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Um uh there's one more person that's joined. Perfect. Awesome. Can everybody hear and see the intro slide that says upper limb trauma on it? Just drop us a message on the chat. Guys don't need to be shy. I think everyone needs their coffees. They don't wanna listen to my voice like on a Saturday evening. Yes. Yes. Do let me know and I can start Minera mhm Streaming, you know. OK. Yeah. So welcome everyone to our second session uh in the Trauma and orthopedic series, Upper limb, upper limb trauma. It's hosted by our favorite registrar, Khaled Mohammed Fare and he is a trauma and orthopedic specialist registrar in our trust uh Ashville and Peters uh in uh Cherts. Um So without further ado, let's call it start. Hi K welcome. Welcome to the session and thanks for doing this on a Saturday evening for us. Thank you. Thank you for having me. Um Good evening, everyone. I hope everyone can hear me loud and clear. I will assume that you guys did cause silence is a sign of satisfaction. So, um we'll go through upper limb trauma. I know this session said lower limb. But um I thought we would just continue on for those who especially joined us from the previous session. What we'll do is we'll focus more clinically on upper limb trauma, please. By all means, if you have any questions, please drop them in the chat box, I'll answer you to the best of my ability. And um yeah, uh let's get started. It's a, it's a slightly long session. I'm very sorry, but bear with me, I'll try and cover everything we can and yeah, uh we'll be asking you guys a few questions as well. So I will stop my camera now and then we will go through our slides, right? So we'll discuss everything. We'll try to go all the way from the top of the shoulder down to the digits. Um Obviously this is um not an exhaustive list of things, but these are just some of the things that you might come across um in your career, whether you want to do orthopedics or if you're doing a rotation. So we'll try and cover as much of it as we can. So we'll start at the top end, which is clavicle fractures. Now, these are very common. Um Mostly it happens in younger people, active patients and so um most of them occur in the middle third and if anyone can drop some answers for me as to why that is, that would be great. I will judge you later on. So don't worry. Um uh But they are quite um common injuries. They can be associated with things like rib fractures, pneumothorax, floating, shoulder neovascular injury. So it's really important that when you take a history from the patient, you identify what the mechanism of injury is and you look for some of these things specifically looking for like numbness weakness if they've got any trouble breathing. And of course, don't forget your A S. So, um, assessing airway and breathing is important as part of any trauma screening as you'll come to learn more. Hopefully, through all of these sessions that we're gonna do. And of course, specific examinations include you checking your skin condition, pulses, sensation and motor function. So these are just some classification um systems we use most commonly, we use this one, the near classification. So it goes based on the location um of the fracture. So type one is in the middle. Type two is usually the lateral um three subtypes of those. We'll discuss that in a second. And then of course, type three, medial, which is closer to the sternum or the sternoclavicular joint. So especially with type three is always look out for things like lung injuries, contusions cause it's not very often that you get this type. It's most often that we get the middle side and often the um distal or the lateral side, right. So, yeah, Carlin, the I'm sorry for interrupting the slides are not moving. Are you trying to move the slides Oh, I am so sorry. Please bear with me. Apologies. Gu you know, I I'll just share the entire screen. I think that's the easiest thing to do. Um Before we continue guys just let me know if you can see these. Right? Yeah. Yeah. No, now it's perfect. Yeah. Fantastic. Sorry. Going back again. So clavicle fractures, as you guys can see here, this is a left clavicle fracture and it's very clear that there's a disruption in the continue of this bone, you know, back again to near classification. I'm very sorry. So as we said, type one, type two and type three. So type one is uh the most common of the two of the three types and some of you guys will be expected to answer that. If not. Don't worry, I'll tell you at the end of the session, type two and type three, not as common. And type three, especially you guys have to look out for because this is closer to the sternum sternoclavicular joint area. So you just gotta be careful about it. So, um patients often present after a fall. This can be both high, low energy mechanism. And of course, like we said that what's most important in these is asking some certain key questions. Um social history is important, what their function is. Um are they right left-handed and whether or not they smoke or they take any recreational substances? So, distal clavicle fractures now, like we said, thankfully, these are not very common um but these can incur a lot of problems for patients as you guys can see over here. So can you guys all see this, Mora can, can you see as well? So we've got many different types, type one, type two, type 34 and five. And you guys can see that there is a lot of uh ligamentous structures in the surrounding in the vicinity and depending on the subtype of these, we may need to sometimes intervene surgically. So, especially if, as you can see in type four or type five injuries such as this one, there is a lot of disruption to the articular surfaces, but there's also um an element of what we call attending, right? So your conoid ligament, trapezoid ligament also known as your clavicular or a chromic clavicular ligaments. These are the ones here. So these are also what helps um stabilize your um your clavicle distally especially. So, now the question is um should we fix this or should we not fix this? So, Moira, would you please be able to kindly share the first poll? So let's have a look. So what do you guys think are some of the what we call absolute indications to fix a clavicle or to fix a fractured clavicle? So there's four choices there. Um Please don't worry, I'm not gonna judge you. Uh No wrong answers. All of these are reasons to fix um clavicle fractures, but which ones do you guys think are an absolute must for us to say? Ok, we need to fix this. Very good. I can see some answers there. Someone said more than two centimeter. Shortening. Yes, athletic patient, good answers. Any others? Ok. Someone said symptomatic nonunion. It's a close tie. It's actually um one for each. Very good. What about combination? Does anyone think that that is an absolute indication for us to fix it? Don't be shy guys, please go for it. Honestly, this will be, this will be good. You the answer will surprise you. What the answer is in these cases? Ok. Mohammed Mora said, nope, nope. To what severe comminution, I presume. Ok. So just to carry on with the session. So believe it or not, it's actually symptomatic nonunion. That is an absolute indication in this instance. Now most of collar bone fractures luckily can be managed non operatively. And often it is the case that you have to counsel the patients really well. But some of the absolute indications where we have to have to operate on these patients include of course open fractures or floating shoulder, which is essentially ipsilateral scapular injury tending. So if the skin is threatened, for example, if the patient has arterial or venous injuries or if there's any neurological compromise and symptomatic nonunion. So all of the others that we mentioned are all reasons to fix a collar bone fracture, but they are not absolute, they're actually relative indications. So that includes more than two set in combination polytrauma and athletic patients. Of course. So the reason we would want to operate, so it's important when you speak to a patient is that they know what they're signing up for. So yes, while there is a faster union with surgical treatment and a slightly improved overall shoulder function, statistically speaking, it's not a very, very major difference. So you have to choose your patients carefully. So the for the young fit and active, you'd want to probably offer them surgical treatment if you find any of these indications, the relative ones and just instruct them that unfortunately, there are also some risks. So the main ones are, of course, because it's so close proximity to a lot of major nerves and vessels, there's risk of damage to that. And of course, because it's in close proximity to the lung, there's risk of pneumothorax. And of course, um um iatrogenic lung injury, right. The most common complaint that people who have surgical treatment of clavicle fractures is that there is prominence of the metal work, approximately 30% of patients will say to you, you know what I just want you to take this out. And of course, um in this case, it's obviously you revisit these same risks again. Um So it's important to just have a conversation with these patients because a clavicle is quite a prominent bone and it's very superficial. So all of these are risks, infection, of course. Um But of course, the main and greatest independent risk to these fractures, not healing is smoking. So you also have to counsel your patients about that and generally smoking carries a risk for nonunion anyways, but specifically with clavicle fractures, um research and evidence suggests that it is the greatest independent risk and you often have to instruct people to quit smoking before you offer them surgery. Now, as you guys can