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Ok. Uh Welcome to uh session five of uh orthopedics, 101 back to basics. Uh Today we have Mister Wong and Mr Hallum, uh both consultants, uh the Norfolk and Norwich. Mr Hallam is uh a shoulder and elbow uh surgeon and Mr Wong is a hand surgeon and uh thankfully, they've given up some of their time to take us through uh trauma and injuries around the elbow and the forearm. Um And uh yeah, Mister Wong will be taking us through the injuries to the forearm to start with. I'll uh I'll let him take it away. Thank you. Um Can we have a winning volunteer or unwilling? Otherwise we'll just stay on an x-ray for about half an hour. I can be a volunteer and someone else who is keen as well. Please let us let me know in the chat if anybody is willing to volunteer to uh to have a few questions. This is completely informal and a friendly chat and we can't have any more like any friendlier consultant here today to take us through those injuries. So, no pressure at all today, a and the earlier you volunteer, the easier the case as well. That's my advice that. Oh yeah. Who, who, who was speaking? Ah, thank you, Mr Goodun. Um, I have, er, five clinical vignettes at, for, on, er, trauma and we're gonna go through Viber style probably about six minutes each if that's ok with you. You ready? Yes, it's from ro, a 40 year old lab. Can you see the x-ray? I can. Yeah, a 40 year old laborer was lifting a heavier than normal weight at work when he felt a sudden sharp pain in his forearm, describe this x-ray. So we've got a plain film, a lateral of the right forearm, wrist and proximal uh carpal bones. Uh of the gentleman you just mentioned, um the obvious a form to note uh is the uh mid, mid radial fracture um with no obvious displacement angulation translation. Um And there's also evidence of a synthetic cast on this patient as well. So as as he may well have already been manipulated, so this may not have been it position. Um I would like to assess his patient on the basis of, well, we taking a full history first of myself and making sure he has a pain and he is comfortable at rest. Uh Initially, I'd like to make sure there's no other injuries at all. Uh I know the the history is actually relatively low mechanism. So not necessarily have to go straight into an A LS style primary survey. Um But with more fractures and injuries, you want to be aware of that typical injuries, especially the distracting injury. Um And then I have to assess the neurovascular structure of this chap's arm. Um and uh assess whether it's an open closed fracture as well. Um We've got the A P and lateral radiograph. Um I think that this is something that could be potentially treated in conservative management and be referring to a fracture clinic in the next 24 quarters. However, excellent. So what specific thing are you testing for in the examination? So, thinking about there actually, so dis so front to the radial nerves are essential, the arm, uh ulnar nerve. So uh getting a piece of paper or checking interosseous function um and uh median nerve function. So the most muscles um I also thinking about where that is, I I might be totally wrong here. This I I think you can block there for a superficial radial nerve block. So checking for cutaneous function, the superficial nerve, especially over the the dorsal aspect of the thumb um unlikely and, and taking another step back, what other things might you want to ask about in the history? Um Actually, so that was a very low mechanism, a young lad. So ha has he had any any symptoms that might imply malignancy? I think it looks like it doesn't look like a pathological fracture. Um But has he had any preceding pain in that bone at all? Has he had any night sweats, any back pain, any long term cough or change in bowel habit. Has he, um, and also he also, what medications is he on? Is he also got a background of R A and he's been on steroids for 20 years or has he got a background of oden and, um, or anything else that might cause a weakening of the bone? Excellent. Do you need any other investigations, um, provided this is a very benign history. Nothing that you asked about was, was true. And clinical to examine is a closed neurovascular intact injury with no physical deformity then no, at this time, no, we do. But I'd like to get a repeat x-ray in two weeks to check for callus formation that it is he OK. And uh what did you say uh your uh management options were so you can broadly divide into conservative and operative management. So I think this would be a good case to run with conservative management basis that we've got. No, um, oh, wait, hang on. No, I can I go back a step? I would like another uh investigation. I'd like an x-ray of the elbow as well because this is actually like a pelvis. This is actually a joint, this is circular thing. So I wanna make sure there's no proximal injury to this as well. Um On the basis of just this x-ray, if there's no other injury, then I think this should be work rather conservative management. Fantastic. Um Your elbow x-ray shows no additional fracture or dislocation. Excellent. Ok. So then I'd like this with a below uh below elbow uh synthetic cast, which in um specifically, we need to allow the elbow to be free. Um a any other options to managing this other than a below elbow cast, I'd imagine. Yes, but I can't think of one. Um What about a different type of cast? Um We're trying to prevent rotation, I suppose. So it could be put in a sugar to, but a sugar to deal with that, that use your, doesn't it? So sugar to or that's true. Um In, in our learning objectives for this talk, we have to know what the options are and what the rehab is. So you're right, there are different forms of cast and if it's below elbow, you could make an argument that you're mobilizing the elbow sooner. Um But if it's above elbow, you've got more rotational control and sugar to is somewhere where the Americans think it's a bit of a compromise and their theory might be correct. We don't actually have any high level evidence demonstrating um either the other. So all those are good options. Um What are the pros and cons of uh fixing this operatively? So obviously, fix will allow him to mobilize much, much sooner um by having a definitive fixation and especially if he's a young chap, especially if he's not. Maybe if he's self employed, but then to help him to mobilize and use his limb at an earlier date, go for um preservative management. There's also lessen the chance of displacement. But I think the likelihood of this injury is, is low and that form. And how long would you cast him for? Um I would, well, so initially, at least two weeks, at which point, I'd get him back to repeat. X-ray, I've got evidence of healing at that point, I'm throwing a number out, but I would say based on clinical review at the end of that point, well, actually do they even need clinical review if he's got no pain at 4 to 6 weeks, you just get pass off at home again. You can argue either way. Um Someone I personally would prefer to watch it until I'm convinced of a decent level of Clinical and Radiological Union. Uh Radiological Union, you will not see until week six. So you can't, at week two, your x-ray can only check alignment and not level of healing. Yes. Clinical Union at week two is, you know, the improvement of pain. Um, but I personally would like to watch this um with casting for about six weeks. Um, others might feel differently. But, er, so, you know, I don't know if Mr Haen feels differently. No, pretty similar to you. I think I can, uh I on my screen and it's quite difficult to pick up the fracture there, isn't it? It's um 80 th this is a warm up so well done that for volunteering on the easiest