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Hey guys, we'll just give it a couple of minutes. Um We'll aim to start around five past six. Can you guys hear me? Um If you just want to put it in the chart, just a thumbs up or? Yes, just to double check. Can you hear me? Yes or? Mhm. All right guys. Let's start. Um So hi guys, my name is Rishi and welcome to the second orthopedics revision tutorial run by BISA. Um Today we'll be covering a range of topics including material on shoulder, elbow, hand and a and wrist, anatomy, physiology and other clinical conditions. So, I hope you find this session useful and um, please do interrupt me. If you have any questions throughout next week, we'll be covering lower limb and spine to complete the series. And uh we'll complete the, the four part series with a um plastic surgery talk. So the sessions today should last for roughly an hour or so. Let's get going. So we start off with a question. So a 52 year old female with diabetes presents with generalized deep and constant pain of the shoulder. On examination. There is joint stiffness and a reduced range of movement. The doctor suspects a diagnosis of adhesive capsulitis. So which one of um the following is a surgical intervention for adhesive capsulitis. Is it a vasectomy? A manipulation under anesthetic, a supraspinatus repair and acromial resection or a total shoulder replacement. So, if you wanna put your answers in the charts and then we can go through um each for the responses, you wanna put it in the chart. OK. Well, maybe, maybe we'll just go through it. So, so the answer is um number two. So manipulation under anesthetic. So, um adhesive capsulitis is actually a self limiting condition. But recurrence is not uncommon and recovery can take up to months and years. Um and some patients will, may not even recover a full range of movement. So, potential surgical interventions include um a joint manipulation under general anesthetic to remove any sort of capsular adhesions to the humerus or a surgical release of um the glenohumeral joint capsule. So, adhesive capsulitis, so also known as frozen shoulder. So it's a condition where the glenohumeral joint capsule becomes contracted and adherent to the humeral head. So it can result in shoulder pain and a reduced range of movement in the shoulder. So it's more common in women and there's a peak age of onset between 4070 years of age and those who have previously been affected from adhesive capsulitis are more susceptible to developing the condition in the other shoulder. So the contralateral shoulder, so adhesive capsulitis can be characterized as primary um, so idiopathic. So, the cause is unknown or secondary and this is typically associated with uh rotator cuff, tears, subacromial impingement syndrome, previous surgery or trauma or um unknown joint arthropathy and the condition is typically associated with other inflammatory diseases. Um, and in males have an autoimmune element and that's why many patients with diabetes suffer from adhesive capsulitis. So usually the the condition progresses in three stages. So first of all, there will be a painful stage. Secondly, you'll have a freezing stage. And thirdly you'll have a thawing stage. There's limited evidence to support this theory. Um but pain and reduced range of movement is typically present throughout each of these stages. So, moving on to clinical features and investigation. So typically a patient will describe um a generalized sort of deep and constant pain in their shoulder and associated symptoms include joint stiffness and reduced function on examination. There may be a loss of arm swing and atrophy as the muscle wasting of the deltoid muscle. There may also be generalized tenderness on palpation and principally adhesive capsulitis affects external rotation and flexion of the shoulder and it's typically a clinical diagnosis. So, x rays are often unremarkable and MRI can be used as the Gold Standard investigation and can reveal a thickening of the glenohumeral joint capsule. So as I said, the condition is more common in diabetic patients. So any patient um presenting with adhesive capsulitis should have a HBA1C and a blood glucose measurement um checked. So, management and complications. So, adhesive capsulitis is typically a self limiting condition. But recurrence of the condition is very common. Initial management as with every sort of orthopedic condition involves good education and reassurance. And patients should be encouraged to keep active and all patients should receive physiotherapy. So management of the pain um can follow the who analgesic um ladder. So you can start off with simple analgesics and then you can progress to things like glenohumeral joint steroid injections. And if there's no improvement following prolonged physiotherapy and painkillers, surgical intervention may be considered. And as I said, potential surgical interventions may include joint manipulation under anesthetic, um as well as a surgical release of the glenohumeral joint capsule. So some patients will never regain a full range of mo movements in their shoulder. And some, um as I said, uh the condition may progress to occur in the contralateral shoulder as well. So this sort of brings us to the end of adhesive capsulitis. Um And we'll move on to another question if you guys don't have any questions. Um