see on the left side, so this is a midshaft clavicle fracture. This is a fracture. I hope you can all see this and this is how you fix it. You put a plate on top of the bone, you span the fracture site and this tiny little screw here and the function of that is to just hold the two bony fragments together to achieve compression. Now, this plate here, as you guys can imagine. Now, this is quite an irritating thing to have because all the joints are so small. This is called the hook plate. We usually use this in um distal clavicle fractures or a lateral third of clavicle fractures. And this again can cause a lot of irritation to the shoulder joint that can lead to adhesive capsulitis or frozen shoulder. And people just generally really, really hate this plate. So yeah, you have to just think about how you choose your treatments carefully, right. So um we move on now and talk about something very close to clavicles, which is your chromar joint. Now again, um like clavicles, many of these injuries can actually be managed conservatively. But as you imagine, there's quite a lot of ligamentous uh structures and it's often a isolated ligamentous injury and they happen in the same uh mechanism and mannerism as a clavi contractions. Now, what happens with these is you've got something called the Rockwood classification. So, as we mentioned again, there's lots of um ligaments and lots of uh def forming forces acting on this. Um The main one is of course gravity. So um after disruption, and the clavicle actually lays in its place. It's all the rest of these structures that actually fall down. And that's a common mistake that people try to make when they're operating is that they try to push that down when what they should be doing is that they should be lifting the arm upwards. So gravity is the greatest enemy when it comes to these. That's why you often offer them a poly sling or a broad arm sling so that it immobilizes everything. Now, this classification is extensive. I'm not gonna go through all of it with you, but essentially what it is is you've got to just keep in mind that you've got your chro clavicular and your coracoclavicular ligaments. And depending on the degree of tear, of course, you might want to offer patients surgical treatment on these, right. So type four, type five and six are ones where we often offer surgical treatment for these patients and let me just move this away. Sorry, that's disturbing you guys. And um as we say, the achromic clavicular distance is clearly widened here. As you guys can see, the only time where the clavicle actually displaces is type six here. But this is very, very rare. It doesn't often happen. It's most often these 1 to 5 types, right? So type six is rare for you to ever see. It's mostly academic. So these are the ones you offer surgical treatment for. And the aim of your surgery is as we said to try and restore it to this type of appearance rather than have it looking like that. All right. So now we move on to the next slide, which is, we talk about our next part of the upper limb, which is your shoulder. So proximal humerus fractures. Now, luckily, as you'll get to know in upper limbs, generally, a lot of things can be managed without surgery. Proximal humerous fractures are very common in the elderly osteoporotic and they are often two part and we'll talk about the parts in a second. Most commonly affects females. As you guys would imagine, people who, um, hit menopause, for example, are often at risk of developing osteoporosis. That's why you find that more commonly in females, the most associated nerve injury with those is the axillary nerve. And of course, from previous sessions, um, we discussed that the blood supply is primarily supplied by anterior, posterior circumflex arteries. Now, as you imagine, there's lots of attachments in the shoulder. So you've got your pectoralis major uh which displaces your clavicle or sorry, your proximal humerus, immediately your deltoid, which um attaches at the, just uh just distal to the proximal humerus and that displaces it laterally. Then of course, you've got your rotator cuff muscles, the um supraspinatus infraspinatus, terris minor work on external rotation and the subscapularis works on internal rotation. So this is another um so when you're, when you're thinking about cla ins specifically, when you're thinking about which ones that you should operate on, you have got um something called the Hertl criteria, which is essentially, these are very complicated terms, don't pay too much attention to them. Um Unless you're of course interested in orthopedics. So this is a criteria that determines head ischemia or predicts it. And it focuses on three main things which is the medial calcar hinge. So this distance here. So depending on the displacement and the medial hinge displacement. So if you guys imagine this is the shoulder joint here, that's the gratitude prostate. So that's the lateral side, that's the medial side. So this medial calcar will be the most important thing when you want to think about which ones you want to s fix. So if it's um less than eight millimeter hinge, so if this distance is very small, then you'd want to think about surgical treatment because there's risk of avian and head ischemia and displacement of the medial hinge that same side here, if it displaces inwards, right. So, in relation to the shaft of the humerus, so this ball goes in that direction, the um the shaft of the humerus is in that direction. If that's more than two millimeter displacement in that plane, then you think about surgical treatment, anatomical neck is another one. So um head split is another one that you want to think about. So if there is a head splitting pattern, which we're gonna look at in a second, then these are all predictors that the patient might go into a vascular necrosis. So that's something to just keep in mind when you're um treating these patients, near classification is very commonly used. It functions the sort of um four different parts in the humerus. It's like a jigsaw puzzle. So you look at the surgical neck, the greater turo, the lesser turo and the articular surface. So one part fracture or two part fracture, three part and four part. And as you guys would imagine, the more there are parts in a fracture, the more you are likely to require surgical treatment. There's other subtypes, um valgus impacted which impacts and then it goes in that direction. So valgus, so away or lateral from the body and then of course, the head split which we have discussed. So this is one that you guys would imagine would need um surgical treatment as well. So looking at these, these these fractures we have just discussed. So between these three. So I'm gonna if you just bring up question too, please. So out of these three fractures, which one do you guys think will need surgical treatment? A B and C? Let's go back again. Sorry. So I'll keep this on for a couple of minutes. Then I'm going to take a look. Let's have a look at the pulse. OK. Someone mentioned C OK. Two people, men B OK, let's back again. Just remember guys, you've got a lot of um if we go back to the criteria in a minute, just think about the alignment, the overall maintenance of the proximal humerus check between all of these three. Which one do you looks like it's the worst displaced or the one with the more parts and the one with the calcar disruption as you guys can see. Sorry Mohammed. Can you see these? Sorry, let's go back to them. Can you see the powerpoint enough to A B and C? OK. The, so it's a tie between type B and type C. So I'm going to stop the question now. OK. So, absolutely. Right. So I think type C is actually really well maintained if you guys can take a look. So yes, there are multiple fragments here, but actually the overall alignment specifically the medial calcar is actually not so bad now with type B on the other hand, as you guys case, so this is all disrupted. So it's all sort of smashing on top of each other. And of course, there's a lot of fragments here. I suspect there might be an element of a head split. OK. So this is where the head is. And of course, the greater tuberosity is also displaced. Now there's also extension into the shaft. So all four parts, I think this is probably a four part fracture with a possible head splitting injury. And of course, type A. Now there's a back shadow there. That's where the humeral head is. So I suspect this can also be offered some form of surgical treatment. But also if you apply color and cuff to this patient, which as we'll get to know now, um this can probably avoid surgical treatment, but I think between the three of them, I'd probably go for B as well. So well done to those who chose type C is actually um I think the only thing what might want me operate on this is if this greater tuberosity displaces in the future or of course, if the medial calcar gets disrupted. So like we said, most can be managed non operatively with the collar and cuff. And the idea behind the collar and cuff is that it attaches to your wrist as well as the neck and it allows the elbow to drop down. So in this event, in this case, opposite to the clavicle gravity is your friend. So you allow the elbow to drop down and hence you restore the alignment so that it looks something like this rather than it being impacted, like. So I'll come back to this point later and we will discuss it again. Um GT fractures that bros, do you remember guys? It's um an attachment site for a lot of the rotator cuff muscles. Three of four patients who are low functional, low demand or of course poor surgical candidates. So very old, very frail um extremities of age, pediatric fractures are actually mostly managed non operatively and you encourage them to mobilize the shoulder. So you instruct them to