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Good afternoon, everyone. My name is UO. Um Today, I'll be speaking on, on wrist fractures. Um This is the outline I'll be following a few weeks ago. Doctor Michel Alaa spoke about wrist and an anatomy. So that's what OK, for or not for my um teaching today, but I'll still just do a brief anatomy of the wrist. And then we'll go on to talk about the uh fractures. Uh So the wrist joints and articulation between the radio distal radius, the articular disc of the distal radial ulnar joint and the proximal the three bones of the proximal of the carpal. So the scun I tr the PCI form is not involved in the wrist joint. Uh It's a type of Sinova and it has strong ligaments, the palmar, radiocarpal ligaments, those are radiocarpal ligaments are both help to, you know, ensure that he unfollow the forearm and uh during circulation and pronation, it provides stability to the wrist joint. We also have the ulnar collateral ligament and the radial collateral ligament. Uh I see now, um with respect to movements, he allows flexion extension abduction adoption. Uh We also have blood supply from the dorsal and palma, copper branches, innervation from median nerve through the um anterior um branch, the posterior branch of the radial nerve and the dorsal and the branches of the ulnar nerve, which is important when you assess um patients with risk fractures to accept uh uh to assess the neurovascular status. So today, um uh I'll be talking about distal radius fractures and scold fractures as part of the wrist fractures. But of course, because the wrist strength goes beyond the distal radius and scold you could have lunates involved or the tri. Now, this thyroid just fractures are the commonest orthopedic injury. I know that in every trauma meeting, there's at least one or two steroid just fractures. So, um that's something we can all relate with an dot But a Multicenter study actually shows that about one out of 27 point 900,000 person years. That's the incidence incidence in the UK. And it's twice as common in females compared to males. However, there's a bimodal age distribution when it comes to the um age distribution for dis fracture in the sense that for the 2nd and 3rd, we have a younger age group in younger men in their 2nd and 3rd um decade due to their dens of bone structure and high energy trauma. Whereas for the older population in females as well, for low energy trauma fall from standing eyes, the typical one cases we would see in wording, 50% are actually intraarticular risk factors for uh this thyroid fractures would include uh osteoporosis, uh which explains the um the second half of the ba age group, also trauma, uh osteopenia as well. Now, with respect to the distal radius anatomy itself, the dista just is responsible for 80% of the AZ R load at the wrist. It articulates with the scaphoid bone, the lunate and the distal ulna. Now, if we look on the diagram under um right hand side, now on the attic of the distal, there, there are three forces which are important in the wrist joint are not. Um in the wrist joint anatomy, we have the scaphoid for away as with the scaphoid bone, the linear facer and the sigmoid notch way as with the distal ulnar and there's some three columns as well which are also important in in what in the wrist joint anatomy, the radial column, intermediate column, which are just along the fost and the ulnar column. Now, with respect to this carriages fracture, the commonest causes fall on outstretched uh arm uh and um typically standing ice in elderly patients, younger patients from sports, um motor vehicle accidents, I on ice pins. And apart from the dis getting involved, you can have fractures, you can have soft tissue injuries. And the type of, I mean the fracture pattern, the degree of communism all depends on the kind of fall the patient has had their bone quality. If they are osteoporotic, the age of the patient, the weight of the patient energy involved, the position of the hand at the time will tell you if you got uh a do displaced fracture which will come to in a minute. And of the the vi mean the the of the hand and at the time of impact will all impact the kind of pattern of fracture that uh is is seen on x rays. Now, there are different uh schools of thought with classifying um these fractures, I would not go deeply into this today. There's the Fernandes uh classification which uses the mechanism of injury, whether it's a sharing force, a compressive force, the classification, what looks at. So basically fici as the about five stages and looks at also the joints move involvement, the distal radiocarpal, the radiocarpal and the distal radioulnar joint. And if the ulnar styloid is also involved, there's the mao and there's the association for the study of internal fixation, this all just help you to classify the fractures better. Uh I've just got a little quiz here so that uh we can all participate and uh I think you'll be up to for learning today. So um my array is on the first image I'd like someone to um please tell us what type of distal we reduce fracture we have in the child box, please. The one that you can see. My, no, also the uh the very first um picture on the left hand side or you could just give the uh answers to the three. OK? You could unmute yourself or you could just type in the chat box this way. Absolutely. Anyone willing to try the? Ok. I think some people are trying to type in the tr room, so I'll give you a few minutes. This is inside, hold on the water. I mean, if