As I said, if, if you have any questions, just put them in the chat or feel free to interrupt me. So, um question number two. So 55 year old female presents with pain over the lateral aspect of the shoulder. There's been no trauma. The patient is a smoker and they have diabetes So jobs test is positive on examination. So what muscle is likely to have been affected in this rotator cuff tear? Is it number one supraspinatus? Number two, infraspinatus, number three, pteris minor, number four, subscapularis or number five deltoid. So again, if you wanna put your um responses in the chat and then we can go through the, the responses and you wanna put the response in the chart. OK, fine. So, well, the answer is number one. So supraspinatus. Um so job's test also known as the MTA test can be used to assess the function of the supraspinatus muscle and the muscle is typically involved in abduction of the shoulder. And other specific tests that can be used in the assessment of rotator cuff injury include uh Gerber's liftoff test and also the posterior cuff test. So we'll go on to uh a bit more detail about these two tests in, in the next few slides. Um But sort of as an aside, the risk factors for um a rotator cuff tear include obesity, smoking and diabetes. So rotator cuff. So the rotator cuff is essentially a group of four muscles that support and rotate the shoulder joint. So the glenohumeral joint, so rotator cuff tears are more common in, in individuals aged between 4070 they can be classified as either acute. Um So those that last for less than three months or chronic, uh lasting for more than three months. Um They can either be partial thickness or full thickness tears. Um full thickness tears can further be classified into small tears, medium tears, large tears or massive tears. So more than five centimeters and involving multiple tendons. So as I said, the rotator cuff is made up of four different muscles. The supraspinatus involved in shoulder abduction. The infraspinatus involves an external rotation. So too the teres minor and the subscapularis involved in the internal rotation alongside movement, they act to stabilize the shoulder joint and acute tears tend to happen in younger patients um where the force required to cause a tear can be quite large. So typically, it's seen in in sort of trauma, chronic tears um occur in individuals with sort of degenerative smaller micro tears to the tendon that, that tend to develop over time and occur following overuse and they are typically seen in older individuals. So the clinical features. So patients will typically present with pain over the lateral aspect of the shoulder and an inability to abduct their arm beyond 90 degrees. On examination, there may be tenderness over the greater tuberosity. Um and the there may be atrophy of the supraspinatus and infraspinatus muscles. So as I said, there are specific tests that can be carried out in order to um identify um the presence of a rotator cuff tear. So as I said, jobs test, also known as the M TCA test test, the supraspinatus muscle. So usually you place the shoulder in a 90 degree abduction and 30 degree sort of forward flexion movement and gently push down on the arm like this. Um and a positive test is uh if there's weakness on any sort of resistance. So, Gerbs liftoff test um test the subscapularis, so internally rotate the arm so that the dorsal aspect of the hand rests on the lower back and then ask the patient to lift the hand away from their back. And again, a positive test is any weakness in activity of lifting the hand away from the back. Finally, the posterior cuff test at test the infraspinatus and the terras minor muscles. And again, it's a positive test if there's any sort of weakness on resistance. So, investigations and management. So patients presenting with signs and symptoms of a rotator cuff tear should have an X ray to rule out any sort of a fracture. And once a fracture has been excluded, you can perform an ultrasound scan and subsequently an MRI scan in order to detect the actual size, the characteristics and the location specific loc location of any tear. So management um is dependent on the type of tear and essentially the functional status of the patient. And conservative management is typically opted for if uh patients are not limited by the pain or any sort of loss of function. Corticosteroid injections can also be trialed um for those patients who present two weeks after the injury or remain symptomatic despite any sort of um conservative management can be referred for surgical intervention and repairs can be done either arthroscopically. So keyhole surgery or open repairs as well and prognosis um is typically very good. Um And I suppose the main complication um from um any sort of rotates cuff tear as I alluded to earlier is a and this can lead to prolonged stiffness and um sort of reduced range of movements in, in the, in the shoulder joint. So let's move on to another question. Question number three. So a 27 year old male presented to Ed with a thinly rotated right arm, having fallen awkwardly on the football pitch. On examination, there is a flattened deltoid and an anterior bulge from the head of the humerus. So the doctor suspects a shoulder dislocation and they request an x-ray to check for any other injuries such as um a ban heart lesion. So what is a Bangkok