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Um Can everyone see that? Now, would you mind checking the chart? II can even see that. I think they can now see it. OK. Is that all? OK, perfect. So where was it? So um yeah. Well, so we'll quickly run over. I don't want to cut into ra time. So I run through it quite quickly. All slides should be emailed out to you. So you can be looking at it and then um run over the elbow again, just look at the images quite quickly. Then we look at the forearm and we'll look at very common uh clinical cases. So regarding the ulnar, there's free articulations, you have your humera ulna, your proximal radio and your distal radioulnar, your radius, you have four, that's a humeroradial, the proximal radial ulnar, the distal radial ulnar and the radiocarpal I mentioned earlier, you want to know the ones in red. So regarding the ulnar, you want to know the radial notch, the electron and process and the trochlear notch, the electron itself, it kind of falls part of that trochlear notch and it's the tip of the elbow, just this part here. The trochlear notch is kind of formed by the electron and the coronoid process just there. And that is where your humerus kind of sits in the trochlea, your humerus sits into there. So that sits as your ulnar and then the radial notch at last is a lateral surface of the trochlear notch and it articulates with the head of the radius. So your ulnar is mainly for stability and then your radius is mainly for movement regarding the radius. You have want to know your head, you want to know the radial tuberosity and you want to know the ulnar, not the head. The he the head is kind of this disc shaped which is concave and articulating surface. And that takes part in the proximal radial ulnar joint. Um The radial tuberosity is also very important and that is where your base has brachy muscle attaches. And if any kind of fractures affect here, you can result in function problems with brace and biceps. So, yes, your joints, you have two joints in your elbow. Well, you have 22 articulations in the sinovial hinge joint of your elbow. The elbow may use flexion extension. You can see on the images on the right. And we should know that by now, but you have the trochlear notch, which is so one articulation is going to be the trochlear notch of the ulnar and the trochlea of the humerus. The second is going to be the head of the radius and the cope of the humerus. So that is going to be the elbow joint. It's three bones, two articulations and then move on to the sinovial pivot joint, which isn't counted as part of the elbow joint. It's just kind of distal to it. You can see it just there on the bottom left image. This is a sinovial pivot joint. Um and it's kind of formed between the head of the radius is formed between the head of the radius and the owner. So ligaments once again mentioned the radio collateral ligaments on the lateral side, it prevents excessive medial, excessive medial movement, medial, medial movement, and then the ulnar collateral ligament prevents excessive lateral movement. The annual ligament is going to be keeping the radius and the ulnar together. So bursa of the elbow, main thing to know is electron and bursa is the one affecting the bursitis. And these are used to decrease friction between tendons, bones and skin during the movement, cubital fossa be covered. Um and you can cover the slides after I'm not gonna go through them all again. But the main things to know about the cubital fossa is the contents that it has. So you have the radial nerve going from lateral to medial, is going to be the radial, the biceps tendon, the brachial artery and then the median nerve. So the one I have missed out is going to be that medial um vein, the medial pubertal vein, which is the one mainly used during venous puncture. And the main reason to know about the contents in the cubital fossa is there's a lot of elbow fractures and you wanna see which if, where the fracture is, what is going to be affected. But you also want to know if you're doing which you go, which kind of neurovascular structures are very close by it, you have to look out for. So if we don't go to the next slide conditions, which is gonna be the most important for everyone is going to be lateral and medial elis. So presentation peak incidence is going to be in the ages of 35 and 54 they're both gonna result in pain and inflammation around that associated area. So either the lateral epicondyle or the medial epicondyle and they are due to the overuse of the flexor. If it's the medial epicondyle or the extensor, your lateral epicondyle is going to be inflamed and in pain. So, an easy way to remember is the media epicona, which is used for is where the origin of flexors are for the forearm is going to be, which mainly occurs in golfers. A easy way to remember is because golfers aim for the middle of the fairway while lateral is going to be tennis as tennis players. Mhm As tennis players may aim for the lateral side of the line. So the treatment for it is going to be rest kind of ice and also physio and if it gets really severe, you can use corticosteroids, injections by the predniSONE, not be predniSONE. So an important thing to also know is this is kind of a clinical diagnosis. Imaging isn't necessarily required as the patient will