start physiotherapy when it is safe to do. So. Now, operative on the other hand, so all of these things that we discussed. So we look at the Hertl criteria again, head splitting fractures. Of course, if the GT is displaced more than five millimeter because this is a site of insertion of the rotator cuffs dislocation. So you gotta be very careful with these uh patients who have got a fracture in this location. These are um quite troublesome to manage as you'll come to know, we'll discuss these locations in a second. Um You have to just be very careful with these um 3 to 4 fractures in younger patients. Uh So these are some of the indications that we think about surgical treatment. There's still a lot of controversy. There's a lot of research going on about what is the best type of uh surgical treatment to offer. But some of the things we offer are open reduction, internal fixation, intramedullary nails. So these are especially when you have an associated shaft fracture. So for example, if it's extending beyond the proximal humerus, such as this one, for example, so if the uh fracture extends downwards, so it goes down to the mid shaft, for example, you would offer them an intramedullary nail. And then of course, as a final solution, we do arthroplasty. So these are patients where we don't think that the head will survive or if it's poly poly combination, uh patients who are elderly because as you imagine arthroplasty will actually um need revision at some point. So as we mentioned, so when you want to treat humerus surgically, so this is from the previous um uh lecture. The main thing is you want to try and achieve as much anatomical reduction as possible, specifically the medial calcar that's gonna be the most important um terminate in your um following the Hertl criteria, of course, and something central column diaphyseal angle. So you draw a line straight down to try and identify what the central axis is. And then you draw a line uh from one end to the top of the GT here and then another line from there dissecting those. So at 90 degrees and that angle is usually 100 and 35 degrees. So if it's anything more than that or if it's less than that, then you are most likely going to have a failed fixation, right? So then you ask yourself, how do we achieve a stable fixation? We do that using this guy, he's called the Felos plate. Um You don't need to remember these names, but essentially what you need to know is after you've reduced everything, after you've put it into absolute perfect anatomical alignment. To the best of your ability, you put a plate with a bunch of screws, some of which go into the head or they go through the neck and not through the head, hopefully, and uh some that are stabilizing into the shaft as well. So it acts as a device that recreates that 135 degree angle that we like to see. Now, this number here, 5 to 8 millimeters um is essentially to suggest where you should place these plates. Because if you imagine you put the plate somewhere there and then you try to drill some holes as it's going in this direction, it will not do anything. It will in fact, just irritate all the structures around here. It will just be nasty business for you and the patient. So always remember this, if you decide to do orthopedics, just remember this um small distance, just keep a small distance away from the tip of the GT so that you can place this safely without compromising any pro any of the um rotator cuff or the rotator interval or any of the other soft tissue structures in the surrounding. Ok. So moving on arthroplasty, as we mentioned is an option. So there's still a lot of debate on when you should fix when you should offer shoulder replacement. But as we said, specifically patients who are elderly with poor bone quality or have severe combination that fit any of the criteria we discussed before. And they are um essentially someone who could comply with surgical treatment, who are good surgical candidates, you would want to offer them um shoulder replacement surgery in the younger population, you tend to avoid that because as we say, shoulder replacement or arthroplasty in general has a shelf life of about 15 years, 10 to 15 years at best. And what you want to do is you, you don't want to keep taking the patient back to the operating theater. So you gotta try and um uh avoid shoulder replacement in the younger patients. So yeah, that's um that's essentially proximal humerus fractures in a nutshell and we will keep moving into dislocations. So most of these uh if you work in any uh hospitals, emergency departments, uh you'll come across these a lot. So because they are the most frequent major joint dislocation mo a majority of which go anteriorly, they typically happen um as a result of contact sport or high energy in younger patients. Of course, in um older and frailer patients that can still happen. Although that is not as common. Um it happens with forced external rotation um that you dislocate the shoulder anteriorly. Now, posterior thankfully again, is not very common, but it does happen a lot with people who have seizure episodes. If you imagine when you go into a ses episode, it goes into a force, internal rotation of the shoulder with a slightly abducted arm electrocution is the same thing because it puts you into that state and of course, traumatic injuries. So 5% of those are posterior, the majority are 95% are anterior dislocation. Now, let's show question number, I think it's number three. So if we look at this X ray here, who can tell me what the sign is called and what does it mean? Let's have a look. OK. Light bulb side, anyone else? Oh man, you can't see it. Sorry, Mohammed. Can you see it now? OK. Yeah, I'm sorry. Uh I don't know what's going on there. Mohamed. But um OK. So just to move on. So this is this is called the light bulb sign. Absolutely right. Whoever answered well done you. So this looks like a light bulb like so exactly like a light bulb and this is a sign that there's a posterior dislocation. So it's an internally rotated arm. So the humeral head is actually looking backwards. So you can see here that's the greater tuberosity, right? So that's the lateral aspect of the shoulder. So instead of it being somewhere here, it's actually facing you anteriorly and that is a sign of posterior joint dislocation. All right. Now, management wise, um of course, any dislocation is an orthopedic emergency. Now, shoulder dislocations have been reduced from the days of Ancient Egyptians. There are more than 20 published techniques, all of which have their own pros and cons, of course, um depends on what works well for you. There are many different types. Some are obviously much more aggressive than others. You'll get to see in a second, you have to just be very careful as we said earlier, if there are associated fractures or if the patient is elderly, because there were instances in which a patient um who's elderly sustained the dislocation. And when we tried to reduce it, a fracture took place. So you just have to just be very careful. Um take your time with it, make sure the patient is appropriately analgesic and sedated. Um And of course, if you're struggling or if for whatever reason, you cannot reduce the shoulder, if there's an associated fracture. Um There's always an option for you to take it to theater. Um especially if there's concern of neovascular injury in these instances, you might need to do an open reduction. And sometimes if you find any bony defects, you might need to fix it then and there um once you've done a successful reduction, you keep the patients in a sling now in patients who have got recurrent instability, people that keep dislocating their joints or if they've got things like a slap lesion or um any other um things like Hill Sacs, for example, then you'd want to do further imaging specifically an MRI or an Mr Arthrogram so that you can assess the morphology of the shoulder and so that you can hopefully achieve a situation in which patients um uh will have surgical treatment and not required to have to keep coming back to the emergency department with this location. The only um sort of exception to that rule is patients who have got epilepsy, for example, or some form of convulsive disorder, you'd want to usually um aim for a period of seizure free um activity specifically up to a year is the general guidance before you offer them any surgical treatment. Because if you think about it, if these, if these patients have um instability and they keep having seizures, then the shoulder just keeps on popping out. There's no point of you putting them through the risk of surgery. And of course, um it leading to future problems now always get two views. Sometimes it's not very clear. So luckily in these pictures, we can clearly see it that there is a posterior shoulder dislocation here, but this is often missed. So make sure you get a second view. Usually we call this an auxiliary view. So almost a lateral and then you'll be able to determine which direction it's going. Now, as we mentioned, there's a lot of techniques to reduce the shoulder Hippocratic one, you guys can see that's um it appears a bit primitive, but it actually works really well. So you are putting pressure onto the axilla whilst you are on the arm and externally rotating it. And what that does is that it puts pressure on the humeral head and of course, pushes the chest wall away and it allows you to essentially use the arm as the lever so that you can reduce the shoulder cockers. Um you just essentially reverse the mechanism of injury and stimson's and of course, milch. So these are some techniques that you can use to reduce shoulder dislocations, specifically anterior shoulder dislocations, no moving away from the shoulder, um going a bit distally diaphyseal