lesion is an avulsion fracture of that creates tuber tuberosity, an impaction injury to the humeral head, an avulsion of the anterior glenoid labrum, a fracture of the anterior inferior glenoid fossa or number five, a glenohumeral ligament avulsion. So again, if you wanna put your answers in, in the chat and then we go through and you wanna put the answer in the chat. OK. So we've got number three. OK. So the answer is actually number four. So it's, it's a fracture. So it's a fracture of anterior inferior glenoid fossa So, shoulder dislocations are many uh sort of commonly associated injuries and bony Bangar lesions are the most common present and those with sort of recurrent dislocations. A hill Sachs defector, which is something that you may have come across as well is an impaction injury to the posterior and superior portion of the humeral head. And these are present in in 80% of traumatic shoulder dislocations. So, shoulder dislocations, they account for over half of all major joint dislocations which present to Ed and if they're not managed appropriately, it can lead to chronic joint instability and chronic pain. So, the most common type of uh dislocation is an anterior dislocation. Um and this accounts for upwards of 95% of all shoulder dislocations. An anterior shoulder dislocation is caused by a force being applied to an ex extended, abducted and externally rotated humerus. So, in other, in other words, falling backwards on an outstretched arm, a posterior dislocation is typically caused by seizures or um electrocution. But um it can rare rarely occur through, through trauma as well. So, moving on to the clinical features, so as with all dislocations, they're gonna have a painful shoulder, they'll have a reduced mobility and a feeling of general instability in the shoulder joint. On examination. There's often an asymmetry with the contralateral side and you'll notice a flattened deltoid and also an anterior bulge from the head of the humerus. So it's really important to assess the neurovascular status of the arm, which can be compromised in some cases, especially the auxiliary and the suprascapular s and shoulder dislocations have many associated injuries which can be divided into bony injuries and ligamentous problems. So as I said, a bony bank heart lesions, so they fractures of the anterior, inferior glenoid bone and hill sacs defects are impaction injuries to the posterior and superior portions of the humor, head fractures of the great tubs and the surgical neck of the humerus can also occur. Although they're much rarer. And finally, ligamentous injuries include um glenohumeral ligament, avulsion or rotator cuff injury. So, investigations and management. Um so, X rays are always gonna be required including an ap um and lateral view. Um anterior dislocations can typically be viewed on a anterior posterior um shoulder X ray. And you can clearly see that the humeral head is visibly out of the glenoid fossa. A light bulb sign is something that you might come across in your exams as well. And this suggests a posterior dislocation as the humerus is fixed in internal rotation. If we're suspecting any sort of rotator cuff injury or any ligamentous damage, you may want to request an MRI scan of the shoulder as well as with any sort of uh management of acute trauma. You should manage the patient uh using an A to E approach um and ensure that the patient has adequate analgesia as the painkillers in terms of management, good reduction immobilization and rehabilitation of three sort of principles to any sort of uh dislocation. And for all the diss ations, a closed reduction should be performed and you must first assess the neurovascular status. Both pre and post reduction, a failed clothes reduction may warrant a manipulation under general anesthesia and once the shoulder's adequately been reduced, so put back into place, the arm should be put in a sling physiotherapy may be required after shoulder dislocation. Um in order to assess any further um instability and uh joint movements as well. So, question number four. So a 22 year old male presents with a fracture of the distal third of the humerus. There is a loss of sensation of the dorsal thumb web space and a weakness in wrist extension. So what nerve is likely to have either trapped? Is it the median radial ulnar musculocutaneous or the axillary nerve? Ok. If you wanna put your answers in the chat and then we can go through them and you wanna put it in the charts or just not too sure. OK. Well, well, the answer is number two. So it's the radial nerve. Um and a whole sign Lewis fracture is a fracture of the distal third of the humerus and this results in entrapment of the radial nerve. Um and any sort of resultant nerve injury will result in a loss of sensation in the radial distribution and also a wrist drop deformity. If this is the case surgery is typ surgery is typically required. So another question. So a 42 year old female presents to a GP with pain, affecting the elbow and radiating down the forearm. There is tenderness over the lateral epicondyle and the patient is a keen tennis player. A diagnosis of lateral epicondylitis is suspected. So, what test can be performed to further sort of um, identify the diagnosis? Is it af test tt test, luck's test, coins test or fins test. Bit of a tough one. I see what you make of it. Ok. Well, the