case, er everything you said is true and I think you got everything including that. Awesome last minute. Save of getting the full view of the um forearm ring because the radius and the ulnar combined with the intraosseous membrane and its proximal distal radial ulnar joints forms an entire ring where you're unlikely to just break one aspect of it unless it was something similar to a stress fracture or a direct contact injury. So you're very right to um, see if that forearm fractures carry these certain patterns, which leads very nicely to case number two, if we can get er, another, er, vi, I mean volunteer. Yeah. Hm. Wow. Ok. That's impressive. Uh uh Yeah. No, your, uh, your connection went a bit sun then Ken. See you back and to me, I can hear you but you're breaking up a bit, Mister Wang Emmanuel. Did you want to volunteer for, uh, for this next case? Can you hear me? Yes, I think, say something else. Can I think you might be back now? Uh ABC de Yeah, you're back. You're not splashing so much. Now, I think your connection has been reestablished. Oh, sorry about that. Uh Please, may I have another volunteer? I'll have a go then if nobody's putting their hand up. Oh, yes. Ok. I was going to volunteer after the voices. Keep cutting off. So I can't hear much. Oh, there's somebody, somebody speaking. Who's that? Hi. Um, my name is, I'm one of the A CCS trainee. I just keep, uh, hearing the voice interrupted. I can't hear it fully. Sorry about this. I can hear you perfectly right. Can you hear me? Yeah. Now it's better, but a minute ago it was just one word and then it goes out for silent. Ok. Would you, would you like to volunteer for this next case ed while we have you on? Sure. Yeah, of course. Ok. Can you hear me? Yes, I can know that's better actually. So a 50 year old, er, mail slips off the last two steps, banging his forearm onto railing and sustaining this injury. What other specific things might you want to know, ask about in the history? Um, I would think best is, um, uh, his past medical history and what medication he's currently on and, um, anything specific to this injury that you would like to know? Um, I mean, I, I'll be worried about uh arteries because I think the brachial is a bit close in that area. Um, and, uh, if you would have some form of compartment syndrome in that place, I mean, that's the two things that the top of my head, I'm not sure if that's very good. Um, when, when we're going through case vignettes like this, there's often a very simple and logical structure. Um, if you ask about the history, you know, the next question is gonna be about examination and then the next question is going to be about investigations. So at core surgical training level, we do expect quite a high level of presentation. So, you know, it's focusing on this injury. You're right. Um in the history, you want to know whether there's a level of pain consistent with compartment syndrome. Um there is a risk of vascular injury, although the patient might not tell you that also with the vascular injury, there are also nerves close to it, right? So you might want to ask whether or not they have any pain tingling, any weakness in the hands, which is um quite separate or distant from the injury as well. You also want to check things in addition to your standard pa smear history, you want to check about hand dominance, job occupation, hobbies and that sort of thing. All right. And if you're worried or alarmed about compon syndrome or something with this x-ray, you want to know uh the features of your ankle history. In other words, your uh allergies when you last ate and drank and that sort of thing, in case you want to take them to theater urgently, did you get that? That's a good point. Next question is um what specific things would you to examine for when you're seeing this patient? Um um I would definitely see his range of motion. How is it affected? And um if he's able, um, to check if there's other, uh, fracture in his like, uh humerus or his shoulder joint. And I would check with, uh, also for nerve injuries like to extend. How exactly would you check, uh, for nerve injury? Um, um, I would ask him like, test for sensation if he's feeling, uh, a around the area or, uh, distal or close. Um, I would also, um, uh, I feel like if it feels uh the pain and that's one of the thing if you still have sensation of pain and if it's not around that area or distally or proximally. Mhm Anything else? Um I would also check like uh his uh fingers and just uh over there like this um see what makes sense of this uh fracture. And if he's able to uh move the fingers do some position or just to just like uh because um the nerves would definitely supply like you get that area of the uh the ulnar nerve and uh medial nerve and the radial nerve. Yep, everything you said is true. And of course, you, you mentioned vascularity as well. So how do you check distal perfusion? Um I mean, there is a uh the allen test, we can check that uh and we can feel the pulse on, on the radial and the uh uh uh arteries. And lastly, you mentioned the very important compartment syndrome. How do you check for that um compartment syndrome? Um You would check if it's uh there any, uh I mean, uh you, you, first of all, you check the uh the size of how, how extent of how uh like the swelling is around that fracture. And then you would see how if you have some pulses, periphery or not. And you would ask if his hand is like pale or red or uh like congested. Not sure. I haven't been, I haven't seen a case of component in the upper arm. So I can't tell I put my hands up. I haven't either. So this is a fellowship training unusual, isn't it? It's very unusual. So you made some very good points there. Um But try to just unpack everything you said about examination. First of all, I wouldn't expect a good range of movement from this patient's upper extremity. So I wouldn't, when I examine his patients with x-ray, I wouldn't obsess too much about what his actual range of movement is. But yes, uh for the wrist and hand, I wanna make sure that's the muscles are working to the fingers at a very basic level. I just want to see that the thumb is extending, the thumb is flexing, you know A B is working. So that's your median nerve and your fingers are flexing, extending ing and abducting. And then hopefully, if you've got a compliant enough patients, they'll demonstrate that they've got some flexion extension at a very basic level. If it's a lot to process, the individual nerves don't worry about it. The extremity is an extremely busy area for all the nerves. So fist injury, median radial and ulnar nerves are all at risk. You don't have to identify the precise lesion. You just have to document initially in that these specific movements are whatever out of five. And do you know sort of unpacking more about what you were saying? Um Allen's test is, is to check the patency of your radial artery and ulnar artery. Most people don't really realize that the ulnar artery is really the dominant blood supply to your hand. And then Allen's test you sequentially obliterate one or the other to see whether the hand reperfus to see whether or not the the artery that you're testing is actually patent in this situation. All you need to do is feel that they have a real pulse and a bonus. All you need to do is feel that they've got a pulse as well. You don't specifically have to test Allen's test and then, and then for Compartment Syndrome. Um you've got your six ps right. Um You may have read in the book, the six Ps are pain, pain, pain, pain, pain. That is the single most important clinical finding. You may look at something more nuanced like a very swollen extremity, maybe a crush mechanism, maybe pain on passive flexion or extension. Um