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Yeah, uh starting day one. So, yeah, we'll be, we'll be all right to go by. Yeah, your life go for it. So, um fractures of the humerus, proximal humerus are really common. About 4 to 6% of all fractures. And um er, and 80% of fractures of the humerus are proximal humerus fractures. Um It's a bimodal presentation, the vast majority are elderly, um frail people who have a fall from standing, but there is another er, subsection. They were young, er, sort of high energy injuries. It's the 4th, 4th most common fragility fracture after vertebral fractures, uh neck of femur and distal radius. So, just a bit about the bony anatomy. So, um firstly, I think if you um define a proximal humerus fracture as basically anything proximal to the uh to the deltoid tubercle. Um So that's anything of the surgical neck of the humerus um up to and including the um the articular surface of the humeral head. Um Bony anatomy wise, you've got an articular surface which is spherical and roughly 46 millimeters diameter. Um You've got 100 and 30 degrees of inclination typically and it's retroverted by 20 to 40 degrees, got a greater tubercle or tuberosity which is lateral to the BPI groove. And then the lesser tuberosity which is medial, uh you got the shaft which is anything below the tuberosity. Um The anatomical neck is at the base of the articular surface um between the articular surface and the tu roses. Um And then the surgical neck is basically anything but below the tuberosity and but above the deltoid tubercle. Uh so soft tissue anatomy and deforming forces you've got the supraspinatus um that pulls the greater tubercle, um posture medially. Um You got the less tuberosity that's pulled Antero medially by the subscapularis, er shafts pulled medially by pec major and the head is pulled laterally. It was pushed laterally by the glenoid. Oh, this slide did look really nice. So, um just a bit about the blood supply. Um I mean, this is pretty similar to another uh another ball and socket joint that we've got. It's not, you know, not dissimilar to the um to the neck of femur, uh blood supply to proxim, proximal humerus is retrograde. And that means that it's sort of prone to a VN if it's um if it's fractured. Er, historically, we always thought that the anterior circumflex, er humeral artery er was the predominant supply. And I think the, the thinking now is that it is the predominant supply unless it's fractured. In which case, it's the posterior circumflex, humeral artery takes over um anterior circumflex certainly is more important for the, um, greater tuberosity. Um, there's quite a few sort of recognized variations of the anterior circumplex hum artery and that sort of depends on where it splits and where it ascends whether it's medial or lateral to the biceps tendon, which is all very interesting. But what does it mean for you? It basically means that it's something for you to consider when you're doing any sort of proximal humerus work, you're fixing a fracture or doing any, um, cuff repairs or anything like that, basically don't stick your anchors or a screw, um, at the, at, at, at the proximal um, part of the bio groove and definitely don't go blasting it with a diathermy if you want the, if you want the head to tuberosity to survive. Um, so, uh, how do you assess people with proximal humerus fractures? And of course, in the exam, you'll say that you'll do an A TLS assessment and make sure they've not got any other life or limb threatening injuries and you'll treat them first. Um, otherwise the history exam is pretty simple. Same that you do for anything. But of course, um, er, but typically you'll, you know, as a registrar, you'll be seeing these injuries actually in the fracture clinic rather than in A&E. Um, I suppose that's quite an important thing to note. So if you're in an interview and they, they give you the scenario and they, they see, they say that you're in the fracture clinic and there's probably not really any point in mentioning that you're doing a Tatls assessment because, um, you know, that ship sailed. Um, anyway, uh what, what do you want to take a, um, talk about when you're taking the history particularly is, er, any other sort of medical conditions that they may have that may preclude or delay any surgical interventions. And definitely you want to get an idea of their functional demands. And you know, if they, if all they do with their life is get up in the morning and watch telly and they get their food cooked for them by someone else and they get cleaned by someone else, et cetera. They're not gonna have the same functional demands of a shoulder as someone who's 50 still plays tennis every Wednesday. Um with regards to the examination, you want to check for any other injuries and manage those accordingly. Um You definitely wanna check a, a neurovascular status of the limb. So check the distal radial pulse and cap refill. Although arterial injuries are pretty rare, but you definitely want to check neurology um with regards to media and radial ulnar nerves, but also really importantly, the auxillary nerve, because one of the treatment options for proximal humerus fracture is a reverse shoulder replacement. And that relies on having a properly functioning deltoid muscle. And so if you've got a knackered axillary um nerve, then uh a reverse shoulder replacements. Not, not gonna work very well. Uh, the radiographs that you should get, um, you want, uh, th this is an auxiliary view. Um, oh, there were some other views, sorry. Er, yeah, cos they're all on the same one but basically you want a, um, an auxiliary view, uh, an, an A P view and a scapula wi view that'll give you, um, the views that you need to make sure there's not any uh any dislocation of the shoulder. And um er and, and it usually gives you sort of enough information about uh about the fracture characteristics. Um with regards to further imaging, CT scans can be really useful to give you a bit more detail on fracture configuration and they can help to guide management. You'll uh get a CT angio if you've got concerns about vascular oh, sorry, arterial compromise. Um MRI scans are not really indicated in proximal humerus fractures. Um but you probably would think about getting an outpatient Dexa scan and so that they can start on some bisphosphonates if uh if it's indicated particularly in your elderly frail patients, if it's just fall from standing. Uh sorry, the um I suppose there is one reason that you do an MRI and that's if you, you, you had any um uh abnormal neurology and you thought there might be a brachial plexus injury, then that probably, you know, that would be a good reason to get an MRI scan acutely So as for classifications, the ones that you really need to know about are the near classification. That's the most commonly used one for proximal humerus fractures. It considers the head, the greater tuberosity, lesser tuberosity than the shaft all as separate, distinct parts. Um But a part is only considered a distinct part if it's displaced by either one centimeters or 45 degrees. Um And as such, you can actually have quite, er, comminuted proximal humerus fractures. However, if it's any minimally displaced and if it still more or less looks like a proximal humerus, it might still only be considered a, a part, a one part fracture. Then there's the modification for if there's a, er, a head dislocation or not, there's also the, her all criteria was um published in 2004. Um So it's, er, this basically looks at radiological sort of criteria and whether they're a good indicator or a bad indicator for, for the patient getting um, er, a head avascular necrosis. Um The, the wording is a bit difficult in the actual paper and he uses phrases like good predictors and poor predictors, but that's not actually a, like this is a, a good predictor, er, that they won't get a VN or anything like that. What he, what he means by that is um this criteria is, er, correlates well with getting a VN or not. Um And then when he says there's a poor predictor, then that's a criteria that doesn't correlate so well with getting, er, head, a VN or not. And, um, so, so you would think, um, for example, that, er, a, a head dislocation, um, was almost certainly going to end up in a VM. But actually in his paper it didn't, it didn't fully correlate with that. But anyway, essentially if you've got, er, a, a, um, a medial calcar hinge of greater than eight millimeters, that's a, that's a good thing. Um, if you've got a medial hinge that is displaced less than two millimeters, then that's a good thing. Um, and if you've got a fracture through the anatomical neck, then that's a bad thing. There was main three. So management can, er, considerations, how do we manage proximal humerus fractures? And the, the big decision is for surgery or not, um, to come to this decision, you've got to consider quite a few different variables and fracture configuration is, is one of them, but arguably not necessarily the most important we have to consider. Like I said, what the functional demands of that patient are and what are their medical comorbidities? Are they likely to, uh, you know, is an, is an operation, the, the best thing for them and will their function realistically be a lot better after surgery? Um, than if we do no surgery. Um, are they likely to tolerate having a proximal humerus fracture? So, this probably is a bit more applicable to your young high energy, um, would probably, uh, manage, um, things a bit more aggressively in, in younger people. Um, and, uh, and then for, again, for your older people, are they gonna tolerate having a, a fixation that might go wrong and might go on to having, er, er, requiring