present with a history of both in that kind of not just in that age, but it also present with activities which are causing those micro tears and that repetitive injury. So moving on to the radial head fracture presentation like all elbow fractures are mostly due to falling onto that outstretched hand. This is gonna be followed by elbow pain and possible swelling and bruising. And the radial head fracture itself is due to the radial head being forced up into that. Cetil investigations is going to be both ap and lateral x rays. And I mentioned cell sign there and it's gonna be easier for you to understand what I was talking about from before. If you can see my cursor, you can see I there's I do three lines on this image. The first one on the left pointed at the radius itself is going to be a fracture. The one just above is pointed at an anterior fat pad just in front of that humerus and the elbow just anterior to it. So an anterior fat pad doesn't always mean pathology has occurred. It's not always pathological, sometimes you can have just one there, but this one is elevated. The posterior fat pad is always pathological. You should never have a posterior fat pad. So if you see that there is some sort of trauma, some sort of injury. So there's a class of three things you want to look for when you're x-raying any kind of elbow in the lateral view, you wanna look for a fracture and you also want to be looking for those flat pads. Management wise is gonna be based on the amazing classification which you can see down the bottom, right. And this kind of guide your treatment of if it's surgery or if no surgical intervention is required. So, supracondylar fracture, then just a bit up, just a bit more proximal. So once again, it's gonna be falling on to the outstretched hand, but this time with your elbow extended and then you're gonna be having that swelling deformity and limited range of motion, which is very common for all of those elbow injuries, this kind of swelling, this pain, this not being able to move it very, very common. And then you're gonna be having a peak age of around 5 to 7. Um So mainly when kids are running around quite a lot, they've fallen off a lot of playground equipment, they're doing lots of kind of jumps and being very risky. It's normally around that age investigation wise, you ought to be checking the neurovascular and that's because of your nerves being very, very close to it. And you don't want to when you have a super fracture, you can actually injure your median nerve, which can result, recover later, but you'll then result in those muscles, not be able to function properly. And you'll also be losing that kind of sensation. And if you don't sort it out quick or notice it quick, it can result in both vascular and nerve compromise later on down the line. So it also could be affecting your anterior interosseous nerve. So any kind of elbow fracture, like I mentioned is you want to check both the joint above and most of the joint below as you can occur as fall onto your hand might not only just fracture something example like a scaphoid, but it can result in another fracture of the elbow management is going to be by the Garling classification. Once again, just guides the treatment if it should be conservative or if it should be surgical. Um Not much more else to say on that the final ones electron and fracture. This one's quite obvious as you can see on the image on the right. It affects both very, very young but also very old. It's more common in the old by kind of low energy um falls and movements. Um And it's holding onto that outh hand once again, what happens here is you have a sudden pull of your triceps, which is why the electron on you can see on the image on the right and the X ray is very pulled far away. With this, you can on examination, you'll be able to notice it very obviously, as the triceps were put away and they won't be able to have that full extension. Once again, pain, swelling, reduce range of movement. Um And the management also depends on the degree of the placement and also on uh how suitable it is for the patient. So sorry, that was a bit quick. But I think we're running short for time. So if we go on to the forearm, um you have the two joints, the proximal radial ulnar and then you have your distal radial ulnar. So the distal radial ulnar is kind of just proximal to that wrist joint is the articulation between the notch of the radius and the ulnar um head. It is going to be having these anterior and posterior ligaments which strengthen the joint. The fibrocartilage just ligament which is also the articular disc. You can see an image of the right has two main functions. So first of all, it's going to be binding that radius of the ulnar together during the movement. And the second is going to be separating the distal radial ulnar joint from that wrist joint. This um yes, that should be once again, they moved the wrist is mainly for the the function for the wrist is mainly for that supination and pronation. Now, muscles you have the anterior forearm and then the posterior for is how you describe it the anterior form is going to be the flexors the posterior for is going to be the extensors and you can see a quick breakdown of it here. It's gonna be, I'm not gonna run through every single one and all the functions