answer is number four. So it's um cousins test. So, Phalens and Tinnell test is typically used for compartment syndrome, Lachman's test. Um for ACL rupture and Finkel signs test is typically used to assess for any 10 S nephritis. So it's a bit of a um an unusual test cousin's test. You don't usually come across it, but it's also known as the wrist extension test. So let's go on to talk about epicondylitis. So, um epicondylitis is um a chronic symptomatic inflammation of the forearm tendons at the elbow and affects males and females equally with a peak age of onset um of 35 to 55 years. So, there are two common types. The lateral epicondylitis known as tennis elbow and medial epicondylitis known as golfers, elbow and lateral epicondylitis is the more common of the two. So the median and lateral epicondyles are the small sort of bony tuberosities on the distal end of the humerus, you can feel them on your, on your own arm and elbow. And the the medial epicondyle acts to flex the wrist. And the lateral epicondyle acts to extend the wrist. So the common extensor tendons attached to the lateral epicondyle and repeated overuse of these tendons can cause micro tears. Um and these micro tears within the tendons can lead to multiple tears. Uh the subsequent formation of granulation, tissue fibrosis and eventually um what we know of as um lateral epicondylitis. So, the main risk factor is overuse uh particularly in tennis players. And if you think about it hitting a backhand consistently can precipitate um a lateral epochs. So the main feature is pain affecting the elbow and this can radiate down the forearm and the pain worsens over weeks to months and it com commonly affects a dominant arm. So on examination, the patients will have localized tenderness on palpation over the lateral epicondyle. And as I said, there are two specific tests to ate, a diagnosis of lateral epicondylitis, cousin's test, as I said, and Mills test. So these are quite unusual tests, as I said. But um a lateral epicondylitis diagnosis is ultimately a clinical diagnosis. And ultrasound or MRI imaging can be used to confirm the diagnosis or to detect any sort of structural abnormality. So, cousins and mil tests. So these are typically for physiotherapists to perform. Um But it's important to, to remember that epicondylitis is essentially a clinical diagnosis. So, moving on to management. So patients should be advised to reduce any sort of repetitive actions that can cause the condition. So golf or tennis, in this case, also simple painkillers, um paracetamol, topical nonsteroidal antiinflammatories. These are drugs that can be prescribed quite safely if this fails to improve the condition. Corticosteroid injections can be given every 3 to 6 months. Uh following this physiotherapy can be used to provide long term relief. So, as you can see, there's a pretty much a a common for human in uh managing most orthopedic conditions. So, simple analgesia, physiotherapy, corticosteroid injections, and also for uh lateral or medial eons, wrist or an elbow brace can be used um for longer term symptom relief surgery can be um opted for if um conservative management is unsuccessful and sort of arthroscopic or open debridement or release of any of these damaged tendons um can be performed in theater. So in media epicondylitis, also known as golfer's elbow, um the pronatal, the f the carpi radialis. So these are the two tendons within the forearm, these are most commonly affected tendons. Um So that's something to be aware of. And so just just be aware of the anatomy of um and the compartments of the forearm to the muscles of the forearm as well. So this brings us to an end of epicondylitis. Um and if nobody has any further questions, we can move on to question number six. So a patient has seen an e having fallen on an outstretched hand. It's a following clinical and radiological assessment, he is diagnosed with an essex lares fracture. So which of the following most accu accurately describes this fracture type? So it's again, quite a complex fracture and there's a fracture that you may not have come across so far. But, but let's see, let's see what you make of it. Mhm Any takers? No. Ok. So the answer is number four, it's quite a complex fraction. I mean that you definitely wouldn't have come across um during medical school. Um but in essex, lares fracture is a fracture of the radial head with dislocation of the dis distal radial ulnar joint. And this type of fracture will always require some sort of surgical intervention. Um uh Number one describes a Gallie fracture, whereas number five describes a Monte fracture. So radial head fractures. So um these fractures account for roughly a third of all elbow fractures and they have the highest incidence in those between the age of 2060. So at the elbow, the radial head articulates with the capitulum of the humerus and the proximal ulnar. And this allows for flexion extension and supination as well as pronation of the elbow. So, radial head fractures usually occur by indirect trauma and they often present with a history of falling on an outstretched hand f fu so typically known as a foch fracture and the patient will be in pain. And on examination, there will typically be tenderness on palpation of the lateral aspect of the elbow. And the radial head radiohead fractures can be missed on an X ray and