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So I just need to go to the to the loop quickly. I'll come back. That's all right. Yeah. No, Ashura is in, I think she can hear us now. Hi, Ashu. Can you hear me? Is she here? Yeah, she is here. Fantastic. Ok, cool. I'll be right back. Yeah, thank you. I sure. Can you hear us? Yes. Uh can someone uh tell us if you can hear us before proceeding? Yeah, I can hear you guys now. Yeah. Thank you. Yeah. Hi. Hi, how are you? Nice to see you. Nice to hear from you. Yeah, we live. Fantastic. Excellent. So we'll start in the next five minutes. Sounds good. How can you see who's, who's joined and stuff? Uh You can click. Mm. Did you guys share your screen yet? No, not yet. Not yet. We'll, we'll share in a second. Ok. What did you say? Sweet. How can I find out who's, who's joined? So if you go to people, people, um I don't think I can see it. That's fine. It's ok. It doesn't matter. Yeah, you let me know when you're ready to start. You sure. Are there people in the chat box? Or in the chat box? Can you see the chat? Um, yeah. No, I can see the chat books. Are there people in the session? Yeah. Hi everyone. Good evening. Let me know if you can hear me well. Ok. Yes. Uh, yes. Fantastic. Thank you. Yeah. K I think we'll start, uh, I'll introduce you first and then we'll start. Go for it. Yeah. Hello guys. Uh, I'm sure one of the greatest in Ashwood in ST Peter's Hospital. I have done a rotation in trauma and orthopedics and currently I'm in Upper gi and uh this is a start to a series of uh sessions that we are planning to take on orthopedics particularly. So, uh I personally feel that orthopedics is not very well taught in medical school and a lot of us uh don't go into the as much and uh particularly that is the reason for a lot of us not choosing orthopedics as a post uh posting in their foundation years. Uh II, understand that this has changed a lot in these recent years, but still to give you a valuable insight into what orthopedics is and what orthopedics entails as a discipline. So we have started this series of uh lectures. So as traditionally believed, orthopedic is not just breaking bones and fixing bones. It involves a lot of medicine, a lot of surgery, a lot of different approaches and a lot of anatomy. So we will look into anatomy first of the upper limb and then we will go into the surgeries and trauma of upper limb. And then uh for the lower limb, we have two more sessions, which includes the anatomy of the lower limb. And then we also have uh trauma in a uh lower limb. So to teach decision, uh we have a very competent uh registrar with us. Uh So, uh the register today I have with us uh is Mister Khaled Far. He's a distinguished uh trauma and orthopedic specialist register from Ashford and ST Peter's uh NHS Foundation Trust also. So he has expertise in trauma and sports surgery. Uh He worked previously in institutions like uh Barts Health and Royal London Hospital, which is one of the busiest major trauma centers in Europe. So Khaled will further continue and bring valuable insights into our sessions. So I'll hand it over to Khaled so he will continue. Thank you. Thank you. Thank you very much. Thank you for your kind words. Hello, everybody. Good evening. Um I'm Khalid Mohammed Faris. I'm an orthopedic registrar as really kindly introduced. Um Today we'll be doing upper limb. So it'll be part one of part of two sessions. The first session we'll talk about just some applied surgical anatomy. So, I mean, there is so much anatomy to go through. So I'm not gonna bore you guys. I know it's just for an hour. It's late at night for some people. It is 7 p.m. here in the UK. So some people have just left work. So we'll try and make it as soon as possible for everyone. Make it interactive. Of course, if you have questions, do drop them in the um in the chat box and during the session there will be polls, obviously, don't worry, I'm not gonna grade you. I'm not gonna get upset with you if you get it wrong. All right. So no further ado, let's get started. So, um I'm gonna just start sharing my screen and then I'll switch my video off. So you don't get bored out of my face. So, can everybody see this? Please drop a message on the chat box. If you cannot see it, we'll see what we can do about it. Fantastic, Gus. All right, let's get started. So we'll talk about surgical anatomy in the upper limb, specifically in trauma setting, right? So, we mostly use these, there's many different approaches. I'll talk through the most common ones, specifically ones which are relevant in um um upper limb surgery. So we look at proximal humerus fractures, mid to distal humerus approaches. And of course, wrist fractures, so many different ways we can fix things. It's not just all about fixing bones. You have to respect the anatomy, you have to respect all the structures and the surrounding. Otherwise you'll run into a lot of trouble. So hopefully from today's session, we'll be able to show you guys what some of these things are and what the approaches are specifically for upper limb. So we'll look at proximal humerus fractures, specific anatomical considerations and classifications, the Delta Pectoral approach, which is one of the most common and most favorite approaches in upper limb surgery. And of course, we'll talk through some more approaches to the humerus. Finally, to conclude the session, we'll talk about distal radius fractures, which are very, very common orthopedic injuries. In fact, they are the most common and we'll talk about how you can approach these and how you can fix them. So right off the back, we look at the famous near classification, which looks at the humerus as sort of a um like a lego almost if you want. It's got four different parts to it. So you've got your um greater tuberosity, you've got your less tuberosity, you've got your neck and you've got your head. So as you can see on the right side, so it's either classified into one part, two part, three part and of course, four part with some variations where there is something called the head split, which is down here at the bottom. Why is this important? Because if you think about the humerus, it's exactly like a block, right, like we said, and each structure around the shoulder joint which allows mobility. So you've got your static and dynamic stabilizers of the shoulder, these all attached to the humerus in some form, right? Um But more important than that is that you want to restore the function. Ultimately, the main goal of treatment in orthopedic surgery is to restore function, restore mobility as best as you can. Um in some cases, if you have a situation where you've got a head split pattern like this, then that puts the