So those are the things you look for in Compartment Syndrome, but obviously, exam is limited in this sort of injury pattern. Um My last question is, do you know what this injury pattern is? Mm. Um It's not really sure. Sorry. Begins with AM and it a Italian surgeon, I think and then probably contradict myself because eponymous names are not very helpful or tell me which is broken. It's the it's in, in the distal uh sorry. Uh it's in the proximal one third of the uh ulnar. Uh Yeah. So, and it's like uh he got some, a piece in the, in the lower and, and basically, and the radius, what's going on with the radius uh look like dislocated. I think it's like moved up the anterior. Perfect. So, proximal, the fracture with a radial, proximal radial on the joint dislocation is sounds like mo and ends with Adia. Oh, no, I'm sorry, this is a Monia fracture pattern. Um There's different classifications, don't worry about. We'll move on to the next one. Thank you for that. Um Brave volunteer. We'll get another brave volunteer if that's OK, bri. Yeah, thank you. Are these your cases, Ken or ones you've picked up from other institutions you work at? Um Well as the Oh dear, Ken, I think your connection's gone again. Very. No, we could just hear intermittent scratching noises at the moment. Hello? No, can't hear you. Hello, doctor can start. Yeah. Hello. Yeah, I think it's, it's still intermittent. Yeah. You just, it uh sorry about that. I've closed my phone, I've closed my apps, my mail app. Anything. I think it might well be thunderstorms. Actually. Ken. It might well be because you're, we can hear you again now. Yeah. But it looks like we've got a volunteer. Hi, Julia. Are you volunteering to do this? Yeah, I can have a go. Um, I won't be very good but I can have a go. I love it. Um, you get, um will give you so a 20 year old fell awkwardly off skateboard when attempting to jump, sustain this injury. So what specifically did you? No history? So I mess up what specific feature do I know in the history? So he's fallen on an outstretched hand. Yep. And what else would you like to know in the history? What else would I like to know? Yes. Um So I want to know if there was a wound at the time if it's been open. Um, if you're under the influence of any um intoxicated substance and if he's complaining of any injury elsewhere, um I'm just a background about the um, he said he was a 20 year old man just past medical history for him. Excellent. Um And also what, what initial treatment was given at the time before this x-ray was given no initial treatment you've seen him in and he's just got his arm in a sling. How would you examine this patient? Um So given the mechanism that he's fallen from standing height or it might have been a high, I don't know, I would um consider if I need to apply at s principles for full assessment, but if it's just isolated injury, then I'd um be looking at the particularly concerned with whether this has opened. Um and whether there's neurovascular compromise as we've gone through. So um assessing the function of the nerves and um the your pulses in full time. Um And yeah, also, I think he'll need um urgent manipulation and so preparing him for that in terms of getting him adequate pain relief and assembling an appropriate team, um possibly for um in A&E and plus tax support um if possible. So you are in A&E and you have a willing a restaurant to provide safe and a couple of other H CS to help you out. Uh How would you, this is a close injury, how would you manipulate part of this? Um So I haven't actually described the frac story, but um so, well, so this is a distal third radius fracture with distal ulnar dislocation and keep with the gay um fracture pattern. Um As we've already mentioned, I do need a x-ray of the elbow as well. Um See if there's any fracture dislocation at that site. Um But urgently put this in a um kind of reduced position, it would need um traction, there's significant shortening of the radius, it's completely translated. Um And it's also sort of dorsal apex angulation. Um So I would be considering those factors as I attempt to reduce it. So, main mainly with traction you e excellent. So you've put in the plaster, it looks a bit better, but it's still significant short and still seems to be rotation. Malign what would be your um management option? OK. So, definitively, um you could consent him for um and anyway, so um manipulation under anesthetic um in theater. So you might be able to get a, a better reduction there. Um plus minus open reduction and internal fixation. Um and mainly aiming to restore the length of the radius. So you do that with um uh probably a dorsal night. Um And then you're also aiming to get the owner back er do dis where, where you put the plate is not exactly prescribed. Um There are different approaches to re the ra some people would go through Henry's approach, although there are modified ones from the, from electoral such as the Thompson's. Um So let's say you reduce and fix this anatomically with the plates through. I view this under Henry's approach. Um What, what's the place of the raids? Are you then done with the operation or is there any other considerations? Um Well, it depends what the stability is like at the elbow. Um But the elbows fine after pla the elbows fine, after plating, you would then need um consider mobilizing in a cast. Um Yep, because what type of cost well to protect. Yeah. Put them in a cost. Um I don't really know what your question is leading to. That's ok. Um It, it might relate to how you counsel a patient preoperatively. Some surgeons may choose to fix an unstable distal rate on the joint with K wires. Now, no one knows the answer as to whether or not when to fix the D um or at all to fix it. My, my appraisal of evidence, if you fix the DJ, using some temporary K wise, then the patient should know that they're temporary and they needs to be pulled out. That might increase the chance of the IJ remaining ent, but it does leave them with quite a significant amount of stiffness. Um As surgeons, you don't want things ever being dislocated. So, so I think it is important to talk to them pre activity that they may have wires in addition to a plate in the radius. Um They may have wires that might have to come out at a later date, whether it's left proud out to the skin to be pulled out or whether it's left buried to be pulled out under local anesthetic or something at later date. So that's the only consideration that, that mm in interactively, once you've plated the ras you then test the stability of the distal. Yeah. So it's um people use a piano key test where you literally just ballot it up and down and, and then there's a subjective assessment as to how unstable it is or you can just take a static x-ray and it doesn't even sit congruent. If the, the joint doesn't sit congruent, most people will be, feel too compelled to reduce it and have some form of fixation. And then usually, and plaster the um the forearm in supination above elbow as this, this your stay position for a OK. So those are just technical things that you won't need to know as training, but at least I've heard it once today. So this is the gal we fix most of these and it's a 20 year skateboarder. That's pretty non controversial. So, thank you for breathing. That thank you. Uh, a green or ra bone in. Sorry, I think your Mike was gone again, Mister Wong. So I didn't catch most of uh, what? No, I'm happy to go, but of course I've already been. So if there's anyone else who's really been there, let's, uh, let's wait and see if, uh, if, if somebody else would like to, to put their hand up, just turn on your mic and, uh, and join us guys. Actually, Karen just whilst we're waiting for someone to, um, become