it, your whole dysteria fractures. So, but what type of angulation and any any extra pain involved? OK. I can see a few answers. Colleagues, Fracture Col Smith and colleagues. OK. We have another one. Is it Todd? OK. So yes, the first one is uh it is, they're all dyar fractures, as I've said. So the first one is got um dorsal ation which eponymously we call the cis fracture. The one in the middle is got evola uh displacement which would call uh a Smith fracture. Why? The this one? Uh unfortunately, I'm not able to zoom in on this slide show. But when you get your slides from the um me resources at the end of the program, which show that there's intraarticular involvement in this in this one is totally also angulated. Thank you for calling and NASA for, for responding. Oh, we have two more, two more images for the quiz if we want to try. So it's basically the we have two more images if we want to try, there are also discourage us fractures that help. But I just want us to look at the fracture pattern and put our thoughts in the comment section, please. ST of fracture from nausea. Thank you. So I believe that's for the uh one on the right. What about the other ep the other x-ray any other person, child? Um Oh OK. Yeah, I I've just heard that you can zoom. OK. So what I was trying to show there is a led fossa fracture so you can zoom when you get the powerpoint because I also cannot zoom on this PDF show or I could just change to powerpoints instead of PDF or carry on. OK. OK. So uh these are like the answers to these little quiz we've just gone through. So uh the eponyms, I think in daily practice, we um they encourage us to just actually describe the fracture pattern or just go by the so that we actually know what we are saying. But is they all uh it's a Doz displaced fracture typically push onto outstretched arm. Uh And it's an extra articular fracture there or where it's vally displaced, then there's the buttons fracture where there's an intra articular involvement. But then if it is vly displaced or doesn't even decide if it's var button or do a button, then when you have a, an intraocular ra styloid fracture, one of the X rays in the last slide is the SFAS fracture. And when it involves the lunate fossa, it's a dye punch fracture. Uh what's the next slide. Now. So uh how would these patients typically present to us in A&E or in need to see? Um typical history is that the patient has fallen onto out stretch and whether they slipped or tripped or they were in a vehicle accident on examination. Typically they, of course it be swollen, deformed. If it is displaced, might be bruised uh on a on palpation. We I expect it to be tender, limited range of movements uh in collecting these patients in, apart from assessing their pain level, the age of the patient is important. Their doin is important in as part of our history, their occupation because it also helps you to determine what you're doing. For instance, if you're doing operative versus conservative management, uh they are obese, you could have somebody who is elderly, 80 years old, but then person plays the piano every week, plays the guitar for a living. All of this is important when we talk about management, their functional level, their past medical history as well. Also, you also want to know if the skin is intact or not. So if it's a closed or an open injury, because if it's an open fracture, even if it's just uh a small laceration, but uh you suspect that will be communicating with the wound, that's important because it means the person has to go to theater. The both guidelines just says to remove gross, the conta uh gross contamination or not. To do washouts in a and so it's important to take note of open wounds and let the orthopedic doctor on call know that an open fracture. Uh We talked about innervation and vasculature area. It's important to document on the time of examination, the ne class of the and pre and post any manipulation. Uh Apart from the distal radius, there are other structures in that area. We talked about the scaphoid, the lunate. So it's still important to palpate around the car carefully because there may be uh associated injuries uh and also the elbow as well, that trauma may have gone up, I mean, more proximally to the elbow. So that you're not just treating the wrist, you're treating patient as an old patient and um she documents any um findings appropriately. Uh So what imaging do we ask for? So typically we need X rays, of course, two views. AP and a lateral view at best. I mean, at the very least uh the things that we are looking at at on the AP view. And later, it's important that we look at the radial height and the radial length. Um because this looking at. So there's some parameters I've, I've put here for the X ray that we need to make decisions when we are deciding who will be for non operative treatment or for surgery. So the radial heights is like a distance between the tip of the radial styloid. So there's a line going through like Paular to the axis of the ra uh radius then, and then you have this line going through the uh radial style process and then another going through the art office. So, uh so, so measuring the radial is acceptable one, you won't accept any less than five millimeters is shortened and you want to correct that you also want to look at the radial inclination as well. Uh And then the, the uh the the dorsal seat or the full out seat as the case is here on this uh diagram because if there and then if there's any um step off on the articular surface, which