a, um, a shoulder replacement in the long, you know, in the longer term, or is it best to just crack on and do that, um, straight away? And these are all sort of questions that you've, you've got to ask yourself when you're seeing these patients. So, conservative management is, er, you know, frequently used for these fractures. Um, so for people who've got really low, low functional demands, they're unfit for surgery. And then as for the fracture, maybe it's, it's a stable or minimally displaced fracture, maybe it's only a one part near fracture or two parts. Um, contraindications would be really grossly displaced fractures. So, if there's no opposition between the shaft and the, and the head that's really unlikely to, to heal and, um, and then fracture dislocations again, that's, that's, it's not something that's going to heal. Um, but even these, if you've got someone who's medically extremely frail with lots of comorbidities and, er, you know, you, you might still think actually conservative management is the best option for them. Um, complications of conservative management are stiffness which is almost inevitable after, after shoulder injuries, um, rotator cuff dysfunction, particularly if the tuberosity are, are off, um, you know, off in the wind and then maun and a VN as well. Oh, so what is conservative management? So if you see them in A&E then the acute management is a collar and cuff and just giving them, give them a bit of advice on, on how they can be sort of most comfortable. So I typically say you got to wear the collar and cuff so that the arm dangles and that helps it, the humerus to come out to length. It might make your x-rays even look a bit better. Um And it, and it can help to realign any sort of anglia angular displacement of the shaft. Um, don't put them into a poly sling because that will tend to pull the humerus up into the head and that can cause the angular displacement to, to be worse. Um Tell them that they'll get a bruised arm and that's a normal thing to, to happen. It usually comes on, comes on after a day or two and often you see them, you know, a week and their whole arms sort of black and blue and purple and that is, that's completely normal. So tell them not to panic and not to come down to A&E because their arms bruising up because that's, that's a normal thing. Um It's a lot better to sleep in a chair and definitely don't prop the arm up with a load of pillows because that will make, make make the, um, the deformity worse. Um, as the pain allows, then you can start doing what's called pendula exercises. And what you get them to do is basically hang over a table and dangle their arm down and, and slowly gently swing it around in, in circles as if you're drawing circles on the floor with your finger again, that can help to, to stop some of the stiffness that they get. And then progressively as the pain improves, then they'll start doing sort of passive range of motion and then active range of motion exercises. Uh Do we have any questions so far? We crack on, I'll do crackling um surgical management. So we talk about Ori first. So locking plates now with the sort of mainstay of treatment here. Um Historically, you know, before we had locking plates, then you'd use the sort of non locking T plates. And I don't know if any of you have been to the sort of basic fracture management courses yet, when they get you to screw up one of these fire los plates onto an apple and you show that if you use non locking screws, it pulls out easy peasy. Whereas if you put locking screws in, then it's, it's actually pretty difficult to pull it out. And that's, that's the, the basic principle of, of the locking plates is that it, you can screw into something that's soft and mushy and it will still hold it in the right place. Uh, you know, on the whole, um, and the way that it does that is, it's got lots of these screws all pointing in different directions, er, plates also got little holes all around the edge so that you can stitch the, er, rotator cuff back in place because, you know, these screws, they invariably don't catch the, um, greater tuberosity and, and they're nowhere near the less tubers. So, so you need, so if you've got separate fragments and you need to control them with sutures, um indications are proximal humerus fractures and they can be t three or four part uh plus minus dislocation. Although, you know, um dislocation is pretty high risk for a VN. So you might be thinking other things at that point. Um Again, contraindications are people who are too medically unstable for surgery or too medically frail with really low functional demands, also get hooked plates for isolated um greater tuberosity fractures. And whilst the rest of the near classification says that it's for um fragments that displaced by more than a centimeter, which greater tuberosity fractures. If they're displaced even by five millimeters, then that can be um you know, it can be quite restrictive for the patient with um sort of abduction. And um er so, so there's a sort of lower cut off for displacement with greater U fractures. Arthroplasty is also the other option and whether that's a, a reverse shoulder replacement like this or a hemiarthroplasty um indications for that are fractures that are not amenable to open reduction and internal fixation of the plate. And so that would be sort of highly comminuted fractures, er, really high risk for AVN like fracture dislocations or head split fractures or, or if there's been a big crunch in the, in the articular surface and it's not no longer a circle. Um then, then there are all sort of times when you would think about doing a reverse or a hemiarthroplasty over, um, over and, or if again, contraindications are medically unstable or if there's any active infection in, in, in that arm. Uh, and the, the, you know, they, they're sort of stemmed prosthesis. So, I don't know if any of you have seen, um, shoulder replacements but a lot of them, er, er, an anatomical shoulder replacements have just got a little keel. These ones have got to be stemmed because, er, because of sort of tuberosity involvement, the stems typically come with little holes on them again so that you can stitch the cuff back in position. Um, because there aren't any sort of screws or anything that hold the tuberosity on. It's all done with sutures, um, are surgical procedures that you might see. You might see percutaneous wires. I, I mean, I can't, I can't say I've ever seen them. Um, but it might be something that you'd consider in a, in a young person with a proximal humerus fracture. Um, certainly not um appropriate for anything that was comminuted. Er, and then you might also see some intramedullary nails and these are, uh you know, these can be used for fractures of the surgical neck. Um anything more proximal than that, you're not really gonna get enough screw hold. Um It's quite nice because you don't need a massive um surgical exposure. You don't need to do a full delta spectral approach like you do for any of the, for all the others. But it does require that a bit of the superior part of the cuff is removed from the tuberosity. So you can get access to the um to the medulla. And um so it's, it's not something that you would ideally use on a young patient because you don't want to tear their cuff off. But uh but if it's in an older frail patient probably hasn't got any cuff left anyway, then that's uh that can be a, a good option. So, um which intervention, luckily, we've got some um some pretty good literature on proximal humerus fractures. There's the um proper trial published in 2015. And if you asked about a proximal humerus fracture in your interview, then you, this would be a paper that you'd definitely be expected to know about um what it, what it does is a multicenter randomized control trial and economic evaluation looking at the management of proximal humerus fractures, comparing non operative management with operative management. Um And basically it shows that there's no difference in sort of in functional outcome. There's, uh, oh, sorry, inpatient reported outcomes. Um, there's some sort of caveats to that and particularly that some of the exclusion criteria a bit, er, bit questionable. Like, for example, one of them is clear indication for surgery. So, you know, if it, if it defined what that clear interven clear indication was and I'd find that a bit more acceptable but it doesn't. So you, you're always gonna get some people who are more in to do uh, surgery in that instance. Um And also there's very few sort of near four part fractures or isolated greater tuberosity or less tuberosity or head split fracture. So you got to be a bit careful when you're extrapolating the findings of it. And certainly it didn't include any reverse shoulder replacements whatsoever. Um Coming up is the proper two trial that's due to finish soon. And that's for your elderly patients with three or four fractures plus minus head dislocation. And it's looking at whether they, whether they fare better with a hemi or reverse. Been a fair few papers that I could find looking at this exact same thing. And they basically all say that, um, that they, that they all have similar patient reported outcome measures and the um, uh range of motion is slightly better in the reverse than with the he a. So I suspect that that's what profer two will find as well. But prof two is a, a massive trial and these are all, er, either small trials or, um, uh, meta analysis of several small trials. Um, so onto the cases. Does anyone want to be questioned? Otherwise I'll pick names. Ana anyone good Ben? Ok. Can anyone hear me? I can hear you, Tom, let me, yeah, don't worry. No, no, we're, we're here. Uh, let me