highest uh non rate is about 30% non union. Uh So how you fix them or we fix them with plates or hoco plate? Oh ble in the market. Now, oil and this uh uh this distal clavicular plate will have melon um uh multiple screws which you could insert and the flattened distal end of the clavicle. There's o plate as well which um need to be taken out at some stage. Uh time. Uh Three usually doesn't make uh much uh not much basement and you treat it. No, number three. Now, when there is a fracture clavicle and uh uh clavicle ligament injury. Um There's a, a paper uh this paper done in Cadaver uh model. Uh They use four types of uh um repair of the cor clavicle ligament. They use either cortical but or suture, anchors and plate button or suture, ankles and no blade button or a suture around the cor or the bla of the clavicle. The conclusion biomechanically uh they are more or less the same. There's no significant difference between them. So take home message from the clavicle. It's a very common fracture. Uh mm Always be aware of that. A neurovascular status being examined. C spine being examined uh chest and abdomen. If any concomitant uh injuries, uh x-ray will be ordered accordingly. Uh be aware of uh nonunion with the uh displacement of the fracture site and shortening about two centimeters who like to go for nonunion. Be aware of smokers and female whom they have more. No rate. Now I'm gonna move to a fracture, uh distal radius history, quick history. So hip angel and um spoke about it and they thought it's a dislocation of the wrist. So they've been documented that been document, sorry um spoken about the wrist dislocations. Then vito who first described uh the frac fracture forearm on the ras and the French was um 17 83 is quite quite long time ago. Then Abraham Cols Irish surgeon er described this fractures in 18 14 and um Edinburgh medical journal that description was 81 years before uh invent the invention of the uh x-ray er which was in May 1985. So Abraham Col er described the dys fracture. Ok. So epidemiology, this fracture account for about 17% of all the fractures which is very high in adults. Um They um often and occur in different two groups, either elderly or osteoporotic uh bone uh usually um minor trauma, OK, or young noodles. Um between 18 and 25. Uh this is related to um high energy trauma, uh motor bike accident, uh falls, uh rugby, uh cycling, uh things like that. Um Generally this fractures at about four times as often in females than males. So look at here uh there it is the females uh in the younger age group, males uh 16, 20 slightly higher. Uh Then abo about the age of 30 females start to be a bit higher. Then from us, skiing of osteoporosis uh from 60 years old will go higher and higher and with the age, it will be very high uh in the seventies and eighties if you look here. Uh and this gra uh the, the uh dark blue uh as the ra or wrist fractures, ok. Uh The left side is then if you look there, we, we get at about seven, at about 60 we'll go higher than higher and higher until um 80 84 and go really high. Uh compare that with the men. Uh same, same dark blue, uh not much difference and the slight increase after uh from the 7 75 plus. So obviously here, the risk is this fracture is osteoporosis like other osteoporosis fractures. I'm just gonna think about cause fracture. Uh One of its names um companies enter and extra art fractures this radius with do Ace roar. Uh most common fracture and, and usually due to also she had uh Smith, we've been told he's the cousin of uh uh Abraham Col Colles to Colles. Um wall of displacement of the distal fragment. Button fracture was a volar dorsi or roll uh sugar fracture of the steroid cys a fracture of the radius. So um uh we're all being told that a for fractures, we located that this is called fracture, distal mark, this dors and radially and this is the Ner fork. Now, this is uh Smith fracture and lower right side and this is Burton and the left one is a fracture, the steroid there. Now uh either fractures like uh osteo. So to the osteoporosis and just minor falls will cause this uh fractures like this lady here or um high energy uh motorbikes accident falls from height, et cetera. So, but we just spoken about it because the bone can break easily. Uh but and and younger age, we need more load to broke uh bones. Uh Always look for uh other fractures. Uh like a Humes fracture happened to be once I seen a patient in a department, I diagnosed her f then the boss came over and the first thing he checked, he checked here, sorry, shoulder, she cannot move your shoulder. We xrayed here and there was flection be aware this risk is the belong to, but he always check please for tias, heart problems, why they had, uh, fall down the muscle vehicle. Ok. Uh, and then the, uh, best thing to kill the pain is the splint or the back or splint or whatever. So most of the pain will go away. Now, um, what x-ray, we need to order a be and less, at least if you have ale, we will be better. Now, what we're looking for. So we're looking for BM or tilt. Normally it's about 10% 10 sorry, 10 degrees. So the this ray is good