humerus, uh risk of avascular necrosis, right. So all of these are important. So the more displacement there is that will also help you determine how you're going to fix it. Of course, there are instances in which there is also dislocation associated with this. So the most common approach for the humerus fractures is called the delta pectoral approach. As the name suggests, it's a plane that is developed between your deltoid which is on the side there and your pectoralis major. So you have to develop a plane in between these two. And this is usually indicated in, as we said, trauma, surgery for the proximal humerus, things like open reduction, shoulder arthroplasty and of course, open washouts now important landmarks as we said. So the main ones obviously are the deltoid and the pectoralis major, right? So you identify your clavicle here, right? And then your coracoid process which is round structure just a centimeter or two below the clavicle, you palpate for that and then you draw a line that extends outwards so laterally, right, aiming towards the shaft of the proximal humerus, right? This is extensile. We will talk about this in a minute. But the main one is that the delta pectoral approach usually terminates somewhere around there. So about 8 to 10 centimeter incision, right? So now delta pectoral approach and every other approach in surgery is not harmless. So let's bring up the first pole. So who can tell me what are some structures at risk? Sorry, I will just get out just so we can take a look. Can you guys see the poll? OK. Good. We got a response. Come on guys, don't be shy. So OK. Nice. I like that. Someone said, axillary nerve, someone said all of the above. Come on guys, give us some more answers. Yup. Axillary nerve. Very good. Excellent. We'll wait for a couple more answers and then we proceed cephalic vein. Very good. Excellent axillary nerve. Fantastic. So in fact, that's all good. We'll stop sharing the poll. Now, in fact, all of you guys are correct. All of these structures are all at risk, right? So sorry, all of these structures are at risk. So your cephalic vein, your circumflex vessels, your musculocutaneous nerve, the axillary nerve, even the brachy plexus. So, you know, as we said, it's not all about fixing bones. You have to respect a lot of things on the way. And the first guy that usually finds you is called the cephalic vein. So as soon as you make your skin incision, that's usually the first structure that you find, right? So you gotta just be overall careful when you make your approaches, you can retract these, we'll talk about the detailed dissection in a second. But these structures are all at risk, even the brachial plexus. So if you place your retractors somewhere proximal, then these are at risk as well. Right. So now, you know, like me, I'm sure a lot of you enjoy beaches. They are just beautiful, you know, but in this instance, unfortunately, as surgeons, you don't get to visit them much. But in upper limb surgery, this beach chair is very important, right? It's the most important thing you need to establish because positioning will be key for your procedure. So we do something called the beach chair position. And this is the optimal position for visualizing the shoulder to get your anatomy correctly. And of course, if you need to use a X ray machine, which you will be using in trauma surgery, this will be your best friend, right? So beach chair position, as you guys can see, there are many different setups. So there's a headdress there, there's a small armboard on the side. And then of course, the patient is strapped almost with a seatbelt, right? And all of this will allow you to perform your procedures safely. So, Deltopectoral approach, as we said, we make our skin incision there and you identify your deltoid, your pectoralis and of course, your cephalic vein over there, right? And then you retract that to the side, then you come across this so called clavipectoral fascia. So clavicle pectoral and you make an incision through that usually in this fashion here and your conjoined tendon is quite close. So you just be careful when you're doing that, then we identify our tendons. Usually, what we tend to do is we tend to place stay sutures over these so that we can um use them later on if we want to repair some of our um floating bony structures. Because as you guys know, um the subscapularis tendon attaches into the proximal humerus as well, right now, as you can see here, the axillary nerve, although it is a bit distal to where your work is gonna be. Sometimes if you're not very careful, you can incise that and that could bring about lots of trouble for the patient. So right underneath the subscapularis tendon, you have then retracted that underneath, you'll find your joint capsule and underneath that is your humeral head. Now, second question for you guys. So let's bring up the second pole. Now, when you're fixing a humerus, as we mentioned, um you have got many different different aims and goals of treatment. So what do you guys think will be the name of the angle or how do we change it? How do we bring about a correct alignment? So if you just bring up the second pole history, if you can, thank you. So guys, some more interaction here. So you guys can see a few of those, some of you might know what these angles are. Honestly, don't worry if you don't just try to think about what kind of angles we are trying to correct here. OK. Good. Some more answers. Someone sets off angle. Neck shaft very good. OK. Critical angle of your. OK. F I said medial calcar. Actually, it's not enough to say neck shaft angle. I like your answer. Very good. Now you'll see exactly what we're talking about in a second. Yes, father. That's the point we put wrong answers on purpose. Very good. OK, guys, let's stop the pole now. So we carry on. That's what I mentioned correctly. This guy here that's called your medial calcar, right? So we've got something called your central column diaphyseal angle, right? So it's this angle right here, right? So this arc needs to be about 100 35 degrees for you to achieve reduction. So you guys can clearly see the difference here. Now, this fracture on this side is not reduced. So what happens is that the medial calcar, which is this region here, it almost translates and it goes in that direction like this. And so it goes into what we call varus and that is dangerous, that will lead to a lot of morbidity for your patients. And of course, here, your great fibrosity is also not reduced and it is the site of attachment for most of your rotator cuff muscles. So it's important to restore this angle and this will be your guide as to whether your fixation is stable or not. So as we said, the