just see if I can, uh, add good button to the speaker list since you've selected him. Yeah. Well, he's the only one who's replied saying yes, please see. So he's, he's been invited to the stage. How long have I got? Well, you're six minutes over but uh I think that's uh fair enough. You started about five minutes late anyway. So if we do a couple of cases and then we uh you know, just the one case and then we can move on to the next speaker if that's ok. Yeah, that's fine. I'll pick a decent case then this one's a bit boring. So um case two, Mattie ready join the stage when I should be getting an invitation to join the stage. Hello, my, my name is Meghan. I'm the doctors calling from the hospital. Oh, hi, Matt. Hello. Hi. Ok. So you ready for friends? Yeah, connectivity issues. Fine. So case 2 77 year old fit and well retired nurse right handed. So right, right side fracture. She previously had a left frozen shoulder otherwise no medical problems, not diabetic or nonsmoker and she's fallen over from standing and she's sustained this injury. So, first of all, do you want to tell me what you see on the x-rays? Uh Yeah, so it's uh so it's a plain film x-rays the right shoulder, it would appear that the shoulder is, is in joint. Um It appears to be a comminuted fracture of the proximal humerus and I can see at least two parts, I think maybe three. it seems relatively minimally displaced though. So, actually, on the basis of what you said, I want to get a CT to further define it, but this may well not fall into the category of being a comminuted multipart fracture actually. Ok, good. So, um so you said, yeah, it looks to be in joint, but obviously you'd need a, you need a wide view view to say that for sure. Um But I can tell you that she did have an auxiliary view but I just haven't got it here and it was in joint. Um And then you, so you said that there was three parts. Um I mean, er but then you said that they're minimally displaced. So if we're talking about near classification, then there's not three parts, there's one part. Yeah, it's a one part fracture, isn't it? Um But there, there are multiple fractures, there's a one part community fracture and er where, where, I mean, where do you think the main fracture lines are, do you reckon? I think, mostly extending through the sort of the anatomical neck of the humerus and there's also something anteriorly as well. Um, but it, I think it, it's difficult to say, but, yeah, mostly through, well, mostly just through the anatomical neck. Yeah. So, I mean, so I think that there's an anatomical neck fracture. I think there's, you can probably see there's a fracture through the surgical neck there as well. Um And then there is, I think a line going up probably splitting the um greater and lesser tuberosity. So I I'd say that it's a, it, it's in four pieces, but it's a one part near a proximal humerus fracture. Um So what, what do you think the plan was for this lady? I think she would have been conservative management. Perfect. So that's what that's what she had. Um And do you want to see what happened? You get, what do you think of that? So there's been collapse of the humeral head. So that's kind of in keeping with AD N Well, um yeah, so that, that was the worry actually. So she came back at six weeks because she was still in pain. Um And these, these are the x-rays at six weeks and there was a bit of concern over resorption of the greater tuberosity. So, um she, she did actually go for an MRI scan to see if she had any AVN. But actually, in hindsight, there's er, I think the, I mean, well, number one, it's displaced so the sort of pendulum exercises and stuff haven't really done the job for her. But it looks as though there is a fragment that has moved. Um, and, um, the MRI scan basically showed that that was the less tuberosity fragment. Um, and as a result of it having moved it, um, worn away all the cartilage from her inferior glenoid. So, um, uh so she's on the waiting list to have a reverse shoulder replacement. Um Usually that doesn't happen, usually, you know, for, yeah, and I don't think in retrospect, you'd do anything differently because that proximal humerus looks exactly like a proximal humerus, albeit with some, some fractures. So I think that was a, a reasonable thing to do, but unfortunately, it didn't work out quite so well for this lady. Um So that's that case. Uh What, what ab what about uh let's have a one that worked out well. What about this one? So cases 4, 54 year old chap, right hand dominant postman. I take it there's no one else that wants to go. No one's jumping in. So, Matt, you can have another go then. So 54 year old chap right hand dominant postman, he's got a bit of high BP, just takes amLODIPine, but otherwise he's completely fit and well and very active. Um So what do, what do you think about this? Is that displaced? I think what I think the main d distracting force there is of what you're putting up earlier is biceps is pulling the distal fragment um medially and the glenoid shoving the whole head later. So I think your risk of a VN here is, is a bit of a whopper. Yeah. So, so this is a displaced um fracture. I mean, how m how many parts do you think it is? At least th th yes, at least three cos I I think the, the greater er truck is off by Great Greater G Ros is off by at least one centimeter. Yeah. Yeah. So his, his Great Ubers is displaced. Um and there's what we call medial displacement of the shaft. So that medial hinge is more than two millimeters displaced. The head fragment is, is um is angulated. Um Probably I'd say by 45 degrees. Um There's no medial um Calcar there either. Um So his risk of a VN is certainly not zero. Um But he's a young guy. So um I mean, do you want any further imaging on this chap? You need a CT? Yeah. So he got a CT. I was gonna show you the CT but it's not going to let me show you the CT. So, but the CT essentially shows that um he's got a displaced greater tuberosity fracture. There's AAA fairly sizeable head fragment there that is attached to the lesser tuberosity. And um and he's young and you or relatively young and fit and well, so he's probably got fairly good um, bone quality. So, what, what do you think the management is for this chap? I think he needs. No, it, yeah. So locking plate, that's what he got. Um, anything to say about the plate. It's a lovely reduction. Yes, that's what you always say, you say. Wow, this is a great, great result for this guy. It's um, it's a bit high but otherwise, uh nicely reduced and the, and the, the, the shaft is pointing where it's supposed to be relative to the head. So, so that's pretty good. Um, he, uh, he was pretty happy with it but he had some limited abduction and that's probably because the plate's a bit high and maybe he's getting some sort of impingement on the acro but also on his follow up radiographs, the greater Ubers just looked a bit like it might be disappearing. So, so perhaps he, um, he's lost some, er, um supraspinatus part of his calf as well. So, so, but anyway, he's on, he's on the waiting list to have this plate taken out and see how he's doing afterwards. Um, so I think that'll do for my cases. Now. Um, does anyone have any questions on any of the things that I've just said or? Ok, thank you very much, Tom. I'm not seeing any questions in the chat box, but, uh, we can, uh, if we get any, we can, uh, promptly answer them as well. Um, thank you very much. That was very useful. Um, so next we're going to move on to S Stock and Dice. Humeral fractures. Hello, everyone. Let me try, share my presentation. I hope it will work. I'm not sure. Um, can you see my presentation or is it like lots of, um, we can see your presentation as well? Yeah. So is clear now, isn't it? Right? OK. So, um yeah, so my presentation um I, I will um try just to keep it like more simple. I'm not getting too much into details because you can read very easily through Miller or um textbooks about the humor shaft fractures. I will try just to keep it simple. So I'm going to talk about the humor shaft fractures, call it diy um fractures mainly. Um The objectives of this um small teaching session is um how to assess the fracture clinically and radiologically. And um at the end of this, um teaching hopefully will help you make decision about the treatment options whether to go for conservative or surgical treatment. Um If you go for surgical treatment, which approach would you like to use? And um if you're going for um surgical, which implant would you like to use? And which mode of fixation, um would you think the best for this patient? And um we'll talk a little bit about um some ongoing level one evidence and a few um radiographs where we can discuss the management and finally they call message. So um does everyone have um sli do or just mobile phone to scan this um barcode and open sli do? So you have seen this radiograph of um humerus where there is a very clear shaft fracture is middle one third. So if everyone can um get this bar code or open slider dot com and put this um reference number, it's hash 3206365 and I will open it from my side as well. Great. Can everyone see my screen? So only one person has voted the brace. So we'll give you a few seconds. So, um so basically, yeah, sure. So the treatment here will be a brace, fixation or unsure and you would like to do something else and this is the x-ray here. So we'll give you 23 minutes to think about it. Um It's nothing fancy. It's just keep it simple. Yeah. So five people majority said brace. Um 40 people said unsure. So anyone else would like to vote? Don't worry, it's all anonymized guys. So um I'm not going to to pick on this to put anything you think is um is the right answer and people just