ing now in a view, we look for uh radial height which is roughly about 12 millimeters and inclination is about 23 degrees. This OK. Now, this is uh on average but there's a big study, uh different studies show different numbers. Uh for example, radial length here between eight and 17 uh inclination between 16 to 29 and a uh tilt between zero and 22 degrees. Um maybe um uh um look for the other wrist x-ray to compare. OK. Now AC T scan um I'm not sure about CT scan will be needed, but I know a lot of police, they order a CT scan, the CT scan will just show you more com and makes you more fright frightened to operate on them. So I usually most of the time I just order x-rays, order the x-rays hardly. I request ct scan unless for my union or something later there. So what's the treatment? So the treatment for this 11, from this first, we want to restore patient to prior level of function. Ok. So the goal is to refer patient to prior level of activity, regardless of the age doesn't mean that somebody is 80. We need to ignore them because could, they could be very active, still playing golf and uh doing most of their daily activities independently. So we have three barometers uh treating the fractures and try to take a step off. We usually accept less than one millimeter of in art step. Now, more than two millimeters is not accepted according to American Academy of orthopedic Surgeons. A A OS which is uh evidence based clinical practice guidelines. Now, radio, radio um or could accept to neutral but no, no tilt more than 10 degrees. No, a lot of a lot of patients. Um they have tilt up to 45 degrees but they're still functioning well. Uh This is a bit of conspiracy here. Um For me, um I won't accept 45 degrees. It's really unsightly. Um But uh I've been seeing some papers saying that that some elderly people, they can function only with those through displacement, 45 degrees um radial length, uh two millimeters, radial shortening, but mo more than five millimeters. OK. Now, um I want to train trainee in uh side. Uh we used to do uh a lot of hematoma work. Um I thought this can be helpful uh when um facilities is not uh optimum hemato look under local anesthetic is 1% a cane. I usually come from uh uh proximal to distance. I mean, we just go to the fracture uh from proximal to distal to inject because you need to go and sign the fracture. So, aspirate it will be dark block inject. Can I usually go those three? No, Roary. This is going here, Rollie. Uh I wish you go dose three. It's much easier. OK. Uh Give, I usually give a 10 of the de cane on the same. Then I wait, don't go straight, wait for at least five minutes, minimum five minutes or 10 minutes. I usually after that, ask patient to move the wrist if they manage to move the wrist, that means most of the ve not disappears if they couldn't, that means you need to wait more. So the idea to wait and not go straight inject and go straight. Now there's ways to treat uh over operate on the ras uh close reduction and percutaneous spinning. This CK wires uh from steroid bru and dorsal. Uh You could um you could do two from which I usually do. I do the divergent uh one near to the fracture side and one away from the flusher side or you could one from uh you go one from dorsal uh sorry, you come from dorsally uh this uh proximity or one from uh several bruces uh to converge them. There is another way the bui technique, as some say, used to do that. It's um I found it difficult to do uh it takes time. Um Then my worry is you go through the fracture side and always risk of infection if you're going to the fracture site. So um you're creating the tunnel through the fracture from the exterior. Um The idea of the bee is to go to the fracture site. And as the xrays, so as the figure shows here, um this place use the K wire to reduce your uh um radial tilt and uh you go from dorsal dorsally to reduce the dors of displacement. Once you have these two wires, uh reducing the fracture for you, you always need to go to the other cortex uh to make this um stable. I been uh OK. Uh So what's the communication spending? Um sensation problems, you could injury to the sensory nerve be signs always looks not nice for me. Uh You could migrate, have migration pains under the skin. Uh That means we have to take them under anesthetic. Uh You could have infection. Mm. Uh Osteomyelitis can happen rarely at less than 1%. No, do do. Uh I remember when I start training, uh they come out and uh those plates uh very good. Um If you look here to the left side, that's the um section of the dis ras, you see all the extensor compartments fill up the extensor tendons. So you measure, you got a bit blade there, what will happen to these tendons? So you'll have irritation and likely rupture of the tendons. That means you need to take this place out. So you're putting in the patient for two surgeries. So generally, um this we gone away from um bleeding do, then we have a patient. Uh Now the market is plenty of wall of face, different angles, different combs, reducing them, uh, easy to use, uh, straightforward, um Henry approach, ok. As well. They still