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So II joined a bit late because I was logged on to um some kind of speaker test for a while. So, um we are, um I'll introduce myself. I may have been introduced already. So I'm Mrs Phillips. I'm one of the hand surgeons from Mid and South Sex Trust. Um Currently sort of working in hospital. Um And here we are for the Eastern De. So let's let's get back on. We've got a apologies. If there's any questions, please shout them out. Um I'm gonna struggle with to monitor the chat and do the presentation. So if any, if anyone sees some good questions coming up in the chat, please shout them out. Ok. So, um, fractures um very important fractures. Um Can someone tell me then why, why they are difficult fractures? I think we can all agree on that. Um And you know, you can see them quite commonly in the on the internet. Um And you can see pictures of them and they're always helpful neighbors like that. So there's a, there's a picture of a fracture. Now somebody just shout out one of the many answers to this question. Why are fractures difficult fracture. What makes them difficult? Is there any answer we'll do? Just dip your microphone and just say, why, why are they difficult for? Why are we even having a lecture on the possibility of baby? And so speak up a bit possibility of AVN? Yes, I think that's everyone, everyone says that. Um first of all, so um there is definitely a possibility of AVN, that's what they're sort of famous for. And why again, just shout as loud as you can because I'm perhaps I'll put my volume up. Why is there a possibility of AVN due to retrograde blood supply actually? Yeah. Yeah. The blood supply is very tenuous. OK. And someone else can answer now if they, if, if you don't want to answer. But now just tell me why, why is the blood supply so bad uh in the K five? Why is it retrograde? And why is it a single blood supply? You done anybody? Well, that's the question we will answer next week in the biomechanics lecture. So basically, we will skip through it this time. Um Essentially, if you look at this role here, the bromo carpal ro. Well, you got to ask the question which we'll ask in a bit more detail next week, why, why are there so many bones in the carpus? Are they all the same? They all do different things. Um And it turns out and we'll have a look in a second this row here, the proximal carpal row um acts as a what we call an integrated segment. It's like this sort of ball bearing that rotates between the radius and the um and the distal carpal road. So it's sort of all these bones are sort of covered with cartilage in all directions. And so the only place the blood can get in is through a small place where there is no cartilage. Um And that is, that is there and that's why he's got a blood down a bit because I'm getting a bit of feedback here. Ok. Anyone else? Can anyone tell me why there any other reason I VN and the tenuous blood supply, that's not the only reason. No problem. Can somebody else give me a reason why I to shout something out. There's a lot. Nonunion. Nonunion. Ok. Nonunion. Um, and the nonunion is partly to do with the blood supply. What else calls it the nonunion because of the manner of the blood supply. It's, um, in retrograde manner. Yeah. Well, you guys, this is my point. It's not all about the, the non union doesn't only happen because of the blood supply. Why else might, might there be a non, it's to immobilize. Yeah. Well, it's, now you're all coming up with the right questions. It's a little bit difficult to hear you unfortunately, because it was, and it, it is to do with immobilizing as well. So if we, if we, um, think about these fractures what you can have is um a sort of fracture where you have the fracture, you don't notice you've had the fracture, you don't have any symptoms from the fracture. So you don't immobilize the fracture. So really the, the AVN isn't an issue there at the moment. The problem is making the diagnosis. So can someone else the, the, so the question is, can you even make the diagnosis of, because what sort of fractures are these? Are these fragility fractures or high energy? There's a lot of background noise, the noise coming through. I can't, I can't hear anything. Sorry. Is that better? Thank you. Um So you have um uh a a fracture which you can have. So my question was, is this a high energy or a fragility fracture? High energy, usually high energy? Absolutely. So this is a different fracture from the fracture next door to it in the radius. So the distal radius is a generally a fragility fracture and you notice you've got that one. This is a high energy fracture. Um and therefore it it it happens in different people. It happens, you know, the the distal ages fracture can happen in anyone but it's more common in the elderly patients. It's a fragility fracture. People notice they've had it. The people who tend to have a scape fracture are the people who don't have distal radius fractures, they are younger, they are fitter and as we'll see soon, their wrists are more flexible so they can get their wrist into a position where the stress is transmitted across the scaphoid. So it's a fracture which you can have, um, in, um, without noticing it. Anything else, anything else that makes it difficult? That's, that's a very easy one. I'm showing you there because you can actually, well, you can, you can tell, um, when, when, as, as a, as, as registrars you are often, I guess in clinics where you're shown people who are presenting with a fall and pain in their, in their scaphoid. I said something pain in their scaphoid area in an anatomical snuffbox. What, what, what do the fractures normally look like on imaging undisplaced? They look under displaced. So how do they, how can you, can you see them if they are undisplaced? You, you can either not see them initially because there is not enough bone resorption for a fracture to occur on the X ray or if you can see them, then you need to be very careful to pay attention exactly to the cortices. Absolutely. So basically there, there, there's all sorts of problems with it. So they're difficult to see. That's a very easy one to see because it's quite displaced. It may be old. If you look at it, it has a bit of VN. So let's, let's go through, as I say, when we're in a lecture theater, it's easier to have this sort of question and answer things. So, basically scaphoid is the most frequently fractured carpal bone right after the, not the radius. Um, of the carpal bones is the most frequently fractured because it's a funny shape. I guess it counts up to 15% of acute wrist injuries quite commonly injured. Um, and the pro there are lots of problems with it, which I'm sure you were or shouting out and only one of them is vascularity in a sense. So the first thing is it's almost completely covered with cartilage, right? As we'll do in our lecture next week, um It, it needs to rotate in all sorts of directions to transmit force between the, the radius and the distal carpal roll. So it's almost completely covered with cartilage. That, that has several major problems. That means that almost every fracture of the, of the scaphoid is intraarticular, which means it has to be reduced um anatomically or near enough anatomically. Um It's also the scaphoid flexes, it moves, it's a, it's a funny bone because it moves out of the way when you, I hope you can see this. I can't see if you can see, oh I can't see, you can see when you, when you do that, when you do radial deviation, the scaphoid has to flex out of the way. OK. And then it flicks back into position when you go into own the deviation. That's why it's the shape. It is OK. It, it's always reinforcing the thumb stabilizing the wrist, but it can only do that by getting out of the way. If it didn't do that, you wouldn't be able to make this movement. So it's uh it's always intraarticular. And because of this movement, when you fracture it, it tends to flex the whole of the scaphoid tends to want to flex, then there's vascularity as well. There's problems with the imaging which we didn't really have a chance to chat. They're difficult to interpret, right? They're difficult to image the sca the scape ro is a long thin bone that's curved. So it's actually quite difficult to image, it looks very straightforward, that looks like a, you know, peanut shaped bone. That that's not really right view of it. It's actually sticking out of the plane of the hand at about 40 degrees, 45 degrees. So it doesn't look like that, it looks longer than that and it's at an angle. So it's quite difficult to interpret the, it's difficult to image because it's in a funny position and it's difficult to interpret the images. So sometimes even when you're, you know, when you're doing an operation to fix the scaphoid, you look at the scaphoid in front of you, you can see it and the images that uh that you see um on the X ray are not on the imaging. On the ii really don't even correspond. And therefore it's difficult to fix because of the difficulties with the imaging because you can't really see where to put the screw other problems. And people have said this, I won't say I won't drag it out of you because it's so difficult in, in, in this environment. Um Malunion is problematic. OK. Now tell me somebody, tell me this one. So why is malunion? So malunion means a humpback deformity. Why is a malunion problematic? Somebody shout out anybody probably is to do with the biomechanics of the, of the carpal bones. If one bone is flexed, then the movement in the ad joints will be um will be affected. Yeah, so thank you very much Miriam. Um So basically, if, if, as we'll go through next week, um the shape of the scaphoid is very important because it's um if it's not the right shape and particularly if it's got a humpback, then it doesn't perform the right function and particularly the, the distal pole of the, of the scaphoid starts to uh as you flex it, it starts to hit against the uh uh styloid, the radial styloid. So you get arthritis there very quickly and non union is even more problematic because the two parts come apart and then they move separately and that disrupts the biomechanics. OK. So non malunion or non union problem, patient factors. Again, the sort of people who get this are not little old ladies who, you know, never have who notice when they fall, they tend to be young, fit working people. I mean, it it's often men, but it, it's young fit working people. They're often doing sports or manual jobs. So they are used to having injuries in their hands and they're used to having sore hands. And this is just gonna be yet another sort of the many sore hands they have. And so they don't treat it, they don't consider it a major injury and the symptoms themselves may be very minor. Ok. So this is a really, you know, it's a, it's a, a difficult fracture in all ways. And I want to stress that everyone says vascular issues that those are very important, but there's far more to it than that. Ok. Almost everything is against you or you know, if you like everything is great because it gives me plenty of jobs. It, you know, keeps me in employment for the rest of my career dealing with this difficult fracture. And in fact, today, we're not really going to get to avascular necrosis because that's a long term problem. We, we consider that in a separate lecture uh which would be about, you know, VN and the problems of non union. OK. So just to reiterate then, so the incidence of SK fracture uh by age, it's a young person's fracture is not a fragility fracture. There's no bimodal distribution. It mostly happens in young people and it mostly happens in young men for that reason. OK. And the anatomy is, as you said, the main issue I guess with the anatomy of the most famous issue is the vascularity and the vascularity is is this. So the radial artery comes up. This is a volar picture from greens. Um you get two branches, one goes volar which is drawn here, which gives um blood supply to the distal pole. And then there's a dorsal branch there which goes behind the, the fold, dorsal, the fold and then I've drawn it in there and it curls around and gives most of the blood supply to the proximal pole. And that's really that, that vascular supply tells you why we have all these issues with vascularity and, and, and really gives you most of the algorithm for treatment because you can have a fracture there, you can have a distal pole fracture. Now, if you have a distal pole fracture, the vascular supply to the proximal pole is still preserved. If you have a waist fracture, you, you may be OK. So that artery may still be outside the bone. At that point. If you have a proximal pole fracture, you, you're gonna be in trouble. And so the algorithm is distal pole fractures. Generally, you don't need to fix, you know, with lots of caveats, uh waist fractures, you may have to fix or not depending on displacement, et cetera and proximal pole fractures you really would like to fix because all of them are gonna have vascular compromise. OK. So it is really that picture that tells the story now then. So there are ligaments um that we, we need to know about and we again, we'll come into these in, in more detail next time. So this is the volar er er ligaments of the wrist. This is the dorsum of the wrist and on the dorsum, you can see there's far there, there's less ligaments, right? There's less strength, there's less ligaments on the volar part. They're quite thick and you can see s the scaphoid there, l the lunate tq triquetral, they all form a row of bones linked together by these complex ligaments between them and none of these three bones are particularly strongly linked to the distal row or to the radius that much. So they tend to swivel as they are pushed around. And so because they swivel like that, that's why they're covered with cartilage. OK? And that's a diagram for the proximal car. So what you see really is on the volar side, you see the scaphoid here. This is one of my drawings. There's the scaphoid, what you will see is the radios uh capitate ligament uh like that. And you, you see the scaper capitate ligament as well and the scapholunate ligament. So that's a beautiful diagram. It looks really nothing like that in the sense that all you see is lots of, lots of interrelated fibers, but that's the best way to think of it. So the radioscaphocapitate ligament is a ligament over which the scaphoid is thought to flex. And so it may have a role in fractures. You can sort of imagine that if the, if the scaphoid is flexing or extending, then there may be a fulcrum of force at that point. And that's why you get these fractures. Ok. Scapholunate ligament will come to next time because that transmits force between the scaphoid and the lunate and a scaper capitate ligament is a pain because you need to, that's in the way when you want to fix it because you have to get the screw into that part of the scaphoid. And this ligaments in the way from the dorsum, you see this uh sort of chevron going the other way, which is the dorsal intracarpal ligament and the ra triquetral ligament. So they form a Chevron sort of sideways. Um This gives us a nice approach here. You can see you, you can imagine, you could see a nice view of the proximal pole of the scaphoid. Um And those, so this is why you do the proximal pole of escap um fractures usually dorsally, but you're very limited as to how far you can go because uh the dorsal and decara ligament is there and the artery is inside that. So you can't just dissect the way there. OK. So, and, and this is what green says, green says there's the radio scale for capitate ligament. Um And that would explain if you like that gives you a sort of kind of a feeling of why you get all these waist