humeral fractures. So these can be, as you guys can see, it can be the proximal shaft, it could be the midshaft or of course, it could be the distal shaft. They are common um injuries of long bones, bimodal distribution. So you get them both in uh uh very young in our patients, which is uh often the case in polytrauma, for example, or um excessive high mechanism injury and you can get them in patients um of extremities of age as well. So elderly patients, um they're important because they are the insertion site for a lot of muscles. And therefore there's a lot of deforming forces. So you've got your pectoralis major which attaches somewhere along there, your deltoid and coracobrachialis somewhere down there. So there's lots and lots of different attachments. Um So these are important to just look out for. Now, it's also the origin of your brachialis muscle, your brachial radialis and of course, the tricep posteriorly. Now looking at some of these pictures, um wonder if we can bring question number four, please. What is the most associated nerve injury with a diaphyseal humerus fracture? Ok, good. Someone said radial nerve, musculocutaneous median ulnar nerve. Are you guys able to see the pulse? Ok. Radial nerve. Very good. Yeah, it is the radial nerve and just drop in the chat box. Tell me what you guys think the clinical signs. So those that attended the last session will know, please drop an answer in the chat box. I'll now close this pole and we'll go back just because I don't wanna keep you guys here very long. So radial nerve is the most commonly injured uh nerve with this. That is one of the indications of why you should operate on this no more often than not. We offer the surgical treatment um in the event that the patient is of course, again, not a good surgical candidate, someone who's um for example, frail and at risk of a lot of things from general anesthetic or if, if you're concerned, for example, that they will not comply you tend to go along the conservative route where we place something called the humeral brace, which attaches on either side of the humerus. But as you guys got to see, there's a lot of muscular attachments here. So this can lead to a lot of problems and the fracture can displace. In fact, the humeral brace might be challenging for some people because it can be prolonged. Now, as we said, if there is a suspected nerve injury, nerve palsy, it's more common at the distal third. Um then you want to operate on these, you want to offer them surgical treatment, open fractures, displacement, and of course, nonunion. If the fracture fails to unite and you often give it some time, then you'd want to think about surgical treatment. Um Intramedullary nails again, um can be offered to patients in these instances. But what you gotta think about is all of this is done so almost percutaneously. So if you try to pass a rod all the way from the top of the shoulder down, then you might encounter the radial nerve somewhere. So that might be a problem. So, um that's why there are surgeons who are generally wary of using intermedullary in NS. But you can also use humerous um plates over here such as the one you see there. So you guys can see it's quite an extensile approach and um but it's, it's a good way to achieve union. Now, on the other hand, distal he fractures. Now, the, they tend to be a lot more sinister and luckily they're not very common, but they do affect um uh young males and older females. Typically, they represent approximately 2% of all fractures and they're classified into either supracondylar. So you imagine the condyles or somewhere there? So, anything above that, that's called a supracondylar fracture, then we've got our single column. So either the medial or the lateral side. And of course, the more common of the two is the B columnar. So where you fracture both of the columns. So that one and that one, this is uh we'll talk about the classification a second. The elbow joint is a hind joint. Typically, it's about six degree valgus, five degree external rotation and 30 degree flexion. So that is the resting position of the elbow. A lot of structures are surrounding it. So you've got musculature and ligaments, of course. So you've got your common flexor and common extensor origins, uh your M cl and lateral collateral ligaments. So these all provide stability for the shoulder, um radial nerve, not very far. So, but it's, it tends to be a slight bit more posterior uh as it crosses over in that direction and then comes down that way. So it comes down from here, comes up there and then your ulnar nerve is very close proximity here to the um medial epicona. So when we talk about classifications, so the one on the right hand side is the Milch classification. So this is used for, as we said, simple or singular column. So as you guys can imagine, so it's either medial or lateral conduct. So type one or type A and type B. So type A, uh you've got two types, type one and type two. And either of those can be managed conservatively if they're very minimally displaced specifically type ones. So both of those um but type twos often need surgical treatment because they tend to displace and they tend to involve more of the articular segment, uh Jupiter classification. So you guys can see it involves both of the condyles. So this is again, just to orient you, that's your radius, that's your ulnar here, that's your humerus, that's your electron and fossa. So many different subtypes, as you guys can see depending on the fracture configuration. So some are t type injuries, others are I shaped and some are H shaped. And then of course, there's variations to the T shape. So these often, so Jupiter or bicondylar fractures typically need surgical treatment. Now, the question is then how do we treat it? So, as we said, Milch type ones, uh which are undisplaced are the ones that we usually manage without surgery. Most of the others tend to be managed um with either plates and screws or of course arthroplasty. So that is an option because remember this is a joint after all. So you can sometimes if you fail to reconstruct this, somehow you will need to um replace the joint. Now, same as before. Um again, arthroplasty, you tend to reserve for patients who are, for example, again, elderly and low demand, um patients who have got very, very comminuted fractures so much. So to the point that um essentially we call it a bag of bones really where it's just, you know, everything is just falling apart and there's just nothing that you can do to fix that. These are the ones you tend to offer arthroplasty for. So open reduction, internal fixation as you guys can see here. So whoever's done this did a not so bad job where they had put plates on either side and then just filled it with screws and just ensure that all of these screws are sort of interlocking. So it almost creates like a triangle effect, right? So if you guys have good imagination, so that's your lateral condyle just to orient you again, that's the radius, that's your ulnar here. And that's the distal humerus. It almost looks like a triangle. So the function of your plates needs to reproduce that or it needs to look similar to that. All right. So arthroplasty. So the ones on the left that's called the hemiarthroplasty or half hip or sorry, half elbow replacement where we do um replacement of just the distal humeral portion or we can do total elbow replacement like the one you see here. So where we replace that part, as well as the articular surface of the proximal ulna. So these are some of the treatment options. I'm not gonna bore you guys much with the details, but these are essentially the type of things that we can offer patients. So now on the other hand, we were talking about adults and um elderly patients in Children. It's very, very different. Um supracondylar fractures are can be very nasty injuries. Um They are especially seen in the younger of patients, specifically 5 to 7 years old is the commonest age group. It typically happens as a result of a fall on an outstretched hand and this can uh lead to what we call an extension type injury. I'll tell you guys about that in a second. Um The reason they're so serious or they can be serious is because um in Children, especially there can be vascular compromise. So there can be a lot of pressure on the brachial artery and of course, neurological, that's it. Now, the most common nerve that we tend to see uh affected is your interosseous or anterior osseous nerve followed by a radial and of course, the ulnar nerve which happens more with the flexion type of injury. Um Things that you have to look out for when you examine these patients is you've got to check uh the skin for compromise, you've got to assess a neovascular status. So you want to check the pulse you want to check the functions of all these nerves that we mentioned and you want to check sensation. Now, if we can bring the next question up, please. Sorry guys, I know I've, I've sort of shoved a lot of questions on to you. Now, when you think about um we said the an interosseous nerve is the most affected after the nerves, what you guys think will be the most commonly observed sign for these kind of injuries. So if you can show the next question up, please. Question number five. So out of these. So you've got weakness in wrist extension, digital flexion, thumb, interphalangeal joint, flexion and weakness in finger abduction. Now remember anenterous nerve is most affected. Which of these do you guys think is gonna be the sign that you see in these patients? Yeah. It's a difficult question, isn't it? Go on, throw some questions, throw some answers. Don't worry. Even if you get it wrong, it's not a problem. It's not an exam situation. I think people are just generally shy. Here we go. Some people answering