out of interest people who have put unsure, what would you like to do or what's the next step if you can't make just decision based on this radiograph? Um can, can you can, can anyone um, un mute, the mic and reply or do you have to go on the speaker, um, list to be able to speak? Uh, I've invited everybody on to this stage so they can participate whenever they like. Uh, and if you're shy about, about speaking out, just send a text in the chat and a message in the chat. Yeah. So I, I don't have access to the chat or, um, I'll tell you when the answers come in. Yeah. Ok. So um so basically um no one has picked fixation which is um like very strange. Er I'm not sure why but I will elaborate more on this slide a then. So um people have um said unsure, that's really good. I like this because we can't just make decision based on the radiograph. You have to assess the patient clinically. You have to see the patient in general. Is this patient, elderly frail young? Is it a high energy trauma, low energy. Is this patient coming as part of a poly trauma injury or just um patient was walking and tripped and fell? You'd like to know the age of this injury as well? Is it something recent? Is it old? How did this happen? And um you want to to to know some of the background of this patient, is this patient having background diabetes, um any history of tumors. Um and finally the social history, a little bit of baseline mobility occupation. Smoking is patient right or left handed. And this is all going to help with the the formulating the management plan. And um once you've seen the patient, then you assess the limp. Is it isolated injury or um is it common with contralateral hum fracture? Is it part of floating elbow? You check the skin, is it open or close injury? And then you assist the neurology including brachial plexus and you assist the radial nerve most importantly, and you examine joint above and joint below. And finally, you check for the compartment syndrome, which is not very common with such injuries. Um Once you've done the clinical assessment and and if taken the history that you move on to the radiology, starting with plain radiographs, ensure that these are adequate films, including the whole bone from shoulder to elbow, um including joint above joint below, get two views at least A P and could be transthoracic. The patient can't get lateral view because it's all broken. And um you need to find out whether this is um midshaft diaphyseal metaphyseal or proximal. And you do this by uh doing the molar square, we measure the widest part of the proximal or distal part of the humerus. And you measure this and then you get the square based on this um diameter. And um if it is um beyond this molar square, this means that this is uh falling into the shaft is not proximal or distal humerus. And you check the pattern? Is it transverse? Is it spiral or long or short, oblique or commuted? And the way is the actual location in the shaft? Is it more of a midshaft extending proximally or midshaft extending distally or just through midshaft? Then um not all the patients will require a CT scan unless it's really too proximal or too distal. And because you want to confirm whether this structure is extra or intraarticular and this is really important if you want to plan the surgery, whether you're considering nail or considering double plating. And finally, MRI is, is not important for the actual management or planning the surgery, but it's important to exclude any tumors if this fracture was atraumatic. And if the patient has got a background of any tumors, so you might need to get MRI whole bones, see if there's any interim dully occult lesions. Um moving to the decision making. Um It's very simple, either non operative or surgical. Um in the UK is most commonly, um they are most commonly using the functional bracing around 70% and this is from the hush trial survey. Um There are a few indications for surgery, sorry for non operative if the angulation is and t is less than 20 degrees varus valgus, less than 30 degrees shortening is less than um three centimeter. But again, there's no based on a strong evidence. Um the advantages of non operative um is less invasive, um less risk to the radial nerve. However, there are some disadvantages because it take longer time. They take 3 to 4 month, there is high risk of nonunion around 20%. And finally skin sores. That's why they need regular skin check in the plaster room and moving to the surgery could be or if with plating or nailing. And this is more commonly used outside the UK. And, um, I think they are getting advice. Um, even in the UK, um plating may be used for traumatic injuries, nailing mainly for tumors or poor soft tissue if there's like open fraction and they won't just to do um internal fixation without much soft tissue dissection and the advantages early recovery. So um two around two weeks, they get a sling and after that, they start early mobilization, they still take some time um avoiding lifting heavy objects or doing contact sports, but at least you don't get the issues which happen with the non operative bracing like muscle wasting and stiff joints and skin sores and definitely higher union rate. However, it's um it's expensive. There is a high risk of radial nerve injury. So far, there is no any um level one evidence to check the cost effectiveness comparing the non operative versus surgical treatment. That's why there is a current level one RCT run by the N I hr it called Hush trial. It's for midshaft humor fractures. If you've got the equipoise whether to um do fixation or conservative management, um you can add these patients to this hush trial because no one knows which one is better on the long term in terms of the functional outcome. Um Is it the brace or the surgery? So um if if you see this uh this radiograph and you go see the patient, you find lovely elderly lady in a wheelchair come from care home with dementia, close injury, new of us get intact. So can everyone go back please? To not this one? This is my children's school application. Sorry. Oh cancel this one. Sorry you guys. So if everyone can go to the slide again and let's go to this one. So how would you manage this now? Um if say do a brace or fixation, do you still have the Sligo code is the same code we'll give it just one minute. Can everyone hear me? Yes, it's just not giving us new uh answers. So I guess everybody would have to edit their response. Uh ok, that's fine. Yeah, no problem. Yeah let's let's do it again. Ok, that's fine. So um yeah, so I'm sorry I will just reset it again and let's start again. I need to I think to do a I think it's fine if everyone just press edit response and then change it. No, that's fine. I've done re so it should be fine now. So let's let's do it again now. So I've done reset. Can everyone see my screen? Yes and if we could see the x-ray again. Yeah. Sure. So there's x-ray. So it's a straightforward, so close injury ne of us can really big. It is fine. She, um 85 years old lady background with dementia just tripped and fell in the care home three days ago and uh brought to a and they've done this radiograph and they found this fracture. So how would you manage this now? Right. So five participants said brace. So, yeah. So patients a ne you, you don't have plus the technician, it's just the junior doctor like a CT one just starting their on call, the non residents. So um yeah, it's fine. So the management will be conservative management and we'll talk about the conservative management in a later slide how to start this. Ok. But well done. So it's conservative management in general. OK. Um If you see the same radiograph, we'll say a patient who is this one? So it's more sala er was playing football and Phil coming in A E with this sling. So it's high in trauma. Um skin is intact and radial nerve is intact and he has got this fracture in his nondominant hand. Let's do reset to the results and then we'll do it again and then we'll see what will be. Yeah. So it's the same radiograph. OK. So we open it now. OK. So three people answering uh fix. Um Few people answered unsure. Uh It's getting less. So it's more fix. Yeah. Uh, great. So just out of interest, people who have said, unsure, w what would they do differently if they don't fix? It is straightforward, close isolated injury, neurovascular intact, smit shaft him what he wants. I'd put the options to him. He's got, it's a, it's a long fracture. He's got a pretty good chance of healing. Um, without any sort of need for surgery chap like that is you probably want to be taking that plate out um because of the risk of per prosthetic fracture. So that's two surgeries for a football player. So, you know, I'd put the options to him. Absolutely. Absolutely. That's perfect to. Yeah. Um Exactly. So it's patient center decision basically. So you speak to the patient, speak to them about the two different options. Yes, because you could fix this one or you could do bracing and doing fixations. You going to um get him back to the football because you will still need to wait for at least 88 weeks for this fracture to, to fully consolidate and heal completely and be able to return back to football safely. And is um is fixation going to be better than brace? We don't know the answer. That's why the hash trial is currently working. Ok. Yeah. Well done and then moving to the non operative. Um so um you don't start with the brace, so you start with something called coarctation cause it's just like temporary stabilization. And the patients coming to ne it's like just U shaped cost and you put a single cor coff to um hang the arm until the patient goes to the plaster room. If you are working. And in your head, we