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So we're just going to have a quick roundup session. And Ben's gonna do a few cases where we, uh we just have a chat about it. It's just some interesting stuff. Um, he's already done some with some of the guys next door. So we're gonna do the ones that you haven't done. So it's a bit more. Uh, because otherwise you'll know the answers if you've done bed sessions. So, uh, yeah, um, should we just you want to just whack a case up, and then we'll just throw it to the floor? We're gonna do this as this is the morning trauma meeting. Okay, So, uh, yeah, a lot of 20. And these get systemically harder as it goes on. It's been so for those of you next door. Ambien fishermen, trauma surgeon who weren't next door trauma trauma surgeon in Liverpool. Uh, major trauma, limb recon. And so this is Daniel. He was on a motorbike coming out there. He was cycling by motor biking, buying a white van. Hit him. Um, he's got this, uh, open femoral fracture. Um, he's in resource. He's, um hemodynamically stable. Um, it appears to be an isolated injury. Um, right. Uh, all of us sat there looking at his phone. So he gets it. I'm afraid so. Uh um. So, what's what's going on? Kendrick? Yeah, it is open. So that's the lateral of his knee when he was super in resource. Yeah. What's the other concern if he's got high image injury and a smashed femoral shaft fracture? 80. Less approach, from my perspective, is hemodynamically stable. Isolated injury. It's open, but it's a thermal shaft fracture. And it's high energy. High energy femoral shaft fracture. We're worried about hemorrhage in the first instance. Uh, it's a hemorrhage in the first instances, making sure that that's controlled. Uh, then, uh, soft tissue, um, element of the open fracture would be, um, what else would be concerned about any other image you want to see? Yeah. And you said AP Knee, and someone said, Yeah, So why do we want a pelvic extra? I think it's 10% chance of a concomitant femoral neck fracture. Perfectly trauma. You passed your driver. Can you go to the next slide? What? Can I move it on? So there you go. All right. So what do you see? So this is classic exam fodder for the trauma of either. So what you gonna do? How? You're in the trauma meeting. The Fifth staff has sat next to you wanting to know what kit you want. How you're going to position the patient. What are you going to do? Well, come come to you now, because you've same like yeah, it's lateral. Uh, a couple schools of thoughts essentially need to You need to fix the shaft and the neck. Um, the method that I would use would be to focus on the shaft fracture first to give me something to put traction on to do a D. H s higher up. So I do a retrograde nail of the femoral shaft followed by DHS and across the streams as it were at the top to make sure the DHS come again. What do you think about popping a wire across the neck of femur before, as you do in the retrograde nail daddy Daddy to I mean, you could you could post put a wire in. The position is in to prevent you from displacing it any further. Do you think that's going to help? Probably not. Why not? It's going to be a three meal wire. It's not how much energy is gone through his femur to create the femoral chef fracture in the neck fracture a metric ton. Yeah, exactly. So you're not going to be able to recreate that in theater whilst you're retrograde, retrograde nail in the femur, are you? And unfortunately, if his hips not going to go into, you know he's going to get a vascular necrosis. The dye has already been cast. All right, so that's a really good answer. And again, your head and we talked before about scoring an example. Your sixes. Sevens. Easy now. All right, So Okay. So what? That's way up. Yeah. Look at that angle of the hip fracture. You see, it's actually a big massive there. Yeah, uh, is the pope is the point of work. What can you say at the top? Good, bad, indifferent. Powell's classification bad. Yeah. So what's the risk of non union? Yeah, So I can't remember what it is in his paper. Stephen, you know, it's about 80%. What about his asking? The crosis more so as you go more vertical yet heading into the the higher echelon. So 80 90%. So as per this man at the front, I said to this guy Postoperatively pretty sure we can get your femur to heal. That's not a problem. The main issue is going to be whether we can get your hip right. OK, um, some bone fell out when we were doing the the debridement of his femur. I don't work in Bristol, so I didn't put it back in again. So we shortened him acutely. Um, and again that said to him, I can give you a length back. Don't worry about it. And he wasn't bothered. Um, so that's the situation. Anyone have done anything different with the neck of femur fracture? Oliver's sort of not convinced. So we went belt and braces It. Fortunately, it was I think I would have done. And I know there's a school of thought. Now it's going away from saying you need to get these right, but I still think you do. I think that's the thing. I think when you when you're treating an inter capital fracture in, a young patient has to be back on, okay, it's so insane, and that's absolutely pretty good. But a lot of the time you don't get just arguing whether it actually needs to be an anatomical cat. What