some things, digital flexion, thumb, I PJ flexion. Anybody else wanna answer? OK? Someone said thumb, I PJ flexion. OK? Anybody else don't be shy guys, I'm showing you guys the polls. So you guys see who's answering what I give you guys one more minute. Tik Tok, Tik Tok tiktok. OK. Good. Some more responses. Someone said thumb, I PJ flexion. OK. Very good. So the most commonly observed sign with anterior interosseous nerve damage is thumb, IPG flexion. OK. So that is a specific test. That is the one that you want to look for digital flexion partly contributed, but it's mostly through the median nerve. OK. So it functions to flex um your F DPS, fdss. And that's why it is not often the case that you see that deficit. All right. Now, some of the things you need to look for now, especially if you're just starting off, some of these might be very, very confusing, but some of the indications that something might be wrong is the following. So we've got something called the fat pad sign, right? So this is uh normally occurring, but you should not see it unless there is some occult fracture or some hematoma that's causing this fat over here surrounding the distal humerus to expand. The one that is pathognomonic of the two is actually your posterior fat pad antifa pad might be visible in some patients. But in the context of trauma, you got to think is there an occult fracture? Now, some of the other parameters that you want to look at are your Antero humeral lung. So that typically needs to cross over down to the capitum here. So it dissects it. And if for example, that's not in continuity, then that line is not going to bisect over here, it's going to go either that direction or that direction. This is more obvious with um a slightly more flexed elbow. The other one is your cap and bisecting the radius. So if the radius goes in that direction, all right. So if that dissects that, then that is an indication that this is normal. And finally, the bowman's angle, so it's drawn from the lateral condyle going in that direction towards the electron. And the line dissecting it is the descending down from the shaft of the humerus down to the meeting point here. This angle usually measures about 75 degrees and if there's any disruption to that by five or 10 degrees, that's when you start to wonder whether there's something else going on. So elbows can be complicated to look at, especially for the inexperienced eye. Um Even I struggle with it sometimes, even though I've seen a few. Um but it's just if you stick to these principles and these measurements, then you might be able to identify whether there's something wrong. Now, gland classification is to tell us um what type of injuries that we expect. Now, in type one, as you guys can see here. So if you guys can look at that, you see that posterior fat pad that tells us that there might be a fracture there somewhere. Although you guys can see it's not so visible, it might be something going on, there might be something going on there. It's not very clear, I'll just zoom in so you guys can see a bit, maybe something there. But more importantly, this is what we see, we see this posterior fat pat sign here. Now, these are often managed conservatively. All you need to do is simply immobilize them for a short duration of time and then you allow them to exercise. Now, the problem then becomes when you have a type two A or type two B fracture. Um So as you guys can see what I was saying about the extension, so if you think about the humerus and the elbow joint in general, if you extend or hyperextend an injury, it's gonna head in the direction of the extension. Whereas if you flex it, then the flexion type will occur more in this direction. Does that make sense? If it doesn't, please uh drop a question in the chat box and I'll explain it again later. So extension, so we talk about the distal portion or the distal segment of the injury. So this part, so that's proximal and that's distal. So that goes into extension. That's the extension type I was talking about flexion type is going the opposite direction. So think about your own elbow, try to extend it and try to flex it and it will make sense to you. Now, with these twos, type two A and two B, these can be quite displaced as you can see here type two B is more displaced. So there's disruption and there's translation. So you lost your anterior humeral line as you guys can see here. And if you look at the bowman's angle, so if you try to draw it something like that, it will be very displaced, right. So there's clearly something not very right going on here. Um These are ones that we can offer surgical treatment for depending on the degree of displacement. And of course, type three, which is very obvious and very clear as you guys can see, this is very, very close proximity to your, your brachial artery or anenterous nerve. And this can actually lead to a lot of problems. So these are ones that you want to offer urgent surgical treatment for the typical algorithm is that once you see a supracondylar fracture, the main thing is whether there is a concern of um neurovascular deficit, um open or impending fracture and all of that. So it depends on what we see. Um if there is vascular injury or if there is uh impending open fracture, then you want to take these usually to theater urgently specifically, if there's an impending open fracture or if there's vascular injury. Now, for nerve injuries, you will most likely need to go to theater anyways. Um And these typically tend to improve once you've reduced and aligned the fracture a little bit better and held it with some fixation. But sometimes it might take some time before the neurological deficit results. Obviously involve your senior colleagues very early on the key take message here is that if you are concerned, if you see a fracture that looks like that or if it looks like that, obviously, call your senior straight away and um don't try and delay things, especially with pediatrics, usually have a lower threshold to, to intervene, right? Um, neurovascularly intact. If you see a supracondylar fracture on the opposite side that has got um none of these problems, then you often need to offer them surgical treatment, but you don't necessarily have to rush into operating overnight. Um keep a close eye on neurovascular observations. Remember, even if you put a plaster on a patient, um a back slab or a full plaster, you have to still check the neovascular status and you repeat the X ray to make sure that the displacement has not gotten worse. Ok. So that's the takeaway message for supracondylar fractures. Very common. They can happen and they can be problematic. So just be careful um when you're managing these, these are how we fix them typically. So um either we do criss cross K wires two millimeter usually and if the patient is less than five, use 1.6 millimeter. So cross sectional one from the radial one from the ulnar side or you do two from the radial side, but you have to make sure that these um cross each other, not where the growth plate is, but instead they cross out of the um out of the side of the growth plate and we have got to get good purchase of one side and onto the opposite side. As you guys can see, obviously, don't make it protrude so much because that can irritate the soft tissues. Um but just generally how we tend to do it now for the radial side. So this is the radial side here. So that's the lateral aspect. You can do this percutaneously with very, very small incisions. But on the medial side, you have to be a little bit more careful because this is where the median uh sorry, the ulnar nerve tends to cross over. So you have to make a slightly bigger incision, not too big, just about the size of the media that become that and you identify the ulnar nerve and you protect it throughout your procedure and these wires are smooth so they don't have threads in them. Um Because if you imagine you're trying to drill that all the way across to the opposite side, you are going to cross through the uh growth plate and you don't want the continuous spinning action which has threads on it to cause a lot of disruption to that. Um I hope that makes sense. If you have, if you guys have any questions, if it's not clear, please drop them again into the question box and I'll return to them after the end of the session. Another one that's um the bane of the existence of many um elbow and upper limb and trauma surgeons in general is this terrible triad. And the reason it's so terrible is because it involves every possible structure that you can think of surrounding the elbow. It's a, so it's um characterized by elbow dislocation, radial neck or radial head fracture and fracture to the coronoid fractures or the coronoid process, which is here. So that's your coronoid here. That's the elbow dislocated. So you guys can see that that electron is not sitting in its happy place. That's in a different postcode to that bone over here. So, um and of course, um as we said, coronoid fracture and radial neck fracture. So if you guys can see over here, that's the radius and that's the fracture here somewhere and that's your coronoid process here. So, sorry, apologies. No, typically happens as a result of firstly, injury to your lateral collateral ligament. So the ones on the radial side and anterior capsule disruption. So this is your anterior capsule here. Sometimes it can be associated with also medial collateral ligament injury. And as you guys would imagine, these are ones where you have to operate, you have to reduce the elbow, of course and fix it. So you stabilize the elbow, you want to repair your ligaments and of course, you fix whatever fractures you can fix. So sometimes your coronoid process, you might sometimes need to put a couple of screws there to