fractures. Yeah. OK. Right. So let's quickly look at it. This is my notes again. So perhaps a bit difficult to see on this thing. Um Basically, um there are lots of theories about how the G five fractures. Um I'm not sure you at FRC S need to know what the current theories are. Um This is the, the ancient theory, um which was done by Weber in 1978. Now, he took a load of cadavers and he, he put them in that position. I hope you can see that as a hyperextended, hyperextended wrist to 95 degrees. And he put a load on the wrist where the red arrow is. I think he dropped them out of a window or something. He put a load on this and he found that if you get the wrist into that position, unload it and continue to load it, what will happen is you will get a scaphoid fracture or a scaphoid waist fracture rather than a distal radius fracture. OK. And that's kind of one of the few findings we can say. So what he concluded from this, excuse me? OK. What he concluded from this was that it, how can I put it it the way to get a scape for fracture is to get your wrist in that position and load it. And that's been my sort of feeling to try and explain why young people can get this fracture because young people are the only people who can get their wrist into that position. So the kind of presentation is often the hyperextension injury by a footballer, a goalie catches the ball, it strikes their hand very hard. It hyperextends. They have a painful wrist for a few days and it turns out they fractured their sk fight. So what they're doing is loading their wrist in this hyper extension. People who come off their motorbikes and or, or roll at speed coming off their push bikes, they put their arms out, you know, but they, they sort of land on the, on the ground and they do a full somersault and as they do that, their hand will be pushed into hyperextension. So that's my theory um of explaining how you get this sort of fracture. So you talk to people and try and get a history where they're saying, well, II, you know, had a high energy ish injury. Um and I'm a young flexible person so I can get my hand into that position. An elderly patient who does this, I don't think they can get their hand into that position. So the disor ages is loaded before the SCA OK. So tell me then we need, we need to talk about imaging. Um Can anyone shout out anyone except Maria? Uh shout out um What are the, how many images do we get of the scaphoid normally? And just plain films. How many? And about D four I think. Now Emma Theobald, I pick a name at random. How many images do you know? Um Well, typically, unless you ask for them, you'll just get an AP and later and then you can ask for dedicated scaphoid views, which in my trust is only one additional view or one additional. Ok, thank you very much. Good answer. So normally that's exactly what II would say, four views of which two are, as you say, two are the simple risk views. And then there's two special views to go beyond that. So let's have a look at them. I want to ask you to name them. Thank you very much for uh shouting at them and being picked on as well. Um So there's the first view, what we say this is just a pa view. Um People will say as pa without a deviation that does help because it gets things out of the way. So what you see is most, you, you get a reasonable view of the foot and that's a really good pa view. Um without a deviation, you don't normally get anything as good as that. What you can see is you can see a lot of the distal pole. You shouldn't be able to see that because the, the trapezium is usually in the way it's in the way a little bit there. You see some of the waist and normally you don't see as much of the proximal pole as that because the radius is in the way and you can see them both slightly in the way. It's usually worse than that. But that's a reasonable view. If it was a displaced fracture, you'd see it on that view. Second view is the standard lateral of the wrist. Now, this is difficult because you everything superimposed. So the the scaphoid is there that bone there sticking out. Yeah, and then everything oops everything else is um hidden by the lunate. So you could see a distal pole fracture to some extent. And you might see, you know, a dizzy deformity which we could come to later, more flexion, more humpback deformity, not terribly useful. And then the other special views are what the oblique view. So this is a pronated oblique. So you get your your hand, I you can see it and just put it down at about 30 degrees. So the beam is coming in like this instead of being a lateral, you just put it down to 30 degrees and what this one. So this is the oblique, oblique or or sometimes called the pronated oblique. What that shows you is that that is the one that gives you a very good picture of the distal pole? Ok. Now distal pole. Well, you tell me why, why do we need to see the distal pole? Anybody George Houston Horton, why do we see the need to see the distal po obviously, we need to see it if there's a fracture. Is there any other reason any other reason why this view is particularly useful and why this view is a view? You should practice if you, if you're in theater and you have a scold or a wrist, try and get this view because you really want to see that part of the scold. Anybody, anybody shout out, why do we need such a good view of the distal pole when it's not generally a one that we fix? It's not generally a fracture that we fix. Why do we need it? Is it and what can I ask you to contribute? Um I'm not entirely sure but does it perhaps tell you the stability related to this? OK. So how when we gonna fix when we're fixing this case, how do we fix it or someone else is shouting? But II really can't hear you. Whoever you are. Shout out loud. Is it to make sure that I II I'm not, is it to make sure that this is not uh it's buried? Very good. Whoever said that? Thank you very much. I'm sure other people were saying the right answer as well. I apology. I I'm not really not trying to pick on people. I'm just, it's just nice to have an interaction even even in the middle of this storm over the over the internet. So the point that that person said is, is, is very true. So apart from, just see that everything is OK, the screw that you're gonna put in usually goes in somewhere along here. OK? And first of all, you need to get its position right. You can't just stick it in at the edge or it won't go around the corner of the, the bent scaphoid. Um, you need to get it in position. The position is like one third in two thirds from the other side. So it's about there and you need to make sure it's buried. So that's really useful view. If you put the screw in the wrong place or you don't bury it, you've caused a lot of problems and you can only receive that on that view. And then the final one is this a here, this one here. Now, this is the sort of scaphoid view. Um So this is, let's see if you, I don't know if you can see this on my, my picture. So this is normally you would say an AP comes, you've got your hand flat and the ap, the beam comes down vertically, what you're gonna do here, the hand is flat. The ap the, the beam is gonna come down at about 30 degrees. So it's gonna come down like that. And that means it's going to be at right angles to the scaphoid. So what you're seeing here is the scaphoid side on, that's why it looks so nice and, and that's why it looks so long because it, it sort of is that long if you look at it the right way. Um, and that's the best one to see any fractures. And that's the best one to see reduction. And that's the best one to see the length of your screw. Because when you see the length of your screw there, what you'll see is the screw will, will not have an ellipse at the end because it's at an angle. You'll see a flat, the flat end of the screws. You will know that it's sunk top and bottom. OK? You can't see all the distal pole. You can see how that's starting to be covered by other bones, but it gives you the best. It, it's a side on view. Yeah. OK. How are we doing with this? Oh Yeah. So, um the other thing you're going to need is the problem with, with imaging of the scho plain films is, is it's very difficult. Nobody. Let's just go ahead. I mean, you start to get things like this, right? This is the sort of typical thing that's presented to you. So this is a, a scaphoid view of some kind. And they're saying is that scaphoid broken the patient's fallen, he's young, he's got pain and you look at it and you think, oh God, I can't tell you look a bit closer and the more you look, the more you start to think hang on, I can see, I think I can see something and you can't tell because you start to see the trabecula and you start to pick out in your mind or your eyes start to pick out Trabecula that line up and you start to see a fracture. So what we know that there's very little intra observer reliability, picking up er, er fractures of the scaphoid on plain films. So what you have to do is a CT and you do something like this. So you get a CT. So it's not a brilliant CT and you may well see a fracture like that. Um And the thing with that is, although it's, it's shown you that there's a fracture. The problem here is that um it doesn't tell you the whole story if that was the fracture. Well, you probably may, may not even fix that. If that's the fracture, you could just put a screw down it if you wanted to fix it. But the problem with the scaphoid is that it is a three dimensional object and what you're seeing is just a slice through it. Um And what you need to see is the lateral view. OK. So what do we, what's happened there is there's the fracture, this is the scaphoid again. It looks funny because we're looking at a slice of it, but you can already see what's happening here, right? We call this a humpback deformity, the cortex as, as Maria was saying earlier, the cortex has slipped off itself there and it's parting there. So, on certain views on the AP or the X ray on the AP of the CT, you don't see an awful lot. It doesn't look terrible, but you can see it starting to flex and as it flexes it becomes, it doesn't fit, doesn't fit in its position and it causes problems. Ok. So you get something like this and here's an even worse one and we say this is the interscaphoid angle. It should be about 3040 degrees. This one has already developed into Humpback deformity. 66 degrees. OK. So off on the ap it might look not too bad. It's only when you get the CT, the lateral CT that you um that you see the problem. The other thing is you could see you could get act because you see something, something like this or you get a CT and you see something like that. Now then that's a fight. So this patient has come in. He's a young man. He said, oh, II, you know, I fell uh about a week ago and I got my wrist is really sore. Came off my, my electric scooter. My wrist is really sore and you take a CT and you get that. Now you tell me what's happening there. Somebody shout out what's the story here? What's going on? This is SK for Yeah. What's the story? Anybody can I pick random names? Greg Greg again? Um nonunion. Yeah. OK. So perfect. That's all, that's all I wanted you to say. This is a nonunion. So a lot of people will present with, you know, the story of an acute injury and you get a CT like this and it, it may be visible on the X ray, but it's certainly visible on the CT. And what you're seeing here is a non union of the S. Now this is a complete the different kettle of fish to the acute fracture. In the acute fracture. You have an algorithm where you can consider non operative or you can fix with a screw in this one. You've got a whole different ball game which we haven't got time to address here and this is partly your vascular problem. So here what's happened is that the tree fight has tried to heal. Um There's no colors because the scaphoid can't form colors, right? It's covered with cartilage. It doesn't have a periosteum, it has cartilage. So it doesn't heal by, by uh by secondary healing. It only heals by primary. So you don't see cartilage, but here, you're seeing a sclerotic fracture, you're seeing some evidence of cyst formation. So and you may well even be seeing some AVN, oops, some AVN there. Yeah. So what you've got here is a non union and you will often get people coming into your clinics saying um they've got an acute fracture perhaps because they're embarrassed perhaps because they can't remember the initial injury, perhaps it is one where they had an injury a year ago, two years ago, it wasn't particularly painful since then. It's been niggling and gradually it's got more painful and they've had a fairly trivial injury. Now, now it's something they've noticed and now they're coming to see you about it, but you need to know the difference. Obviously, you can't simply go in and try and fix this because there may be all sorts of vascular issues. You certainly would want to bone graft it because that's not going to heal if you put a screw down. So the CT is very useful. CT is very useful to, obviously to confirm a fracture if it's difficult to see. CT is very useful for looking at the geometry of the fracture to plan the operation. And CT is very useful for aging the fracture um and finding out really what's going on and then you, you, you have a different sort of algorithm. And then the other thing is you can use as an MRI. So an MRI, the reason for doing an MRI is if you have uh a patient with um the um symptoms uh no fracture visible on an X ray, um then you might even do act and find no fracture visible on act. Um But what you will see, sorry, what you will see is something like this on an MRI which there's a scape fol you've seen a bone bruise um And usually the, the, the radiologists are pretty good at reporting it. They'll see a breach of the, a break of the cortex, bone bruise, plus breach of cortex means fracture. So you can treat it as a, as a fracture. Ok. Right. What else? Right. Let's just go through, you know, where time is ticking on now. So I'll, I'll, I'll, I'll speed up. We have a, I'll give you a treatment algorithm. It's, it's quite difficult to, to, you know, teach this bit of the um the course because there are very, there are many different algorithms. Um I think you come to the exam, you won't be expected to um give a definitive algorithm at present because we have different algorithms in different different units. Um But this is a reasonable algorithm. I think it would be not unreasonable for you to say that this was what you were gonna use. Um So I hope you can see this. So this is my own uh writing from when I was doing FRCS. So this is a fracture of a scaphoid, uh acute fracture scaphoid. So the question is, is it isolated injury or is it with associated with other injuries and really with a scaphoid, if it is associated with other injuries, you really usually that will push you very much down towards the fixation route. And that's because scaphoids take a long time to heal. So they're going to have to be immobilized for a long time. And if they're, you're immobilizing the hand or the wrist for a long time with other injuries, the hand will get stiff, ok. The other injury, other injuries are, are almost certain to heal more quickly than scale five. So you're gonna, you're gonna, you're gonna give the patient a stiff hand almost always. Ok. So if it's with other injuries, it really often means that you will, will operate to push you down that. So generally surgically fixed now, then isolated sca for fractures, we divide into three and we again, we're just gonna do the waist fractures, which are the ones that are interesting for you, proximal pole fractures, you almost always fix, but they're very difficult to fix. So there's all sorts of complicated things there. But I think if you