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Emily Wise, Lund University
Madeline Smith, The Glasgow School of Art
This presentation by Morris Kleiner (University of Minnesota), was made during the discussion “Competition and Regulation in Professions and Occupations” held at the Working Party No. 2 on Competition and Regulation on 10 June 2024. More papers and presentations on the topic can be found out at oe.cd/crps.
This presentation was uploaded with the author’s consent.
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This presentation, created by Syed Faiz ul Hassan, explores the profound influence of media on public perception and behavior. It delves into the evolution of media from oral traditions to modern digital and social media platforms. Key topics include the role of media in information propagation, socialization, crisis awareness, globalization, and education. The presentation also examines media influence through agenda setting, propaganda, and manipulative techniques used by advertisers and marketers. Furthermore, it highlights the impact of surveillance enabled by media technologies on personal behavior and preferences. Through this comprehensive overview, the presentation aims to shed light on how media shapes collective consciousness and public opinion.
0x01 - Newton's Third Law: Static vs. Dynamic AbusersOWASP Beja
f you offer a service on the web, odds are that someone will abuse it. Be it an API, a SaaS, a PaaS, or even a static website, someone somewhere will try to figure out a way to use it to their own needs. In this talk we'll compare measures that are effective against static attackers and how to battle a dynamic attacker who adapts to your counter-measures.
About the Speaker
===============
Diogo Sousa, Engineering Manager @ Canonical
An opinionated individual with an interest in cryptography and its intersection with secure software development.
2. FRACTURESHAFT HUMERUS
• Introduction
• History
• Epidemiology
• Mechanism of injury
• Classification
• Clinical features
• Investigations
• Treatment
• Complications
3. INTRODUCTION
• 3%to 5%ofall fractures
• Most will heal with appropriate conservative care, although alimited
number will require surgery for optimal outcome.
• Given the extensive range of motion of the shoulder and elbow, and the
minimal effect from minor shortening, awide range of radiographic
malunion can be accepted with little functional deficit
4. GENERALCONSIDERATIONS
• Current research --decreasing the surgical failure rate through
• New implants andtechniques,
• Optimizing the postinjury rehabilitation programs
• Minimizing the duration and magnitude of remaining disability.
6. EPIDEMIOLOGY
• High energy trauma is more common in the young males
• Low energy trauma is more common in the elderly female
7. ANATOMY
• Proximally, the humerus is roughly cylindrical in cross section, tapering to a
triangular shapedistally.
• The medullary canal of the humerus tapers to an end above the
supracondylar expansion.
• The humerus is well enveloped in muscle and soft tissue, hence there is a
good prognosis for healing in the majority of uncomplicated fractures.
8. ANATOMY
• Nutrient artery- enters the bone very constantly at the junction of M/3- L/3
and foramina of entry are concentrated in a small area of the distal half of
M/3 on medialside
• Radial nerve- it does not travel along the spiral groove and it lies close to
the inferior lip of spiral groove but not in it
• It is only for a short distance near the lateral supracondylar ridge that the
nerve is direct contact with the humerus and pierces lateral intermuscular
septum
11. MECHANISMOFINJURY
• Direct trauma is the most common especially MVA
• Indirect trauma such asfall on an outstretched hand
• Fracture pattern depends on stress applied
• Compressive- proximal or distalhumerus
• Bending- transverse fracture of the shaft
• Torsional- spiral fracture of the shaft
• Torsion and bending- oblique fracture usually associated
with abutterflyfragment
12. CLINICAL FEATURES
• HISTORY
• Mode of injury
• Velocity of injury
• Alchoholic abuse, drugs ( prone for repeated injuries )
• Age and sex of the patient ( osteoporosis )
• Comorbid conditions
• Previous treatment( massages)
• Previous bone pathology ( path # )
13. CLINICAL FEATURES
• Pain.
• Deformity.
• Bruising.
• Crepitus.
• Abnormal mobility
• Swelling.
• Any neurovascular injury
14. CLINICALFEATURES
• Skin integrity .
• Examine the shoulder and elbow
joints and the forearm, hand, and
clavicle forassociated trauma.
• Check the function of the median,
ulnar, and, particularly, the radial
nerves.
• Assessfor the presence of the
radial pulse.
16. IMAGING
APand lateral views of the humerus,
including the joints below and above the injury.
• Computed Tomographic (CT)scans ofassociated intra-articular injuries
proximally or distally.