origins, um nerve supply as you wouldn't ever learn it just from me talking to you about 3020 different muscles. So I'm gonna just give the main points of each one and I've made some tables a bit later on that you can use in your own time. So you have your superficial muscles which is free flexors of the wrist. Remember wrist is carp, this is why they call it a car with bones. So anything that has the word carp or you just think it's gonna be moving that wrist, anything that says digitorum like the intermediate muscle, there's only one of them is going to mean the digits and anything that's his policies is going to be the fun. So you can see there's four muscles in the superficial layer of the anterior um compartment. You have only one muscle in that intermediate layer and then you have three deep muscles. So if we go on to the anterior forearm, you have four main muscles in that superficial layer. So you have the free flexor, the flexor carpi ulnaris, which is going to and then you have the palmaris longus and then you have the flexor carpi radialis and the pronated terus, the flexor carpi ulnaris the or is gonna originate from that medial epicona like a lot of these, these um flexor muscles in this anterior forearm. And they're gonna, it's going to attach the flexor carpi ulnaris. It's going to attach to that peaceful bone and the hook of the hammer, which is the carpal muscles in the hand. The palmaris longus is absent in about 15% of the population. Once again, originating from that uh medial epicondyle and it's gonna flex, it's going to attach into the flexor reticulum just in the wrist. Once again, this is going to be flexion of the wrist. And this is gonna be supplied by the median nerve, the flexor carpi or nerves I should have mentioned is actually supplied by your ulnar nerve when the other three are by that median nerve. So the flexor carpi radialis is going to originate once again for the medial epicondyle. And it's going to attach to that base of the metacarpals of the metacarpals to two and three. The function of the dish is going to be a reduction of the wrist and also kind of flexion. So the pronator terrace finally is like, I don't know if you remember earlier, but it's the lateral bo the lateral border of the pronator terrace um is forming that medial border of the cubital fossa and it originates from once again the medial epicondyle and it attaches to the lateral side of the midshaft of the radius which you can see just on the image there. So if we innovation, you can see the ulnar nervous for one media nervous for two and three. So the flexor digitorum Suha is the biggest muscle in that kind of forearm. It's in that intermediate layer. So you can just kind of see it here on the image. I'm just worried a little bit for time. So we're gonna speed through these. Um and then we'll go, I'll show you the table. I mean, so deep muscles is the flexor digital and profundus, the flexor pus is lus and that pronatal quadratus. So the ulnar nerve actually innervates the medial two bellies of the flexor digital and Profundus. And the medial nerve is going to be doing the lateral two bellies and also muscles two and three. So I've made a little table for everyone which works quite well as we won't have enough time to run through it all. So you can see the origin is going to be mainly is going to be from the medial epi conda for pretty much every single one. It's rare that it's not. And if it isn't from somewhere else, it's normally doesn't have a head. So the insertion is um varies. But we try to just think of what the name of the muscle actually is. And from that, you can hopefully try to work it out. So for example, flexo carpi radialis, if you think of where the radius is, that is going to be lateral and you can, if you do a radio that say, for example, the flexor ulnaris is going to be going on to that fifth metacarpal, you have to be, it takes um actually, it does take you a lot of time to actually get your head around it. But I'm sure you will um as you do it more and more, but you kind of just have to think of where it originates the name of it and just think of if it has that attachment or that insertion, what kind of action is going to be doing? So, posterior muscles and a lot more, but there's only two layers. So you have the three extensors of the wrist once again caring um then a carpi muscles, then you have the one extensor of the digits two and the five, the one accessory extensor to digit five. And then you have the brachial radialis and the anus, the brachial radialis is the one they know for beer drinking. And it's like kind of in flexion of the wrist, the flexion at the elbow, then you have the diva muscles which are the two extensors of the thumb, the one abductor of the thumb, the one accessory extensor to digit two, and also the super. So I've listed a big list of the muscles there involved in the superficial layers, the radial nerve and the deep branch of the radial nerve is mainly what innervates this kind of posterior compartment of the the posterior forearm. Um the median nerve like I mentioned earlier. Also, the ulnar is going to be that anterior, the posterior is gonna be the radial. So if we don't go on to just a deep layer, the deep muscle, sorry. So you have the super the abductal polis Longus, the extensor polis