aims of treatment here is that we get as best anatomic reduction as we can and the angle to measure that is called your central column diaphyseal angle. And of course, a stable fixation. So then we use this um contraption called the FEO split. So this is very good, it's uh excellent innovation. It has a very good profile. As you guys can see, it's got many, many different holes in them. So these bigger ones are usually where you would put your screws, as you guys can see on the right hand side, and there are smaller holes which can be used for many different reasons. Typically, what we tend to do for that is either we use them to provisionally hold the plate. So we use small thin wires called K wires that hold the plate in position or we can even use them as a means to pass our sutures. So over here, you guys can see this number here, right? So 5 to 8 millimeters, why is that important? Because if you place your plate slightly higher and you can imagine the trajectory of the screws are going in that direction. So you guys can see here, they have done a good job at keeping it at around 5 to 8 millimeters. Whereas if you would have increased that, then your screw trajectory will go somewhere there and that's again, not good because that will a irritate all the soft tissues in the surrounding and B it will be floating around and this will cause problems and the fracture will not heal. So, remember, anatomic reduction and we wanna achieve this angle here, the central column diaphyseal angle, right? So all of that will fail if your plate is not positioned in the correct place, right? So um these are all important things, just small tips and tricks and apply a anatomy and surgery. So now we move on and we go to arthroplasty. So again, we don't know yet, um, whether fixation or arthroplasty is better and the more recent developments are that we do something called a reverse shoulder replacement. So we reverse the anatomy where we put the ball and socket into opposite places. So if this is your socket, your glenoid and the humeral head, we reverse that. And instead what we do is we reverse the alignment of that and that eliminates a lot of the problems. So this is typically helpful for people with um very combined fractures or if they've got rotator cuff arthropathy. And of course, for osteoarthritis. Now again, when you do shoulder replacement surgery, you have to think about your patients and you select them correctly. So if you get a young 2030 year old patient and you give them a shoulder replacement straight away, what that can do is that it will lead to problems because these have a short shelf life typically about 10 to 15 years. And if we offer that to someone who is young, then as you imagine, it will need revising later on. So it's important to select your patients better, as we mentioned, poor bone quality. So lots of combination and low function and low demand. So as we said earlier, from the uh from the classification systems is that we have head splitting fractures which pose a high risk of avascular necrosis, reverse shoulder replacement tends to have superior functional outcomes versus anatomical shoulder replacement. So um many different ways we can fix the proximal humerus. These are some of the ways. So typically, plates or open reduction, internal fixation and of course, um shoulder replacement surgery. So what about if it extends distally? Now, you can see guys here. So obviously, that's proximal humerus just to orient you. Again, this is the elbow joint over here and that's the humeral shaft. Now, again, there is ongoing debate about this, whether to place them in a brace, whether to place them and whether to fix them directly or whether to use intramedullary nails. Now, two different approaches we'll talk about today. Um You've got your um anterolateral approach and of course, you've got your um posterior approach. We'll talk about both of these. Now, absolute indications nerve palsy typically occurs more commonly with the distal third fractures, open fractures. Of course, depends on the degree of displacement and dysfunction of your patient, then we might offer them surgical treatment. So think about our anterolateral approach, a line from the Delta Pectoral Approach, which is extending in that direction. This is essentially an extension of the Delta Peal approach. So this is a very nice approach because you can access the entirety of the humerus. And you can also access the proximal bit without having to do any separate incisions. So again, you start your incision similar to your delta peck and you're curving it laterally. So this is your biceps muscle here. And that's the inner aspect of your arm. That's the axilla. So that develop a plane between the brachialis and the brachial radialis. Typically, we tend to do this approach either if you've got a very proximal injury with an associated shaft injury as well, but even you can even use them for midshaft humerus fractures. Now, let's talk about this procedure. So again, as you guys see, you go through your skin, your subcutaneous tissue, that's your deltoid right here. And that's your coracobrachialis. That's your brachialis here. And then of course, that's the bicep. So you gotta develop a plane between the brachialis and the brachial radialis, which is more laterally here. So that's the plan we go through and guys tell me open up pole number three, what are some structures you think are at risk here? God, let's open up pole number three, my apologies. Sorry. This is Yeah. Yeah. Yeah, the pole is open. Sorry, sorry, sorry, please close the pole. I'm sorry. That's not the time for it. Yeah, very sorry, apologies guys. Ok. So once we've revealed everything, so as we said, you identify your brachial radialis more laterally in the brachialis. And then the most important thing is to identify the radial nerve and you typically identify that easily in the distal aspect. So again to orient you, this is your shoulder here, that's your elbow there. So you identify that usually distally and you gotta trace it and find out where it goes into the intermuscular septum, right. So you gotta trace it. It's really important. Radial nerve is a really irritating nerve and it doesn't like to be touched very much. It's like a child, it will throw a tantrum as soon as you start to disturb it and it's very hard to predict how it goes. So another structure that's at risk here is of course your musculocutaneous nerve. So that's slightly more medial. So again, you can identify that distally usually and you gotta try and protect that. And as soon as you do all that, once you have removed your radial nerve out, the way you guys can see here that you have got good access to your