• CTscanningmay also be indicated in the rare situation where a
significant rotational abnormality exists asrotational alignment is difficult
to judge from plain radiographs of adiaphyseal long bone fracture. ACT
scan through the humeral condyles distally and the humeral head
proximally can provide exact rotational alignment
• MRI for pathological#
28. • RadAiaSlSNOerCvIeAinTjuErDy=INWJriUstRDIrEoSp=
Inability of extend wrist, fingers, thumb,
Loss of sensation over dorsal web space
of 1st digit
•Neuropraxia at time of injury will often
resolve spontaneously
•Nerve palsy after manipulation or
splinting is due to nerve entrapment
and must be immediately explored by
orthopedic surgery
• Ulnar and Median nerve injury (less
common)
• BrachialArtery Injury
32. NON OPERATIVETREATMENT
• INDICATIONS
Undisplaced closed simplefractures
Displaced closed fractures with less than 20 anterior angulation, 30
varus/ valgusangulation
Spiral fractures
Short oblique fractures
33. HUMERALSHAFTFRACTURES
• Conservative Treatment
• >90%of humeral shaftfractures
heal with nonsurgicalmanagement
• 20degrees of anterior angulation, 30 degrees of varus
angulation and up to 3cm of shortening are acceptable
• Most treatment begins with application of a coaptation
spint or a hanging arm cast followed by placement of a
fracture brace
34. NON OPERATIVEMETHODS
• Splinting:
• Fractures are splinted with a hanging splint, which is from the axilla, under the
elbow, postioned to the top of the shoulder .
• The U splint.
• The splinted extremity is supported byasling.
• Immobilization by fracture bracing is continued for at least 2months or until
clinical and radiographic evidence of fracture healing is observed.
35. FCB-INTRODUCTION
• Aclosed method of treating fractures based on the belief that continuing
function while afracture is uniting , encourages osteogenesis, promotes
the healing of tissues and prevents the development of joint stiffness, thus
accelerating rehabilitation
• Not merely a technique but constitute a positive attitude towards fracture
healing.
36. CONCEPT
• The end to end bone contact is not required for bony union and that rigid
immobilization of the fracture fragment and immobilization of the joints
above and below afracture aswell asprolonged rest are detrimental to
healing.
• It complements rather than replaces other forms of treatment.
37.
38. CONTRAINDICATIONS
• Lack of co-operation by the pt.
• Bed-ridden & mentally incompetent pts.
• Deficient sensibility of the limb [D.M with P.N]
• When the brace cannot fitted closely and accurately.
• Fractures of both bones forearm when reduction is difficult.
• Intraarticular fractures.
39. TIME TOAPPLY
1.
2.
3.
• Not at the time of injury.
• Regular casts, time to correct any angular or rotational deformity.
• Compound # es, application to be delayed.
• Assessthe # , when pain and swelling subsided
Minor movts at # site should be pain free
Any deformity should disappear once deforming forces are removed
Reasonable resistance to telescoping.
43. OPERATIVETREATMENT
INDICATIONS
• Fractures in which reduction is unable to be achieved or maintained.
• Fractures with nerve injuries after reduction maneuvers.
• Open fractures.
• Intra articular extensioninjury.
• Neurovascular injury.
• Impending pathologic fractures.
• Segmental fractures.
• Multiple extremity fractures.
47. ANTEROLATERALAPPROACH
• Proximally, the plane liesbetween
the deltoid laterally (axillary
nerve) and the pectoralis major
medially(medial and lateral
pectoral nerves).
48. ANTEROLATERALAPPROACH
• Distally, the plane lies between
the medial fibers of the brachialis
(musculocutaneous nerve)
medially and the lateral fibers of
the brachialis (radial nerve)
laterally.
49. POSTERIORAPPROACH
• Position of the patient for the
approach to the upper arm in
either the (A) lateral or (B) prone
position.
53. POSTERIORAPPROACH
• Proximally develop the interval
between the two heads by blunt
dissection, retracting the lateral
head laterally and the long head
medially. Distally split their
common tendon along the line of
the skin incision by sharp
dissection. Identify the radial
nerve and the accompanying
profunda brachiiartery.
56. PLATING
• Plate osteosynthesis remains the criterion standard of fixation of humeral
shaft fractures
• high union rate, low complication rate, and a rapid return to function
• Complications are infrequent and include radial nerve palsy, infection and
refracture.
• limited contact compression (LCD) plate helps prevent longitudinal fracture
or fissuring of the humerus because the screw holes in these plates are
staggered.
57. PLATEOSTEOSYNTHESIS
• There are several practical advantages to the use of the LCDplates over
standard compression plates: they are easier to contour, allow for wider
angle of screw insertion, and have bidirectional compression holes.