brevis, the extensor polis longus um and then the extensor indices, the extensor poli brevis and longus brevis just means short, Longus just means long. You can see that just in the image on the right, in the orange one is going to go to the distal part of the thumb uh indicated by the Latin pollicis and the Brevis is going to go, the shorter tendon is going to go and attach it and insert a little bit more approximately. So innervation wise, once again, it's going to be the radial nerve and it's going to be that deep branch and also that posterior interosseous, I believe we'll go on to the conditions. Next. Um These tables should all be sent out to you and you can look over them, make cars and very good. Um Way of learning. It's the way I think a lot of my medical school learn is just by having making a table and just looking at it and rewriting it so quick, look at coles fractures, which is very, very common if you fall onto that outstretched hand and the way I learned it is more of a clinical diagnosis, you can get the X ray. But if someone has the history of falling onto that outstretched hand and they have the kind of typical bend in it, like you see up top right. And also from the x-, you can normally diagnose it. So what actually is it is an extra articular fracture of the distal radius and it results in that dorsal angulation. So you can see have the deformity that the wrist is showing. So Smiths which is just a reverse is going to be the exact same, but it kind of results in that vulva displacement. And this is mainly due to people falling backwards. And when they're trying to fall, they put their hand down and then that's what happened, they fall down onto that hand and it kind of forms that fracture. I hope I haven't run over by time too much. I'm sorry, that was not exactly how it was meant to. Um like I said, all the slides should be sent out to you all. Um And you can look over them all in your own time. I apologize for the technical difficulties that we occurred. If anyone has any questions, just put them in the chat and I can answer them now about either mine or else. Thank you. Thank you so much, Harry. Um You've done a lot of the heavy lifting. So my job is a lot easier. All I need to do is the hand, can everyone see the slides? Is that ok? I'm gonna assume that's a yes. So, as I said, my job is to take you through the hands today. The hands are great. Um, the anatomy in them isn't too bad, you know, there's still some stuff going on. But, um, the, er, the amazing thing about the hands is all the different functions you can do all the actions, you know, the, the opposition of the thumb. Um And also because they're quite peripheral, a lot of the kind of central problems that we have start by presenting in the hands. But today, I'm looking at the hands themselves and the conditions that come with them. So we're gonna little quick overview. So start with the bones and we're gonna look at scaphoid fracture as part of that. Then we look at muscles tendons and fascia and three conditions dus contracture and then two types of uh tenure sinusitis, er the veins and trigger finger, then blood and we're gonna quickly go over the skate foot fracture again, cos it's relevant nerves and then carpal tunnel at the end with carpal tunnel syndrome. If you see a little hand up, it means that the hand is up in the picture. I think that's quite self explanatory and obviously hand down means it's dorsal cool. OK. So starting off, this is a picture of our hands. So normally I'd all sorts of questions. Uh but I can't see the chat. So I'm just gonna answer all my own questions. So I was gonna say, how old do you think this person is? Um, and you can tell a lot about age and things like that from people's hands cos you can look at whether there's kind of joint plates that need to be merged or whether there's big gaps between the joints. And you can also look at kind of joint damage. But this is just kind of like a normal, relatively elderly woman. There's, there's not a lot of osteoporotic damage. But what we do have here is some kind of inner bone damage. So sorry, there is osteoporotic damage. I meant osteoarthritic arthritic. But here we've got some, um, some damage in the fingers and some, some tissue swelling and she actually had sarcoidosis. But I just got this photo. So we're gonna start by looking at the carpal bones. Then we're gonna look at the foot in particular, which is down here. And then we're gonna look at the metacarpals and then the phalanges and that's bones. So carpal bones, there's eight of them scapholunate Chatri and then a mystery one, I was gonna ask which one it is, but it's the pisiform bone and then it's the trapezium trapezoid capitate and hamate. The best way of learning them is with whatever in the morning you would like. I have one here. Some lovers try positions that they can't handle. That's going along the, er, proximal forward and the distal four. So scape forward form trapezium trapezoides capitate hamate. Again, you don't need to know, you know, the main relevance comes with kind of their anchoring in muscles and things like that. So don't worry too much. OK, scaphoid fracture. So as we just said, the scaphoid is here beneath the thumb. Nice and simple. The people will often refer to this as a broken wrist. It means the same