enthusiastic. Am I right in saying that everyone on the evenings teaching session is a core trainee. Is that right? Is there anyone below a core training? Uh, no, there's, there's a variety of people. So there are some core trainees, I think there's Luke with us as quickly because I thought I see what's going on. I might get free Viber practice. But then I realized that I may be, um, it might put everyone off if it, if it starts going FCS level vi so maybe I'll just, um, keep quiet. We got one more senior and we got one more junior in the core training. Just we have. So the A&E team have been invited to this as well. It's also, it's gone out on the James. Well, actually the core trainees and found I've seen some F one I work with as well. I was just, I was just interested when it, um, when I start up. That's good. Sorry. Can I interrupt here too? Helena. Would you like to volunteer? That's not, there's, there's a, it's never nice to, um, volunteer other people, but there is someone that I've worked with before on the call who did orthopedics with me in Ipswich? I don't know if she's on the line. I'll give it a try. I apologize. That was coming. It's always good to see you. All right. Uh, so I would like to know more about the patient. First of all, this appears, um, it's an open wound. You'd want to, um, manage it via A LS principles. So make sure that there are no other injuries and, uh, then move on to examine this hand, take a history about how this happened. Um, any symptoms that the patient might be experiencing. So, pain numbness, tingling. Um for an open wound, you're concerned about any neurovascular injuries. Um any fractures of the radius ulna, you want to give an antibiotics, take a photograph of the wound, cover it with a, so saline and uh tetanus excellent um prophylaxis. Excellent. Can you hear me or am I still a robot? I can hear you now. Yeah. Ok. Thank. Thank you for uh brave volunteering. And how this is the 20 year old who harm themselves with a piece of glass. They're, they're feeling uh they have a history of depression. And how exactly would you examine this patient? So you'd want to give them adequate pain relief first, before you start examining them. Um Obviously, after you've ruled out any other major injuries with your primary and secondary survey, you would want to check for any tendon injuries. So that would involve checking your, um, the ex uh flexion at your MC P joint at your proximal and distal interphalangeal joints and also wrist extension and flexion. Um You'd also want to check median and on nerves and how do you do that? And you read? So, um I tend to just ask them to make an ok sign to check for median and then ask them to cross over their fingers or abduct and abduct their fingers for unlock. Excellent. And based on what you can see here, what are the uh structures at risk? Um What specific structures. Uh not the tendon. I want to know exactly uh exactly the structures on the forearm. Yeah. Um So I'm just trying to remember. So you have your um um lexa radialis. Yep. If you say flex or anything, you'd be right. Yeah. So it's all your flexes. So you have your al um flea coffee radialis, plexa, coffee lar. Um And then um did your deeper structures are your flexor digitorum uh Profundus superficialis. Yup. Yeah, everything is true. So examination starts on inspection. When you're looking at this hand, you can look at the attitude of the fingers, which is how they naturally lie. If someone has taken a sharp laceration transversely through the mid forearm, then you might see the fingers held with slightly extended attitude compared to the other sides. And in this situation, his hand looks like it's lying reasonably. Ok. So that's fine. And, and just to unpick what you said earlier, you're right. Uh You can damage all the flexes, you can damage uh the nerves as well. So uh ulnar nerve, median nerve, even branch of radial nerve. Uh do you know which branch of the radial nerve is at risk here? Um So the radial nerve stops being the radial nerve at the level of the lateral epicondyle, right. And so we're talking about elbow. After the lateral epicondyle, it becomes the posterior interosseous nerve and a superficial radial nerve. So, posts nerve is posterior interosseous, that sort of area. So which part would it be in this situation? It would be correct? Superficial radio nerve. So that normally just sneaks under the, um, on the edge of your radio radio list to supply uh the uh first dorsal web space. So you might want to check something there to check your Yeah. Yes. You know. Ok. A making active movements of the fingers. Um What other test for tendons might you be able to do to see if tendon is intact on? Oh, I'm not sure. Generally we want to isolate each one of your um your distal to find your joints and your proximal one by one to see if it's uh superficial or your deep um flex tendons that affected correct and obviously superficial is more likely in is it? Yeah. Um Yes, it was. Yeah. Yeah, deep. But then yeah. Um and then earlier you said that uh you some you want flexion at MC P joint level. Did I hear that? Correct? Yes. Apart from the long flexor, is there any other muscle group that might be able to flex at MCP joint level? Is it your lumbrical? Yes, lumbrical. And what else? I can't remember the other one. So, yeah. Uh you not poma for like a redundant thing, risk flexor thing, something like that. And it's your intrinsic muscles in the intrinsic muscles are intrinsic to the hands. Extrinsic muscles are extrinsic. So all the four are muscles. So the in Xing muscles includes the lumbrical and the sc remember the flex at MC P joint level and extended IP joint level. So you can still get a proper laceration of your F DS and FDP, but still have some in intact flexion at MP joint level because the nerve is firing the intrinsic muscles of the hand and the zone of injuries is away from the intrinsic muscles of the hand itself. Yes. Make sense. Yes, it does. Uh I think, I don't think I had any questions. That was awesome. And, and what was your, what would you be your manage definitively for this patient? So obviously, you wanna manage your open wound. Um I'm not sure if we still wash out in A&E or on the ward wherever the before the it is. But um you want to cover with IV antibiotics. Um put a cline soaked gauze and give them some tetanus. Um depending on whether there is tender in tendon injury, they might need to go to surgery for tendon repair. And before then any investigations, I would want an x-ray to see. I mean, we know there's glass, but we want to see where, how deep the glass is so we can get an a and lateral view of the forearm. I love it. So Luke has trained you well. OK. Thank you. We're done. We're done. Uh I think we're done with my presentation. Thank you. Brave volunteers. And I was going to go in drone. But that's complicated for me. That's a vol ism contract and that's just a summary of what I wanted to go through uh with everyone. Very good. K very good. And so if you go, go back to the, um, that one you just showed me, can you go back to that one? Can you go back to one? So hang on. No, it don't worry. I, I think I clicked. Stop sharing by accident. Yeah. Th that, that's fine. Don't worry. No, I was just going to the LA point about something but it doesn't matter. We'll we'll move on. So um Karen, can you get my slides up? Yes. Ok. So for those of you who don't know who I am, I'm Peter Hallam. I'm one of the uh consultants. I suspect I've seen some of you but not all of you. Apologies if I've not seen you. Um As Karen says, this isn't a mauling session. So anyone out there listening, we really do appreciate you volunteering because it makes one of these teaching sessions so much more