have uh, problems with tendon ruptures because, um, the extensive, sorry, the a the extensive tendons can be injured by the, by the drilling as if you go too ha, too, too far from the, uh, far cor you could, uh, injure or damage the extensor tendons by you then bit. Oh, you, oh, the, the, the screws can be, uh, been put prominent. So that will endanger the, uh, extensive tenders as well. A F fixture tenders can be affected as well because the plate can work as the on the tendons and I rotate them as well. So you could have fri and extensive tender rupture as well. Thank, got so far. I never seen one so far. Now, this is bridging plate. Uh I've seen really few, um, medications when you have very common did, uh, fracture, which you cannot, uh, six and you cannot book an extend a fixator or the skin is very bad. So you could put uh bridging and the fixator, which is the plate. So put in the second met carb or you could put in the middle metacarpal and uh bridge the fracture and reduce the fracture for you reduce the fracture and uh put a plate on it. Um You could come back later on, take the breath out. Uh Once the fractures are heal. Now, extended fixators, I wanna start training. Uh Either we do extended fixator or bi or percutaneous uh uh wires uh then went off the mark mark of the fashion as well. Then Margaret mcqueen and Edin, uh the one on the left side here, numb bridging X six trying to avoid stiffness of the wrist because the this fixator, the ordinary fixator can lead to stiffness of the wrist. I'm gonna speak a little bit about uh uh cr base. Uh It's not very common but very distressing complication can happen to this fractures whether it treated surgically or nour uh But, but generally is this uh non surgical group, it still present about 1 60 64%. It's uh lower in the younger age group and more in the, in their people in their fifties and then goes down and people in their eighties. Um it's more common and of course, overlooking the and uh ex mainly it's about 88%. Uh It's much lower and there cutaneous meaning. Uh, it's about 0.56. So, uh be aware of, um, cr base uh, treatment for that to be aggressive physiotherapy. Uh, I usually fed him to the band team, uh, and physiotherapy. Ok. That's the end of the talk. Thank you very much. Any questions, please. So hopefully we're done 45 minutes, not bossing the 45 minutes. Yeah, that's perfect timing. Perfect. Indeed. Do you want to stop screen sharing? And then you'll be uh fully on our screen for everyone. Does anyone have any questions that they can pop in the chat for us to uh if you just click on the present now, it should stop. There should be an option to stop, stop presenting. There you go. Perfect. Fine, brilliant. So, does anyone have any questions at all? For Doctor Borini? Actually, I do have a question and it's a really basic question I have. Why, why are bones worse in women than men? Why, why, why was there more women that broke their wrists or had fractures on their wrists than men? Well, younger age group, there's no difference because the bones are strong for both males and females. Uh when we reach 40 our bone have fully mature. Ok. After 40 generally, uh bare year 1% uh males would lose 1% of their bones and females will lose 3% of their bones that's related to loss of the uh menstruation. So they tend to have osteoporosis more than men. Much more about three or four times. So, their bones are much weaker than males. Um, the other thing is, well, females live longer than this. So we do have a question. Was it general treatment for Coles and Smiths? Uh, no, they are completely different. Of course, um, courses is different opposite to Smith, uh, s met before you need, before I remember. You always, you need to put uh bleed. But of course, we could always uh operate on them by a screw sorry wires. OK? But um as as everything else, medicine is keep changing now, blading uh can be done for both for uh Smith or Colles fractures, uh more or less the same blade um at some stage uh for uh a Smith uh sorry, we call this rupture and people were putting dorsal blades but is uh one of deficient because a lot of problems with the tendon uh rotation or rupture and the the need for to take this out. So putting the patient for uh um two surgeries, the other thing as well, the this very distal radius, the bone there is um at that roller side is a strong, so putting blade on the Waller side much uh stronger than what you on the dorsal side. The the dis of the radius bowler side, the cort subcortical bone there is quite strong compared to the dorsum wi side. Yup. Perfect. Um Does that answer your question Neli. And does anyone else have any other questions? Doctor Boni, you said brilliant. The lawyer says yes, thanks. You said that you uh could only manage some of your topic? Oh, hang on. We have another question here. Um According to both gu line, I A dis ra f is fix within 72 hours. But if de la any comp is that right? Yes, I cannot see the, I cannot see the question here. Can you see it so on? Um So when you look at your screen, if you, you can see on the right hand side, there's a chat you click