humerus, right? Sometimes if you want to extend a bit more approximately, you might need to relieve the deltoid a bit. So this is where it typically inserts into the proximal humerus and this is close to again where the axillary nerve goes. So again, you have to be very careful here. And as you guys can see, that's the cephalic vein. So that's all again, an extension from your Delta pectoral approach. So I hope it all makes sense. Um Really, you've got a lot of structures on the way, you just gotta be very careful about it. So otherwise you can run into a lot of trouble. So now about the posterior approach, which is another one. So again, you typically use this for distal thirds or injuries around the elbow joint. So, periarticular injuries, you can also use it as a good means to explore your ulnar nerve and your radial nerves. Um Now, the challenge with this one is if you do a delta pectoral approach or if you do this approach, the anterior lateral approach, the positioning of your patient is slightly, you can put them either on a beach chair or you can even do the supine. Typically, we tend to do the supine with the armboard, it's a lot easier for x-ray access. Whereas if you imagine the posterior approach for you to be able to do someone's posterior approach, typically, we tend to do it with the arm hanging at 90 degrees and the person is turned laterally. So it might make x-ray and positioning just generally slightly more difficult, maintaining the sterility. It's gonna be such a small area, but it's again, a very excellent approach. Um We tend to use that in um fixing humerus. It's typically more distal fractures or things around the elbow, as we mentioned now, to identify your structures again. So there's not much of a um sort of in intermuscular plane, but instead what you do is you go through your skin and the superficial fascia, then you have got your long head and lateral heads of the triceps and you identify the plane between those you can do what's called the tricep splitting approach or you can do a tricep preserving approach. So either either of the approaches are not wrong, but what's really key here is that you've gotta again try to identify your radial nerve. And of course, right next to it is if you profunda brachial arteries, so just be very careful. Typically, what where we tend to find this is if we go back is typically just around the apex here. So take your time in dissecting, you gotta try and identify that it goes and crosses over the radial groove as you guys know. So it comes from that direction and as we mentioned earlier, pierces to the intramuscular spectum and that's where it goes somewhere around there, right? So it all correlates to the initial approach that we used. So like we said, split, you can split the tricep, you can even retract them both. But typically, we tend to do that if you're going more proximal and you retract your lateral head of your bicep laterally and the long head immediately. So that's your lateral head here, that's your long head. And then right underneath that, you'll find your humerus. Of course, remember to protect your radial nerve at all times. Now, once again, another view as you guys can see, so this is all sort of dissected very nicely. And the person here has protected the radial nerve and you've just gotta push it to the side there and this is your humerus. So now we bring up pole number three. Sorry about that. I brought it prematurely. First time. Tell me what are the clinic signs of radial nerve palsy? What features will you find? Ok. Very good. Very good. I think that's an easy one for everybody. Wrist drop, wrist drop, wrist drop. Can anyone tell me where you get clo hand and waiter ST deformity? Ok. Someone said waitress did deformity. Tell me, where would you get that? Just drop a comment on the chat box. Herbs, palsy. OK. Tell me about herbs, palsy, low hand ulnar nerve, C 56, ulnar palsy. Is it C five and six on the nerve? Her? OK. Herbs of C five and 60. OK. So I'll leave that with you guys. Debate amongst yourselves. Way to step thematics. Yes, absolutely. It is C five and six herbs palsy. Now you mentioned C five and six gives you ulna nerve. What are the dermatomes for ulna nerve? Which which, where does it come from? Is it C five and six? Does anybody know? It's no problem if you don't. So think about it, the ulnar nerve tends to give you which one? Yes, waiter ST deformity, C five and six C eight to T one. Absolutely. Well done guys. Good job. Fantastic. So, like we said, this approach is very good. I'm sorry. So it's very good to a approach, the ulnar nerve. And if you want to identify that, that is usually the first one you identify in this approach. Typically, it tends to run somewhere there along the medial Epicona. So again, you've gotta be very careful as you guys can see here, it's not very obvious, but sometimes you will be able to identify it and you ideally should always try and find it first. So always find your nerves because as soon as you start putting your plates and you start screwing around and you start drilling holes into the bone, you know, the last thing you want is to drill something through the nerve and then the patient will have all sorts of problems later on. So as you guys can see more than one way to skin a cat, as they say, and you've got your posterior approach, you've got your anterolateral, either of the approaches are both very good and it really depends on what you're trying to achieve. And of course, depends on the theater set up. You've got, they tend to use anterolateral approach quite frankly, um in third world countries such as my own, um because it's just easier logistically and you know, X ray guidance and all that everything will be good. So now we carry on, we move on from that and we look at distal radius fractures. Now these are incredibly common injuries. In fact, as we said, they are the most common injuries orthopedics. So if you work in orthopedics, you'll often girls about these pill, you can get them as young, um infancy, not infancy, you know that that will be a problem. But you get them in pediatrics, you get them in the very old people. And of course, you get everything in between. Typically it's a fallen now stretched hand or the opposite direction where the hand is flexed and 80% of the loading through the hand goes through the distal radi. Now again, operative versus non operative treatment depends on the fracture pattern. And we'll talk about some of the anatomical considerations when you wanna think about that. So an easy way to think about it is what we call the three column theory. So exactly like three pillars, as you guys can see, there are three columns here. And if you imagine this will be your