got experiences CTS and we've got brace facility in the plus the room available 24 7 and you, you're happy to put a brace that's really well and good. Um And um second step after a few days, once the swelling settles down, the patient goes plaster room, then they get um functional brace and radiograph after that. And um the main problem with the conservative management and the brace is the skin sores, which happen on the axel especially. So they will need weekly skin check in the plaster room or two weeks. And the brace tightening with adjusting, um you need to get radiographs um in 123, in six weeks and then every 4 to 6 weeks un until the fracture starts to heal. Er So, um if the fracture is non united, they, they will need to get fixation plus or minus bone grafting with a plate and screws and this is very expensive. It might cost up to 15,007 lbs. So, uh moving to the operative, there are main two arms. Um So plate and nail use mainly the plate um through um two approaches more commonly used. Uh If the fracture is too proximal, you'd like to do untra approach because you can extend it to the delta pectoral to get a better compression. I'm show some radiographs and further slides. If the fracture is uh more of a mid shaft or extending distally, then you'd like to do posterior approach. Or if there is radial nerve concerns, you might, you might need to do post because it gives you better access to the radial nerve and exploration it and it gives you better access distally as well as you'd like to do double plating and they will show some radiographs as well. So, fixation mode, um if the fracture is transverse, you would like to do compression by compression, plating. If the fracture is spinal or oblique, you like to do leg screw and neutralization plate. Um Nailing is mainly for pathological fractures, poor soft tissue. It like open fracture with um significant soft tissue damage and the want to disrupt this just you do nailing. However, there are risks to the nail fixation rotator cuff disruption and you don't, we don't like to do this in young athletic patients. Um However, there are some talks about the cuff sparing approaches where they go through the cuff interval claiming that they um don't disrupt the rotator cuff. Um Main problems with this. Um sometimes it lacks good compression and ends up with non union and um radial uh nerve damage. It happens if you're doing medial collateral uh distal locking bolts, muscular musculocutaneous nerve damage. If you're doing anteroposterior bolts or screws. So, uh back to a few cases and then we'll um do the, take home message and, and finish. So, um, if everyone can get their um slide again, I will do reset. So you have seen this um radiograph, this is in, in a patient who's um right handed and this is the left humerus is closed. Radio nerve is intact. Patient was on ladder and tripped and fell and it isolated injury. No, any other associated injuries. So, how would you fix this one? So we'll go back to our slide though. We'll do different question. So sorry, we'll just move this one. So we'll just uh do this one. Ok. So let's have a look. Ah but we have a question uh regarding uh braces, how do we put a brace on somebody whose body habitus causes displacement of the fracture? So, um you have to um what happen is like what um is it like patients with large rest or? So, I assume that's what they mean. Somebody whose body habitus is uh not suitable very well for a brace or somebody who's either big and their arm is very large for the brace, somebody who has a larger breasts. Um So I think you just um you try to um um just fit the brace as much as you can and and the breast could be always moved away with like a tight bras or um or um just um try to, um, get the patient to lean on the other side of the fracture site. And by, by this, you will get the all the soft tissue and things getting in the way away from the fracture site and then you adjust the brace nicely, um, which will be on the side of the patient and, and these things, there is no right and wrong. Once you've taken conservative, the decision of conservative management for these patients, you just see what's the best position that they can do if they're not fit for surgery. Um And uh it's really hard to, um, put plaster. All right. So, yeah, well done this compression um late or yeah, if you go conservative to be um very difficult to control because it's transverse and sometimes they end up with this big callus and traffic non union because it lacks good stability and this nice plate that you see here and again, this one be the last one and then we'll finish off. So we've got only five minutes. So we'll go to this one. bear with me. We'll just do, um, sorry, we'll just do another one and we'll do reset. So how would you fix this one? Show the radiograph again? Yeah. Can everybody see the radiograph? So sorry. Uh What's this one? Uh Yeah. So, yeah. Can you go and see? Yeah. So how would you fix it? Compression plate? Is this a new one? Yeah. Yeah, I'm pretty soon. Yeah. And, and this pla will be, yeah, the like f plate proximal humerus and you have to go intra lateral with the pectoral approach or you can do nailing. Ok. So nail is fine as well if the patient is elderly. All right, uh we just finish off. Um this one is uh more of the same years. Uh What's the name of this uh fracture? Can anyone know? Got one minute? Yeah. So this the ST lowest um type fracture with high risk of radial nerve injury around 20%. You have to be mindful of a radial nerve injury with this one. And this fracture has to be fixed through steer approach because it might need um double or single plating, extending distally to get better control and might to um get like screw fixation as well. Um So take home message um with these structures, you have to see the patient check the background, um has to assess the limb, check the skin, radial nerve and um make sure they've got adequate images. Uh CT is, is mainly for surgical planning and um it's patient centered decision. Um You have to speak to the patient, explain to them all the treatment options and um and we have to make the decision together and um which one is better brace or surgery? There is no strong evidence to say which one is most is more cost effective than the other one from the hash trial, which it's still working at the moment. Thank you. Any questions I will just now. Thank you very much for that. Um That was uh very useful and concise, very clear. Uh It's uh patient center decision making and uh how to go about discussing it with the patient and the concerns regarding e every mode of management. Uh If any, if anybody has any questions, please send them in the chat. Otherwise we want to. Hi, thanks Katie for that. Um, any commitment to k, you are the upper limb expert or if there's anything, first of all, that's the, that's the only thing you've got wrong today. Ahmed is that I'm not the expert and I, I love the way you try to get everyone to interact with the, the polls. Er, that was good. Er, I can see that you, er, and I like the, the way both you and Tom had the different cases to get people thinking and stimulate them. Um, I just hope that, you know, I can, you know, carry on the same what you and Tom have put together, but that was really good and the, the evidence, you know, basically no one knows what is the best method and that's why the hush trial is there. Exactly. Yeah. Thank you. All right, mister K, you're on da da. Let's see. Can I get my, uh, and just, uh, thank you for giving us the time. I know you're on call. And, uh, you may be uh pulled away at any minute, but thank you for being here. That's all right. I'm, I'm leaving, I'm leaving your colleagues to, uh, to manage in the, er, on, um, now because of the peculiarities of medal. Can you tell me, can you see my powerpoint presentation? Yes. Good, good, good, good, good. OK. All right. So there we go. Um, and great to, yes, ing goes on, doesn't it? Um, so why did I have Bono playing a beautiful day for this is because he himself sustained that distal humeral fracture. As you can see in the picture on the left hand side, the, you know, reenacting how he fell off his bike and got the distal humeral fracture and that's actually a picture of his fixation um, in the probably daily mail. I don't know. Um, that's the usual source, isn't it? What are our objectives today? So, it's about decisions and incisions and making that leap from knowing your anatomy, your how to interpret a radiograph and then being able to recognize the patterns and then a few technical tips to help you get through the, the long case in terms of, er, if you've ever been involved in fixing these or, er, replacing these even. So, um, this graph tells it all in that it's distal humor fractures. Obviously, you got the supracondylar fractures that are common in young males usually. Uh, and then there's the more frailer elderly females who also have a high rate of these distal humoral fractures. And I'd like to thank my colleague Graeme Tiley Strong for er publishing that in 2003, 20 years ago. Alright, I have to bear that in mind. So I'm going to show you the di diversity and inclusivity of distal humor fractures here. You've got example one which is just a simple extraarticular fracture. Then you can mix it up a bit and go intraarticular. You can see a little bit of er comminution with that middle fragment there and then you can make it a little bit worse and finally you can go all the way and it be a kind of explosion within there and it's just dust particles. Oh, this makes my eyes water. Um I'm not expecting you to know the classification system of distal humeral fractures and to be honest, there are several of