occasionally only an elbow effusion may be seen an elbow effusions on a lateral projection x-ray is termed a sale sign and it can be seen as elevation of the anterior fat pad. And you can see this uh via the blue arrows on, on the image, the image below this um shows a typical Essex lopresti fracture. So, question number seven. So what eponymous classification can be used to describe fractures of the radial head? Is it Gardens Mason Shatt Hawkins or Lou Hansen? Ok. Well, the answer is number two. So mason criteria and radial head fractures are sort of classified according to the degree of the displacement and whether there's any intraarticular involvement. So Mason type one fractures are typically non displaced or very minimally displaced less than two millimeters of displacement. Type two partial articular fracture with displacement of more than two millimeters. And type three is a comminuted fracture and significant displacement. So as with any sort of fracture management, again, always remember to perform an A to e assessment, adequate analgesia and ensure that the joint is joint has been immobilized and definitive management again, can be guided by the Mason classification. So type one injuries um can be treated nonoperatively. Type two, they can be treated. Um as per type one injury, if there's no sort of mechanical block, but if there is any sort of mechanical block, then these may require surgery in the form of an opioid reduction. Internal fixation. Type three injuries will nearly always require some sort of surgery. Um Again, either via an open reduction, internal fixation or a radial head excision or in certain circumstances, uh a joint replacement, the patients can typically expect a good prognosis following a radial head fracture. But later on in life, any sort of fracture increases the likelihood of osteoarthritic changes. So this brings us to the end of uh radial head fractures. Um And if you guys don't have any questions, we can move on to question number eight. So a five year old child falls on an outstretched hand, she has sudden onset severe pain and is reluctant to move the affected arm. She is visibly pale and there is a delayed capillary refill time. So which of the following is the most common initial management for supracondylar fracture with neurovascular compromise. Is it number one? And RF number two, a closed reduction with KWS. Number three, external fixation. Number four, a closed reduction followed by conservative management and casting. Number five, casting only any takers. Ok. Well, the answer is number two. So um typical management for supra fracture with neurovascular compromise is a closed reduction with stabilization using KWS. And if this is not possible, then an or if can be um considered. So an open reduction, internal fixation and typically the Garland classification can be used to guide management planning with types 23 and four, all requiring surgical intervention. So, supracondylar fractures. So they're the most common pediatric elbow injury and they're almost never seen in adults and the peak age of onset is between five and seven years. And um as with radial head fractures, the most common uh mechanism of injury is a fall and outstretched hand. Um Features include sudden onset, severe pain. And in Children, there'll always be a reluctance to move their affected arm. On examination. There may, there may be signs of swelling, limited range of movements in the elbow bruising, um particularly in the antecubital fossa region. So in these types of fractures, it's really important to examine the median nerve and also the anterior interosseous nerves, the nerve that allows you to form the o the ok sign like that. Um You should also check for features of um vascular compromise such as any uh cool temperature parallel, delayed cap refill time or any sort of absent pulse. And if there are any signs of vascular compromise, an urgent vascular review should be performed. So, um investigations and classification of supracondylar fractures. So subtle signs on an X ray for uh supracondylar fracture, um these include a posterior fat pad sign. So you can see a bit of a lucency on the lateral view as seen by the white arrows on the on the X ray image, um there may also be a displacement of the anterior humaner line. Um So in Children over the age of five years, this large would intersect the middle third of the capillin. But as you can see the, the, the yellow line has been displaced um in an anterior position. And then as I alluded to uh the Garling classification can be used in in um classifying supracondylar fractures and can also be used to, to guide management. So type one fractures are typically undisplaced. Type two is displaced with an intact posterior cortex. Type three is displaced in two or three planes and type four is fully displaced with a complete periosteal disruption. So management. So um patients with a supracondylar fracture and any sort of associated neurovascular compromised, as I said, will need immediate closed reduction. Conservative management can be opted for in patients with type one fractures or minimally displaced type two fractures and they can be managed in an above elbow cast, typically placed in a 90 degree flexion types 23 and four. Supracondylar fractures will require a closed reduction and ky fixation and all open fractures will