• Theoretical advantages include decreased stress shielding and improved
bone blood flow due to limited plate-bone contact.
58. PLATEOSTEOSYNTHESIS
• Recently angle stable or locked plating systems have gained wide
popularity.
• By locking the screws to the plate a number of mechanical advantages are
gained, including areduced risk for screw loosening and astronger
mechanical construct compared with conventional screws and plates.
• With locking plate systems, the pressure exerted by the plate on the bone is
minimal asthe need for exact anatomical contouring of the plate is
eliminated.
59. PLATEOSTEOSYNTHESIS
• Atheoretical advantage of this is less impairment of the blood supply in the
cortical bone beneath the plate compared to conventional plates.
• For humeral shaft fractures,MIPO has been considered too dangerous due
to the risk of neurovascular injuries, particularly to the radial nerve.
67. •PEUAsReLaSnaAnNteDroPlaItTeFrAalLaLpSp—roaCcOhMfoPr
mREidSsShIaOftNorPpLrAoxTiImNaGlfractures, and aposterior
approach for distal fractures.
• Use a4.5-mm compression plate in most patients, with a
minimum of 3(and preferably 4) screws proximal and distal.
A4.5-mm narrow plate is acceptable for smaller individuals.
• Insert alag screw between major fracture fragments, if
possible.
• Check the distal corner of the plate for radial nerve
entrapment prior to closure following the anterolateral
approach.
• The intraoperative goal is to obtain sufficient stability to
allow immediate postoperative shoulder and elbow motion.
68. INTRAMEDULLARY NAILING
• Rush pins or Enders nails, while effective in many caseswith simple fracture
patterns, had significant drawbacks such aspoor or nonexistent axial or
rotational stability
• With the newer generation of nails came a number of locking mechanisms
distally including interference fits from expandable bolts (Seidel nail) or
ridged fins (Trueflex nail), or interlocking screws (Russell-Taylor nail,
Synthes nail, Biomet nail)
69. INTRAMEDULLARY NAILING
• Problems such asinsertion site morbidity, iatrogenic fracture comminution
(especially in small diameter canals), and nonunion (and significant
difficulty in its salvage) have been reported
• the use of locking nails is restricted to widely separate segmental fractures,
pathologic fractures, fractures in patients with morbid obesity, and
fractures with poor soft tissue over the fracture site (such asburns).
70. INTRAMEDULLARY NAILING
• One point emphasized in most series of large-diameter nails is that the
humerus does not tolerate distraction. This is arisk factor for delayed and
nonunion.
• Antegrade Technique
• Retrograde Technique-best suited for fractures in the middle and distal
thirds ofthe humerus
71. PEARLSAND PITFALLS—INTRAMEDULLARYNAILING
• Avoid antegrade nailing in patients with pre-existing shoulder pathology or
those who will be permanent upper extremity weight bearers (para- or
quadriplegics).
• Use anail locked proximally and distally with screws: use a miniopen
technique for distal locking for all screws.
72. PEARLSAND PITFALLS—INTRAMEDULLARY
NAILING
• Avoid intramedullary nailing in narrow diameter (<9 mm) canals: excessive
reaming is not desirable in the humerus.
• Choose nail length carefully, erring on the side of ashorter nail: do not
distract the fracture site by trying to impact a nail that is excessively long.
• Insertion site morbidity remains aconcern: choose your entry portal
carefully and use meticuloustechnique.
76. EXTERNALFIXATION
• Is a suboptimal form of fixation with a significant complication rate and has
traditionally been used asatemporizing method for fractures with
contraindications to plate or nail fixation.
• Theseinclude extensively contaminated or frankly infected fractures ,
fractures with poor soft tissues (such asburns), or where rapid stabilization
with minimal physiologic perturbation or operative time is required
(“damage-control orthopaedics”)
77. EXTERNALFIXATION
• External fixation is cumbersome for the humerus and the complication rate
is high.
• This is especially true for the pin sites, where athick envelope of muscle
and soft tissue between the bone and the skin and constant motion of the
elbow and shoulder accentuate the risk of delayed union and malunion,
resulting in significant rates of pin tract irritation, infection, and pin
breakage.
82. COMPLICATIONSOFOPERATIVE
MANAGEMENT
• Injury to the radial nerve.
• Nonunion rates are higher when fractures are treated with intramedullary
nailing.
• Malunion.
• Shoulder pain -when fractures are treated with nails and with plates .
• Elbow or shoulderstiffness.