interesting. Um And that's why I was asking earlier about who we've got because I can give Luth drilling at the end and I can give someone a very simple case now. So for example, if anyone is from A&E listening, now this next case would be just great for them. So we'll just wait for cam to get it up and then maybe whilst that's happening, someone can volunteer and put their hand up and see how we go with this case. Can you see my screen? It's all. Yeah, that's it, Karen. Ok. That's good. That's good. That's very good. If you, they can make it bigger a little bit by taking away the outside. So we just looking at the x-ray but it doesn't make too much difference. Yeah. Perfect. That will do it right now. Has anyone, um, got the confidence to uh describe what this x-ray shows? That's all I really want for the first bit. Excellent MG. Who's MG? That's me. Sorry ma it's Matt. Um I've got there's one who I work with who be, you know, just started but I be to just have a simple go through an A P and you Yeah. Yeah. Well, that's it. That's why I was asking because I can be very, very basic with this because this is a nice basic slide. So yeah, get them on if you can um incentivize them somehow you happy then. Good. Yeah. No, I'm happy. Very simple. Um kind of matches me to A T. So thank you very much. It really makes a massive difference to people like us if we can actually talk to someone. Um Great. So, ok. Well, that's all I want you to do. So if you could just have a look at these two x-rays and just um tell me what you see. So straight away you can see that there's a big old dislocation of the elbow. Um and it looks like it's uh like posteriorly. Very good. Indeed. Excellent. So, just for the people who are not so uh good as you, why did you say it was posteriorly dislocated? You are correct. Do you know how you classify dislocations with the bones relative to each other? Um It may have been a lucky as, but I think so, it's kind of where the most proximal part of the bone is in relation to the connection. Isn't that? Yeah, you could do either. I think traditionally you could say that the ulna which is, is dislocated posterior relative to the humerus. Does that make sense? Yes, you could. I think it wouldn't be wrong to say the humerus is anteriorly displaced relative to the ulna. But I think Ken can correct me if I'm wrong. Traditionally, we talk about the distal part relative to the anterior part. So you're absolutely correct. That's the posterior dislocation of the elbow. So that's on the lateral view. You can see that, I mean, for bonus points, can you tell me on the A P view? Do you think it's gone media or laterally or just straight backwards? Um It looks mostly straight backwards but maybe a little bit and I forget my rings, um maybe a little bit on the warm. Yeah. So the, the ra Yeah, I think you know what, what you said the first time it's just gone directly backwards. I think it had gone laterally, it would be displaced toward the radius side and if it had gone majorly towards the ulnar side, so I think that's gone directly backwards. So I think you're absolutely correct. That's a straight posterior dislocation of the elbow. So the next question is then, um what are you gonna do? Patient is obviously pretty sore. Um I mean, start with some level of analgesia. Um We before kind of any intervention probably want to assess if there's any neurological deficit. Um the assess the sensation kind of along the hand. Um the dermatomes there and then once they're kind of probably dosed up on, then we can just relocate it. Yeah, good. So I think when you're answering any question like that, you did very, very well. So first of all, it's a, I suppose, you know, you go right back as an explanation to the patient as to what's wrong with them. But I think you take that for granted. So yeah, pain relief, describe what the problem is and then describe what you're gonna do. Your overall objective. I think everyone would agree is to try and reduce the elbow because you can't leave it like that. You mentioned about giving gas there. So are you gonna do this in accident emergency or you're going to take him to the operating theater? Where do you imagine this reduction may take place? Um I want it to be done in in A&E, um, or like, depends where they felt. I say that just because I had a friend who dislocated their elbow and it was relocated at the site where they desiccated it by the, um, paramedics. Yeah. And I think that's right. So this is quite easily, um, reduce the, I think in A&E, or even outside of A&E, um, given enough analgesia, do you know, for bonus, bonus points? How you would try and get that back in? I mean, obviously, let's just say you're stuck in a and um you're trying to get that back in. Do you know what you physically do to get that back in? Um Can you, can you get them to rotate that arm to help encourage it back in? Yeah, you could try that. What about uh if it's gone directly posterior? What about, do you think you might want to apply to the forearm? Um because downwards traction pull down on the arm? Yeah, you would pull on the forearm and that will bring the anterior translation of the ulna um down, won't it? And then would you, is this likely to be more stable when you flexed the elbow or extended it? So once, once you've got it reduced, let's say you pull on the elbow and everything clicks back in, I think it probably would, would you then leave the patient in the extended position or the flex position? I mean, it's a difficult question that you might not know the answer to just what you think would be more stable. My instinct would be flax, your instinct is correct. Exactly. So, if this was left in an extended position, it could just pop back outwards again. So once you got it back in, you flex it up to 90 degrees. And how would you keep it at 90 degrees? Give him a poly. Yeah. Yeah, you could do that. So, what about before you put them in a policy? Is there anything you wrap around the arm? Would you put a plaster on? Do you think a plaster is unnecessary? Um I I'm not sure if you're trying to leave me into a yes answer. But yeah, it's a bit unfair. So what options are that? Nothing? OK. You could just say, well, I'll put you in a poly sling and you can start moving the elbows, the pain allow us, you could have um a plaster or some sort of brace. So I suppose what I'm really trying to say is do you feel happy just asking this patient to do what they want in the policy or do you think you probably ought to apply some form of immobilization to it? I think some form of mobilization especially initially because I think you said a brace before that would probably be my go throughout of Yeah. Yeah, I think that's fine. You could put a cast on. No one's going to criticize you for that. Er, what type of cast would you put a full plaster on and wrap the plaster around or would you put a half cast on a back slab just going back to sort of basic? What would be a danger of wrapping the whole elbow up in a big plaster? Um I mean, we said from a previous case about compartment syndrome. Excellent Excell, you were listing, that's very good, very good. So if you, if you wrapped it up in plaster and you uh the pressure in the elbow might go up, you might end up with a compartment and you have to split the pla to release the pressure and everything. So initially a back slab, half the plaster would be best for, as you said, a press. Ok. That's good. I think that's enough um for you. That was well done actually. Very good. Thank you very much. So, what we really need now is someone to um take it to the next level. If there's a little uh a volunteer that could take this to the next level core trainee Pota, potentially. Here we go. Yeah, little clue on