radius of your ulna and this will be your carpus and of course your hand. So it's all stabilized through these three columns, right? So disruption to any of those may actually indicate that the injury might be a bit unstable. So as you guys can see, there's lots of different structures. So this is the radial column to start with. And it's got obviously your, your styloid over here, scaphoid fossa where you've got your brachioradialis tendon, your radial ate ligament and RACA capitate ligaments. Don't worry, you don't have to memorize these names. Um But essentially what it does is that it resists carpal radial translation. So this is the carpus and this is the radius, right. So it prevents translation. So translation is essentially to move from side to side, right? And then your intermediate one, which is where we've got the unit and this allows transmission of load from the carpus to the forearm. So again, it's very important. And finally, the ulnar which is all on its own has got your triangular fibrocartilage. It is complex. OK? And this can be injured during distal radius fractures. But more importantly, it stabilizes your distal radioulnar joint. So these three structures are very, very important. As you guys can imagine, when you want to treat fractures, you've got to think about once you've seen that one of the columns is disrupted, um it can cause a lot of instability to the carpus, which is over here, right? So I hope that makes sense. Obviously, drop all your questions in the question box. I will answer as soon as I can and um we'll go through any of your concerns. And thats now some more angles that we measure here. So normally your radius, as you guys can see is typically longer than your ulna. In some people, you might have an ulna that's slightly higher. So these are people who have had previous fractures, for example, or some people are just anatomically positive. We call it here. It's called your ulna variants. So ulna variance is essentially to determine just how far your ulna is from the radius. So positive ulna variance means that your ulna is higher and then negative means that it's lower. Now, the typical thing is that you've got the 20 to 1111 rule. So as you guys can see there are some numbers there. So first one is radial inclination. So because the radius is typically longer, right? And if you do a cross section from the top of the radius that bisects onto the top of the ulna going that direction and you find out where your top of the ulna is and get it to bisect the radius. The angle between these two is usually around 22 degrees. So again, this is an indication to stability, right? And this is how you check whether you have achieved a good fixation. Another one is radial length, right. So radial shortening as the slide suggest. So that's the radial length here. Again, this is usually around 11 millimeters, right. So in difference of height, so once again, you can check how well you've fixed or how well you've reduced your fracture based on that. Finally, if you look at an X ray laterally, you've got your volar tilt. So usually, as we said, so as you guys can see, it's a bit like that. So it's like almost a uh tipping cup of tea, right? And typically the volar tilt is around 11 degrees. So if a fracture is heading in that direction or that direction, then, you know, again that it's not necessarily in a perfect anatomical position. Just a few considerations. These are things you can come across in your practice. And yeah, just remember 22 1111 and these are the numbers you look for. So again, radial inclination length and volar tilt. All right. So we fix fractures which are intraarticular displaced. So intraarticular like this one. So this is involving the joint, you guys may not be able to see it very well, but this is the top of the radius and there's a split that's going through it, right. So that's one indication. Second indication is dorsal angulation more than five radial shortening and of course, displaced extra articular fractures. The nice guidelines are sorry, the uh British Orthopedic Association guideline suggest that intraarticular fractures should typically be fixed within 72 hours and extraarticular should be fixed within one week. But of course, in real life practice that never happens. So there's very poor compliance with that and it's very different reasons. We don't have to bore you guys with. Now, the question then becomes, how do we fix it? So we've got different approaches you have got on the right hand side, this is called your dorsal approach to the wrist. So dorsal is on the posterior aspect volar is on this side, right? So either trans E PL or trans edq. So these are all names of tendons. OK. So extensor polyp is Longus extensor digital over here on the left hand side. So typically these are reserved for indications we'll discuss the most common one we tend to use is this one. So your FCR approach, right? So your Henry, your modified Henry approach and we'll talk about that in a bit more detail. This approach, a volar extensile one is usually typically used for carpal tunnel decompression. And sometimes you can use that for a fasciotomy, right? So we'll go through the modified Henry approach. Now, how you do it is you put the patient's supine on an arm board. It's a very easy um logistically um planned surgical approach and you place tourniquet. Some surgeons in more recent times have been developing the so called wall or the wide awake local anesthetic, no tourniquet. It depends on you and your preference. I tend to prefer a tourniquet and your plane is between your flexicort radialis tendon and the radial artery. So you'll go between these two, I need you to approach the distal radius using that most of distal radius fractures tend to be fixed using this approach and we'll talk about that. So this is the plague guys can see there are lots and lots of tendons here. And the main muscle that you will encounter during this approach is your pronatal quadratus, right? So you identify your flexor carpi radialis, as we mentioned earlier, you make your incision there and you retract the tendon medially. So as you protect the median nerve, which you guys can see here, so it's well far away from your approach. So you shouldn't run into much trouble. So as you go through the layers, the first one is, as you mentioned, the FCR tendon, the flexor carpi radialis, the next one will be your flexor is laying longus, which you all retract immediately. Finally, you come across your pronator quadratus. Here, you incise it usually in an L shape. You can even incise it directly. And as soon as you do that, you will identify the distal radius. This um this needle here is used to just localize the end