thing. And I might ask, why do they account for 70% of all carpal bone fractures? I mean, that's the majority, right? And you might give me a reason, but the reason why is when people fall on their wrist, the scaphoid is squished between kind of the bones of the thumb and the gretch above it and the radius and it fractures in that sense. And as you can see, it can fracture in a lot of different ways. Um And then I might ask you, your typical patient is. So for something like this, Harry mentioned Coles fracture, that's what would happen if kind of an elderly person fell on the outstretched hands. But the kind of a, a young adult, you know, maybe like 15 to 25 they're the ones most likely to fracture their scaphoid. Alternatively, people in road traffic accidents tend to as well cos they're kind of crushed, er, crushed against the steering wheel. Younger kids don't tend to cos they have a lot more joint space. Um so their bones can kind of take more of a knock when they, they fall on their own stretch hand. So it's mainly that kind of active sporty age group in the middle, as it says there, it can fracture along loads of different lines. But the main two are these kind of the, the waste waste lines where it kind of fractures across and that's kind of problematic. And we're gonna look at that uh why that is later when we talk about the blood supply, often patients are gonna have tenderness in the anatomical snuffbox. I'm hoping you can see my camera, but that's right here beneath your thumb in this little groove here. Uh And the worst case scenario, as I said because um it fractures along the scaphoid uh and the blood supplies retrograde, which again, we'll talk about it can cause avascular necrosis, which is otherwise known as pre disease. Again, we'll come back to that. So two pictures here, both of them have a s scaphoid fracture and one of them is very different to the other because one of them is a, a child's hand, this one on the right, I'm assuming it's right for you as well. I don't know why we flipped. Um You can see here that the growth plates are still not fully fused and there's much bigger gaps between the joints and on both of them, we have a scaphoid fracture along those lines. If you can see that clearly here. This one looks like it might not uni er, unify correctly and that would be an indication for surgery. So, normally these things are managed conservatively with pain relief, but if there's a risk of nonunion, then it would be a consideration of the surgery. Cool. Next is the metacarpal. So you can see all the joints here. Radiocarpal is from the radius and ulnar to the carpals and then the mid carpals is between them. Carpal, metacarpal is then to the metacarpals and they're numbered from 1 to 5, going from the thumb, um pointing finger or index finger, middle finger, ring finger and then your pinky at the end. So 12345, nothing too tricky so far, right? I think the hand is pretty good sometimes. So, joints wise, you've got your M CPS, your P I PS and your D I PS. Uh and that's going from proximal to distally. So MCP is between the metacarpals and the proximal phalanges. P IP is between the proximal and the intermediate. And then the D I PS are between the intermediate and the distal. Obviously, the thumb is missing this intermediate phalanges. So it just has a proximal um and a and a distal, a metacarpal pharyngeal and a and a distal cool. The reason why that's so important is cos when we go on to think about things like arthritis, certain joints in the hand are more likely to be affected than others. So for osteo, you're looking at the D I PS and you're looking at the base of the thumb. And when we think about why osteoarthritis is very much a degenerative kind of grinding condition. So it happens with old age almost inevitably. So the joints which receive kind of a lot of work. So the gripping with the end of your fingers, uh and the base of the thumb with the grip as well, tend to wear out. And rheumatoid affects um the index finger and the middle finger, the proximal, the P I PS and the M CPS cool. OK. Bones are done muscles now. So the muscles of the hand are kind of crazy. And Harry's done a lot of the heavy lifting because he's done all the extrinsic muscles, which are the ones which go originate in the forearm and then insert the hand. So I don't have to cover any of them. Uh But I'm gonna be focusing on the muscles which are in the hands themselves. So originate in the hands known as intrinsic muscles. There's a lot in the hands and I don't think this is the best way to learn them because obviously it's crazy. So we're not gonna do that. We're gonna break them up into some groups. So the first group we're gonna look at is the thenar muscles, which essentially just means dumb, right? Um And they will have the word poly in just to make your life easier. There's a tenderness kind of sheath here again, I would have asked. Um But I'm hoping that everyone knows that that is the flexor retinaculum. And why that is so interesting for us, is that alongside the carpal bones? You can see underneath that, that's where we have our amazing carpal tunnel where the median nerve will run. So it's good to keep in mind for later. And a lot of stuff originates from that as well like that attaches to it cool. OK. So the thumb, all of the thenar