fix the radius. And in the event that you failed to do so you might need to replace it. So there's a radial head replacement as well. So, nasty injuries, they have um generally not favorable outcomes, but if you treat them early, you can achieve the best possible outcome that you can achieve. Um So yeah, like we say, it's not, it's not very nice. That's why it's called the terrible triad of the elbow. Now, forearm fractures. So we move on. Sorry guys. II know I've talked a lot. We're, we're, we're getting there, the fingers are not so far. Now, um we're gonna get there eventually. Um Both bone forearm fractures tend to be more common in pediatrics than in adults. And in fact, they are the most common pediatric b injuries that you see. Uh they happen typically as a result of a fall from a height uh or direct trauma. So for example, night stick injuries, if you guys have heard of that, or someone might try to sort of defend themselves or defensive injuries. Uh if someone's assaulting them, for example, direct impact to either of the bone can lead to problems and it will lead to these fractures. Um Associated injuries include your elbow and your distal radio ulnar joints, your Galei and Montas fractures. We're not gonna discuss that much in detail just because of time constraints and because it's a bit too complex. So we're not gonna dive too much into that. All you have to know is that you just gotta keep a close eye on these two joints because remember um this can happen as a result of high energy trauma. Um just keep an eye on your elbow and your wrist and orthopedics would like to say, examine the joint above joint below. Um So always keep that in your mind um as you guys can see here, so for the keen eye, you can see that that elbow is also dislocated. So that's not a very nice injury to have these are fractures to both your ulna and your radius. And this is the second view that you can see. Now on this side, of course, you can see that this is a child. So the reason we can tell that is because this is where the growth plate is, it doesn't look like a normal radius. So this is what your normal radius would generally look like. But when it looks a little something like that, then that's a pediatric forearm fracture. All right. Now, you have to be cautious with these. So you examine them, you manage them um by identifying the injury, of course, examine your patients, check your neovascular status, always do that. Make that just your basic foundation for orthopedic examination and check for signs of compartment syndrome, specifically increasing pain and um not responding to analgesia, that sort of thing. Um Pediatric forearm fractures are generally more forgiving than in adults. They have good remodeling potential. You have to just consider how much um displacement there is. And based on these tables here, you can see it depends on the angle. So the angle is determined, looking at the lateral view. So if it's more than 15 degree or if it's less than 15 degrees, you can usually accept that and not need to do anything malrotation. So 45 degrees and of course, apposition. So if the fracture is going in that direction, so that's uh that's not opposed. So that needs to be somewhere there. So if there's more than one centimeter, then you generally tend to think about surgical treatment here. Um Greater than 10 years. Of course, the angles decrease, the malrotation decreases, bone opposition is there. And if someone has got um s or approaching skeletal maturity or someone whose bones look a little bit, something like that, then these are the ones you want to think about surgical treatment in these. Now, typically in Children close reduction and inline traction. So you essentially pull the bone to length and you apply a plaster which goes above the elbow. So it immobilizes both the elbow and the wrist joint. Um These are ones that you want to, that you want to just keep a close eye on it, you gotta monitor them regularly. And of course, if there's any concerns or further displacement, you might want to offer them surgery. This is the type of procedure we tend to offer Children. It's called tens nail. So the reason we don't use plates and screws here is because it is way too much disruption to the bones. And that could lead to a lot of problems, especially like um in patients who are skeletally immature, um use the flexible nail, tens nail, which eventually requires removal. Um And it occupies roughly about 60% of the medullary canal or the total diameter of the uh of the bone adults, as we say, um less forgiving injuries, they typically tend to require surgical treatment, plates and screws is the usual treatment of choice. Um The reason we don't like to use intramedullary nails here is because they don't give you that type of uh stability that you want. And it does not restore. It's very difficult because you imagine the radius has a bend in it. So it's very difficult for you to do that with a nonflexible nail. So an intramedullary nail is usually straight, right. So it's very difficult for you to try and correct that radial bow or the radial bend um as well as the ulna as well. So, intramedullary nail are generally not very favorable for these fractures. Um So you tend to reserve it for patients, for example, who have got um very, very poor skin conditions. Um But typically, most of the time we tend to just go for plates and screw fixation. Now, distal radius fractures, they are the most common bony injuries in adults. Uh You'll see this a lot. If you do an uh e job, if you do orthopedics, you might know someone who has broken their wrist before. And the reason for that is because if you think about it, if you trip and fall, the typical response, your human response is to essentially stretched out your hand so that you can break your fall. These are very common. Um, as we said, most common, they typically happen due to result of you falling on the outstretched hand. Um that can be either extended or flexed. Typically, it is extended. And the reason they're so important is because 80% of loading from the forearm through the hand comes through the distal radius joint. Um Again, same as everything in orthopedics. Um There's often chance to do both operative or non operative treatment. All depends on the fracture pattern, depends on some of the factors we'll discuss here. And if you attended previously, you'd recognize some of these things, the three columns. So if you think about it, that's um so if you imagine it like a structure that over there at the top, that's the wrist joint. And then there's the three columns which uh contain multiple different um articulating processes and incur stability. So any disruption to any of these can indicate that a fracture might be unstable. Now, as we mentioned, so the radial column is usually the more lateral third or the more lateral 60% of the um distal radius and the intermediate column is in between that and the ulnar column. And then the ulnar column is self-explanatory. So it's on the side there, each of them has many different articular points. So the radial, as you guys can imagine contains a lot of the um stabilizing factors such as the scaphoid fossa, which contains uh a slot for the tendon, uh radial ate ligament, radioscaphocapitate ligament. And of course, it prevents carpal, radial translation, which means it prevents the carpus or the um carpal bones from sliding above the radius. So it provides a lot of stability. The intermediate column is where the lunate sits. So we'll talk about the lunate in a second and it transmits load from the carpus to the forearm down this way. And finally, your ulnar one is responsible for stability of the distal radio ulnar joint also known as your wrist joint. So all of these are very important just when you think about what fractures you want to treat. These are some things to consider um some parameters we've discussed this before, but I'll go through it again quickly. Um Just for those that have not attended the previous session, what's really important when you want to treat a distal radius fracture is remembering these parameters. So these are all what a normal wrist joint would look like. Usually um radial inclination, the radius tends to be sort of going in that direction if you feel within your own wrist, you'll find that your radial styloid is often higher or has a higher height than your ulnar di load. And that parameter is usually around 22 degrees. Um You've also got your volar tilt on here. So if you look at the lateral view, dorsal side, um and of course, volar or palmar side, so the radius typically tilts slightly volar around 11 degrees. And finally, your radial height, which is around 11 millimeters. So that typically tends to be longer. So these are just some measurements that we use so that we can determine whether the um distal radius is again in the correct position or not. These are gonna be the parameters you use later on when you consider fixation, no, always anatomical reduction. So take away for any fracture management is that you want to try and keep it in the best anatomical alignment as possible for distal radius fractures, you typically want to reduce it. Um And reduction means that you restore the alignment or the anatomy. Um Your aim is to reduce the angles these angles that we mentioned. So typically you do inline traction or you pull from one side to the other, you exaggerate the deformity to try and disimpact the fracture if it's impacted and then you correct it. So if it's going more on the volar sides of your fracture is going there, you wanna try and push it in that direction and if it's going more dorsal, which is typically where it tends to go, you want to push it in the opposite direction. Ok. And then of course, you want to plaster it. So that should be