of the joint. You don't necessarily have to do this. I don't tend to do it. Um But if you're struggling or if you have very um disrupted anatomy, you can use that to help guide you always, always, always guys, you can never pull enough, right? So, distal radius fractures and generally things in the hand or the upper limb need a lot of patience and need a lot of time. So if you imagine a fracture that is being fixed a bit later than it usually should be, will be very difficult for you to reduce or restore the anatomy of. So, remember your angles, remember the 22 1111 that we mentioned earlier, always try to essentially give inline traction. So what we call pulling, so you pull in that direction and your assistant is pulling in that direction, someone is giving you countertraction right now. You need to sometimes exaggerate the deformity, right? And then you correct it. And the reason for that is because sometimes if you do not exaggerate the deformity, then if you try to push your wrist in either volar or dorsal direction, then you may be met with resistance. I'll pause here for a moment. I'll open my camera, I'll stop sharing and I'll show you guys what I mean by that. So if this is your fracture here, right? So this is gonna be the distal part. So this is gonna be the hand part that's gonna be your shaft here, right? And you're pulling and you're pulling and you're pulling and you're pulling and everything is going so well and you can feel that the bone is moving for you. But then what happens if you try to push it like that? Right? As you guys can see that surface, which is the distal end of the bone is being caught over here. And so you will struggle. So the reason we exaggerate the deformity is because you want to let it go almost like this so that it slides down when you push it, right? So try to do it again. So this is your distal radius fracture, right? So this is the distal end. So this is the part where the hand is and this is the part where the forearm is. So you are trying to bring the two pieces so that they sit in here. OK. So you are pulling and pulling and pulling and pulling and pulling and pulling and you think you got good length, right? And you try to push it down. So if you try to push it down, you are often met with resistance from this part, right? Because this part is not so mobile compared to that. So what you instead do is you exaggerate the deformity. So you force it to go into that plane almost so that it's vertical, almost not so much and then you push it down and all of a sudden you've got good alignment like, so does that make sense guys, please tell me if it doesn't and I'll repeat it because this is very important acknowledgements. No, people are shy. Thank you. OK. So a Lua look. So this is your distal radius, right? So you've got, that's your wrist, that's your forearm. Yeah. So if we imagine this is the forearm and that's the wrist. So this, this is two parts of a fracture. OK. So this is the wrist side and that's the forearm side. OK? And this is the fracture going like that. So it's overlapping, right? Exactly like the picture we saw. So in order to reduce it, you have to do the following, right? So you pull, OK, we call this inline traction, you pull it, you pull it, you pull it, you pull it so much and then if you try to immediately push it down that part, which is the wrist part is gonna knock into the forearm part. OK. So it's gonna knock there. So therefore, what you're doing is you're not achieving this connection. Instead, what you're achieving is this, this is where your fracture is going to sit. Whereas if you exaggerate the deformity. So if you go like Z you are pulling at the same time, you are exaggerating, exaggerating, exaggerating. Eventually you'll reach a point where you can push it down so that you connect the pieces. Ok. You understand, does it make sense or not yet? If not, don't worry, I can explain it to you afterwards. Good. Excellent. Right. In that case, let's carry on. So I will share my screen again. So corrected ulnar deviation. So the reason you ulnarly deviate you move the wrist to the side is because you want to restore the inclination. So we go back again to the sl so Ulna and rad and radius. In order to restore that tilt, you gotta ulnarly deviate. So move it in that direction. That's typically what we tend to do. Nope, main risks as you guys can see. So, of course, it's a plane between FCR and radial artery. It's really rare that you damage the radial artery. Of course, unless you have, unless you want to damage it. Um but these things can happen. So it happens to the best of us. So not very common, but that is one thing at risk here. Um Your extensor poly longus tendon can be irritated by the long screw. So if you look at this image here, so a screw that's that length or maybe even longer might irritate your extensor, Pulis Longus, which tends to run in this direction here, right? And as we mentioned earlier, your median nerve is thankfully very far. But if you're not very careful, if you make your incision slightly more medial, so closer to the median nerve, you can injure that. And of course, as you guys can see here, the palmar cutaneous branch isn't very far. So, retraction, identify your structures. Take your time. This is why I prefer tourniquets. It just makes the field bloodless and it helps you identify your structures and therefore just protects everything. Now, last and final pole, please, I'll switch my video off. No guys. Why don't we do the dorsal approach? Now, some people might say to me, OK. But what if the fracture is on the dorsal side and I tell you, you're not wrong but why wouldn't you do the dorsal incision? And before you answer that question, I want you guys to have a feel of your own dorsal side and tell me where do you think you can feel the bone more prominently? Do you feel it more on the dorsal side or do you feel it more on the ulnar side? Ok. Someone said metal work can irritate extensors? Someone said reduced function. Can you expand on that? Tell me why do you think it's reduced function? We are split 5050. So I want the guys who answered, reduce function to tell me why they think that if you do a dorsal approach, you'll have a reduced function. Leave your answers on the chat box. No or feeling a bit shy. Someone mentioned risk of injury to the radial artery. Ok. Non cosmetic scar. We've got a plastic surgeon between us. OK, guys. So I want you guys to do this with me, right? So this is your wrist. So this is dorsal. We all agree and that's volar. So try to press down really, really press down and tell me what do you guys think? Where can you feel the bone better? Can you feel it more on the dorsal side or can you feel it more