muscles and that's obviously the tha eminence here, your big thumb muscle is made up of a three. Uh and they all are innovated by the median nerve. So keep that in mind for later for opponents policies that um originates in the trapezium and it inserts into the lateral first metacarpal. So it's very much kind of the lowest one on your thumb. And that is for opposition of the thumb. So that's bringing your pinky and your thumb together. Luckily for you, they all have their actions in the name as well, which is perfect and much easier to learn. Um So keep that in mind going forward. Abductor Pollicis Brevis is in the trapezium and thee foot. So we talked about that foot earlier and that attaches into the proximal phalanx of the thumb. So a little bit further up and again, that's for abduction. So you can see here that's both palm or uh sorry, that's radial abduction. And then in this sense, abduction kind of across the palm. Um and infer flexor polys brevis um inserts into the base of the proximal balance of the thumb. So it's similar to a Doctor Pois Brevis and that flexes the thumbs pretty much because they're all innervated by the median nerve. If you notice that a patient has a particularly kind of absent thumb muscle so that you can barely see any sort of thenar eminence. Obviously, you have to expect that some older people can have a bit of muscle wasting. But if it's really absent and they're younger, you've gotta think that maybe carpal tunnel syndrome, which we're gonna look at later is reaching a point because obviously it uh compresses the median nerve that is probably gonna need surgery to fix rather than just kind of conservative management. So keep that in mind for later when we look at carpal tunnel, ok, hyperthenar. So we're looking at the other side of the hand. Now, this bit here and these are your pinky muscles not too complicated. Again, there's three in that compartment, there's another one which is sort of related and we'll talk about that in a second. So opponents digiti mini me opposes the little finger abducts a digiti mini me abducts the little finger and flexes a digiti minimi brevis flexes the MCP joint of the little finger. So again, all in the name, um So don't feel like you have to learn these actions if you can kind of get through with um a bit of logic and there uh they originate again in carpal bones and insert into different bits of the pinky finger. But here because they're all innervated by the ulnar nerve muscle wasting here can indicate ulnar nerve neuropathy. So that could be from diabetes or other kind of, you know, mononeuropathies, something like that. There's obviously loads of neuropathies but keep in mind little finger, ulnar nerve, thumb, median nerve, cool metacarpal muscles. So these are kind of your muscles which do the kind of finger movements more so than the kind of bigger movements of the hands. So the dorsal interossea, er they insert into the proximal phalanx from the metacarpal. So you can see them here. Er and they abduct the digits and they assist with flexion and the palmar interossea is essentially the same they in certain similar places uh but they add up the digits. So it's coming apart and coming together with the palm of dorsal as for the lumbrical um oh and sorry, they're both innervated by the ulnar nerve. For the lumbrical, we're looking at the tendons of the flexor digitorum profundus muscle is their origin and then they insert into the extension expansion of the hand. So as you can see here, the key thing with the lumbrical is that two of them are in innervated by the median nerve and two by the ulnar nerve and obviously the medial two by the median nerve again, nice and easy two more muscles. And you can go over the origin of insertion of these in your own time. But the main function of these are the palmaris brevis is to improve grip. And that's just below all of the other um hypothenar muscles we just looked at. So the pinky finger muscles and it's quite a small rectangle muscle and it just tucks in there and it, it helps you grip things, you know, it supports that kind of bottom, bottom part of your grip. And the ab the AUC a poly sort of should be a thea muscle, right? Because it does the opposite of the um abductor policies, but we can't consider it one technically cos it's, it doesn't originate in the um, same place as the others so that a abducts the thumb. So it brings the thumb back towards the pump, think of abduct, abduction is abducting someone and abducting is the opposite of that, obviously, cool jus contracture. So I would have asked what is contracture? Essentially, it's a shortening of the um, of the, uh, what's it called the tendons in your, your palm? And it, it causes these big nodules to form, er, and in this scenario, you'll often see patients with kind of a permanently contracted pinky finger and ring fingers, it's normally kind of stuck in that position. Uh, and they can't really fully extend it. Um it's rarely painful and to assess whether, you know, they have dupers contracture, you ask them to put their hands on the table and you see if they, if they can, um, can do that without, you know, cos obviously their fingers are permanently contractor. So they're gonna have a hard time management wise. Mostly it's conservative if it starts to cause problems. And you can look at, uh, fasciotomies or fasciectomies, which essentially means getting in there with either a needle or surgically and kind of loosening. Um The tendons cool. Now tenure synovitis is from repeated strain on a tendon. So this happens with either the thumb or the fingers. If it's the thumb, then it's DEA veins and if it's the finger, then we get something called trigger finger. Um with Decca veins. 