the er slide there. Any core training we could have Mat back at this stage. I suspect that it's probably at Matt's Street. Maybe unless anyone else wants to be brave, I can have a go but uh I don't know how up my street is. Yeah. Ok, ma so um if you put this is, is this a sli one mister A Yeah, the one with the looks like a fortress on it. Yeah. OK. OK. If you could um show us that, that's good. OK. Now, so Matt again for other people listening, I can't see or can't hear. I gather there are some core trainees there when we talk about the stability of a joint. OK. The stability of any joint. How can we think about it? So I cranking up as simple as possible. I think um you start with how much of one bit of bone to congruent in another. So the elbow you've got relatively decent quite, you sort of quite well and close. I mean, I think this is in the middle with shoulder being rubbish and it being great, this example sort of cover articular surface coverage of the joint. Yeah. So I'll just stop you there because A you're correct and b for some of the others who may not be as um knowledgeable as you. So any joint, um it's stability depends on uh the bony anatomy, doesn't it? So, Matt is right that the shoulder has a huge range of movement. And so the bony stability is relatively less. Whereas the ulnar ulnar humeral joint mat the elbow is bony stability more important for that. Ok. Yes, I think it got it. So you can get away with like e as much as you like to allow that movement. Was that? Yeah, I think that's right. So the, the elbow joint is by definition, one of the joints which is stable because of the um of its bony component. So if you look at my little fortress there, um you have the ulnar humeral articulation at the top, which is one of the most important stabilizing factors of the elbow. And then you have the ligaments. So which ligaments do you have around the elbow? Um I'm not lateral, lateral ligament. Yeah, you have the medial ligaments and the lateral ligaments. So they're the outside of the fortress. So they are the primary stabilizers. OK, of the elbow and then the secondary stabilizers for the ones inside. So if you've breached the out of fortress, the ones inside will render some stability. So do you know what they are? You can read them off properly? Yeah, that should be really that long. Yeah. Yeah, I think so. That's fine. So they would be the common extensor origin, the common flexor origin and the radio huer articulation. So, um it's probably maybe a little bit top end even for the core trainees. But just when you're talking about stability of the joint, the take home message is really is that joint dependent for stability on the bony anatomy? In which case the elbow? It is or is it more the soft tissues like the shoulder, which are the ligaments and the muscles? Um OK. Ken, I think that might in retrospect have been a little bit top end. So we'll move on to a much more straightforward case. Uh Karen, can you move us forward? We won't talk about this because II, I think that we might be getting everyone very applaud and that might all, everyone to swim and that might bore everyone. So we'll go to the next one. That's better. Good. OK. So this is much more straightforward. Um Anyone volunteer for this one? Anyone know that I, I'm happy to be uh just calling somebody to join now, volunteer someone um be up here. You're at the top of the list. How about you? Uh You have a go Yeah, that'll be good. Then if um, Karen, can you get that x-ray back up? Yeah. No. So I been uh struggling with the hospital wifi. He said, ok, no worries. Is there anything else that we can pick on? Otherwise I'll go to the mat Manuel? No joy. We'll try one more at random and then it, in which case it's back to. Good old Matt. Ok. George. George Pitt. Hello? Good, excellent George. Can we go back to here? Ok, George, can you um, can you see that? Yes. Yeah. Very good. George. So can you describe that one? So it looks like there's a spinal fracture of someone's left humerus distillate. Very good. George, do you want to be an orthopedic surgeon? This is the point I should say yes, isn't it? But um, that's very good. I mean, I'm not just joking. But that, that is very good. It's a fracture of the distal hum. That's 100%. Right. So, for very, very, very big bonus points. Do you know the eponymous name for this fracture? I don't, but you probably will actually. No. Um, no, I don't actually. Ok. Matt. Do you know what it is? Yeah. So this is a Holstein Lewis record. Yeah. Yeah. Ok. So we'll, we'll go back. So it's a whole ST Lewis fracture for what it's worth, um described by a gentleman presuming called Hol ST Lewis. There's a spiral fracture of the distal humerus. So the question really about this fracture is um, nerve injury. So, what nerve uh where are we back to the person who started to ask? I started with what be one sec? Yes, there is. What nerve is it danger of being injured with this fracture, do you know? Um So is it the? No, well, actually Ken is correct really in that any nerve potentially can be injured in upper limb fractures? Um on the nerve less likely I'll give you one more guess. And then I'll tell you, I'll tell you what, I'll give you a clue. Ok. It's the nerve which allows you to straighten the wrist. Does that help? No. Um No, I don't know. No, that's fine. So it's the radial nerve. So, um for the core trainees who I may be listening, it's the kind of thing they probably ought to know, not so much your fy one level, but the radial nerve travels around the distal humerus to that level and um can be injured. And if it is injured, then the radial nerve supplies the wrist extensors. Um So I'm sure you can see me here. Anyone who's looking. If the radial nerve is out, the patient has an inability to straighten the wrist. Ok. So we end up with a wrist drop and we currently have a patient waiting an operation, Norwich with this uh injury with a radial uh nerve palsy. The one thing I wanted to say, uh it is difficult because I'm not quite sure who's out there and who's listening, who wants to know. But if you examine someone in a plaster and the pla that comes up at to their knuckles where my fingers are here and you ask them to straighten the fingers, they will still be able to straighten the fingers even though the radial nerve is out. Because as was mentioned in a previous talk, the ulnar nerve may be intact which is working the interossei muscles, which actually straighten the fingers. So to determine whether or not a radial nerve is working, you must look at wrist, extension or extension of the fingers at the metacarpophalangeal joints, extension at the interphalangeal joints is done by the interosseous muscles which are supplied by the whole nerve. Ok. So I hope that has gone into someone who's um at the appropriate level listening in um Karen. Since you're there, I might as well give you this question. How would you treat this fracture? Um It would depend on whether there is uh any uh neurovascular damage uh to the patient, the age of the patient and their level of function. Uh But in a patient with no neurovascular injury, I suspect we uh would have to treat this with production internal fixation using uh a plate, uh potentially uh la screws as well as this is a spiral fracture. So provide a lot of good bony contact after uh uh an an inflammable reduction. And uh using um um uh I would I would you be tempted to use uh bilateral uh sorry uh sort of bi plate uh due to the distal extension of the fracture. Uh as if I try to approach this posteriorly and use a posterior plate, it would uh go into the uh electron fossa most likely. Yeah. Ok. So, um I think Karen's right. I mean, it gets a little bit top endless, but it is a fracture which needs