said in the exam, I would be inclined to, you know, discuss with a senior hand surgeon and, and think about fixation that would be reasonable. Distal pole fractures unless they're grossly displaced, usually don't need to fix because the vas because they, they tend to heal and then the waist fractures are the ones that you are the most common for the reasons we said. And these are the ones you'd be perhaps expected to talk a bit more about. And really the question is whether the presentation is acute or whether it's delayed. Ok. And delayed means in this case, I hope you can read it greater than two weeks with no immobilization. Ok. So, uh, acute means they've come in or you see them within a few weeks and the day they had the injury, you have a plausible history of the injury, uh, occurring and they went straight to hospital and were put in a plaster or put in a splint and they haven't taken it off since. Ok. So it is, if it, if it's an acute fracture, it means it's either either brand new or they've been immobilized from pretty much the moment that it happened. Ok? If it's delayed, if they say, you know, if they've been two or three weeks without immobilization, we'd consider that a delayed fracture and that means that it's likely to be moving toggling every day with every movement of the wrist. And that has a really bad implications for union. Ok. So if it's delayed, you know, that's gonna push you towards fixation, not, not every time if it's a completely undisplaced fracture and they've got no symptoms. You could watch it very carefully. But um, any, any delay in in immobilization will push you towards fixation. Acute is basically how displaced is it? And we are very stringent on this. So you, you can't tell to me, you can't tell on a, on a, on an X ray on a plain film, whether it's displaced or not, you have to have a CT and I hope you will see the displaced means greater than one millimeter separation, greater than 15 degrees of angulation. Ok. So what we're saying there is we think that that sort of one is, is unstable. It is out of position and it's moving or it's likely to move. So we should fix it if it's undisplaced on CT, if it looks, if it, there's just a crack, it doesn't look as if it's moved, then we can treat it conservatively. We can plaster it. How long we plaster for it for? Is, is, is up for debate? Certainly six weeks and then you just look at it very carefully. Ok. Oops. And that's it. So that's one a reasonable thing to say that you could deal with an acute waste of scaphoid fracture. Yeah. So is it acute? II, has it been immobilized from the time of injury? And is it displaced and displaced on CT means very minimally displaced? And then there will still be debate about what to do for each of these? Yeah. Ok. So what's the surgical treatment? Um uh non operative, what, what other treatment? Sorry. Um So non operative treatment can be um uh done in a colleague's cast. You don't need a, a thumb spiker cast. Um And we're looking at stable non displaced fractures, which is most of them to be fair. Most people, you just see a crack that you know the difficulty is making the diagnosis and then you see that they are, they, they're not displaced. Um So these can be treated very well. Um in, in conservatively. Um and they have a, a union rate of 90% provided they're immobilized from the time of injury. Um Effectively surgical treatment for the other branch of the um algorithm um is the standard treatment is an or or open open reduction. Um You could also percutaneously put a screw through them. Um That's, that's more technically demanding and you would need to be able to reduce it. So it would need to be either reduced or very easily reducible for you to do a percutaneous screw fixation. And then the question is which approach to go for and generally, um the volar approach, which we'll go through very quickly. Now, the volar approach um would be for waist and distal pole fractures and we'll explain why. Um And particularly with Humpback flexion deformities. If you think about the Humpback flexion deformity is pushing is the, the distal pole is bending forward. So if you want to correct that and push the distal pole backwards dorsally, it's better to, to attack that from the volar part because then you can wedge a bone graft or something in um in the fracture to keep it um to, to, to, to correct it. And you can see how flexed it is. The difference. The difficulty with the dorsal approach in flexed fractures is you can't really see how flexed it is. It's quite difficult. Uh The dorsal approach um is used for proximal pole fractures. Um And it's, it's a very nice approach for that and it's a very nice approach in general, but you are limited, you can't dissect too far distally because you interfere with the dorsal blood supply. Ok. Some people, you know, um but you've got to be careful with this. Some surgeons uh fix most of their fractures through the dorsal approach, some, most of the approach so that you don't have to do this. This is the general way to do it. But some people will do almost all their fractures through the dorsal approach and they feel they have a very good result. So it, it is a little bit surgeon dependent. OK. So let's quickly, let me see who else is, is, is Shia Sara here? I can't see. I'm just looking II, I'll go through the eye. Sure. Hi, how are you doing, mate? Do you want me? I, I'll just quickly go through these operations or you are you very short of time? I've got a case to do it at half three. So, um if you can um I can do, I will literally go through these very quickly. I don't want to steal your time. Ok. So, I mean, all of you guys can look this up on or bullets or not on awful bullets on the AO site AO foundation site. Um And the nice thing about both of the descriptions of the, of the fixation of the Sapho in this, in the site is that they are quite accurate. OK. So that's what you do. This is the volar approach. If you go through it, it is actually pretty much what you see. You get down to the capsule, you cut the radio skull for car carpal ligament. You see this is the scaphoid, you have to go a bit distal, so you get into the joint, that's the radiocaps. S TT joint, ok? So you have to get into that to get the screw in. You have to see where the fracture would be somewhere like that. And it does look pretty much like that. This is what you're seeing. That's what you want to get to. You're gonna see a fracture which is possibly humped back like that, be careful. Uh You're then gonna do something like that, extend it to get it back in position. You may joystick it in position. Uh You're gonna have trouble because the, er, you're gonna get, there's your entry point or there's your entry point. So the, the trapezium is annoyingly in the way you have to hyper extend or sometimes even take off a little bit of the trapezium. You put either one or two K wire through, uh, and then you put a screw. OK. And here was the question answered early on. This is why you need that view. This isn't that view, but you need to get the entry 0.1 3rd in compared with two thirds from the elder side. OK. If you come, the temptation is to go very lateral, but then you can't get it right down to the bottom. OK? And then you stitch it up. Dorsal approach again is quite small and neat. Um uh And you know, you see the retinaculum, you get the superficial branches out the way you get things out of the way things out of the way things out of the way. And eventually you see that you actually see the proximal pole. That's the scale for you see the fracture, you can't really see how flexed it is, but that, that's what you see, you try and reduce it somehow. I would use a Ky there. People have done a AAA reduction like that. You get a guide wire in and it looks something like that and then should beautiful picture and then you put a screw in. Um, it's fiddly. Um, but if you, if it, if you can, you can get the entry point much better because the distal pole is right in front of you and the distal pole is a difficult bit and it looks something like that and cross like that. OK. Then folks, I will not because we've got other people who are busy, busy. I will um stop there and er, just quickly any emergency questions actually tell you what, I'll let Mr Sarka take over from here and then any questions you've got, um, I'll stay on the, I'll stay on the uh the, the meeting and then you can ask at the end. OK. So I'll, I'll stop sharing now. Uh How do I, I'll stop sharing. I will stop sharing now and hand it over to my colleague. No. Uh Thanks a that was very, very good. Sorry to have rushed. You. Can everyone hear me? Yes, I can hear you. OK. Fine. I'm gonna try and see how I'm doing this as well. This is the first time I'm doing this. It's so much more difficult than, than MS teams. Well, I'm gonna mute to share my entire screen. Ok? Can you guys see that? Yeah. Yeah. So that's working. Yeah, you can see my first slide because I can't see, I can't see anyone on the screen when I'm doing that. Is that, is that correct stan you can't see anyone else so you can just see your own slides slide and nothing else. Ok. All right. So ulnar side of wrist trauma is quite a difficult thing. I mean, the ulnar side of the wrist is quite a challenging part. Um So I'm going to try and keep it simple and basic because we can go on and talk about, talk about this for hours. So the side of the risk is known as the black box of the risk just because people don't really understand it that much. And there's a lot of sort of confusion and I think this is still developing quite a bit. Um the way people have approached that has changed uh dramatically over the years. And I think, um you know, the current vogue is to manage these things arthroscopically and we have a slightly better understanding. So, because um the hand and wrist term is a three year term, uh this year, we're just focusing on hand and wrist trauma. So I'm just gonna look at the traumatic sort of issues that deal specifically. So if you guys can see that red area, that's what we're gonna look at. We're gonna look at the D I UJ, we're gonna look at the T FCC and we're gonna look a bit at the EC U tendon. Now, all of that work um closely related to each other. They're all one sort of big composite and integrated. So when I was doing this lecture, trying to break it up, it was quite difficult because everything is related to everything else. So I think the first thing that we sort of need to consider is to understand a bit more of the anatomy because um as a trainee, I found this quite challenging and I'm only sort of beginning to sort of understand it now. So, I mean, this is the lead on from Romina to, but 40% of distal radius fractures have an ulnar styloid fracture. And so that the literature shows that the TFC injury is to be uh is reported to be about between 35 to 78% in distal venus fractures. So there's quite a wide variation. And then there's a look at, you know, if the ulnar styloid fracture, does that mean that there's a TFC injury, does it? Not some people, the initial thoughts were if there is ATF if there's an ulnar sty fracture, the T FCC must be damaged to some extent. But in the current by Andrea Adze, who's, um, a big name when it comes to sort of TF CCS and we'll talk about him slightly later. Um It shows that they're not really interrelated and there's no association um really between the both. So we have to look at those things separately. Then obviously, uh glizzy fractures can cause uh the I UJ instability T FCC injury as you can see on the X ray, you know, by the virtue of the fact that the ulnar head is so dislocated and displaced. You, you know, you have to assume that the uh T FCC and all the other stabilizing structures are completely um injured. So in terms, it can be an isolated injury if you have forced ulnar deviation with axial loading and over pronation and supination, because the main aim of the D I UJ is, you know, pronation and supination. And we just have to remember it's not the ulnar that's really moving, it's the radius, uh that's moving because the radius has two surfaces at both ends that can help pronate and supinate. Whereas the ulna is fixed into your humerus uh at the electron. So it's a relative motion. So that's an important concept to understand. So I think the anatomy of the D I usually is important. So uh the, the pictures here are all either from greens or from some landmark papers, which I can let you know what they are. The first thing to sort of notice is that uh there is a mismatch between the curvature of the sigmoid notch and the head of the ulna. So, you know, it's just not pure pronation super nation. There is a bit of translation sort of that goes on. And what's important is that the shape of the sigma notch um is important in terms of its inherent stability. And if you read greens and things, there's a lot of different variations. And what's really important is to consider the volar and dorsal radio ulnar ligaments. And that's what confers a lot of the stability, primary stability to the Dr UJ. And then you have your secondary stabilizers um such as part of the T FCC, the EC U subsheath, the EC U itself as well as the pronatal quadratus, right? So on the, on the one on the right, you can see that and the radio ulnar ligaments are essentially made up of two components. You have a deep and superficial. So they both start from the ulnar edge of the radius of the sigmoid uh notch and the superficial branch obviously is more superficial and it goes and inserts into the radial styloid and then you have the deep part of it, which is also known as the ligamentum sub creatine and that inserts into the fovea. So that's quite an important concept because um it sort of differs in terms of what your treatment is gonna be and how you assess the stability of that so far. Everyone can hear and see the light. Yes, we can see your slides. Yeah. OK. Fine. All right. So, so that's the D and then we're looking at the anatomy of the T FCC. So this is uh some images in all three different planes, sagittal coronal and axial. Um So what's important? Obviously, you've got your, you've got your uh var and dorsal radioulnar ligaments, fovea and into the tip, you have your ec U tendon and the subsheath, which is part of it. Then you have your meniscal homolog and then you have your ulnar lunate and, and, and ulnotriquetral sort of ligaments here, the ulnar carpal ligaments that form like a Hammock. So you'll read a lot in the papers about the Hammock structure. And basically what that does is that the, this part of the T FCC is suspended um by the ulnar carpal ligaments onto the carpal bone. So it's part of a thing, but it's not your primary stabilizer of your D I UJ. So, and obviously, you know, the D I UJ, you've got your bony anatomy. And you've got these ligaments here. So you can see there is a inherent chance of instability. So you've got your articular disc uh in the center here. So if we look at that, you normally have a gap with the pre of recess. And like the meniscus, the articular disc is more vascular at the periphery and the ulnar portion of it as opposed to the radial portion or the central portion, which again affects management um of it. Um So, you know, repairs are better in the periphery of the ulnar edge, whereas at the radial side of the central tears are not so good in terms of repair. Um And then if you're looking at that uh on the sagittal, that's how you see the ligaments that are coming in and touching. And that's what confers your sort of stability to the whole area on the ulnar side of the wrist. Any questions so far? No, I will continue. So, as mentioned before, the radio ulnar ligaments composed of the deep and superficial components, the deep part goes