might be the advantages of so depressed capsule Candida? Uh, probably about reduction. You could put a plate on the medial culture. Nervous. Been up to here, right? Right. So yeah, I should And and that's why I went with 33 wires and the DHS took the Took the obviously over ring for the dead for the luxury for the DHS cut, there was two wives and thought there actually in a reasonable position to put two can delighted screws. If he was 50 I would probably still done the same. I think I would too, if this wasn't Yeah, no. So take a seat, and then you might say you might go to you again. You were next door and we were discussing it. So though we've mentioned the calcar plate, I didn't I didn't think I needed it here, and I don't want to open again. And it was seven o'clock at night, so I definitely don't want to do it. And the those the case that we saw the completely smashed up one. Those cannulated screws were in lieu of a calcar plate. So that was as close to the calcar as I could get it blind. Um, and then we obviously use those screws as a cantilever through the plate. Anyone heard of any research? What? Your options? Okay. Example. Thanks. Cool consolation Any any any any large multi center. The international randomized control trials. Did faith say that angle stable implants are better, But that was elderly patient, not young. Okay, so there are some biomechanical studies that suggest that CALCAR plate and the DHS with a D rotation where wherever they want to do it are actually more stable than others. For the same reason, Steve described in the sense that the ice cream cones not going to fall off the cone, the ice cream is not to fall off the come Sorry, right. So he ends up right. That is a bit short. So we offered him length thing, which he got. That's the paper about, but so because he had a precise nail and he's one of my patient's. He ended up in prison. So both my precise nails are in it. That's not from the get go. No. So that was an exchange. So that the picture on the left is retrograde femur as it's healing with these leg length discrepancy. The picture second in is from the left is the precise nail. So you can see we've added an extra couple of blockers. They're really just to prevent That's reverse planning. If you believe that sort of stuff yet. Yeah, and you wouldn't do. Probably because they're designed partly because the strength. So if you're if you're not aware, it's made out of this is detainee. Um so they did bring out the strides Steel, stainless steel. And there are a lot of issues without rheumatology issues, and all the rest of it the locking bolts and they only provide rotational stability. Admittedly, but you can see they're only threaded on one side, so they probably wouldn't give you enough rotational stability in a in a cute, fragile scenario. Um, so you may end up with a sort of a gun. A pain, not a miserable nonunion. So I would never use a precise as a an acute device. No. You want you want to make sure. I mean, this is you're talking. Yeah, and equally you don't want to be messing around with this because this is 12,000 lbs worth of kit that your chief executives going to string you up for if your weight. That's right now. So that's really it's actually really very difficult to do that, Um, but yes, it's possible. But it's for me. It's two devices, and it's the femur first and the proximal femur. Second, for the reasons that we discussed here, because you want to get something that you can, you want to get some hold distantly so you can then put it on attraction table. You can then think about your open reductions. If you've got no stability down below and you're trying to do an open reduction, it's going to be all over the place. And the way to do it if you're doing an open reduction is a couple of 3.22 point eight millimeter wise. If you've got threaded 3.2, so they're really good, use them as joysticks. Click it in, fire a wire up and then put your car car plate on It sounds horrendous, but it actually makes it a little bit more straightforward. The fact of the matter is, though you can't do that on your own, you need a couple of people with you who are fairly savvy and know what you're trying to achieve. So it's not. This isn't enough. This isn't one for the middle of the night When the general surgical scrubber is is sort of open, the kitten doesn't really know what she's looking at. So the, uh, the femoral shaft open femur makes a little bit more complicated. But we had a session at 40 s a few years ago with a chap called Mess who works in Bristol. Nothing to do with that. But we looked at the things that probably make a difference in terms of inter capsule fractures and young people. And the sort of things that probably make the difference are good reduction in a stable fixation. Okay, so having it done by someone who knows what they're doing and not doing these in the middle of the night, So the whole six hours to theater? No. Okay, because you're more likely just to bugger up by doing that than doing it properly during the day. It's like all of these things isn't it's like open fractures. We don't take the theater in the middle of the night because, well, bugger them up. So do it. Unless it's an absolute emergency during the daytime. The other thing was the capsulotomy, and we don't think