require will require an open reduction with um percutaneous pinning. Complications include nerve palsies and the anterior interosseous nerve is most commonly affected by the initial injury. Um but during so intraoperatively, the ulnar nerve is at risk during insertion of um a medial kwire. So malunion can also occur and finally, something known as a volkmanns contracture can occur following vascular compromise. So this is where ischemia and sort of subsequent necrosis of those flexor muscles of the forearm can result in the wrist and hand to be held in a permanent flexion like a claw. As you can see in this image, the X ray above uh shows the use of K Ys to, to, to fix it. Um an unstable supracondylar fracture. So let's move on to question. Number nine, a 54 year old lady presents with pain and numbness in both hands. There's paresthesia. So, pins and needles throughout the median nerve sensory distribution and the symptoms are typically at night. So, Phalen's and Tinel's tests are both positive. So what endocrinological disease is linked to the presence of bilateral carpal tunnel syndrome? Is it hyperthyroidism, acromegaly Addison's Hashimoto's disease or Cushing's disease. Again, if you wanna put your answers in the chat and then we can go through them any takers. Ok. Well, the answer is number two. So how come megly and so there are many associated conditions linked with carpal tunnel syndrome and aromatically results in excessive secretion of growth hormones. And this causes um you know, the soft tissues and the bones around the carpal tunnel to grow and compress the median nerve. Hypothyroidism is also associated with the condition, but there is weak evidence. So, carpal tunnel syndrome involves compression of the median nerve within the carpal tunnel of the wrist So just a bit of anatomy to begin with. So the flexor retinaculum, it's essentially a fibrous band that wraps across the front of the wrist. Um And between the carpal bones and the flexor retinaculum is the carpal tunnel and the median nerve and the flexor tendons run through this carpal tunnel. So you shouldn't also be aware of the fact that the palmar cutaneous branch of the median nerve, this provides sensation to the the palm, but this branch originates before the carpal tunnel and does not travel through the carpal tunnel. And so is not affected in carpal tunnel syndrome. Instead, compression of um digital cutaneous branch of the median nerve leads to the symptoms of pain, tingling, um and numbness in the lateral 3.5, um fingers and digits. So the median nerve also supplies motor function to the female muscles. So these muscles over here and um these muscles are responsible for thumb movements and the risk factors for carpal tunnel include age, female pregnancy, obesity and any sort of previous injury to the wrist. So, clinical features, as I said, pain numbness, pins and needles throughout the median nerve sensory distribution, um are the most common symptoms. The symptoms are worse at night and there may be a history of the patient putting their hands um over the side of the bed, which can sort of relieve um the symptoms, sensory symptoms can be produced by tapping over the median nerve. So Tinel's test or holding the wrist in full flexion for one minute. So like this and that's you should, you should hold that for at least one minute. And if there's any sort of pain in the carpal tunnel distribution, um that is a positive test in the sort of later stage of carpal tunnel syndrome. There may be wasting of the thenar muscles as well. So carpal tunnel syndrome is a clinical diagnosis, but sometimes nerve conduction studies may be useful in order to confirm a median nerve damage. So it's initially treated conservatively with a wrist splint and corticosteroid injections can also be trialed. Surgical treatment should only be performed in severely limit limiting cases where conservative treatments may have failed. And treatment involves carpal tunnel release. Um in order to decompress the tunnel involves cutting through the flexor retinaculum and so reducing pressure on the median nerve. So a couple more questions and then we're nearly done. Ok. So a 72 year old female falls on an outstretched hand. She has a past medical history of osteoporosis and an X ray confirms a Barton's fracture. So which of the following best describes a Barton's fracture, an intraarticular fracture of the distal radius, extraarticular fracture of the proximal radius, intraarticular fracture of the proximal radius intraartic fracture of distal ulnar or an extra articular fracture of the proximal ulnar. They all sound very similar. But um yeah, they are different good. So the answer is number one Yes. So it's an intraarticular fracture of the distal radius. Um So, so fractures of the distal radius. So, these represent a quarter of all fractures seen um clinically um and fractures can occur through the distal metaphysis of the radius. Um So, with or without um articular surface involvement and they typically occur again following a fall um on an outstretched hand. And due to um osteoporosis, these the risk of these sort of fractures um increase with age. And there are three common types of uh distal radial fractures. Um The most common being a collies fracture. And this describes an extra articular fracture of the distal radius with dorsal angulation