into the fovea, superficial into the styloid. Now, we talked about the ulnar, not really moving but subject subjectively, the ulnar translates dose during super. So the dorsal deep five is tighten and the ulnar translate var doing pro so the lar deep five is tighten. All right. So that's sort of important because obviously late when you're trying to examine and assess which part of the var. Um the radio ulnar ligaments are damaged. It's quite important to understand which pos position is um causing which part of the fibers to tighten. The next thing is the, considering the Eber concept that has been sort of proposed by Andrea Aze and Ricardo Ti. And I think this is really sort of an important thing and it has changed the way we sort of manage these sort of injuries. So you've got your, your DCT FCC here, which they say basically is the distal part of it. It's made up of your superficial fibers and your ulnar carpal uh ligaments, which is the hammock and then deep to that line, you have your deep fibers. Now, why it's an iceberg concept because what we see when we are looking at the ra through the radiocarpal joint is just this part of the TF you see, and that's, and if you look at diagrammatically, that's just really a small part. And that's considered mainly to be the uh shock absorber. Whereas below that line, what we don't see is we don't see the deep ligaments and that is considered to be the most important part of this T FCC. So it stabilizes the D IU and it stabilizes the carpus as well. So what they're trying to say is that your deep ligaments uh actually the most important ligaments, but it's very, sometimes it's very easy to uh not assess these proper properly when you're doing arthroscopic assessment of the T FCC because you're only doing the radiocarpal. So what this suggests is that if you have a tear go underneath the 10 and try and see whether you can see what's happening to the, to the deep fibers that insert in the foia. Or you can do AD I UJ arthroscopy to see whether the foveal part is elevated and their recommendation is to do all of these under dry scope because if you have a lot of fluid, you can get false positives as well. But so basically, the whole concept of this is understanding what are the stabilizing structures of the DR UJ, the components of the T FCC. And in essence that the deep fibers are the most important part of the T FCC immunity, which you need to look for that. So in terms of examination for uh TFC, um what we need to do is how do we sort of examine this? So there's a co there's a couple of tests that can be done uh to examine the T FCC. So you have the fovea test which apparently is a very sensitive and specific. So it's basically looking at point tenderness over the ulnar capsule, just palmar to the EC U. So you can see where whether it's drawn and pain is exacerbated by passive forearm rotation. Um and you can get the exacerbation of the pain and there may be a click or a bit of crepitus as well. Um it definitely does kick, you know, I've got a T FCC tear on my right wrist and it does kick in certain positions. Uh The next thing is the ballot test, which is on the right hand. That's quite important actually. So, what you want to do is you just stabilize your hand and then use your fingers to stabilize the ulnar and then you're balloting it in the AP and PA translation, you do it in the neutral position first and then you test it in pronation and if it's unstable in pronation, then you suspect a volar deep ligament tear. And if and then you test it in supination and if there is instability, then, then you think of a dorsal deep ligament tear, which is why we were looking at which position that the fibrous tight in. And the other thing that Andre A mentioned is also to consider whether it's a soft or firm endpoint, if it's a firm endpoint, then those tend to do better because it definitely stops at some point. Whereas if it's a soft endpoint, then that indicates there might be a lot of laxity and those might then progress to becoming a full tear. So those tend to do worse with um non operative treatment. Now, he also suggested that these are best done under regional anesthetic and intraoperatively because you can have the secondary stabilizers such as the palmaris sorry, such as the pronator quadris and the EC U which then go into spasm and prevent it from actually um being quite accurate. So I think the key part from here to understand is that every time you fix a distal radius fracture, because of the high incidence of all other injuries, you should always do a block test um to see whether there's any instability of the D I UJ. And I think then the block test in neutral pronation and super is the best way to address this. So in terms of acute injuries, the things that we will quickly talk about and look at are, you know, bony injuries and the soft tissues. So, ulnar syloid, ulnar head distal therapy, ulnar, and then we look at the soft tissue elements T FCC and the EC or the EC subsheath. So these are patients that I have seen in clinic that were referred to me for ongoing ulnar cytopathology after they had distal radius fractures. So with the first one you can see here, you know, there is the distal radius have healed all within in the union. And that ulna styloid is rotated 100 and 80 degree and it flipped and looking and understanding where the T FCC, where the radio ulnar ligaments inside. You can probably suppose that, you know, part of the part of that is probably toward and unstable, which is why that's causing him inherent instability. Uh with this patient who I saw recently you can see on the lateral and the ap, even though it doesn't look that badly displaced, it hasn't really healed and it's just near the foveal insertion and at the base and you can already see that she probably does have a bit of instability and clinically when I assess her, she does have the instability. So that's why it's really important to assess this because if these injuries were treated at the point, um at the initial point, then, you know, it it might have been, had a better outcome for them. So what is it important? It's to realize that not all ulnar fractures are unstable. If you have ulnar stent fractures at the tip, then those are generally going to be quite stable because you know that the deep ligaments are inserted and maybe there's just the superficial ligaments have gone. Now, if they're at the base here, then, you know, it could just be the superficial ligaments and you're not sure of the deep ligaments. So you have to test that intraoperatively because the fact is that because you have a sh an injury and a sharing mechanism to the ulnar styloid, you can get tears of the deep ligaments as well and that's what's gonna cause instability. So after you fix the radius, you need to look at the, you need to look at the ulnar styloid and you need to test the stability regardless of what it looks like. So it really depends on which part of the radio ulnar ligaments are damaged. Some papers suggest if you've got more than two millimeters of displacement, then you should fix it. I think the test is important ways of fixing it. It really depends on the size of the fragment. So you can either put single K wire, you can do a tension band construct. If it's big enough, you can put a single cannulated screw compression, screw down that as well. Or if the fragment is too small, then you can just shell it out and do a Phobia reinsertion of the T FCC. And depending on what your choice is. Arthroscopically open surgery, uh you can just have a couple of drill holes uh from the ulna going in and then you can just put sutures and then re reattach it here. All right. So that's one way of uh looking at these injuries, um, bony, um then ulnar head and distal one third. I think you need to treat this and merit. Uh You have to assess the stability of the D I UJ. But usually, uh if it's extra articular and further down, the D I UJ tends to be OK. But again, clinically assess that because you won't be able to appreciate the soft tissue injuries on the x-rays and then you need to um assess the rotation. Um I've got a slightly lower threshold of fixing these because these can be place quite easily and you can rehab them quite quickly and it doesn't add on much extra time. Um This is a patient that was done. Um You can see this is fixed the Geminus plate that looked, they felt that that looked fairly well reduced, but then within a week that had displaced and then took the patient back in um and did uh the plating of the ulnar and she's doing quite well now and we got her going quite quickly uh then jumping off the soft tissue T FCC, uh EC U tendon and subsheath. So, again, mechanism of the T FCC injuries, deviation group pronation stresses the T FCC. So a lot of people in the, in doing, going to the gym and doing activities and get T FCC injuries, um injury with a degree of wrist extension and hyper pronation or any excessive uh over supination or pronation. Patients do remember an event that happened. Um And they can, if you uh speak to them, they can remember they felt something in their wrist and sometimes it can be accompanied by a pop or a click when it happens. Um going the classification systems. Um The palma classification system used to be the one that we all know you have your tight ones, which is the focus of this traumatic. So you have your central articular disc perforation, ulnar side avulsion, uh distal avulsion and radial sided avulsion, all right. Um And then you have your degenerative uh changes as well which you can sort of look through. Um So this doesn't really help in terms of your management. So, but this is all the classical system. Um If you look at A and LS paper, they have come up with a more comprehensive classification of T SCC peripheral test and associated ulnar thyroid fractures. And I think this actually makes a huge difference um to it. And you know, arthroscopy is still probably the gold standard. So if you look here isolated styloid fractures without a T FCC tear. So we talked about the stiff fractures where the deep ligaments are probably still inserted, basal fractures where the, where the deep ligaments are still inserted. And then if you do look at the arthroscopically, it looks OK. Uh There might be a slight peripheral tear depending on where the, where the injury is if it's going into the superficial ligaments, but you know, the TFC looks very taut. So, you know, you can either splint it or consider just putting a simple suture depending on your findings. And then as you progress, you can see, you've got your styloid injuries with more tear of the superficial and deep parts of the ligaments. And again, these on the radiocarpal radiocarpal arthroscopy actually look completely, no, completely look completely normal. Uh because the, the T FCC part here that you're looking at, you can't really see much uh during the radiocarpal arthroscopy, but you have to then do the hook test to try and see whether it's um it's uh stable or not. Um There's a couple of other tests. They have a ghost test where you can put the probe underneath uh the T FCC. And you can see the outline of the probe or you can do the suction test during dry arthroscopy where you just take your shaver, turn the suction on and as you turn the suction on, you can see the T FCC lift up onto the shaver which shouldn't normally happen and then you turn off the suction and it drops back down, the T FCC should be quite taught. And those basically, that's when you're going in into phobia refixation. The style fixation, class four and class five are more sort of elective things when you've had chronic nonrepairable tears and D IU arthritis in the rare event that you get a massive massive tear of the T FCC, including the TF the deep ligaments, um the superficial ligaments and then, and it's been there for a long time and you can't repair it, then you have to think about tendon graft reconstruction, which we'll briefly touch on. So assessment, MRI MRI arthrogram, but I think wrist arthroscopy is still the gold standard. And in general, if you have a patient who has symptomatic or a TFCC tear and um on radiocarpal arthroscopy looks normal. You should consider ad iu arthroscopy. If on radiocarpal, you can see a massive 10 and it's unstable. You don't necessarily need to do ad iu arthroscopy, right? I'm gonna play some videos here. So this uh let me know if you can see the video. So this one was a patient who had a small tear but you can see the T FCC is no longer taught. I can put the probe right underneath and lift it up and go and you could, I could stick my camera all the way into the fovea. So you could see that was detached. Can you guys see the video? Yeah. Yeah. So you can see, you know, there is some, it, it, it is like there is some, it bounces a bit but it's not very taught. But you can see that, you know, that might have been considered a central tear where you debride it. But I put the hook in underneath to see and I could lift it off from the foia and that me up with her symptoms of uh gross instability as well. Then what I do is that I make another cut um on the ulnar side of the wrist and using like a like ac like an aiming guide that we use for ACL S. Uh You put that in over the T FCC to bring it down to the FOVEA and then you make some drill holes with K wi with K wires or spine and then you replace them in spinal wires and then you put a suture through one and then grab it and a suture loop through the other. You grab it back and then basically you pull it and can you see that the T FCC is getting quite ta there? So you're pulling it back down to the Fulvia and then you have another incision on the ulnar side where then you just secure that with a push lock anchor. I can share more videos of uh the links for the videos for these as well. So you can see them. I couldn't embed them and then passing briefly massive test if you have massive test that you can't repair with, with that you do a similar thing. But in this case, what you can do, you can take a palmaris, longus graft or, or plantaris graft if you need to and basically drill a hole um in the ulnar part of the radial of the radius where the or origin of the um radial ulnar ligaments are gonna be, then you loop it round and you pass it through another drill hole in the, from the ulnar to the phobia. And this is the sort of similar angle that you put your wires in when you're doing an arthroscopic assisted refixation. And then you basically pull the both limbs through that to try to recreate the footprint. And then the Adams procedure talks about tying it outside. But nowadays, ad and a lot of other people that are doing arthroscopic surgery, you can put a interference screw there. So you don't have anything else on the outside of the ulnar as that can cause a lot of irritation. Now, we'll just talk about EC U quickly as well because that's quite important. Um So the EC U originates from the lateral epicondyle and inserts into the base of the fifth metacarpal. The subsheath is the most important part of the stability to the EC U. Um It goes dorsal during super and translates ulna during pro pronation. As mentioned before, the subsheath forms part of the flow of the T FCC. So it's part of the stabilizing structure, uh mechanism of injury, loading of wrist and flexion during super and ulnar deviation or a certain certain lateral force, the wrist and the EC is engaging strong isometric contraction, ruptures of the EC U are quite rare. It is usually injury to the subsheath ca or causing some subluxation or dislocation. Uh You can see here this is your normal ec U tendon. In the subsheath, you can have a bit of perio stripping or ulnar sided tear which then causes the ec U to sublux or you can have a