10 tenure sinusitis, essentially, it's from repeated movement of that, those big thumb muscles. So these, these um these two extrinsic muscles which Harry would have covered and some people call it mummy thumb because often mums get it or, or dads from lifting up their newborns, cos it's that very specific kind of heavy strain. Uh So that's a good way of remembering it cos you'll never see something like that again. And the symptoms are you get pain which radiates to your forearm and some burning and weakness as well. And there's something called Finkelstein or IO test. Uh people get confused but it's where you tuck your thumb into your fist and if you pull it down like this, I don't know if you can see me or if I'm just doing this, it should be, if you had, you know, tendons avis, you should feel a lot of pain kind of at the, the top of your radius, which is where those tenons are being yanked and pulled. Management wise, we're looking at resting, splinting and pain relief, physiotherapy, maybe as a backup, uh, to kind of encourage people to continue moving their thumb. So it doesn't, um, it doesn't become stiff and then steroid injections are kind of the, the gold standard. Uh, and rarely would you need surgery for this trigger finger? Very sa very much the same. But this, in this scenario, you get a lot of clicking as the nodule kind of extends through the, um, the, the pulleys of the, of the fingers. Um, again, it's a clinical diagnosis similar to, um, the, the other 10 synovitis and management is very much the same, but surgery is more indicated. There's a table with all of these things at the end. So we can go over all of them blood wise. There are two major arteries which, um, supply the hands, the radial artery and the ulnar artery, uh, then they branch off into the superficial palmar arch and the deep palmar arch, er, to kind of make sure everything is covered, um, which artery supplies the scaphoid. Well, if you look there, you can see it's probably the radial artery, it's a branch of the radial artery. But the problem with the scaphoid, as we mentioned earlier is that it's supplied um in it has retrograde supply. So the, the blood flow comes back across and it doesn't have any more anastomosis. So it's very much this one vessel on the scape foot as you can see here. So the problem with that is say, you know, you're 23 you're in your prime, you trip over playing football, hand outstretched, your scaphoid goes fractures. Uh it's an oblique fracture. So it's across the kind of neck of the uh you know, like the um the middle bit of the scaphoid and it cuts the blood supply. The risk with that is now you're kind your proximal scaphoid. So the the bit nearest to your kind of body now no longer has blood. So eventually that will become necrosis and that leads to um Pierre's disease. That's not right. That leads to um Prize's disease, which is that kind of avascular necrosis. And that needs to be treated surgically as kind of a priority because otherwise you risk losing um um a lot of function in the hand as you've seen a lot of stuff inserts in the scale for a lot of thar muscles, ok, venous wise. And this is kind of mainly significant when you're thinking about where am I gonna get blood from going to sign off. Um You're looking at the cephalic vein and the baci vein and they branch off into the dorsal venous arch and metacarpal and digital arches as well. Amazing. Ok. Nerves. Now, so we've looked at the kind of muscular supply of the nerves, as we said, thenar is gonna be median and hyperthenar is gonna be ulnar. Uh But as for the sensory, it's quite a good thing to remember because it becomes, um it comes up a lot when you're thinking about where has the damage occurred, uh which nerves have been damaged and how can I test that? So it's important essentially, if you're looking, if I have my hand out like this, the majority of this side, the palmar side of my hand is gonna be covered by the median nerve up to halfway across digit um four. And that's when the older nerve takes over. And on the dorsal aspect of my hands, the radial nerve supplies this kind of bit. Um As you can see, it's probably easier if I use a diagram. Actually, um this bit with my thumb and the two fingers here, the median nerve covers the kind of finger tips and the ulnar nerve, a similar kind of distribution on the the dorsal aspect. So keep this in mind when you're thinking about nerve damage, when you're looking at kind of sensory exams for, for neurology, you don't want to just be tapping everywhere blindly. You wanna have an indication of what you think might be going on and then confirm it with, with um sensory examination. So if you think maybe there's been some median nerve damage, you may be suspecting. Um um you're suspecting carpal tunnel, test the, the sites where you'd expect the median nerve to innovate and see if you know the sensation is there or if the pins