your um initial management anyways, regardless of whether you choose to treat this surgically or not, that should always be the um, first step you do, you place your plaster, of course, on the side, which has got more displacement. And if you choose to manage these non operatively, then um you just keep a close eye on them regular followups, regular x rays just to make sure that it does not displace. Um Typically you tend to reserve these for more frail osteoporotic patients again, same as every other fracture um or if the fracture is very minimally displaced or if it's extra articular, if it's not involving the joints. So if it's, if the fracture is somewhere there, for example, or if it's somewhere there and it's in good alignment, you want to try and um keep managing these without surgical treatment. Now, if you choose to do surgical treatment, on the other hand, so in this case, you guys can see they've used plates and screws. So this is a front view also known as an AP view and this is a side view also known as the lateral view. So I think they did a pretty good job there. It's not so bad. They have restored the inclination. They have also restored the height and of course, they've reduced the volar tilt over here. So this is all very good. Now, the alternative option when the fracture is more displaced, but less combined than these ones, you can use K wires, as you guys can see they've done here. So you can use the wires, one going through each side, so one going from there to there and one going from there to there, they cross each other. And the idea is that it holds the fracture in good position. But of course, for both of these, you typically need to put a plaster on for a short duration of time. Um especially with the ones who have got wires inside. You'd want to try and reserve um taking them off the plaster for an extended duration because um that will just protect the wire. It just looks generally nicer and uh patients have a better satisfaction rate. Um plates and screws. We typically use these for adults or patients who are approaching skeletal maturity. As you guys can see, there's still a bit of growth plate left here, but this patient's growth plate is nearly fully fused. So you can use um plates and screws in this case or you can use K um K wires in the much younger patients, the younger population. Um because you want to try and disrupt the growth plate as little as possible indications as we said, um intraarticular displaced fractures or comminuted fractures, dorsal angulation. More than five degrees, radial shortening. Um All of this, all of course, with intraarticular elements and displaced them combin into the extra articular fractures. So, yeah, common injuries again, you can manage them both ways. You can do conservative treatments. Um or you can proceed for surgical fixation. Whatever you choose to do, you have to, you have to choose your patients correctly. You have to make sure that the anatomy is reduced to the best of your ability. And you gotta just have a good counseling with your patient right now. Finally getting there, um we move on from the wrist scaphoid fractures. Um carpal bone injuries in general are becoming increasingly common, although thankfully again, not very common, but out of all of them, the scaphoid is probably the most uh encountered injury that we see in our practice. It articulates with a lot of things, radius, lunate trapezium traps in capitate, typically, the way these patients tend to present is that they are tender around the anatomic snuffbox and they have got pain on axia loading of the thumb. So if you try to essentially pull someone's thumb and push it down, these patients tend to typically complain of pain when you uh when you do this provocative test, anatomic snuffbox tenderness, that's uh characteristic everybody knows that. Um And these are how you diagnose the scaphoid fractures. Clinically imaging wise, you typically get um x-rays multiple scaphoid views because it is often the case that these injuries can be missed and you might need to repeat x-rays after a week or so. So that you can confirm whether there is in fact displacement or not because these can be unstable at times. If you're not sure if the patient has strong clinical indication that there might be a scaphoid fracture there. Um then you can get a CT scan, but of course, an MRI scan is probably um the best test to do as it can detect very occult fractures. And henceforth, you can manage these uh appropriately as you see. Um unlike most most bony injuries, uh transverse fractures in the scaphoid are more stable than the oblique or vertical types. Uh The reason they're so important is because there is a risk of avascular necrosis. And the reason for that is because there is retrograde blood flow going to the proximal poles as well as the waist uh sid fracture. We'll talk about that in a second. Uh This is typically from the dorsal carpal branch of the radial artery. Whereas distally the uh it's an antegrade flow. So it means that if you fracture distally, there's very little concern about avascular necrosis unless there is of course, um uh grade displacement, for example. So this is your scaphoid here. So the flow comes in that direction. So if you break it at any point, so this is your proximal pole here, that's your distal pole, that's your waist. So if the fracture is somewhere between these two and it's displaced, you might want to think about surgical treatment. Um anatomic snuffbox, you can palpate that here. So this is typically where they express tenderness or you can do it on the volar side. So along the hump of, of where the scaphoid might be, so they can be tender around there as well. Um axial loading as we mentioned. So if this is your thumb, essentially, what you do is you pull it and push it down like so, and that can reproduce the pain that the patients experience. As we said, um many different ways you can manage a scaphoid, same as everything conservatively uh manage scaphoid fractures are those that are in the distal pole or fractures that are stable or non displaced. These tend to be uh immobilized in a short arm cast. Uh We're moving away from thumb spiker for obvious reasons because it immobilizes the thumb and leads to stiffness. Uh These tends to stay on for about 6 to 8 weeks. And of course, you gotta do serial x rays to make sure that there is uh signs of callus formation, which means that the fracture is uniting. Um As we said, surgical fixation is reserved for more displaced fractures, unstable fractures. So those in the proximal or in the waist of the scaphoid, these tend to be managed um with surgical treatment and the way we treat this is uh what we call percutaneous pinning. It's a small incision. And this place a singular screw that tends to go across the scaphoid. And these are reserved for acute presentations, those that are minimally angulated, um and minimally combined in the event that the patient has combination, if they've got deformity. So if there is a rotational element to it, if it's unstable or for example, if the injury is chronic or has an established nonunion and you need to do bone graft, then you can offer them an open reduction is to go from the dorsal side. Ok. No, the reason scaphoids, as we mentioned are so important is because they are at risk of avascular necrosis, specifically the proximal thirds of the scaphoid. And if you divide it into five, the proximal fifth, the most proximal has a 100% risk of avascular necrosis versus 33% in the proximal third. Of course, if that happens or if the fracture fails to unite or just unites in a incorrect position. Malunion. I don't know why I mentioned nonunion twice, but it just emphasizes that it, it, it is important and it can happen. That's why you have to do serial x-rays and you gotta monitor these quickly and closely. Um this will lead to something called snack wrist or s or nonunion, advanced collapse. If that happens, then typically these patients might need further more severe and more invasive procedures and they can end up with a bad outcome. That's why s scaphoid fractures as you guys got to see they tend to carry a lot of load uh when it comes to these type of injuries and now moving on to again, another rare but very serious injury, uh your lunate and perilunate dislocation. So just to orient you guys again, so this is your radius here. That's your ulna, that's your scaphoid bone and that's your lunate right here, right? So usually these tend to happen as a result of high energy. It takes a lot for you to sustain a lunate and a perilunate dislocation. We'll talk about the sequence in details in a second. Um Again, luckily, they are rare, but they can be commonly missed almost the f fourth of these patients present with a lunate or perilunate dislocation and they don't get identified. Now, it happens in a sequence. So a lot of ligaments um attach around the lunate and the sca for and it happens in a sequence where first thing that tends to happen is scaphoid and lunate tend to disrupt. So there's a ligament here called the scapholunate ligament that disrupts and then that travels in that direction where there is disruption to the lunate and triquetrum. And then thirdly, uh there is something called the perilunate dislocation. So after the lunate triquetrum tend to disrupt the carpus, I'll show you guys an, an image in a second, the carpus tends to move backwards where the lunate stays in position. And finally, step four is after all of that has gone. After all, the ligamentous disruptions have happened, the lunate bone itself dislocates, right? Um These patients present with a possible swelling and deformity, specifically around the volar aspect of the wrist on the pump, painful range of motion. And of course, as you guys imagined, there