to be fixed. It's notoriously difficult to treat. So the previous injury we treated with a reduction in a plaster. This would be very difficult to treat in a plaster. Um particularly in women actually, uh just the anatomy of women means that if you put a brace on this, the brace never fits properly because the chest gets in the way. Um But even in men, it's very difficult to treat. Uh And so it does really need uh fixing to restore the length. Um Just one question for you, Karen, since I've got you on the balance of probabilities, I, is there a greater or lesser than 50% chance that the radial nerve palsy will get better? So the patient may say we look hold, I'm um I know you're gonna fix the fracture, that's fine. But um what about the nerve is that gonna get better? What can you tell him about that or her about that? Uh So I can say that with the no product, internal fixation, anatomic production. Uh this, there is a, well, there's always a likelihood that it does get better or, or it doesn't if I explore the nerve and I can see that the nerve is not obviously uh damaged. Uh Then there is a good chance that this is just a neuropraxia. It would get better as long as the metal work is not uh irritating the nerve, for example, or if it doesn't get pinched between the metal work and the bone or between the bone fragments. But if there's an obvious uh obvious damage to the nerve, then uh there's a higher likelihood of permanent nerve damage. And I would have to involve uh uh maybe the uh uh plastic uh surgeons or the duos surgeons and a uh nerve repair. Yeah. And I guess the chances of recovering fully would be uh would be not very good if it were divided. Yeah, but I mean, Ken, correct me. Um But I'm pretty sure that although there's a high incidence of radial nerve palsy with this type of fracture, the recovery of the nerve is actually pretty good. Um So, is that correct, Ken? Yeah, I completely agree. Um is so important. So, it's a spal fracture then obviously, and the is in and more like in which over time. Yeah, exactly. So you, you was cutting out there, but he agrees with me that the prognosis of the uh, of the uh nerve injury is actually pretty good. Um, but it's not divided. Ok. Good. Well, we might as well go, I think, carry him to the last case. Yes. Well, I don't know if Luke Granger is there. Um Everyone's been very patiently listening to er, the simple stuff but if Luke is there, I could, he could give us a master class in how to answer. Right. We'll give it a go as a senior trainee. So here we go then Luke and, and I think other people would be interested in this because no matter how senior or junior are, I think you can tell that's a very nasty fracture. So, do you want to just describe that fracture? Yeah. So, um, a p radiograph of a, a right elbow and a skeletally mature individual showing a very comminuted intraarticular distal humerus fracture with an associated small avulsion fleck from the medial um ulna as well, um, from likely from collateral ligament. So I'd like to, um, obviously take a history from the patient. Um, finding out mechanism of injury. Is this a closed door, an open injury? Um, is this part of a, a bigger polytrauma or is this an isolated injury? Um, finding out whether they're medically fit any comorbid comorbidities? Ok. So that, that's a good answer. Um, Luke, so everyone, er, can copy Luke in the future for now. It's, he wants to know more about the injury, which is, er, straight forward. So it's a 55 year old bloke who, er, would have actually fell off his ladder whilst he was doing some diy to er, some guttering. Um, unfortunately, it is an open injury, er, it's open around the back but he's otherwise very fit and healthy and it is the only injury he's got. So he is fully conscious in absent emergency, complaining of horrendous pain around the left elbow and this is his only injury. Ok. So as you said, it's an open injury. So that does need to be addressed in itself primarily. Um, so as solo was alluding to earlier, so we'd like to get some clinical photographs of that wound. Um, give antibiotics within an hour broad spectrum, something like car cla give some tetanus or at least check tetanus prophylaxis or check tetanus status, cover it with a saline soaked gauze and um I, I would also like to have another radiographic view here but um um with regards to the open injury, we'd like to apply it, but we'd need those things done before we put the plaster on. That's another, that's another good answer. And everyone else listening in that is the perfect um answer so far. So he wants another x-ray to show him you have x-ray came. I think there's another one. Ok. Is there another x-ray? Yeah, thought so. So any comments there? Um So um again, just shows that there's very common to distal um humerus, there's some gas or air tracking up in the distal humerus which wasn't, was difficult to see on the A P. So that again tells us that it's likely to be an open injury. There's a small fragment um posteriorly that's potentially from. And actually, you can, as you can see some ulnar fracture over the e electron on there as well, potentially. So it's a, it's a very complex fracture pattern. The radial head is not aligned to the capitellum. Um Once we've initially stabilized this and and above elbow plaster and done our measures for an open fracture, then um I'd like to get further um cross sectional imaging in the form of a CT scan to for surgical planning for, for this patient. OK. Very good. Actually, Karen, before you do that, if you can, you put the cursor on that, are you able to move the cursor over that or not on your screen? Yeah. Yeah. Can you just, can you just show the people the gas and air that Luke's talking about? I think it's a little bit, there's a little bit there isn't there. And I think if you go down next to that fragment underneath the skin, just the whole of the back of the humerus that shadow there is air probably, or possibly fluid but probably like to be suggested that it is probably an open fracture. You wouldn't see that it's a closed fracture. Ok. Good. So, um all is, well, so far, so, so far, we've attended to the open wound. So they talk about an open fracture. Um in the, actually the primary problem initially is the wound, not the bone. So hasn't talked about what we're gonna do about the bone at all. He spent five minutes talking about soft tissue injury. So we spent a lot of time looking after soft injuries and we now need a CT scan to see what the bone looks like in order to formulate some sort of operation. So, if you've shown the CT scan, I haven't included all of the slices late. But could you just explain to the more junior people what that shows? Uh So it's like a um t type intraarticular distal humerus fracture. So, you've got um the humerus shaft at the top, you've got the lateral and the medial condyles of the distal humerus, which are largely. Um well, actually the medial chunk, which you can tell because of the medial epicondyle, which is slightly more prominent is, is a bigger bony block. But the lateral side looks as though it's really quite comminuted and would be quite difficult to anatomically replace. So um just thinking in advance for surgical planning, the way that I might try to reconstruct it is to get the larger bony blocks back together to then piece the smaller pieces on after. So I'd be thinking potentially of a posterior approach to incorporate and the open wound posteriorly, excising the skin edges and potentially trying to build the medial epicondyle back onto the shaft and then reconstruct the lateral side based on that with. Um, so the way that I would well just jump ahead, that's fine, just going back to slight for the more junior people. So why in your, what