them. Um this is a ubiquitous, one of the er AO classification and ABC and depending on how severe it is, but you don't need to know that there's a Jesse Jupiters classification with lambda and YT shapes hate shapes. I think that's a little bit easier to, to understand, you know, is it a high t a low T, is it more of a ay er, is it extra comminuted with the condyles off as well? So that, that's an H shape and then there's the kind of inverse Y or the lambda and depending on whether it goes out medial lateral. Um, does that really help a little bit in terms of why do we have classification systems? It's because we want you to be able to communicate what the problem is and, er, if it's something that has good inter and intra observer variation, er, then people will understand exactly what you mean. However, all of these classifications for fractures usually have quite low uh inter an intro observer um variability. So I bet you didn't know that Bono was also an orthopedic trainee. Look at that. He's er, you know, hammering into shape the world. We've got some decisions to make. So you've presented with the distal humeral fracture, you've got to decide whether it's supracondylar intraarticular. And then what do we do with it? Is it, shall we treat it non operatively and, or if or replace it and then if you're gonna replace it, should it be a total replacement or a half replacement? Whoa, that's already blowing my mind in terms of all that decision making before you even seen, got in, got into the theater to treat the fracture. So if you go for non operative decision, number two is whether you treat it um with a cast or do you go for early mobilization and what's known as a bag of bones? So, the outcomes of non operative treatment in patients usually who are frail and elderly as we saw those, they are the highest proportion, the outcomes in this very small series that you can see here, only about 19 patients, they found that there was comparable to having an elbow arthroplasty. The only difference being that there was a lower complication rate in those patients who had no surgery. Whereas with surgery, there were huge amounts of complications, especially with internal fixation. Look at that 342% complication rate. That's just nuts. So I'm gonna make it easy and this one's a no brainer really, isn't it? You know, decision one for this 30 year old with uh this bomb gone off inside their elbow. It, there's no reason to, to think about um arthroplasty because they're too young. Um But certainly should consider an ori so what's the next decision that you need to be thinking of? Well, you've decided that you're going to do the or if, but how are you gonna approach it? So, as you can see, there is the triceps split and paracra approach, you can break some more bones to approach it. An E Lenon osteotomy or you could spare all the bones and go through uh the sides known as the para tri notice, little bit confusing. There's para olecranon and para traci Pital. Hopefully I'll be able to show you in this uh series of images that there's a er, what the difference is between the two. But what I'd like to do is I'd like to cure. Are you able to activate the pole. Uh Let me take a quick look or do I have to, I think you might be able to activate it. Yeah. OK. So I've put this uh image up. That's your patient. You're in theater. How are you going to position the patient? Are you gonna do ABC D or E which you know, supine with their arm across the chest in a trough? Supine with an arm board lateral with a, an arm holder called the trio, put the patient prone with an arm over a bar or put them later with their arm over a bar. Let me know uh what the folks are saying. OK. That's the A I can. So 60% said lateral or with arm over a bar, 40% said supine with arm across chest in a trough and that's a total of five responses so far. Cool. OK. All right. So just testing that there's still some people out there because I can't see anything. Um So yeah, there's look, there's, there's no right or wrong but the, the, the commonest uh way that people do it is later um with the patient's arm over a bar and um more common um more frequently nowadays, especially in the major trauma centers, we tend to need to keep the patients flat on their back. Maybe they've got concomitant spinal injuries, et cetera. So we, er, in the major trauma center here in the east of England, er, we tend to put the arm in the. Oh, well, sorry. In, er, in, in Cambridge we tend to put the arm across the chest in a trough like, so, so there's another different way of doing it. Hopefully you'll remember seeing this and you'll be able to replicate that if you need to help your, your bosses out. And don't forget that when you're do, um, when you're writing up the op note that you need to document whether you use the tourniquet, what pressure it was used at, how you isolated any fluid. Because the reason why we put this, uh steri dr around it is to stop fluid leaking under the tourniquet and causing tourniquet burns. This is, er, you know, something that has happened on more than one occasion, er, um, is, is actually a, an, a never event but they, you may not be familiar with them actually. Um, just thinking about it, but hopefully you're starting to get to know about the bot standards for trauma. So British orthopedic Association standards for trauma and if you are interested in orthopedics, then you should read through all of those because invariably one of them will come up at some point in your interview status, er, stages, right? Could you activate pole number two for me, Karem? And then what I want you for those of you who are still around, if you could tell me what you would do with this extraarticular fracture, whether you would go non up and move it go operative and para cipient approach. Do an electron on osteotomy or a trice split with para Leon approach or some other approach that you mean or know about what, what are the, what are the folks saying? We've got 40% for para uh 20% for Oon uh osteotomy and 40% for tricep with para cool. OK. So this is a uh one I did earlier and you can see that there is no electron osteotomy because it was extraarticular. We could get away with just doing a para tri um because we don't need to see the joint line. So supracondylar fractures, extraarticular, you can get away with a para tri approach if you need to. Now, could you activate that same pole? Let's see if uh there's a difference in her opinion and then if you have to reset it. So this fracture, would you go non op and move it? Would you go para tri pital like the last case or would you go for an electron osteotomy or tricep split with a para Leron approach or some other cool method that you've seen and you want to share with me, I'm just recreating the poll that that doesn't let me reset. So it will be with you in a second. Just gives everybody a chance to take the images and make a decision. Uh apologies of that. So you, you're having to rewrite the whole question. Yes. Write down. OK. All right, then why do we, why don't we get people to on the chat if the people just put in with their preferred response ABC D or E I don't know if you, it's less, less slick than the, the pole, isn't it? Ok. So we've got some, uh some answers now for the uh last fall. So 80% said on ostomy, uh and 20 that's 85% have ostomy and 14% 14% for split with nice. OK. And uh Tom Barker says uh tri split with as well. Cool. And while you're doing that cream, can you set it up again for the another case? Um Cheers. And uh basically, what did I do? I went para ri on and here is some intraoperative images for you to see the, the, the, the parallel approach. So at the top where my arrow is, hopefully you can all see my arrow that is the ulnar. And then this muscle on this side is the anconeus and it the a goes into the triceps and splits the triceps. And you can see the, the joint line there, the articular surface, see the whole of the la lateral condyle. It's very difficult to see the medial condyles so much. But er I can show you here that you can expose that medial condyle there. You can see it quite clearly by subluxing the ulnar off and I'll, I'll come to how a few tips and tricks. Um but there you can see the triceps intact and there's the line kind of a two thirds, one third junction more naturally. And then you can see how much exposure one can get of these pretty fractures. So this is a different case. And you can see there's a sloop around the ulnar nerve. There's the parallel approach to try and subluxed that ulnar off. You can put a drill hole in there and then put your clamp into the, the ulnar and subluxed it off. That was my question, reconstruct it. So, so it creates three windows. So missing, I can ask you a quick question about that. So I from doing the electron and osteotomy for the last case because um you know, because it's in involved the case before that, you said, you know, it's not involving the joint, therefore, wouldn't do a elect osteotomy. But this very much is. And then I, my thought was to see this is a young chap. We're still using the 30 year old, taking the bone off and reattaching to the lovely solid plate or suture repair, you know, rather than taking muscle and muscle belly. What was your reason for taking the this approach instead? Yeah, that's OK. So um good, who am I speaking to? Because I can't see you or er I can hear you, but I ma I'm one of the CT TS of the page at the moment. So, hi Matt. Really good question. I love it. And in fact, when I started off, electron osteotomy was exactly what I would do. And it's just that I've evolved, why have I evolved from the electron osteotomy into the para electron approach? It's because of um my mentor, Lee