is also important for surgery, uh We would ask for act if we suspect intraarticular involvement to further, you know, uh evaluate the intra involvement if there's any commination just to plan surgery or if we think there are other carpal bones involved. MRI if we are suspecting other soft tissue involvement, ligamentous injury, that will help us to uh determine all this injury, non operative management. So what do we uh say for close reduction and immobilization? So typically extraarticular um fractures, those are less than five millimeter radius short in on x rays or those are ation less than five degrees or within 20 degrees of the actual distal radius or you want to put them in below uh elbow casts or splints depending on the fracture pattern. Uh You also want to um we actually, we talk about the three point mo technique and to avoid positions of extreme flexion. And on our division, why we are um manipulate uh why we are immobilizing the um fracture. Um So, yes, I was trying to, so you basically apply a long seasonal traction to try to, you know, disimpact the fracture in the three point moving techniques to be able to audit it before putting your cast. Also, the cast should stop at the uh metacarpophalangeal joint so that you allow free movement. And it also helps you to assess the region of post on your back application and to reduce uh stiffness and maintain your finger movement. So which patients do we uh offer surgery to. So um of surgery could either be close reduction with K Yr or open reduction and internal, which could either be with a plate or a do plate. So, extra um artic fracture with a stable var cortex, uh patients with var or dosa combination where the angulation is more than five degrees or 20 degrees of the contralateral radius or displaced intraarticular fractures or it's the radial height is really short or if we have uh associated fracture, you want to consider these patients for surgery. Um So talking about the both guidelines. So the British orthopedic consultation standard for trauma gives like a summary of uh the what we should do when we have a distal radius fracture. I've mentioned some of these things before, but I'll just highlight them again. We need to document the mechanism of injury, clinical findings, the skin integrity, assess neosar status, pa and lateral views are important if you think manipulation is indicated. Um Both guidelines says we should do it under regional anesthesia and not under just um ox. So nice guideline says um don't do it under Ecton, but you can do it under hematoma block or regional guideline. The both guideline says as opposed to they would want you to do it under regional anesthesia, not just hematoma block. Uh open fractures should need to undergo surgical debridement, which I've said before. Um We shouldn't be doing major washouts in A&E um patients should be referred to fracture clinic and assessed within 72 hours. Um Patients with stable fracture should be considered for early IMIL and when you use a plaster cast to treat a disor fracture, we should keep it in neutral flexion with three point mo and not to all the fracture and not force p palmar flexion. So you don't trigger like an acute um carpal tunnel syndrome. And at four weeks, you should consider removing the cast and start, you know, mobilizing in people that are older than what this is. Five years. We can consider non operative treatment if there's no significant deformity, neurology, compromise or things to indicate surgery or in other, in those are younger. Um We've talked about the indications for surgery then generally volar displaced fractures. That's the sweet ones are unstable and you should consider them for a, um, why do you think surgical physician is indicated? Um, for the, those are displaced, this just fracture. So that will be the what we call, which offer K wire if you can reduce the radiocarpal joint by close manipulation, otherwise, or, or if, if surgery is indicated, it should be performed within 72 hours for intraarticular injuries and within a week for extraarticular injuries. And if it's uh if there's a redisplacement following manipulation, you should do surgery within some two hours of decision to operate, we should repeat x rays within 1 to 2 weeks to assess for displacement where you think you might not need to do surgery. Uh And at the time you are removing the immobilization, you don't need to re x-ray the patient. Now, another thing about this fracture in older population is that it's a predictor for subsequent fractures like nerves. So the GP needs to assess their bone outs. Patients should also receive written information about plato care or full recovery driving as well. Uh So just to give us before we go to scale four fracture, just give us a bit of timeline about this fracture. So patient has come on day zero within the 24 hours. It should be reviewed in VF CIA phone call, documented neosar status pasta care, um taught to, taught to elevate range of movement exercise for their shoulder, elbow and fingers um by day 7 to 10. They should be back to the plaster room for a repeat X ray to determine loss of reduction. Complete the cast and a GP letter should trigger bone loss assessment. By the fourth to sixth week. They should be back in fracture cleaning for removal of cast, uh, optional splints. Uh You can give them some physio and also refer them to physio. You do not need to repeat xrays for both guidelines. By 2 to 3 months, they should be getting intermittent physio and by the end of the first year, they