on the volar side? Feel your own bones? So feel your wrist. Where can you feel the bones better? Ok. Have a feel. Gemma said superficial structures on the dorsal aspect of the hand and wrist. I like that scarring to the area. Metalwork, restricting movement soar, yes, dorsal side, precisely, dorsally. Exactly. So if you think about it, if you put a metal plate to the dorsal side, right, there's very, very little space for you to actually be able to put metalwork safely. Whilst at the same time covering it with a soft tissue flap. Whilst at the same time making sure that none of the structures are damaged in the process, you won't necessarily damage it yourself during surgery. But what could happen is over time, a scar tissue forms and as the metal work just, you know, incorporates with the bone, it can cause a lot of irritation. So that's why we don't tend to usually use the dorsal approach for distal dis fractures. There are certain times where you have to. But the main reason is, as we said, you've got a lot of structures that are on the way and specifically your extensor tendons, your extensor policies, longus and the superficial radial nerve, the radial artery is quite far away from your approach. Um It's more volar, but there is a small branch that goes around the anatomic snuffbox that you have to be careful of. But these are the main reasons because it's so superficial. If you think about the wrist, such a small structure, and then if you put a plate on top of the wrist, then that could lead to a lot of irritation. That's the real reason why we do it. So, dorsal combination of fractures or wrist fusion surgery, which we sometimes use in patients with very, very combined or very low demand. Or even for osteoarthritis, we can to fuse the wrist. But even at a later date, these plates tend to be removed because they cause so much irritation. Dorsal approach as you guys can see. So use your 2nd and 3rd metacarpals and you make an incision straight down all the way down to your radius and this is your extensor retinaculum here. And as you guys can see, there's quite a few structures on the way, right? So imagine you trying to put a plate onto that bone and overlying the plate immediately are gonna be these tendons rather than muscle and that can cause a lot of irritation that lead to problems. And that's why most of these patients tend to say to you, look, I want this removed. It's just bothering me so much. And so that's why we tend to mostly go on the volar side. So I'll compare the two. So if you guys look at the volar approach, now look at how many structures you have to actually get down through in order to get down to the bone, right? So it's just a thicker flap and more protection and actually not a lot of structures are at risk here. Obviously, a radial artery is not so far away. But again, you just, if you are careful and you make your incisions correctly, then you shouldn't run into any trouble, right? So as you guys can see for you to even get down here, so this is the dorsal side, that's the volar side here. So you guys can see there's quite a lot of things that you need to actually go through. And this is called, does anyone know what this is called this bony prominence here? And what important structures lies here? I will take a look at you guys'. Answers, Listrus tubercle. Very good. Mohammad. Can you tell me what structure is important around the debacle or what is its function? What does it do? OK. Mr Sto. Very good Gemma. OK. Does anybody know y extensor compartment? OK. So yes, it's all the extensor compartment. But what structure? So why is list just erle specifically important? Let me ask the question different. What is it a landmark for? What would you find there? It acts as a pulley for what? Aroha I like your answer. So what, what goes around it? You're right. It does act as something so something wraps around it. Which structure is that APL EPB you wanna try again? It's the main structure that goes around it. Very good, excellent, well done guys, well done. Very good. And so like I said, this approach is not very commonly used, oftentimes at the end of the case, you just think to yourself. Oh God. You know, we don't usually like this approach very much, but sometimes if it's necessary, it's necessary. So, again, more than one different way to do things. Um, just keep in mind when you want to operate, as she mentioned correctly earlier, it's not just all about fixing bones and especially with upper limbs. You know, these patients tend to be quite complex, um, in terms of the approaches the surgery, but if you take some certain factors into consideration, um, upper limb surgery is actually a lot of fun. There's really nice anatomy around it. I tend to prefer it personally over lower limb surgery because of that reason and because it involves a lot more sort of challenging approaches. But like we said, if you pay attention to the anatomy, if you do things correctly, uh hopefully you won't end up like Martin Lawrence on the right there smoking and feeling frustrated with life. And yeah, um that brings me to the end of my session. So we have got approximately five or six minutes to go. So I hope you guys benefited from this and I hope it was helpful, please, if questions feel free to drop them, how long to the best of my ability? Uh Three is off the feedback. Don't be shy guys. If you felt like it was crap, please give me a bad rating. Thank you. Thank you all. Please feel free to ask me questions. We still have time. Yes, of course, I can explain it again. So we'll go through it. Let me just share my screen once again. So these are the measurements that you look for. The first one on the left hand side is called your radial inclination. So you can see that the radial and can you share your screen again? So you can see it? Oh, sorry, I'm sorry. There you go. Yeah, fine. So radial inclination, right? So the radius is inclined towards the ulna in that direction. So that's the normal location of the radius, right? So 22 degree angle is measured by taking a line, an imaginary line here from the radial styloid going through there onto the top of the radial aspect of the ulnar going in that direction. The next slide you draw is identifying the ulnar styloid and going parallel in that direction so that it bisects at a 90 degree angle to the shaft of the radius like so, right. So 90 degrees here and here and then from radius to ulna in that direction that usually measures 22 degrees, right. So if there's a fracture, you would imagine that this is going to drop down. And therefore, what's that gonna do? It's going to reduce your angle. OK. So it will make the lines become more closer to each other, therefore, reducing