Van Rensburg, who you may have heard of and he's a bit of an elbow trauma guru or elbow guru full stop. And um he basically from about 17 years ago, when he first started, he did, he tried to avoid electron and osteotomies. Um The problem with electron osteotomies is you, yes, you get a really good view, but the ulnar nerve, you can't flip the ulnar nerve. And so the ulnar nerve is compromised. So that's one problem. Then number two is at the end of this three hour opera, you know, three hour plus operation. Um when er so maybe not in this case, but in some of the other cases, when you've reconstructed everything and you've put it all back then you've got to um put on the plate and sometimes the, you, you may not have got a perfect fixation. And so your osteotomy doesn't fit back as snugly as it needs to. Then you've also got to put in the plate. You've uh you, you, you're, you're clearly quite um advanced because you also started talking about the suture technique. Um I have used the suture technique for electron osteotomies in a distal humerus, er humeri fractures. And um my case um, the experience of two is that one went really well. The other one failed uh, pretty quickly whilst they were in itu flashing their arm around. And so, you know, I've just done a really, er, prolonged operation, getting everything into, you know, sort of the right place. And then, um, I've, uh my uh osteotomy is, is ruined because of the, the suture fixation. So, uh and, and, you know, it may not heal the electron on osteotomy may not heal. So these are the rationale for trying to avoid the osteotomy. But going back to what I said, I evolved into that. And so if I'm starting again, then I would definitely do an electron osteotomy because it is just easier to see, visualize everything and to concentrate and focus and, and put the bits together. So really good that you're picking up on that mat and I wouldn't change your responses. I would still go for the electron on osteotomy, but I'm just showing you what can be achieved even if you didn't go for the electron on osteotomy. Does that make sense? It does? Thank you very much. Cool. OK. So uh I won't, I won't make you do this again. Uh It's not too dissimilar to the other case, but in that, in this one, as you can see, I did do an electron osteotomy and look at that matt, maybe I should have just gone on to the next case and showed you um Can you see that there, here, there is a av sion of the, the frac uh of the uh eon proximal uh to where the plate is. And that is a, that's not an uncommon problem as well occurring with plate fixation of electrons generally. And you can see it's not a perfect um match um er after the er fixation either. So those are this, this x-ray is the reason why we've moved on from trying to do electron osteotomies. But as I said, if you're starting out, it is the better thing to do. I mean, in this case, Matt and anyone else, I, you know, would go for an electron osteotomy straight away. Why does it look like I haven't done an electron osteotomy? Um I have, you can see it there. Um This because this is a after uh an arthro lysis and removal of the uh some of the metal work, I didn't remove the plate because you can see that there was still a nonunion in this um later Condy. And so uh definitely when it's really comminuted or, or just, you know, when you're starting out, then an electron osteotomy is the sensible option. Um So k can I ask you a question about the previous radiograph, please? Um This one. Yeah, it is really lovely. Er I can see just like two pins there. It's like anchors over the medial um media condyle. Yeah. So from um posterior to anterior. So these are called, um, twist offs. Um, basically acumed, make these tiny, little threaded wires but they, they, they call them screws and you, you, you, you put them in on a drill and you measure, you measure what you think, you know, you go with a little wire, measure it and, er, then you get out the, the actual pin that you put in, you drill in and then you snap it off and that's two twist stops. Oh, nice. So it's, yeah, it's like the headless compression screws, but just like a little bit, it's not headless compression screw. It's not a very pitch screws, it's just a wire, it's just a threaded wire wire all the way through and just you put it in and snap it off and that's, it just does a little bit of compression but not like headless compression. No. Yeah. Uh So we'll come on to that again in a bit. Um So, all right, once again, this was uh another case, it would be interesting to see what people might put for their answers on this one. I don't know if you got a, able to put up the poll again. Karem. Yeah. Doing it to see if uh thank you. This is just a me doing a, a little bit of analysis to see if people are evolving, adapting. So for this intraarticular displaced, probably uh y shape fracture. Well, actually it's more a T shape fracture um with a little bit of combination. Would you go for a non op para tri electro osteotomy, tricep split with paracaine or other? Right? Great. Any answers? Hey, green. Sorry, I was muted. Huh? Uh 25% para, 25% Ron ostomy. Uh It's changed now but it's even electron and to a lesser extent. OK. So, uh the para tri will be difficult to see the articular um fragments. And so in your reduction. So I wouldn't go for para tri, I would advocate either an electron osteotomy uh or the triceps split with the Para Lenon approach uh as shown in the other video. Now, matt will be able to see something here. This was one of the ones where I did use the suture technique. And so you can see, I did actually do an electron osteotomy uh back in the day and used the suture technique uh to get the, the joint together right decision for what to do with the nerves. So you must must, must, must identify the ulnar nerve on that medial aspect of the triceps and then decompress it from the medial intermuscular septum, the arcade Strothers, the medial epicondyle, the Li uh Osborne's ligament into the aponeurosis of FCU, the five pinch points of the cubital tunnel, whether you transpose it is selective depending upon whether there is subluxation after the de decompression of the nerve or whether it contacts the metal work, the radial nerve should be seen and not be seen under the plate that that's going on the lateral side. So you don't have to go necessarily looking for the radial nerve. But when you're putting that lateral plate on, make sure it isn't underneath there. So here we have the ulnar nerve and the tip is for whenever you're looking for a nerve in trauma, go to virgin territory. If you go to virgin territory, you're much more likely to find it with ease because it's gonna be where you would expect it to be. If you go to the area of trauma, it will be all blackened, bruised and indistinguishable from much of the other tissue. But then you trace it up and go into um as I said, Osborne's ligament FC aponeurosis. But what about the radial nerve? So a little tip here from AAA er former elbow group was er that if you put the patient's hands bread above the lateral epicondyle their hands breadth, then the radial nerve will be exiting laterally between brachioradialis and brachialis through the intermuscular septum. So that's another good tip for you. And then what about plating if you're gonna do a plating? What plating technique? Now, you've seen three sets of x-rays or four sets of x-rays where I've gone for a parallel plating. Oh sorry. Um Yeah, parallel plating. Whereas traditionally, we were taught um by uh mentors to use orthogonal or 90 degrees plating. So, a plate on the posterior lateral surface as well as on the medial side. But the, um, the randomized controlled trial in, and the literature shows that there's actually no difference. So, biomechanically it's been shown that the parallel plating, er, is, is stronger but that is also very much a, you know, a, um, basic science thing, not a clinical finding. And there's no difference in terms of, um, range of motion union at all between the two different techniques. So a few tips and tricks to, to kind of finish off, er, for orif, um, ahmed quite rightly identified. A couple of, er, threaded wires, er, I used for one of the cases. So that is something that I have really, um, got to like using for when we're reducing the fracture and holding there, even if it's only temporarily during the operation is to use a threaded wire. And, er, I always ask the staff to have these very fine, either 1.1 or 1.6 millimeter threaded wires. And now I've discovered that there's another company that makes 1.25 it doesn't matter what the size is, but the threaded wires are really powerful. They're like screws. Um, and so I use, I like to use those and then knowing which plate. Um, so if, as you can see on this x-ray, my plate here back in the early days would always curve round the, the, the medial Epicondyle, which I thought was, you know, really cool to wrap around it. And I would then have to transpose the, on the nerve. But then if you look, you can get different ones that are slightly shorter. And so, knowing your equipment is really useful, you can see the difference between the left and the right pictures here. Um, one has the shorter plate that doesn't go all the way around the medial condyle and so doesn't, er, affect the, the old nerve, whereas this one does. And then also you can see the difference between the distal screws as well. The, the diameter on the right is the traditional 3.5 millimeters. Here is only three millimeters. And so you've got another two millimeters of space in the er, I know two millimeters doesn't sound like a lot, but when you've got a lot of combination and a lot of metalwork going through there