raided tear which then causes it to sublux or the sheath contracts itself. In terms of examining the EC U, we only examine uh we are looking at examination techniques, not for chemo synovitis, but just for possible rupture or subluxation. Uh So the ice cream scoop test. So if you do pain on resistant active extension with ulnar deviation, you're getting a flex and ulnar deviate and supinate. Like as if you are scooping ice cream, you can actually see it sublux out of the groove. So that's worthwhile. Remembering flexion, ulnar deviation and get them to supinate against resistance. You can feel that um it'll be painful as well as it will to sublux. Dynamic ultrasound scans also very useful or MRI scans between the radiologist should be able to do this quite easily. So by doing maneuvers like which is similar, you can see the EC U slipping out of the, of the groove and they can tell you where the subsheath is torn. And when you do an MRI scan, you can often see that sitting out of the groove as well. Treatment, you can try splinting and casting with the wrist and radial deviation and pronation and the acute onset, throwing a little scar down and heal if that doesn't work, then some sort of reconstruction, there are many, many ways of doing it, um which tells you that there's no one way that's better than the other. And you can do drill holes and then you can implicate the sheath um using um the drill holes and 10 and sutures passed through them, or you can get a sling of the extensor retinaculum and cover it. Basically what you're trying. The main basic principle is you're just trying to recreate another sheath to prevent the ec U from subluxing during movement. So, in summary, there's a lot of structures on the side, we just look at the traumatic parts here and just looking at what stabilizes the D I UJ understanding that, you know, which parts of the D I UJ are important and how to assess them. And basically we need to look for them and treat them adequately. And I think it's in the, in the setting of distal radius fractures where we often miss um these in unstable injuries that we need to look for and assess them. And in terms of treating them during a distal radius fracture, uh we've moved away from, you know, putting two K wires across the D I UJ. That doesn't really do much for it and just stiffens up the D I UJ. It's, if you, if you find an unstable um D I UJ, it's best to fix it either by fixing the ulnar ST or by fixing your ligaments back onto the Fulvia. Um And if it's fairly stable, you can get away by putting it in plaster either than supination and neutral long arm just to help it scar. So that is also an option that you can do. If the, if the head reduces and it feels stable in certain positions, then it's perfectly OK to actually consider doing that. Ok. So I've tried to simplify a um complex. Oh, well, it used to be complex to me. I don't know whether you guys find it complex but trying to simplify it for a better, easier understanding questions, comments. Could I ask you a quick question? Yeah. So you talked about assessing the Droge and the stability and then considering fixing it um when you're doing a radius fracture, but if it's a general, you know, sort of trauma list or maybe even a registrar doing, you're probably not going to do a ligamentous repair at that stage. So, could you finish up plaster up and then refer to a hand surgeon with that? I mean, in the ideal environment? Yes. But you know, there's a lot of variations of whether it happens or not. So if you felt it was stable, you know, I you, you can put it in plaster, reduce it, hold it in plaster and you know, you can then refer it to your friendly hand and wrist surgeon to have a look at it and follow the patient up just because there needs to be a lower threshold of sort of fixing it. Is there a timescale? Like, are you trying to fix them as soon as possible post dramatically or? Oh, no, I think with anything, you know, the, the quicker you fix it the better. But I think with the T FCC, you can get away because you know, when we refer TF CCS, they're quite far down the line and they still seem to be doing ok. But obviously from the patient perspective, if, if you're having to fix the TFC and put them back in the plaster for another three or four weeks. It's a long time scale. Um You know, the ligaments don't really retract unless you've got a massive tear. Uh Because as you look as if you saw the diagram of the T FCC, there's so many different structures there. So you don't really get through retraction of the ligaments more, more, more than anything. But the long, if you have a bad tear, the longer you leave it, the harder it doesn't become because the edges can become a bit frayed. But the, but the thing is the, the benefit of it is that you can grab whatever part you have of the ulnar part of what, what whatever is remaining and you can actually pull it down onto the fovea and just stabilize it there. I've done it quite delayed for some patients where the TFC seem looked horrendous when I went in. Um But they've still done well because I grabbed whatever I could just to stabilize it. So, uh with someone who had that in the radius fracture and a plate in um in a No, would you wait for them to settle from that operation first before you um you know, attack the ulnar side? Um It, I think that depends on how unstable it is. If it's grossly unstable, then no, I'd actually go in, I saw a patient, you know that um patient I showed you the image of with a massive gala fracture. So that was done in the US. And they only repaired the ulnar, the radius shaft fracture. And it came to me 10 days POSTOP and the scapholunate was damaged and the ulnar head was still dislocated. So I went back in and I actually did a primary repair of the volar of the dorsal, the dorsal radioulnar ligament as well as the scapholunate because instead of having to reconstruct it, I repaired it and I'm hoping that gives them a best chance of rehabbing. So I think it's uh you, you have to look at the timing of it because if it's early on, then it's worthwhile doing it because your rehab is gonna be the same where if it's, you know, if you're far down the line from the radius, then you might need to wait to get them moving a bit and doing it. But then if the, if the D I usually is unstable, they're not gonna rehab very well either because they're gonna lose pronation and supination. And then what's gonna happen is that you're gonna get a lot of scar tissue in the D IU which then is gonna make your further treatment difficult. What do you think? State? And I agree with that. Um Well, I think there's that, that case, you just said there is very interesting because what from the exam, from the exam point of view, you guys have got to differentiate between the ligament um and the on the sided ligament tears And really, I think we could say that the, whereas the ulnar sided ligament can wait, Theun ligament tear really shouldn't wait. And you're looking at, you know, and it sounds like maybe that was the reason you went into that wrist at that time was to get to repair the, you must repair the sc unit within, you know, six weeks, six week sooner than that. Um, because otherwise it does, it completely shrivels up and you can't repair it, then you have to take it. So this unit ligament, which we can talk, we'll talk about a bit more next week. When we look at the biomechanics of the proximal row is absolutely critical and should be done urgently by a hand surgeon. Um Whereas the ulnar side, obviously, it would be better to do it soon, but it's not, it's not going to make a difference to the result. And I think the I is, is quite a difficult thing because, you know, the classical we are still evolving in terms of how we treat it. I think our sort of standard teaching was, you know, I just stick two K Ys in and let it heal or put it in and let it heal. And because there's problems in the future, your friendly hand and surgeon can sort it out. But being your friendly hand and researcher, I see a lot of complications with it now and because um my understanding is slightly better. I've got a slightly different threshold. But I think the key thing is to be able to appreciate when they're injured and have a, you know, so that you can deal with it and get someone to look at it more expediently. Yeah. Absolutely. I think, I mean, we've got some, yeah, the key thing is really to a general trauma orthopedic surgeon, you just want to fix the risk or identify the complex injuries. They are still poorly understood even amongst the hand surgeons. So if you see or you're concerned about the T you can get an MRI and then once you've done the interim measure of the dys fixation, if it's urgent, then do definitely get you get your hands, surgeons or hand colleagues in the unit to assess this patient more urgently rather than wait a few weeks or a few months. Because then the window of opportunity to intervene has been lost. And so the outcomes of a condition, even if you've got them first time is not great, getting them three months down the line is even poor. So it's just important for, you know, just a general orthopedic surgeon to identify these injuries and we diagnose them early. Yeah, I think, you know, that should be the takeaway message from that talk sort of just understanding the basic anatomy, what's involved, what the different treatment options. I'm not expecting all of you to know how to fix them, but just understand the concepts and understand that it's an important injury to sort of assess because I think it's a very forgotten thing going through my orthopedic training, the ulnar side of the wrist is always not really emphasized on and talked about much, but, you know, II see a lot of side injuries that I have to deal with. Ok. All right. So, um, Rinna is gonna have a go, um, at her presentation and I, ok. And I think, um, Maria is gonna do a short presentation and swift, hopefully at the end of it, she says she's found a presentation. Is Maria there. Yeah. Yeah, I'm here. Ok. So Maria, are you ok to go through your presentation afterwards after as well or fine. So, so that can be the general part of it done. Um, uh, let's see if Romina can get hers working. Hopefully I'll hang on for that my patients in the holding bay. Huh? Ok. Do you know how to put my screen on if I need to present that? And, and I'm trying to share my screen. Ok. Sorry. Uh, can you see anything because I've, uh, verified the account. I'm trying to share it now. No, nothing yet. I mean, if you're stuck, you can email it to me and I can, I can share it via my screen and then the other people have helped me out so I feel like they can help you out. Let's see if we can do that. I think we'll get better for the next sort of few sessions. We've got quite a few sessions, sort of lined up. We've got some plastic surgeons on hand trauma unit here. I'm gonna be giving some thoughts as well. So we'll try to cover the breath of, um, hand and wrist trauma, uh, during these four weeks. And then we've got, um, some live demos um on the 30th as well. We've got a, a sobon workshop for metacarpal fractures and um we've got some risk fractures kindly sponsored by me and the leader uh respectively and then we'll get a few uh clinical cases to go through as well. And if you guys have any feedback or any suggestions, please let us know that so we can try to address those as well. Yeah. Ok. Should I try to see while we're waiting if I can actually bring my presentation up? See if it is? Yeah, I think that's a good idea why? Because it will take a while. Share the entire screen share again. Are you here? Mm. Did you hurt? It doesn't work. Cancel to try another option for now. Share between. Yeah, like that. Yeah. Hm. Is it on now? Yes, we can see it now. Yeah. Oh, perfect. So at least it works like this one show me. OK. Is this blood work and Maria was working? Is yours? Is that your screen? Romina seem to be sharing it? Ok. Any any change guys? Am I sharing it. Now you're sharing your screen. So if you change your screen to where your powerpoint slide is. Yeah. Yeah. On. Ok. And confirm if they can give you the first slide, it might still be a slight lag because I can just see your metal. What do you see on your display on your computer? Ok. Yes. No, it's still, it's still stuck on. I, I've got, I've got it on mine. I've downloaded it so we can I try to, yeah, sit up, sit up. Ok. Uh, ok. Yeah. Mhm. Shall I share now? I can, I can share, I think. Mhm. Ok, great. I'm going to log off and if that's ok and then we'll get your patient so we could have done it live and that could have been the key. Ok. All right. Let's get this out of the way. Ok. So, uh, Romina, you just tell me what to do and I shall, uh, I can't see what's going on. I'll just go forward and backwards. Yeah. Oh, there you go. Ok. Fire away. Ok, thanks. So, um, for those who don't know me, I'm one of the high risk consultants on. So we're gonna go from phd level stuff, side problems to more a level. So this is area. So I guess the caveat is because it is quite a common well versed topic. If this comes up in the exam, you have to know it in really great detail. So hopefully will mostly be, this is a bit of a refresher for the first half and like I mentioned before, the second half is more of a higher level order thinking. So uh moving on to the next slide, thanks na um it is important to understand the anatomy. So as I mentioned before, the distal radius has to withstand about 80% of the axial load that goes through the wrist. It has to remain burning articulations while the distal ulnar via the intru and the other, with the carpal bone, the radio carpal joint and the risk can be looked at as three columns. You've got the radial column, the intermediate middle column and then the ulnar. So going to the radial column, it involves the radial styloid and it, it's articulation of the fossa. Um This is where you have the br attachment and essentially its function is to hold the car in L and to resist the carpal radial translation. Then moving on, you have the intermediate middle um column involving the L fossa. And essentially that is uh all about transmitting the forces from the carpus to the forearm. And finally, the ulnar column and both has significant soft tissue and bony components to it that he will honor respectively. Um And that's really to do with the stability and form rotation. A lot of which was covered by um Sharia earlier. So next slide, I guess this is again a fairly basic but it's really important to know that up. And I injuries is really important to get a really good picture of the patient in front of you. So that involves not just the basic things like age, the job are they self employed, manual capacity versus um sort of office space because it will guide your management options. And then also looking at the event high energy versus low energy of mechanism uh and then that you're dealing with sort of the two polar opposites. So osteoporotic fail fragility fractures versus those were very young. Good bone starts. We important to understand and engage with a patient regarding their expectations because again, you're building a picture to help you guide management, particularly as there's a lot of injuries in the radius where it's not black and white, there's a lot of gray area and this is where um is really key to understand that in terms of examination, neurovascular is not just checking median motor median on the radial nerve, motor and sensory, but it's also to assess if they have any carpal tunnel symptoms. Again, a key factor, especially when if we're considering operative management and look for those associated injuries. Uh A few of these will mention later down the talk. So what are the predictors of