and dorsal displacement. That's what is known as the dinner fork deformity. A Smith's fracture describes an extra articular fracture of the distal radius with volar angulation. So this is why it's known as the garden spade deformity. And as we alluded to in the question, Barton's fracture is an intraarticular fracture of the distal radius with associated dislocation of the radiocarpal joint. So, clinical features as with every fracture, immediate pain deformity and sudden swelling around the fracture site, any sort of nerve damage can result in um pins and needles um as well as weakness and neurological examination should um include an assessment of the median nerve and Antero nerve. So as I said, the Antero ner can can be tested by asking the patient to perform an ok sign if the ulnar nerve is affected um from a sign will be seen. Uh So this will this is where there will be sort of compensatory flexion at the interphalangeal joint of the thumb. Um And finally, if the radial nerve is affected, there will be a wrist drop. So differential diagnosis of a radial head fracture you should be aware of um is a Gliese or tedious fracture as well. So, investigations and management. So X ray, I mean pretty obvious but it's the Goldstone the investigation um and uh once stabilized, all sort of displaced fractures should um be reached in the emergency department. So following reduction, the arm should be restricted to allow for uh for bone healing. And typically fractures are placed in a below elbow back slab and then radio grafts are then repeated after one week to check for any further displacement. Um Once um there's been good healing of the fracture, um the patient should be rehabilitated um using physiotherapy, but you should be aware of the fact that significantly displaced or unstable fractures, they can require surgery. And the options include an open reduction, internal fixation or a ky fixation. Nowadays, external fixation is is rarely used. So, complications of um radial head fracture include malunion and any sort of secondary um median nerve damage. And as with every fracture, osteoarthritis can be seen later on in life, say one more question. So a 42 year old patient presents with a suspected scaffold fracture and he has had two inconclusive x-rays two weeks apart. So what's the most appropriate next step in the management of this patient? Should we repeat the X ray? Should we perform an MRI scan? Move towards physiotherapy, perform a CT angio to exclude an arterial injury or opt for surgery? Get. Um So the answer is number two. So it's an MRI scan. So if repeat, um X ray is negative, but clinical findings are still in keeping with a sc forward fracture, you should perform an MRI of the wrist. So scale fold fractures. Um So scold fractures, they're more common in, in males um following high energy injuries. Um and the scaphoid is typically divided into three parts. So you have a proximal pole, a waist and then a distal pole and the blood supply to the scaphoid runs in a retrograde fashion towards the proximal pole. So, from the distal pole down towards the proximal pole, and it's five branches of the radial artery and fractures can therefore sort of compromise the blood supply to the sca forward, leading to avascular necrosis and the more the more disable fracture, the higher the risk of avascular necrosis. So, in terms of clinical features, there'll be sudden onset pain and bruising and there'll be tenderness on the floor of the anatomical snuffbox and also pain on telescoping of the thumb. So for suspected cases of scel fracture, x-rays should initially be performed. Um and if there still remains sufficient clinical suspicion. Despite negative initial imaging, the the patient should have their wrist immobilized. First of all in a thumb splint and then a repeat X ray in 10 to 14 days for further evaluate further evaluation. If the X ray is still negative, but um the clinical suspicion remains, then you should perform an MRI scan and this is the definitive investigation for scavo fracture. So finally moving on to management, a undisplaced fracture can typically be managed with um sort of immobilization in a plaster cast and a thumb splint, but displaced fracture of the proximal pole have a high risk of avascular necrosis. And so surgical treatment may be required. So all displaced fractures should be fixed operatively. And the most common technique is the use of a screw which can be placed across the fracture site to compress it. And as I said, complications um include avascular necrosis and uh malunion. So this brings us to the end of um this presentation on upper limb. Um I hope you guys found it useful. Um If you have any questions, please do put it in the chat. Um And tomorrow we'll be going over lower limb and the spine. Um And then next week, I'll be doing a talk on a plastic surgery. So if you guys don't have any further questions, I'd be really grateful if you could complete um um a feedback form for me before you guys leave. I'll just put it in there in the tract. Ok. I hope this link works. Let's see. No, wait, hold on. Ok. There you go. Hopefully this, this work hang around for a little bit just in case you guys have any questions. Um But once you've completed the feedback form, please feel free to, to go. All right guys, thanks for attending. Um I'll see you tomorrow. Hopefully.