is, why are you trying to restore the articular surfacing? What, what, what? So the goals of um any orthopedic surgery, but especially around a joint is to restore um length alignment and rotation. And when it's intraarticular, you'd also aim to restore the articular surface as as good as possible. Usually with the aim of reducing future risk of osteoarthritis. If you have a very disrupted articular surface, there's a high chance that that might progress to post traumatic arthritis. So if you can restore that as good as you can, you're trying, you're reducing that chance in in this case, I think it will be challenging because there's significant comminution. But you can offer the best chance by, by trying that. And if, if you intraoperatively do not feel it is reconstruct at all, then there are options. Um in most joints and in the elbow for arthroplasty, either a hemiarthroplasty or a total elbow arthroplasty. But um in, I think you try to reconstruct this and it should be reconstructive but just challenging. Ok. That's good. So I hope everyone sort of understood Luke's um philosophy there, which is true. So we're gonna try and restore the articular surface. So the patient doesn't get stiff arthritic, the elbow in the future. So I've got about five minutes left. We might as well let Luke keep going and then we can all have a sort of conclusion. So keep going, Luke. So in terms of approaching this fracture, how are you gonna approach it? Um So, uh in an appropriately marked and consented patient, I would have them. Uh I, I would have the supine or I'd do it lateral um over an el bar. Um So that I'd have the arm hanging down. Uh Yeah, hanging down so that the distal humerus is directly looking at me. Um I would do a posterior approach, which would be a, it's an intraarticular, very difficult fracture and I therefore would probably, I would do a Leon osteotomy to increase my exposure for the um distal humerus. Um That involves a Chevron cut. So like a V shape into the eri on, you take the electron off and that takes the whole triceps out of the way so that you can see posteriorly that's good. That's good. That's good. So, um I know you can do that. So um and then the kind of last couple of questions, so the orientation of the plates, where would you put the plates on the back of the Humes? So there's been various studies to show that there's no difference between parallel and oral plates. And I would use a system that I'm familiar with. And I've, I've used the uh acceded system and I, I do um parallel plating was actually apologies. Orthogonal plating was the, is the one that I'm most familiar with, but there's no, there's no evidence to support either one or over the other. You have, you have a plate going down either side. Um on the, on the medial side, we then the medial side of the distal humerus. But on the lateral side, you've got a choice between the two of them. And I believe it's O Dr's rules of the elbow, which are to some principles when trying to fix distal humerus is where every screw goes through a plate. And um and you're locking screws um just trying to maximize purchase and hold on on the very common fragments. Ok, Karen. So show him what we did. Is there another slide, Karen, the next power points line. You there. Yeah, there you go. So there you go. Um And you probably recognize this man co operated upon him. So just um, Karen, can you just point your cursor for more junior people? I think Luke's done pretty well. Can you point the cursor at the elect Quon process? Where do you want an appointment, sir? I'm sorry. The one keeps breaking a bit. If you on the lateral x-ray, just underneath the big screw, you can go back to where the ulnar is fractured. So just there folks, um Luke described an electron osteotomy. So what we do is we actually break the proximal ulna around the electron um so that we can see into the fracture site. So we have to create another fracture which we have to fix at the end of the procedure and that's why that big screw is down there. Um That's good luck. And then that's fine though. I think we we could go further, but I think we are at risk of boring everyone completely rigid with this. But that, that, that I think for FRC off, that was, that was more than fine. That was good. Um What done Karen? I think that might be it for me. Are we able to see your face came? Yes. So do we have any questions from anyone about all of that or is it all as clear as mud? Um I can't see any questions so far? Just a lot of support from, uh Mis Luke through. Uh, here's one. How long does it take to down? Uh, never mind. Sorry. No, uh, no orthopedic questions. Just technical questions so far. Does anybody have any questions? I'd like to ask Mr Mr Wong or Mr Granger before? I, I, I've just got a point, quick point to raise if, if anyone wants to look up more information on these topics like Ortho bullets is aimed at it has all the information. So a lot of it is quite high level, but it's a free resource. So if you like, especially if you're a core trainee and you don't want to buy an orthopedic textbook. Just the Ortho bullets needs to be your quick place to look. You can download it as an app and it's just something if you don't recognize half of the things that we've been talking about, then you can just have a quick look on there and it's a, a good reference point. Mm. Yeah. No, I agree. It's a lot good. Now, now you have like a, a bit more of an understanding of what's going on. If, if you're starting a topic, Ortho bullets could be a little bit daunting, but now you've got some, uh, expert explanations of, uh, elbow injuries and for injuries, you should be ok with the orthos going forward. We haven't got any questions. So, yeah. Can I ask one about the, um, last case you just discuss the difference between doing parallel oral plates and can you explain the difference between them, please? Yeah. Yeah, sure. So, Karen, if you go back to the POSTOP x-ray, um can you do that, Ka just give Karen a few seconds to get that because without that, it's quite difficult to explain. So hopefully you'll be able to share your screen, you be able to do that, Karen. Yeah. So you can see Luke said, um then you can have all Fogo or parallel plates. So I think you can appreciate the on the left hand of my screen is a and an A P view of the humerus. Can you see that? Um And you've got a plate going down the radial side, you can see the radius, you see the radius and you've got a plate going down the ulnar side. So those two plates are actually just about parallel to each other. OK. So one plate is on the lateral side, one plate is on the medial side of the humerus. We could have put the lateral plate posteriorly rather than being on the lateral side. In which case, it would be orthogonal to the other plate. Does that make sense? Yeah. Would they be at 90 degrees or does it not really? Yeah, that's what orthogonal means. I think it's a long time since I've done Trigo, but I'm pretty sure that's what it means. So um that's what it means. So it just, um, it means 90 degrees to the other one. And as Luke said, there'll be various arguments as to which um, construction may be better, but I don't think it makes any difference. Probably it's whatever you can do best at the time. Um, so does that answer your questions? Yeah, that's great. No problem. Any other questions? Yeah, I'll take care. Ok. Uh I guess that's it. Thank you very much, Mister Adam, Mister Wong for uh for taking us through those topics. Thanks Luke for the expert answer and uh hopefully uh see all the participants next week. We'll be talking about wrist and hand fractures and uh hopefully, Mister Wong may be back with a stent. Thank you very much. Yeah. Yeah. Thanks very much.