outcome? It could be broadly split into three categories. You've had the patient factors, the injury pattern and the management, the patient factors are patient age if they've had additional injuries or is this an isolated injury, their occupation, socioeconomic status. And then looking at the pattern itself, intraarticular, significantly displaced commuted fractures. They again, they are sort of have red flags for potentially poorer outcomes that are not managed well. And do they have any concomitant ulnar fractures too? Then we move on to the management and that looks at essentially relates to the adequacy of reduction, the stability of the fixation and if the patient any POSTOP complications, so you can see that it's a myriad of lots of factors that come together to essentially um look at what the outcome is for the patient long term. So next slide, so this should be quite a common diagram for most of you, plain X rays, give us a lot of information and majority of information in vast majority of cases. And you're looking at four parameters, essentially radial height, inclination and volar tilt and then the articular surface if there's a new art to step off. Now, I used to remember sort of the normal motion as 11 2, 11 which are by and large near enough the normal parameters. But you're looking at what is acceptable. So we can um tolerate a degree of shortening, but it has to be less than five millimeters or the degree of loss of radio inflammation, articular step, more than two millimeters tend to do poorly. And then you're looking at dorsal tilt again, they both they don't do as well if it's less than 10 degree, um more than 10 degrees or 5 to 10. So once you've got that picture, if you find yourself that there's actually fractures a bit more commuted, looks more significant intraarticular, then act is a very good option, particularly for preoperative planning. This helps us understand the morphology of the fracture specifically in terms of operative planning. Does it need a dorsal plate? Does it need a vote or that fix? And as I mentioned, if there is any sign of uh ligamentous injury, whether that's Dr UJ stability or ate, do consider MRI, although it's randomly done, go to the next slide. So this is a big slide. I hope everyone's uh very familiar with this version. So we're just gonna um run through them very quickly just to summarize. So, um if we just uh click on each point, so you need to document full assessment, particularly pre and post reduction hematoma block isn't really recommended for pneumonia patient, but actually, that's fairly, quite common practice. Um But again, you just go with your local class guidelines with regards to this. Um And then moving on these injuries need fracture risk assessment within 72 hours, whether it's via VFC or face to face. Um The, the important thing is if you reduce the fracture or, and we're going down the operative route, the car seat have uh three point molding essentially. Um And if you go to the next ones for, and that's really to reduce, that's really to reduce the risk of displacement. Sometimes you find the cost application is in quality cost and traditionally there's excessive force or and patients just come into clinic one week later with severe carpal tunnel symptoms, if you have to actually reduce the cost and put in a reduce the fraction and put it in such an extreme range of mo position and uh the have pe people still see the screen? No, it's gone, it's gone as well for me. OK. Let me just can you can you see, I can see the screen. Sorry guys. Can you see the screen? Very poor? No. Oh I stop sharing and start sharing again. I'm gonna stop sharing and now I am going to start present now, share your screen. Uh Got you. Can you see it now? Yeah. OK. OK. Sorry about that. I was saying how if you have to produce a fracture to an extreme position where it causes carpal tunnel, no management is not the way to go. So really important to have three point M and other close to colleagues. Um Moving on. If it for patients who are uh elderly 65 plus with dorsal dispatches, we should be thinking about. No, but this is a guideline. You have to look at the patient um and make sure that it's patient centered, uh look at the functional demands and consider the acceptable criteria be a bit more aggressive with younger patients particularly with the variants, if there's space fractures, that they're mostly the majority of the time for fixation. If in terms of time, the fixation is recommended if they're intraarticular within 72 hours, and if it's extra than a week, less than a week, if you're in the gray area where I'm not sure it's in a good position, but it may slip. Then these patients really need to be looked at carefully with sterile x-ray the first two weeks at the very least. But also have that, that talk with the patient that if it and may need ac at a later date. And I know during my early years of training, we used to, I was always sort of taught six weeks, get xray, make sure the fracture is healing. But actually that notion has changed at six weeks, you take up and get them moving, no need for a radiograph again, unless there are clinical concerns. Um And for those patients, the reduction is achievable and also the extra articular fractures should be the option to go for making sure that these injuries also have that adjunct therapy of fall risk, especially for the elderly fragility fractures. Um and also that they also have contact with fractured knees and services, which actually has it normally has it uh good protocols or pathways in our hospitals. Moving to the next slide. OK. So the management uh can be broadly cat into non operative versus operative. Now, with closed reduction class for 4 to 6 weeks. Therefore, the simple extra articular fractures with the acceptable criteria. Um, once they're out, of course, whether they go through the surgical route or non surgical route, it is really important to assess patients. Sometimes some patients are ok with just sort of risk exercises and et and they're on the way. But if you find that patients have disproportionate levels of swelling or this pain and stiffness, these patients really need hand therapy input and by and large aggressive hand therapy input. Otherwise they tend to do poorly in terms of operative. The options are fixation for those able to be closed, reduced, uh extra articular patterns, fractures and then fixations reserved for really the more complex intraarticular dispace and commented fractures. Then you go on to even more severe significant injuries where they might be open polytrauma or you're in a damage control orthopedic sort of setting. Then you're looking at salvage options like X fix or dorsal bridge facing, ok. Moving on to the next one. So with regards to the no, this is for again, good reduction fractures with that tend to be extra articular. You go for below elbow cost and again, what as we mentioned three point molding. So can someone tell me about the cost index in the in the audience? What is cost index and why is it important? I ratio Yatim? Yeah, it's a ratio between of the width of your cast on the lateral projection and your ab projection. And ideally you want that ratio to be under 0.7 as an indication that your cast is fairly well molded. Ok. Yeah, so sorry, you're breaking up there. But yeah, I think you mentioned that it's a break between if you go to the next slide, uh that is between the lateral versus ap in the diameter, the inside the edge of the cast. And you look at our cast index of less than 0.8. If it's any, any larger, then you worry about redisplacement and the measurement is at the fracture site. Um So I think that is what's the most so well done. If you move on to the next slide, what are the other causes of redisplacement or risks? So again, you think about age, elderly patients with poor bone of, of course, that they're more, more unlikely to hold a position even if a and you manipulated them and got into the position. Uh the fracture pattern. Two things you need to look out for are commun and concomitant fractures there. They have suggested those two are really important factors of displacement. And then you look at the prereduction position on the first xray that had if there is a positive variance. Again, that's another key indicator of red displacement. OK. So can someone who's on the audience that would like to discuss this case? Mhm. Uh Hello. Can you hear me? Sorry, I'm using your ears but it's your ears chrissy. Sorry. So yeah, so I'm going to look into this x-ray. Um from here, what I can see is this is an ap and lateral radiograph of a mature skeleton focusing on the wrist. The most obvious abnormality when looking at this is a distal radius fracture that is intraarticular commoner and appears short with dorsal angulation. Um There also appears to be some positive ovarian secondary to the shortening. Um But what would you be your option? How would you treat this? So, obviously, the patient factors. So it very much depend on the age of the patient, their comorbidities. Um and obviously generally hand dominance and all these other questions that we discussed, but uh most for, for a reasonably fit and well er individual who was suitable for an anesthetic, given the fact that this is intraarticular, um short and dorsally angulated, you could just look at fixing this um because of the risk of this obviously causing issues in terms of articular surface in the future arthritis. Um and obviously falling back if you were to put it into a cast, the chance of this obviously needing a manipulation and then an operation is higher if it's an elderly patient. Thanks. So this is extra articular. So this is not working out for me because II can barely hear you breaking up. So I think you said you're gonna discuss the age of the patient with the sort of um but this is extra et cetera. So this says extra articular. Um and it's, you're heading for surgery, you've not been able to achieve manipulation. And so you're going for what? In terms of surgery, in terms of? So I would be looking. So could you say sorry Romina that it's extra articular? Because on here on the X ray, I thought it looked intraarticular. So I was just wanting clarification on that. Sorry, I can't see it very clearly to say it's extra articular. We're going for K or uh if it's, if it's extra articular than K wire fixation, OK. I'm just gonna run through this because I think I'm just gonna, unfortunately, it's probably gonna be like that because I'm not getting back here. So if you go to the next slide. Um So yeah, so it's K fixation. The thing I wanted to point out with the principles of it. Interestingly, I don't know about you guys, but um during my six years of training, I've been in units where we didn't put a single K like the N nn. It's always about fixation. This is in adults and then in some places they're K wire heavy. So despite the draft trial, I don't know if much culture has changed, but essentially, it's important to know the techniques, both the techniques well, because you don't know what ends up and also you want to be able to use your, the evidence out there. And when you're a consultant um carry your practice with a good practice with the evidence that's out there. So in principle, for the, it's really important to at least have two ko here one on the radio and the other important thing, this is usually sort of the go to the other important thing is really getting that do the dorsal R wire and do make sure that it is that the entry point is a lot more proximal moving on to the next line. OK. And this is another technique that I find quite useful for when the fracture is not coming together with just manipulation alone. If you use it intrafocal using the technique, and it will essentially insert the wire do into the fracture site and then you pivot it to 45 degrees to help reduce that fracture. Then you continue passing that wire and through the cortex and then use a second to complete fix um moving on. And then again, this management, this is gonna be another interactive thing, but we'll just run through it and I apologies for this. But essentially here, you can see a uh uh fragment that's displaced, it looks potentially intraarticular, but this is most likely a VV fracture. The key thing here is grossly unstable if you look at the var fragment and the carps is actually coming away from the wrist itself. And so this is grossly unstable and means fixation. And here the mode would be if you go to the slide will be a fixation uh to buttress that fragment with that vertical shear force that's caused the injury. Ok? And go to the next side. OK. So this is uh I was going to discuss the options here with you guys about how you guys fix Rectus radius fractures. Now, for senior trainers who might have more experience, you might have a passen, but it's always good to have an approach to any operations. Sometimes quite easy. When you're a trainee, you just follow the bo set up. And sometimes you even think about where the II is, where you're going to sit in the axilla outside and I'm going to fix this, but it's really important for each, for any sort of operation. You've got this method in place. So what's your before, you know, it will be run with a train or a fellow and all? And then you start an operation and you realize that eye is not the right position. So just have those things in place. Think about the incision, the approach you're going to use. Are you going to go for that? You need to address dose? Um and also the exposure of the fracture site, make sure you have a cuff of PQ because that's really important to try and repair that at the end, you go to the soft tissue release. I always think it's an autopilot. You should do it with the release of the radialis because most of the time you've got radial shortening and it really aids the reduction. And if you only it infrequently and when you do do it, it can get a bit worrying and getting close. But you really should see the first, the tenders on the first door compartment and then, you know, you fully release the VR and it helps with the reaction thereafter. In terms of the watershed line, this is really important because it's all about the plate position if you drop to go beyond it, and you're really at risk of um injury or threats to FPL, not even immediately. But it could be six months down the line or a few years down the line though. You really must make sure you understand the and some ways they, how do you um identified watershed line and usually there's a ridge that you can build, but you have the PT fibers and just beyond that, you have the, the, the cap which is white in it appearance. If it's still not easy to uh to sort of identify, you can use a hypodermic needle to get into the radiocarpal joint. Usually you can feel a ridge as well. You really don't want to be going on that. When you're putting the wrist plate on, then you're thinking about factor reduction, which will be direct because it's right in line of view. And how will you hold that? Do you need a radio wire? And where would you put the plate, then you go to decide how to fix this. So will you be fixing the plate approximately and then to the distal screws or will you be fixing the plate distally? First say there's lots of dorsal tilt and then you have the plate to slide it off the bone and you use the plate to age reduction and other ways, right? And it depends on the fracture pattern and surgeons discretion. But those are the things that should be going around in your head when you before the surgery and interoperatively, in terms of making decisions. Next slide, if we can just keep tapping, sorry, we'll just complete, go through that. So in terms of the approach, the approaches S tr it has to be I tend to