should have attained full recovery. Um The other type of fractures will be discussed shortly is the scaphoid fractures. Um 50% of acute wrist injuries are actually due to scaphoid fractures and 60% of all ka fractures are sapid fractures and it typically fall on to IPA doxy or pron wrist. Uh It's common in males in the third decade and the, with respect to this side side is common and so on this slide, we have just a an x-ray showing the different parts of the um the scaphoid bone. So we have the scaphoid tuber called distal pole. So it's commonest in the distal pole than the proximo and the um and then the distal to. Now, one thing to note about the uh scale fold fractures are very important not to miss because the blood supply to the scale fold grade is quite unique in the sense in the sense that the proximate 80% is for the dozer car branch of the radial artery. And it's like they like a retrograde supply. Why the distal 20% is from the palmar artery of the v palmar branch of the var ra artery. So it creates a sort of a watershed area. And that's why if the fractures are missed, they are prone to uh avascular necrosis at the proximal pole. So it's really important that uh we try not to miss in your scale for fractures in patients with um wrist injuries. Um because of the risk of nonunion from this poor um from this vascular watershed area, how these patients presents they will present with again radially. I uh wrist pain, they could present with wrist swelling, anatomy, nerve tenderness. Sometimes it could be bruised or deformed. Now, the because the scaphoid bone lies in the base of the in the like it's one of the content of the anatomy box. You will get an tenderness but it on its own is not enough to say somebody has a scold fracture. So a combination of tests called can increase your sensitivity on clinical exam to think. Oh, I think it's best. There's a eye suspicion for scid fracture and includes the anatomical snow box, tenderness, palpating for the scaphoid tuber cool. So I've got a picture on the next slide. So we have on um picture a just demonstrating the anatomic snowball. So you've got tenderness there, you pop it over the scaphoid tobacco as well. It's tender, you apply a longitudinal compression to the tongue. It's tender, it should really increase one suspicion for sapho fracture. So how then do we diagnose this? So there are some, there are some dedicated x-ray series that we call the scaphoid series uh which includes a posterior anterior view, the oblique view, the posterial view with or division and lateral view, all of this would increase. So once you've done those tests on your clinical exam, and you're thinking, oh, I think this person might have a scaphoid fracture. It's important to ask for this series and it, this series just helps you to look at the scaphoid better than the regular period that we do for the fracture for instance. So you can get to see the scho in its entirety. And but it still doesn't mean you will, will pick a scaphoid fracture on these views. There's still that, that chance that x-ray would mean, I think about 16% the scaphoid series will actually means about 16% of scaphoid fractures. So if your clinical suspicion is high, what you should do is to immobilize the ant in the pet splint. And if you have immediate MRI, the guideline actually says you can ask for an immediate MRI to assess for fracture. If not, uh you can see the patient in 12 to 21 days and then assess again, repeat the x rays. It might then pick it up uh for stable non displaced fractures or waist or distal fractures, we typically will manage them in a short term cast for 6 to 8 weeks with some three. But for proximal pole fractures, if you remember the blood supply, if there's displacement, more than one millimeter or non dissed weight fractures, but the patient needs to get back to work quickly. Or there are some sports person community fractures. You want to offer them surgery, complications of fractures. Nonunion is very common for the reasons we've spoken about before. They can have develop osteoarthritis, avascular necrosis and um the scaphoid or non advanced SCLE, which is a pattern of progressive risk arthritis from a chronic scaphoid nonunion. Um So any contributions or questions, please? Thank you. Yeah, I'm waiting for questions and contributions. You can put them in the chat box, please. OK. A question in the chat box says, what's his snack again? So back to it, snac is scaphoid uh nonunion, advanced collapse. It's a form of arthritis. I think it progresses from the nonunion. I mean somebody has had maybe mica fracture or it's been managed, but somehow it's progressed to nonunion. Uh because of the poor blood supply, it then progresses to this um this uh entity which is a form of progressive wrist arthritis from a chronic nonunion. And we do not want that because it would mess up with the patient's quality of life, wrist function. So it's really important that once you think you once you have a eye clinic, suspicion for K fold fractures and your X ray series have come back negative, please put the patient to the splint, either ask for an immediate MRI or re xray in 12 to 21 days. Ok. Another question is, can we use a plaster cast for scaffold fracture? Yes, we can use a short term um plaster cast for scold fractures. Thank you very much, everyone for all your kind comments. Thank you. That's OK. Six. In in what, in the absence of further questions, this meeting will come to an end now, thank you so very much for coming today. See you next time.