and needles there or something like that. Cool. So that brings you on to carpal tunnel. The carpal tunnel is here in your wrist. That's where people tend to use the cross sections. It's from here. It can be confusing sometimes. So that's where it is and this is sort of upside down. But you can see here, we've got the carpal bones forming kind of what would be the, the base of the tunnel, er, and then this flexor retinaculum forming the top, the kind of superior sheath of the tunnel there. And what's in the tunnel is just the median nerve and the flexor tendons, which Harry's discussed. So, the extrinsic muscles which flex the hand. Um So nothing else. So don't, don't, you know, don't let it confuse you. And the reason why we talk about the carpal tunnel is because um it can be compressed quite easily. You know, there's a lot of things people can do. It can either be the things inside swell, you know, your tendonitis in there or um damage or trauma to your wrist can all compress the median nerve. And that's when we get carpal tunnel syndrome, which is compression of this median nerve and we can see it here. So the transverse carpal ligament, which is otherwise known as the flexor retinaculum, same name um will push on the median nerve and it will give you symptoms which are both sensory and motor related to the median nerve. So you'll lose some of that power in your kind of thumb. Um It depends obviously on the degree of compression and what's caused the compression. So if it's an infection, it might be much more acute. And if it's kind of long term trauma, you might see a gradual change. Um But yeah, we'll see both sensory and motor symptoms. Um And you'll often hear people complain of kind of uh tingling, uh you know, paresthesia in their, in their fingers that are related to the median nerve. So, obviously, thumb, index and middle finger and then half of this, this ring finger, the, we'd investigate that with C two Q uh C TQ, which is essentially just carpal tunnel questionnaire. It's just three questions to see, you know, how likely it is you have carpal tunnel syndrome and they involve things like is it worse at night, which would indicate um, carpal tunnel and also nerve conduction studies to confirm management wise. We're looking at resting and splinting and kind of periodical steroid steroid injections. And then as I said, if kind of you see the muscle wasting or there's more complications then that's when surgery would start to be considered. There's two tests. Uh, well, there's a test and a sign associated with carpal tunnel. So the first one is Phalen's test, which is where if you kind of upside down pray with your hands like this, um, it would be in someone with carpal tunnel that would kind of emulate the sy, uh, the symptoms that they get. So it would enhance the kind of pain or the paresthesia they feel in the in those digits and tel side. I think everyone should try. This is when you tap on your wrist, you'd be able to hit the median nerve. If you, you just have to kind of move it around a bit, find the right place and you should be able to emulate, you should be able to get the kind of paresthesia and tingling in your fingers if you hit the right place, which can be, oh, there you go. You really gotta just keep trying to keep poking but there. So that is that is everything. Thank you so much. I don't know if I ran over. I didn't actually, but if anyone has any questions, uh I'd be more than happy to ask on the chat. Here is a table with all the conditions. I also mentioned these three conditions as well and co fracture I mentioned too about Harry covered that. Um So yeah, think of these, think of conditions in the context of kind of who would be your typical patient. So, uh, Jones contracture is actually quite common in northern Europe and Scandinavia for some reason. But that happens in, you know, a lot of manual labor and as I said, with the pregnant women are more susceptible, but also the, the kind of mummy thumb where people are picking up their babies is something to think about as well. And diabe uh, di people with diabetes often get trigger finger just cos of the kind of sequela of um diabetes. Thank you all so much for listening. Uh I'm happy to answer any questions. I hope that all was ok. Um Let me stop sharing my screen and yeah, if anyone has any questions, we've still got five minutes. So shoot away. Uh And if not, then ask me and Harry, we can send the slides and the tables over. Thank you so much to Harry for. I know he had a little bit less time but he, he really spent through it. So, no, thank you. It was an amazing presentation. That's really good. Thank you. Thank you so much, Harry. It's very kind of you. Um Amazing. OK. Oh, sorry. No, no, go ahead, go ahead. Um I was just gonna say thank you so much. Everyone. The feedback form should be in the chat if you could fill that out for you to get your certificate. And thank you so much, Harry, incredible presentations. Um And yes, feel free to ask them any, any questions? If does anyone have any questions? Because if not, then we can wrap it up there. I think everyone's all good. Thank you so much. Everyone regarding the slides. How how do you, how how do the other students get the slides? Sorry, got it. Ok, thank you. Cool. Ok. Ok. Thank you the best everyone. Thank you.