take the S tr only because it protects the median nerve and also taking the she cutting the sheath just on the radial side helps you sort of avoid sort of violating or injuring the palmar cutaneous branch, which is about four or five centimeters proximal to the risk, be mindful of the radial artery. People think it's really on the radial side, but especially with deformed fractures, the radial artery can come quite midline and be at risk when you're dissecting. And I mentioned the risk capture, you don't want to while you fix the radius. The other key thing to, to really be mindful of is intraoperatively. You need to ensure your screws are in good position. So they're not disrupting or penetrating the articular surface or that they're not dorsally uh and kind of going through the dos cortex essentially and they're at risk of r de tender in particular. The next. Yeah. OK. So this is all about the new kit. Regardless of what kit you use, you just need to be very, very well verse to it. If it's a new kit, we got tech, especially if you're the leading surgeon, which I know se 34 might be just learned to technique. But it's more important really for everyone. If you start thinking, OK, you go to a different center, you've got a new kit, have a look at it. So this is a journalist kit and you've got these now, particularly for this one. For example, I know these are quite small, they can be loose and they have been known to be left in the patient. So make sure you get a kit like this. It's part of the account for simple things like that. You can see here. Now the plate positions and you can see a proximal screw on the images. In this middle images. You can see that's a nonlocking hole and it's put the plate down. Interestingly, this, you've got the K wire fixation K wire through the pit. Now this is again, this kit, for example, is tell you that this is the most distal extent of the screws. So for me, if I've got this image. I know that I don't need to take any further xrays. Really, I'll shoot all the distal screws in and the proximal and the final images. But that's how you reduce the radiation dose and make progress with your, make progress with this operation or fixation. And it really is just a reminder that one must really know the kit that they're using and not to rely on, on scrub stuff by the next line. And this is just an slide to emphasize that important to repair. Now, sometimes OK, you don't get, I totally understand that. And sometimes the fracture itself just the into a really horrible mess. And it's just a looks like God. But you can, if you have a pristine or you got some, just the most important part of the dis and just the first, maybe just the first distal part of the case. And if you can at least cover this one end of the plate that still reduce the risk to some degree. But usually if, if the B and we've made that L in you, you can repair, OK? Next slide. OK? So no one has spend too much time on this because X is really rarely done particularly with the of plate. Um So if this does come up in the exam, in terms of configuration, it's very simple. Uh Can you tap on the next slide as well, please? Thank you. It's very simple. It's two pins. Um in the second metacarpal and two pins, approximately when you're putting the pin in the metacarpal, be mindful of the extensor hood and extensor mechanism. So you want to put it at 30 to 45 degree angle and the flex the M CPJ is a disc. And so with regards to um proximately, again, be mindful of the superficial radial nerve and do, do BB dissection. So you're not going through a tendon um And sometimes we can supplement it by fixation. Um And this is in situations where you want to get the patient off table with a DCR medical, medical unwell patient, open fractures on to the next slide, please. Ok. So this is by and large, even in a DC, this is what I would use. It has many advantages. Um And the main thing is again, it's not only for polytrauma patients or this is a uh bailout option or a salvage option for those really difficult to reconstruct, articulate surface, the fractures that are into pieces and they really can't reconstruct it. Um And the, the main advantage of this is it's a minimum invasive and actually, I don't make an incision in the middle like this thing called, but use a long either on the second one, me and the, the um but essentially you leave the middle area, the the zone of injury or the area of balance well alone. So the soft tissues are not disrupted or further um violated and you and really bring out the lung and let it heal in that position. Now, then you have the dorsal bridge out in about 2 to 3 months. Yes, the patient is going to be fairly stiff. Yes, they have a very high risk of arthritis and, but when you deal with a patient like this, it's really from the outset breaking the bad news that this is a significant injury and depending on, you know, potentially a life changing injury risk will not be returned to normal and that's all. And I mean, going from that, it's not just going back to normal, but it will have significant stiffness and um implications particularly if you're in a manual job or they do hobbies that involve, you know, sports or uh such things moving on to the next slide. Ok. So look for associated injuries with s so, as mentioned, is important on the side. Fractures are important, interestingly, 70% of fractures also have injuries. So the T FCC again, um and so look out for these things because they are there. And if, if there is any inflammation or pro pro in the X rays or mechanisms that's making you think that don't hesitate to get an MRI. Just to another note on the radio star, fractures, fractures alone. If you see a prereduction uh or pre pre X radio star and you see that the car run away from the, the dos radius just have, that's a red flag don't think it's just the radio. And unfortunately I have come across a couple of cases where just the radio so was fixed with AK wire or a screw. And one week down the line or two weeks down the line, they come back to clinic and the carps is off the wrist and blocks all dislocated. And that's because it's a much more significant injury, the dorsal capsules completely been torn away. So it's not just a bone injury. So in those patients, you look out for that, obviously, it's an under red or um fracture. Um fair enough, but if it's displaced and the carpus subluxation in the prereduction or pre x rays, they will need a reconstruction of the dos capsule. So the bone anchors, you'll find that you do the do approach the do it is completely there and that's where you put the bone anchors and bring back the wrist. Ok? On the next slide. Ok. So anyone know what this slide is? What about the signage? Rather Thomas exactly next. Next on it. The Terry Thomas who actually is Terry Thomas because he's certainly not on mine. You know, it is not the next one. Yeah, I know who Terry Thomas is. I'm old enough to know this man. Well, oh, so yeah, this is more kind of my, does anyone recognize this? It isn't it from the J I can tell. I'm so sorry because everyone like Az at the moment. But yeah, if you, I'm not sure it is Robin Hood. So yeah, but if I show this picture to the junior doctors, they still have a cruise. I need to find someone for the gen Z generation who they can relate to but moving on complications and considerations. Right. So patients can develop a carpal tunnel syndrome. Now, that could be at time of injury or following surgery. If it is at the time of the injury, they most likely have a pretty nasty wrist fracture, you must address it at the time of surgery. So I would use a separate incision where possible, but if not do incorporate it and make sure that the there's a curved InVision over the risk crease, prevent inflection contraction. If it's a POSTOP, then you have a low threshold to release it because a um they are very high risk of carpal tunnel and CRP S and also if you don't address it and they have ongoing um, median nerve symptoms, a it is likely to get worse, but also it affects the recovery and rehab. Ok. Ep rupture and vit the things to watch out for are things like this fractures that have maybe a large bony spur and that can just be a direct fracture of the E which is very unlikely or it could be even very innocent fractures on the f and you thinking what the hell is going on? And actually most cases, although this is an uncommon complication. It's more to do with the hematoma from the fracture site. And then that goes into the third excessive compartment, you have intra compartmental pressure on the hematoma and you can get nutritional rupture over time. So it's really important when you see them at six weeks or um or two weeks. Whenever you're seeing these patients in clinic or radius follow up just quickly do as it takes a second. But it's not, it's really important not to miss that because they can occur even on occult or so or fractures. The other cause of rupture is your fixation. So we can cause that to lay your. Um If you go to the next slide, OK, actually, it may be coming up but essentially just make sure that the, the screws do not penetrate the total closet, then moving on to KW, look out for pin site infections. If you are thinking, usually the K should be coming out 4 to 5 weeks and then cast them for the follow the, the last two weeks. But if you're finding that actually, I want to put these in for six week and you made that decision at the time of operation. Um That's not a problem, but I will bury them, uh reduce the risk of essentially infection and worst case scenario, osteomyelitis, which should be an absolute disaster. And then when you're looking at the very, we always slightly minute open. So you can actually visualize and make sure the nerve is not clear when you're doing that because all it takes is seeing that one radial nerve injury in clinic and they aren't notorious for not getting better and it's really debilitating for the patient. Ok. Next one. OK. So this was gonna be interrupted. We apologize guys. So I'm just gonna run through this. This is an extra art this radius fracture, not reducing it. Go ahead for a fix, which is reasonable. Next slide. Uh OK. So there, OK. So this is the comments on the fixation. Uh I'm afraid I can't hear you guys very well. So the reason I would say is yes, it's reduced nicely. But the fixation that I'd be worried about the looks reasonable. But dorsal wire, you can see that actually, you know how I said about the entry point being in the dorsal room, it looks a bit more proximal, it's quite close to the fracture site. This is the one I would worry about. It's living on losing position. So if you go to the next slide and unfortunately, this is what happened. So this patient came to my clinic at three weeks and you can see that the ky that we were in hindsight, it's a great thing, but you can see that it's back out unfortunately, and it's lost this position maybe obviously because it's so close to the site, it doesn't have any grip. Um And it's in reduced or lost position. Completely. So then in that situation, what do you do? Uh, you'd have to, would you care? Why? Again, I personally wouldn't think I don't do the same thing and expect a different outcome. And also you want something more reliable here. So this patients come through a fixation already has these complications probably quite fed up while she was. But anyway, so then you want something where you could fix it robustly and be more confident that this is very, less likely to fail. So we went ahead end of the next slide, I fixation and she's recovered well from that. Moving on to the next slide. The this is another key point that I mentioned about intraarticular group penetration really important. The thing that you could do to avoid the comp is to look for problems interoperatively because that is the place where you can change things. Um So if you are concerned about in a fracture, that's gone through the, so the surface is what you need to look at for making sure you've got good images to make sure that you have elevated 30 degrees off the table and make sure you get this really nice radio carpal joint view. But also we do the sun skyline view where you can see how much of the total cortex if it's penetrated or not. And if it is exchange the screws because they will come back or they'll have to be taken out at a later date. And move on to the next slide. Thank you. So, this is another key area where there we found a rupture. But you can see quite a few of the screws are going through the cortex. And to be fair looking at the view, the screws do not need to go all the way to the dorsal cortex. You only need 75% of the metasis for it to be adequately fixed. However, I appreciate there are some fractures where you really want to get that dorsal fragment squeezed into it or you're worried that it's going to drift away. And in that case, you just look at the technique as well, make sure when you are trying to get those fragments or the dorsal fragment, you squeezing the um between your inner finger and your thumb onto the plate. And when you're drilling, you're not pushing it away. So every time you're drilling, you put, your hand is really squeezing, they do and for you to prevent them to capture those fragments. And, and essentially, that's only for those cases where there's, but for the vast majority, whether you're not worried about this, there's no one to take that risk and take it and put in because a ro then leads to a significant outcome for that patient will need to tendon transfers and then another long period of rehab, moving on to the next slide. OK. So this is just from a cataract study, looking at plate position and the watershed line. This is what we mentioned about how actually even a plate is still really close to FD. And on the right side, you can see the different plates and the position. So here's your plate, it looks like a reasonable position. And then going on here, you can see that it's actually now starting to reach the watershed line and this is a teardrop plate for the really distal fractures. Now, these are quite traditional plates and now I really on the te drop, I would not use that if I do use it. And I've got a options, I'd routinely take that because there's a high risk of FP rupture nowadays with other kids and there's lots of family specific things like hook extensions to the. There's so many options out there. There's really very little reason to use this sort of face on to the next side. So some kind of uh has a nice classification looking for those plate positions and looking at which ones mainly taking out or to keep an eye on. So here you've got essentially a lateral X ray, you've got the R and you've got a critical line which drops down straight down from the. And essentially you look at three grades. So you either have grade zero, which is where the plate is marked by the red line and that the green one is the cortical surface. So you can see that the plate position is also to the critical line. Grade one, the plate is now to the critical line, but it's proximal to the VR here. And then grade three, is it disrupting both those parameters? So it not only is the bonus to the uh PC is also um breaching the very, very high risk of rupture in this situation. It would uh to take the pain out once the job is done around the 3 to 6 months. Um And then you have to have that discussion that the risk of that I have seen doctors even at 10 years, you might see them at six months or a year. You're like, oh, you got great. You're not getting any tethering on with life, that's fine. But always mention that it can occur, you can have chronic ruptures. So either with an open appointment or they don't want a second operation, which is fair enough and tell them if