trying to get all these screws through there is very difficult. So, um using smaller screws is another tip and then just beware of the gap between, on, on either the, the front, the coronoid fossa or the back and the electron fossa because if your screws happen to go through there, then you're gonna stop either flexion or extension, depending on which parts come through. And then the real lesson that we've learned is that all the screws should go through the plate and as many fragments as possible as well as being long and interdigitate that gives it that strong Gothic arch. Um er er principles and er makes it much, much more stronger. This is how I set it up along with my colleague colleagues at Cambridge. So Lee Van Rensburg taught us this and you can see that the eye I comes in parallel to the better the patient is supine arm troph, a DH s trough for the arm coming from the other side and then the I I can come the same side and you pull it off and you can see that the I I isn't quite straight up and down. We've got it at an obliquity, er, so that we can actually visualize the whole of the, the upper, the upper arm and the humerus er without having to um do any funky maneuvers. So, oh, I didn't, I didn't um make a pole for this, but this one, I think, er just cutting to the chase is a different beast. This is a 70 year old, very low fracture and you can just tell that the p he's in many, many pieces and it, er, hopefully you can smell and taste that that bone is like eggshells. Um And here's if to prove it to you, here's a CT scan showing how many pieces it's really in. And so fixation is really, really difficult for these cases. And arthroplasty is another option as well as non operative for these more uh fragility fracture type patients. However, uh even though there is strong evidence in terms of a randomized controlled trial, if you actually read the evidence and you see that there's only 21 patients in each arm part of a pun. Um, it isn't that, er, you know, a very well set up the, the randomized control trial, not like the ones that have been conducted in, in the UK, the multicenter trials with massive numbers of patients. But it showed that there was a significant improvement in outcomes in a much quicker time period if you were to have an elbow arthroplasty, as opposed to an ori and I won't bore you that. But just to let you know that arthroplasty, if you look at this column here, the fourth column along the percentage of patients with a complication, um, whether it's a fixation or arthroplasty, the figures are really high and er, for complications. So I'm not sure which one is, er, is necessarily the better. Um, but definitely we've seen in the current day and times the rise of the elbow hemiarthroplasty. So you're all very, um, keen to get into theater and see and do a hip hemiarthroplasty while the elbow hemiarthroplasty is what? Um, shoulder and elbow, upper limb surgeons are all keen to do and we can see that, um, over the years, it's just a massive rise in the numbers and it's can, despite COVID, it's gonna increase even more. And here's just an example of the outcome of the, the patient after the nasty low supracondylar fracture bore, you with those or complications. Lots of complications. Everything in uh, surgery. Always think about the complications. Um, pick your winners. These patients, er, with the fragility fractures, lots of them just like the hips are gonna die. Unfortunately, if you look at the five year, um, rate of mortality in those patients that have had a, uh, elbow replacement and they, um, they get entered into the National Joint Registry. So we pick up whether they're still alive. You can see there's almost a 20% rate of death within five years, right? So lots of decisions and incisions. So you gotta decide, are you gonna go non operative, whether it's going to be early active mobilization? Whether when, if you go operative, which approach what you gonna do with the nerve, how are you going to fix it if you're gonna fix it? And then which type of arthroplasty? So you can see that Bono was a philosopher as well and er, I tell you to aspire to his er, or he is a philosopher still er, to aspire as well as being a rock star. He just wants to have fun just like all orthopedic surgeons and he wants to change the world. All right. Thank you for your attention. Thank you very much for that, Mister K. We just have one question from uh Eddie who's asking uh as distal humerus fracture lines are characteristic and related to the microarchitecture difference of distal humerus, the 3D mapping of distal humerus fractures, hopefully show the critical fracture lines and morphological features of distal humeral fractures to guide mandatory. Thank you, Audie. OK, let's break that uh question down. Hold on. So, OK, it dis humor factors line the characteristic and I'm ready to the M Yeah. Does CT scanning help plan the operation? Is that why have I interpreted that? Right, Doctor Edie. Um So yes, CT planning does help um especially when you are, it's the pattern recognition. So when you're starting off, you are less familiar with the uh the characteristic fracture lines. And so it will always be helpful to have AC T scan. But as you get, you know, and as you do more and more of these uh like any kind of uh uh operation um or or fracture that you see, then you will just start to recognize. Oh yeah. Uh from the x-rays. I bet you there's this, this, this, this fragment. So, does it help with pattern recognition? Yes, it does. Thank you very much. And I think I had a question as well, Mister Ky. Yeah. Uh Thank you, MS K for this presentation. It's really nice one. Just a quick question um regarding the role of the primary arthrodesis of these um distal com muted fracture where there is no enough bone stock to fix and doing arthroplasty in like small DG hitch where there's no experience the elbow surgeon to do it um in elderly patient has got poor ability and, and struggling with the cost is any role of doing primary in these cases, just like putting plate and removal the th surface, bend it and just fix. Ok. So if you're in a, I, I think the phrase is low to middle income country, um where access to arthroplasty is, is less then. N no, er, I don't think, er, er, I think, sorry, I think, yes. Um, the, er, Arth Arthrodesis is definitely an option. And how would you do the Arthrodesis? Um, it's just, um, get a broad, broad D CPA, very strong, try to get a long arm on the hum part, long arm on the other part, like 45 screws with good compression on both sides move or take a surface, bend it around 2030 degrees of flexion and just keep it simple and just close. Yeah. So, um, I think probably if you're in that situation where you don't have access to the elbow arthroplasty, then you would, you probably treat them like what's known as a bag of bones. So it's that decision one, treat it non operatively and just get them moving. Yeah. Or you keep, keep them in the plaster for a couple of weeks and then get them moving. But, um, so that would be probably decision number one, if at that later date they've gone on to a nonunion and you still can't, you know, you can't fix it, then you go to the artis. Oh, yeah. Yeah. So you keep it as a second option rather than just primarily. So if the is not suitable for art, so there's no enough access to this, then just go with conservative management. If it fails and ends with non union and like floating up, then we do this as a backup plan. Yeah. Ok. So there is, you know, significant um um increase you saw that the graph 20 years ago of fragility fractures distal humerus. And so we're seeing more and more patients because they're living longer, we're seeing more and more fragility fractures, distal humerus, intraarticular, extraarticular. Um you know that we are treating non operatively. Ok. And, and their patients do well and actually probably, you know, lots of them actually either heal or they, or they die before. Um there's any consequence, er, and the key is to get them mobilizing um sooner rather than later. Um because what they need to do is be able to weight, bear through it on their pulpit and frame. So if you just get them a removable back slab um from the plaster room designed so that they can take it on and off, er, and, and they can lean on their crutches frame, et cetera. So that's er, that was, er, answer number one, a Corolla, a coronary from your question is that if patients are being um in the UK, if you see these kind of patients and you're thinking, oh, they're fit enough for an elbow replacement, but I don't have it in my hospital. Yeah. Yeah, definitely. Transfer. So, it's a grift basically. So, get it right. First time transfer to the original unit where there is an elbow surgeon and pulling of the surgeon and the implants where you can have it. Correct. With high volume surgeon. High volume unit. Yeah. Yes. And high volume for elbow replacement is one a month. Oh yeah. Oh, ok. That's not, not too bad. No, I apologize. I think this is all the time we have. I'm sorry to have to interrupt uh Mister K. Thank you very much for your time. Thank everybody for attending and uh we will have a week off next week and hopefully we'll be back with elbow and forearm fractures uh and femur fractures over the next two weeks. Thank you very much, Mr for your time. Thank you and Tom, Doctor Adi, there will be more of these that um er Kareem has expertly organized so he to answer those uh questions because they're different, different topics and in nor for postop er post traumatic arthri. That's a huge topic as well that we can talk about offline. Thank you very much, everybody. Thank you, Mister Ng. Take care. Bye. Thank you mister. Thanks. Thank you.