on there. It's the last one, the last question there. Can you see that according to the guidelines, we see what they no complications. OK. Yeah, I got your question now. So try to abrade them as soon as possible. That's what you mean. Well, um I think, I think you're right. Um um The reason is uh uh for two reasons, uh the reason number one, there will be in pain and they have a broken arm. So if you present them AAA B, uh that's fine. Number two. some of these patients I forgot to mention they have um median nerve. OK. Most of the median nerve symptoms they resolve once they have the re uh you reduce the fracture. Uh If you believe the fracture is displaced, they, they might leave the and damage the median nerve. But most of the median nerve here. They don't need decompression. Rarely, very rarely. I done only very few decompression of median air. Uh one of them um dis the fractures. Uh So basically to break them a ASAB uh is that answer to your question? Brilliant, brilliant. So what I was going to say um was um are you happy to do other talks for us and for the delegates? Yeah, I'm happy to do so. The upper limb trauma is very big topic. It will gonna take a day of me. And yes, generally you don't need to do the carpal tunnel decompression. You don't need most of them. They settle down. Uh And this is the literature, literature or not my practice. So most of the carpal tunnel syndrome or median ma will settle down without surgery just to reduce the fracture and will get better whether you're gonna operate on them or not. Uh If after reduction, for example, um or after surgery, uh still patient having median nerve symptoms at that stage, you could, but this is very rare, to be honest, very rare. So it's not a practice to do to decompress the median nerve in a in every patient. But most of them, they get better just by to reduce the fracture or splint, the uh, splint the, the fracture, they will get better. Most of them rarely. I am going to uh decompress median nerve. Uh I would the fractures um regarding talks uh as I said, or up, it's quite a big talk, think need a full day. Uh I'm happy to give another uh talks or I could speak about pediatric trauma. I am sure the delegates would love to hear any of it. Um And on and on that, on our feedback form which you'll get by email. Um There will be a question there about other topics within this topic. So for the delegates, if, when you get the feedback form, if you could fill that out um for doctor Boro and I can pass it on to him. And if you could like put some of the topics that you are interested in, that would be great. And then I can pass that all on. I think you've got another question. One more question. Do you do we have to fix? No, I don't think so. No, I mentioned hematoma block intentionally because uh when I was in training, uh especially in a very busy hospitals uh with the traumas would be very busy. So trying to offload the traumas. So I use, we used to do a lot of hematoma. This is not for everybody. By the way, for lower demand, patient uh fraction, not very badly displaced, the skin is intact, no other series of injuries. So you need to choose them. I just do hematoma block. And as I mentioned earlier, hematoma block, uh I usually go from proximal to distal. OK, I just go from there and not from here, I'm trying to go and inside the fracture site aspirate you, you will find a dark blood inject there. 10 of do, can 1% or 2%. I usually go for 1%. OK? And then wait, take at least 5 to 10 minutes. Ok? It time for the hemato for the le can to work. Then I, I usually ask this, can you move it if he does that or she does that that? Ok. Let's try to reduce it. I usually reduce. And what I usually do, I usually do U shape plus. OK, I just do that U shape. So, so those and go and leave the this side free. The left side is free. OK? But all are so that will offload your um uh trauma is A B if you're in, in place where you can do not have the facilities for surgery, you could do that, but you need to select your patient. You cannot do that if um very displaced fracture. Uh and young man who needs to be fixed later. Um Shoulder hand syndrome. I don't think we have time now. We could do another day if you want someone was after another talk from you. That's a talk. Uh Can you just talk about 33 mold? Yes. Three mold I should mention about that. Three mold. So you have uh sorry, I wish I wish so. 123. So 1231 A day, one day and one day. So you need to hold it nicely. Uh So less chance of this displacement um filling the forms will be very helpful. You're welcome. Yeah. So after this talk, you will get a feedback form in, in your inbox. If you can fill that out, I will pass them on. Um And then we can come up with the next teaching session, we can put that in and you can be notified all about that as well. Is that ok? So, um it was a great session. Thank you very much for your, thank you for the audience as well. And thank you for the good feedback from somebody that is perfect. So we're going to say goodbye now and hopefully we will see you again soon. Ok? Everyone take care. Thank you. Thanks very much.