they do get clicking or any, any, anything like that to come back or plan for an elective. Ok, ma union. So this is quite a common occurrence. You see these, all these patients come in with like this with United Risk with dos tilt, you know, shortening on the apartment, it's got everything in there. Uh And you're going to think, oh, wow, the skin may need surgery but, you know, be surprised how many patients tolerate this well, and then sometimes with our treatment, uh but it's all about looking at the patient and assessing them if they complain. So I normally say patients are the best for their risk around 6 to 9 month mark. If they are struggling at that point, something needs to be done. It's usually the side pain that they'll have or loss of motion. And here if you get a patient like this and have you think about addressing it. Now, do I fix the radius? Do I do a correct? Was at the radius? Do I do it on a short one or if you have a dos tilt? It's a no brainer, you have to address the radius. You. Now looking at the the illustration here at the bottom, you can see that there's a quite a big do, but as long as it's very contact, that vo fills it regardless of it, you know, patients, but you do need to have that contact. If after this, if after the proactive was um you brought, the height is still not right. Then we might have to do um an shortly was me and there's something to discuss with the patient. If all they have is the variant and there's no dorsal then on shortly, wash to me alone will suffice next line slide rather. Ok. So moving on to uh other complications. Now, CRPS is a really hard moment for the surgeon and the patients because we know it's going to be a long painful journey. Um and it's really quite debilitating for patients. So here in the clinic, you can see the typical features of CRPS, you've got shiny period swelling, usually they have changes as well in terms of hair loss, traffic changes. Um and bud criteria outlined how to diagnose it if you're unsure, but essentially they have a lot of pain. If you see them at the early stages, if you see them later on down the line, the pain becomes less diminished, but it's more stiffness and swelling that they're left with and disuse osteopenia. But essentially the key here is to uh assess them and di them early and then refer on or start treatment urgently because that really helps with the outcome. Um And this CRPS can occur with an space, innocent looking fractures or it could be occur with harsh injuries or, or any other. So it really, it doesn't occur in complex injuries. It can occur with very simple fractures. But if you see them in clinic very early, start them on gabapentin or ami and send them to uh hand therapy. If they need aggressive hand therapy, including neurotherapy. In some situations, you can do a car, consider a carpal tunnel release. But obviously, this is if you're in the subspecialty because evidence has suggested that can reduce, that can help with CRP symptoms, but it has to be with precaution. So you have to discuss it with the patient and also sometimes the surgery itself can worsen CRP S and then moving forward onto other complications or significant intraarticular fractures. They can develop arthritis, posttraumatic arthritis. Again, quite challenging to treat after you've sort of exhausted the non options, then they'll need management in terms of surgery. And there's a whole spectrum of that from low risk, fairly low risk procedures to very invasive high risk um surgical options. So that's risk, innovation to begin with. And then you're looking at salvage options like P RC fusion or replacement. Uh Next slide, I think we're coming to the last couple of slides on papers that you need to know basically. So draft number one cost 2015. So I'm sure we know quite well, but it's really important to know the details of this, especially if for exams and just really for your clinical practice, if you wanted to use evidence when discussing the things with patients. So draft 1 2015 is the RCT compared with with plate fixation in and then they looked at 12 month outcomes with the patient, patient rated risk evaluation. They had an excellent follow up, 90% follow up and showed no difference between complications or patient reported outcomes. And so the conclusion was guys use K ky is cheaper. It's so and it doesn't have any bad or or effects similar to possible. Furthermore, they did a further study in 2019 5, the outcomes and it still shows that there's no difference. So again, for those special and adults can think about chaos fixation. Then moving on to draft two, this is now KWS versus cost and, and again, same patients radius. And it's a pragmatic trial which means it's up to the surgeon, the treating surgeon, the technique of K and they have 500 patients in this study. And it showed again for the same patient reported risk evaluation at 12 months. Again, an excellent follow up 80 almost 80% and shows no difference between either. Again. Interestingly though the caveat is 13% in the cost group need further surgery because the fact is placed within six weeks versus the one patient. But in the end, the patient risk evaluation were not effective. So they were similar. So the conclusion here is go for KW if there's a proposal, do we leave it alone or do we fix? Um But make sure that obviously it's because we were having a more cost and keeping a very close eye on these patients because one in eight patients did require who were do first require further surgery. And this is a key because a lot of the time that are gray areas, you have to have that discussion with the patients. Do you, should we wait? Should we keep an eye on this week? One week, two and week three to think about fix if the patient is going to take that risk or on bo and go through that nonop, which is actually harder to manage. I think going for nonop is a hard decision to make because also it requires a good nonoperative management in terms of cost and keeping a close eye. And so it might have slight, slightly risk operation where it's easier to fix and forget that. Are we doing right by the patient? Who knows? But it is definitely important to have these discussions with the patient to help make the go improve. Then I know there's draft three coming up guys. So draft three is looking at cost versus Splint and I'm sure no doubt there'll be draft 456 and there'll be cost nothing. So who knows? But draft three is coming out to keep an eye for it. And I thank you very much for your patience and I'm really sorry, we can have that interactive component, but I hope you found it useful. Ok. Yeah. Ok. Let's have a look straight over to Maria because um and crack on there and let's see if you can see this. Yeah, I can see that. Ok. Uh We're going to have a very quick run through the swift trial which is basically comparing surgery versus cast immobilization for scaphoid waist fracture. So the aim of this trial was exactly to compare that early fixation versus cast immobilization to treat the adult patients only more than 16 years of age. Yeah. With bicortical sca foot fracture which have more than two millimeter displacement, uh less than two millimeter displacement. OK. The inclusion criteria for this, as I said, is only adults um are the patient who presented in an NHS hospital in the first two weeks after injury. And we were able to actually operate on them in these two weeks. They needed to have a clear bicortical scid waste fracture. And the displacement shouldn't be more than two millimeter. Also, if there is a step or a gap that should be again, less than two millimeter, everything else was excluded if you have uh more displacement or if it's distal pole or proximal pole or associated injury or patients with different types of issues, cognitive impairments, you know, pregnancy, everybody else was removed from the uh the study. It was a big study. 30 one NHS hospital three years period. The randomization was um either early surgical fixation, either immobilization in the elbow cast for 6 to 10 weeks and then the ones that didn't unite, they were uh uh fixated. Then after 6, 12 weeks after the CT scan was done. All right. So going for forward, those were the parameters that were measured. And so they had this um um a patient related uh uh risk evaluation score which were done at different points in time. The x rays were done as a baseline 6, 12 weeks and then 52 weeks, the CT again, baseline and then 52 weeks, uh they um looked into the range of movement of the wrist and the grip strength. OK. Those are the primary outcomes just one second. Yeah. So those were looked for 52 weeks. Yeah, was wrist pain and disability. Um uh this is uh a score given from 0 to 100 a minimum of six points were uh required to, to uh provide a difference. Now, those were the secondary outcomes again. Um they were looking at the bone union range of movement, grip, strength and complications associated with uh every type of fixation or treatment. So it was a large um number of patients more than 400. And as you can see, usually young male, um and um 61% of them had less than one millimeter displacement. Ok. So in the surgical group, 86% of them were receiving surgery and then in the cast immobilization, 97% received the cast. So when we're looking at the results, you can see that at 52 weeks was no statistical difference in the patient related um risk, uh evaluation scores. Um There was some uh some improvement in pain and function at two, at 12 weeks in the group treated with surgery but nothing beyond 12 weeks. So if anything, the difference was at six or 12 weeks, but then when comparing the one year results were the same. So this is the message. Yeah, no significant difference in the pain and function or race, uh range of movement and grip strength. Obviously, the patients who were treated with surgery had some surgical complications. The one which were treated with cast, um had some um uh some cost complications. And um yeah, the strength of the study were that, you know, this was a multicenter randomized um study with a large number of patients, huge participation, you know, 31 hospitals um was centered on the primary outcomes. And um the baseline characteristic of the, of the groups was approximately similar, which was a good point. And with every single study, there are limitations. And um you know, first of all, um you needed to have a very clear scid fracture on your X ray. If you had a fracture which was not visible in ed, that would not included in the, in the study. And then some uh surgeons treated with um uh normal cast, some of them included the tongue. Um And uh obviously, everybody had a different uh PT and rehab regimen. But um what I wanted to you to take as a main message is for this particular group of patients which are waste of the scale weight only and with a displacement less than two millimeter. OK. Or a step less than two millimeter was no significant difference in the pain function, restrain of mo movement and grip strength. That's the main message of this study. Thank you very much. Yeah. Yeah. OK. Wonderful, wonderful. All right then. So, um let's, I mean, that was very interesting, Maria and, you know, very nicely with my presentation there and I think that would be a paper to quote in your exams. Um And you can see how it fits in with that treatment algorithm where you have to define which, you know, which patients you're dealing with. And we are talking about ones with small displacement immediate presentation, etcetera. Yeah. So the, the, the, the result there is OK. Um I don't know what you just to summarize. I get a bit on the most important lecture in the sense today was uh m lecture. That was the one we were going to do. First. That's the one that was the longest. It was obviously the best. But um you can see why she follows the almost the author bullets um kind of style because in the exam that if they ask you about distal radius fractures, they will expect you to know it in extreme detail because it's very common, very important. There's a lot of research and you'll be expected to talk people through the practical stuff as well. And so that, that's where all the bullets and that for the lecture is, you need to know the details for that one. Then the other two lectures, my lecture and Mr Sara's lectures, less detail required. You're less likely to have fixed the scape yourself. You're extremely unlikely to fix the, you know TCC yourself so they can ask about it. It's not something you would need to know in quite that sort of detail, but a paper, they are controversial. Both the, um, the scaphoid as, as we're seeing there with, with Maria's, with Maria's presentation. Um, and the other side injuries are much more open for discussion. Uh So it's a different sort of answer in the, in the exam. Um, Romina, would you like to say anything? Yeah. Anyway, I think it was the way the were changed was the high part of your lecture. Really the way. Thank you very much. So just has made a point. Thank you, Chris. About cost duration now. Four weeks. Well, there's a recent study by JB Js 2023 but essentially, it's actually quite common practice. We've moved away from six weeks in a cast to, you can be between 4 to 6 weeks. It really depends on the assessing those patients. You could do a class at four weeks and move them to a sprint and the advantage really is getting them going sooner. Some patients, it depends, you have the spectrum of patients as we all know, if you find that they're a bit um or they're too sore, then put them back in a cast for two for a further two weeks. But it really depends on the patient once at four weeks. It's been in a cast. It's likely to do well, having said that I have seen fractures displaced even at 3, 3.5 weeks, but it's the majority of cases will be fine. Um OK. Any other questions or guys can I ask? Uh So has the swift um trial uh changed the protocol then for, for example, when your logarithm was one millimeter of displacement, have you, would you change that to two following the Swift? Yeah. So that would be exactly with swift you or am I, am I talking? Yeah, with swift. Then you would the, the answer to this is the thing with the algorithms you would then put swift in. If I could get my slides up again, there's a point in which you can now insert the swift trial in the algorithm and you can substitute one for two millimeters. Absolutely. So the algorithm is a, is a sort of empirical one. And the idea for you as a consultant or as for the exam is to insert, you know, evidence at the appropriate point. So now you're gonna say we know that below one millimeter, a swift trial has shown us this. Therefore, we should follow that above one millimeter. They were excluded from the trial. So therefore we still, we use our empirical algorithm. But absolutely, that should be, you know, that should be incorporated in your answer. And it's quite nice that Maria's presentation was, was next to mine. Basically. Thank you. I think we've drawn to a close then. OK. Yeah. Well, um thank you very much guys, apologies for the um technological difficulties at the start. Um We are back next. Well, I'm back next week with Doctor Mr Janowski. Um, so we will improve, um, the technical side, I think, um, it is difficult to do the interactive stuff, but we will try to do it because if we don't, then it just becomes for you us reading through or the bullets a little bit and I'm not sure that's, that's terribly valuable. So we will try to interact. But if, as, as we had with Miss Bigham today, if it, if it's not working, we'll just have to be a bit more deductive. We would, we would love to interact more, the technology limits us. Ok. Thank you, everyone. Thank you guys. We'll see you. Thank you. Thank you. Bye.