your ankle. OK. So that's the first one volar tilt. So if this is your radius here, you've got your volar side, you've got your dorsal side and this is the fossa here. So your scaphoid and lunate fossa, right? So typically, if you imagine like it's a cup of tea, that cup of tea is tilted in that direction, right? So it's tilted volar. And then again, you draw lines going here and then another line going at the top of the radial styloid and then a straight line going through the shaft of the radius, also known as the mechanical axis, that angle is usually again 11 degrees and that will be your volar tilt. So if it's more than that, so if it's broken in that direction and the radius is collapsing vly, so it's going in that direction and that can increase your volatility if it's going on the opposite direction. So if it's going more dorsal and that line will creep up in that direction and reduce your anger and finally your height, which is the easiest of all. So when you look at an ap x-ray of the radius, you have got over here, the radial styloid, that's the ulnar styloid here. OK. And usually a radius is longer and the ulnar at the wrist joint. And that is the next measurement you want to look at the radial length. OK. So these are the three measurements that you use to determine whether your fracture is something that you can manage conservatively or whether you can manage this with surgery or whether you need to reduce it in the emergency or casualty department. And of course, you gotta think about your columns. So for fractures which are intraarticular, this is typically where they tend to be disrupted. Ok. So three columns, any disruption to any of columns might indicate that this is actually an unstable injury. Does that make sense? Yes. Uh Mohammad, I agree. There are a lot of things that need to be discussed. I just went for the ones that are more relevant anatomically and that are much easier for you guys to squeeze into one hour for future events. Definitely, I will be talking. So for the next session, we'll be talking about fractures, we'll be talking about um how to approach these fractures. We won't talk in much detail about relevant anatomy. The point of this session was to just give you an applied surgical approach. So how to approach some of these fractures in a um uh from an anatomical point of view. Next session will be discussing more about clinical aspects of things specifically fractures will go more into detail about things that are relevant clinically um and less about anatomy. Thank you. Thank you, Gemma. Will it be on demand? Um I don't know. Sure you can answer that. Maybe yes, these sessions will be recorded and uh we will be making it available at the end of four sessions on me. And uh thanks God, that was a really wonderful session and particularly uh when it comes to the distal radius fractures. So I was always wondering why an open reduction internal fixation and not uh uh uh externally fixing it or uh uh just uh putting a back slab. So particularly I knew two indications like um the distal comminution and intraarticular extension need an or f but the other dorsal angulation uh is uh not something that I knew of before. Yeah. And uh the only question I had was uh how do we tend to prioritize upper limb fractures? Uh uh Do the fractures close to the wrist, make more uh are are more important or the fractures that are close to the shoulder are more important. Well, you've got to think about things from different aspects, right? So, first of all, um obviously, if you work in orthopedic trauma, you will always have a busy day ahead of you because there will be lots of trauma, it doesn't stop. You have to prioritize things by what threatens life first and then what threatens limb next. So overall, when you talk about upper limb fractures, they tend to be sort of less lifethreatening than lower limb fractures, right? So specifically hip fractures, maybe even tibia fractures because they are still able to mobilize. Therefore, you reduce the risk of things like infections, clots, mortality, that sort of thing. So that's from an overall point of view now, when it comes to um upper lip fractures, so remember we've got se several indications that would make you want to operate straight away. Right. One of these is one of the patient has a dislocation. So, if it's around the joint and the joint is dislocated, that is an orthopedic emergency, that needs to be, um, operated on straight away if it's an open fracture. And of course, there's compromise the neurovascular structure or if it's a very contaminated wound, then these are ones you want to prioritize again, sometimes you take these overnight if you need to, right? Um Thirdly, um for nerves, you want to explore the nerve as soon as possible, right? So if there's a suspected nerve injury, you would want to operate on that straight away. Now, most upper limb surgery thankfully can, it can be managed actually in a, in a safe fashion without uh without necessarily admitting a patient. So as far as priorities go, they are a priority because upper limb um is notorious for stiffness and loss of function. You can ask many people whether they'd rather have their um arm chopped off or would they rather have their leg chopped off? Most people can tend to say to you that they'd rather have the leg chopped off because if you lose an arm or a hand, your functionality is very difficult compared to a lower limb. But you think about it from a different perspective, as we mentioned, life and limb threatening injuries, you prioritize how you operate based on that. Ok. I hope that makes sense a bit. Yeah, that's com, that completely makes sense because previously, we used to see a lot of lower limb fractures and that, uh, I had a lot of exposure to, but particularly when it comes to upper lymph fractures, uh I did not see a lot of cases. That's why I just wanted to make it clear. Luckily a lot of upper limbs are, uh, a lot of upper limb fractures can actually be managed non operatively. If you know they meet certain criteria, we'll discuss that more in the next session. But most of these tend to actually be um whether it's surgical or non surgical. The aims and the principles are very much the same, but it doesn't tend to be so much of a priority unless it contains any of these things that we mentioned before. Yeah. Thanks again, Khaled and guys, uh I've shared a feedback form in the messages. So uh uh please do complete the feedback form and claim your certificate. Please don't forget to claim your certificate and uh you have been a wonderful crowd and I hope to see you again in the next session again with Khaled. Thank you so much. Thank you guys. Thank you. Thanks for Dick.