would be a nerve deficit which brings us to the final question of the day if we can bring that up, please. So last question. Um What is the most commonly affected nerve in is of the lunate or perilunate dislocation if you can bring up the question, please? Hello, I think Moira felt bored for me. So guys, what is the most commonly affected nerve? Uh Thank you. Welcome back. Most commonly injured nerve with a neonate injury or a perilunate dislocation out of these three. I think everyone got fed up with me. Mora, what do you think? I promise? That's the last question we've, we've almost made it guys nearly almost there. Nerve. Interesting. Yes. Median nurse. Anybody for radium? That's it. I won't bore you guys anymore. Now, I'll show you the X ray again. So this is what the perilunate dislocation looks like. So this is what we were talking about over here. So it's more obvious on the lateral side. So this is your, so this is your metacarpals here. That's your radius and these are your carpal bones. So stage three of the disruption is when this happens, perilunate dislocation. So the lunate itself remains in place. All the structures surrounding it or perilunate tend to dislocate. All right. So they are not sitting in their happy place that usually needs to sit on top of that. It's almost like a spilled cup of tea if you imagine it. Now, at the final stage, after everything has been disrupted, the carpus is actually in good position, but the Leonid itself has gone out. This is called the lunate dislocation. So these are both ap and lateral views of your wrist demonstrating this nasty injury. This is why it's really important to get two views in this view here. So if you guys can imagine this looks like a slice of pie almost. So this is another sign that you may have injured your lunate that's not sitting in its happy place, right? So this is another sign to look out for. There are many different lines. I'm not gonna go through that with you guys. They are important, but because they are so complicated, we are just gonna move forward with the session. I want you guys to go home and get some rest as well and enjoy the rest of your day. So, um as you guys would imagine, this is a pretty serious injury. And the reason for that is not only because of the bony or ligamentous disruption, but rather because over here you've got your carpal tunnel and therefore you can compress your median nerve, right. So whoever answered median nerve well done. You, these tend to usually require surgical treatment. You have to reduce these urgently because prolonged compression to the nerve can lead to functional deficit. These injuries are associated with a poor functional outcome more often than not because they are missed, but also because it's such a serious injury, right. And because there is a lot of disruption to everything going on around it. So although it is rare, it is very, very important that you look out for this kind of injury because often you will need to take these patients overnight if it presents late at night. And the procedure we tend to do is we reduce it, we put it back in place and we reconstruct the ligaments plus minus, we fix if there's any associated fractures. Um Now, if there is a concern of median nerve injury, you also need to do a carpal tunnel decompression as well. Um very commonly performed procedure in orthopedics. But in the event that there is also associated uh traumatic injury or compression of the nerve, then you'd want to think about that. Now say, for example, the patient has got a prolonged or a chronic injury that has been missed. This is where the problem happens because all of this has been disrupted. Now, then there is a lack of stability. Uh So sometimes you might need to do what's called a proximal row carpectomy. So this is the proximal row of the carpus, that's this row. So you need to remove parts of this uh so that you essentially eliminate the need for it or in extreme situations, you do what's called the wrist fusion. So you fuse all of these together. So starting from there all the way down there. So as you guys can see, it is a pretty serious injury. It's a lot of undertaking for the patients if we do any of these cases. So just be on the lookout for them. If you have a patient who has got median nerve symptoms, think to yourself, is this a perilunate or a lunate dislocation? All right. So that's the take, take home message from this. Now, finally, at long last, there's light at the end of this very long tunnel, um digital trauma metacarpals uh typically happen as a result of direct impact or force twisting injury, axial loading onto the finger, such as for example, you'll, you'll meet some people that say, or a basketball or a volleyball or football just went directly onto my stretched thumb and I'm complaining of pain since then falling out stretched hand, of course, again, same mechanism of injury similar to distal radiuses of carpus. This can usually be managed conservatively thankfully and you tend to do what's called neighbor strapping. So you take the two fingers together and you just leave it for some time and of course, um promote early rehabilitation usually within 3 to 4 weeks, sometimes even sooner than that, depending on the stability indications for you to surgically treat. These include, of course, open injuries, uh very open, very severely, um disrupted soft tissue structures, shortening of the digit. So the best way and the easiest way to do that is to compare it to the opposite side. If there is a lot of comminution, um if there's deformity or scissoring, and of course, if there are multiple metacarpal or digital injuries, because these tend to essentially lose a lot of function. So as you guys can see from the x rays there, so this is your metacarpal bones. So number two, number three, number four, number five. So multiple fractures, this can be an indication for you to intervene surgically. Um many different ways we can treat that either with plates which we place on either of those or a new technology develops where we put an intramedullary screw, which is obviously a less invasive technique, but it needs a lot of expertise. This is a finger fracture. So this is the proximal phalanx of the ring finger. So as you guys can clearly see, this is angulated in a way that's not necessarily acceptable. You can often treat this angulation by simply reducing it and taping it to its neighbor. So your neighbor to strap the tube and it hopefully restores the alignment. But in the event that there is still residual deformity, then you want to intervene. And this is what these deformities tend to look like. Now, on the left hand side. So this is called your scissoring deformity. So essentially, if you think about it, like you're throwing gang signs, basically west side, you know, uh you would uh have people fingers crossing on top of each other, that's called scissoring. That's usually an indication that you might need to do surgery. Finally, your rotational deformity. So if you make a fist and this appearance, most fingers tend to be pointing in that direction. So more towards the radial side. But as you guys can see, that finger is not pointing in that direction and it is instead pointing in that direction. And that indicates that there is a rotational um deformity which means that these patients might need surgical treatment. Um That's it for me guys. Very, very sorry. This has been a very long session, but I hope you somehow learned something new. Essentially, it's to say, uh these injuries can be quite common as you guys got to see. But luckily a lot of them can be managed without surgical treatment. So I hope that was helpful guys. Again, please forgive me for taking so long to go through it. I just thought I'd give you guys as much um of the uh of the benefits that you can get. It's a lot of things to learn. I hope you guys at least learn something out of this and the session will be recorded. I think a little bit later. Uh uh Thanks for the session, Khaled. This session is entirely recorded so it will be available uh once the entire series is concluded or uh we could release it earlier if you have request, I have sent a feedback form for this amazing session hosted, uh amazing session presented by Khaled. So uh if you could fill it for us, you could also get your certificate. And uh thanks Khaled for taking out the time to give us such a wonderful session on Saturday evening. Thank you and we will see you again in our next sessions. Yes, please. Does anybody have any questions before we leave? I'm sure everyone's sick and tired of my voice. But please, if you have any questions, drop me a message and I'd be happy to answer it. We'll just give a couple of minutes to see if anyone has any questions I can help with. How was it, Mora, did you learn something new today? Yeah, definitely. I've done a rotation in orthopedics and I think I uh learned more in this session. Thank you. That's very kind. Thank you. Thank you for the session. It was very, very interesting and very engaging. My pleasure. My pleasure, anytime it looks like nobody has any questions, that's good. That that means either I did something good or everyone's asleep. Yeah, I think uh uh this session was really good. Excellent, excellent, fantastic. Uh We had at least six people attending from just my uh from just my my account. Fantastic. Excellent. That's good. Yeah. All right. Uh Thanks. I'm not going to take any further of your time. Thanks for coming. My pleasure for coming. Thank you for everyone for attending as well. Thank you guys. You guys are superstars. Thank you. We'll see you in our next session. Bye. You could send us emails if you have any doubts, we could forward it to Khaled. Perfect. All right, thanks everyone. Thanks everyone. Bye bye.