that really makes a difference either. So if you're getting an open reduction, you will do a capsulotomy because you have to sort of, but not the whole thing. So you just sort of do just at the neck like the fracture hematoma. But it probably doesn't. Do you understand that there's a There's a sort of vogue about releasing the fracture hematoma to potentially take some pressure off the head, but it's probably one of these things that was dreamt up by Professor X, Y and Z in 1932. Mm, maybe a little bit. But I don't have to even do that now anyway. Yeah, it's gonna be torn apart. So it's kind of like done you capture tomorrow. Reason is displaced. Just it's because it wasn't touring it. So maybe then four of, uh, it was impacted. Or can you think it's the slide 62 by then? Right? So this is Charlotte. She is in her early forties. She was treated in a trauma Center ST elsewhere. Her history is that she was She'd been out for a ride on a horse. She was putting horseback in the stable. The horse got skits by can't quite remember what it was. But he got skits. Her foot was inadvertently caught in the rains, and it dragged the two miles down the road for her to sustain an open tibial fracture. And she lost a quite significant amount of the buttock on the left side as well. So she comes to our clinic and can Is she happy or unhappy? Yeah. What do you think happens when she stands on that leg? We can actually see it bend. So she stands and you can actually see it, then. I mean, yeah. I mean, the entry points wrong. They've done some crazy lateral to medial. Look at the bottom. It's distracted. You question the debridement trick? One burning minus is now nine months down the line. And so this is actually no, this is immediate. Immediately post. Uh, that's when she arrives in clinic with the bending leg. And that's in theater when we weighed it, just to see if it how stable things were. So given that history. What you're concerned about? Yeah, Yeah. Infection, infection and more infection. So what's your surgical strategy? What you gonna do? I've given you a clue, because then, yeah, take the nail out. Yeah. Then then what you gonna do? Uh, ceremony. Okay, uh, so removing the implant at the beginning, Uh, you can put a temporary external fixator, or you can actually manage this with just, uh, an external fixation. Yeah. So what's going to determine whether you're going to use external fixation or internal fixation? If there's an infection? If it's clearly infected, you would do It's definitely infected. Yeah, well, no, it isn't, actually. So what you said is a potential so you could use an antibiotic coated nail. Protect. You can make your own antibiotic coated. Yeah. You probably wouldn't want to do both. But you can. You can fill the canal with with antibiotics in whatever, whatever medium you want to use stimulants, merriment or whatever. You could even put a new nail down into a slurry of stimulant. But there's one thing that's probably going to determine it for you. And what you think that might be a combination of soft tissue? Yes, But what we know it's infected. So what's what Do we really want to know? Yeah. So what? What do you think? I've not done one yet, but we probably will do. At some stage. I've swapped slightly dodgy nails out for protect. Certainly. Um, but what do you think might determine whether we go for internal fixation with a nail versus external fixation? Depend on what? Bacteria are growing. Difficult question protest. Very good answer. Very good answer. Potentially resistant. So you want to know what it is? He might even biopsy it. We've gotten possibly could have argued we could have a chance to biopsy the fact the the region of the fracture related infection there and work out exactly what the books were. But they're determined. It's probably not a fair question to ask is Yeah. Yeah, Well, you could You could still nail it at length and masculine and all that sort of stuff, but we knew that we're gonna have to reflect some bones so that nailing wasn't an option. But if the if the bone loss isn't too bad, you can still think about it. So you want to know whether it's grand positive or gram negative because they're they're going to behave completely differently. And you're exactly right. Slow, glowing, etcetera, etcetera. We know we can treat gram positives fairly aggressively and reliably with antibiotics gram negatives, depending on what they look like, whether their escape, pathogens or not, is whether you're going to be able to find a good a good antimicrobial to get on top of them. She actually grew klebsiella good, bad or ugly. Okay, very ugly. So there's some good points there. And there's two main things from that is Does infected bone heal? Does it sometimes So infected bone will heal in the presence of stable fixation. Okay, What doesn't heal? Dead bone. Okay, so that's with this when you look at that and you think, how much of this is dead? Okay, Because that dead bone, if there's a dead big section of dead bone there, it doesn't matter what you do with it. It's never going to heal. Okay? So you can put another nail down that you can put whatever you want frame on that. But if you've got dead bone to dead bone, it's alive. It'll heal. But it's dead. It won't. So that's what you need to work out. And that's whether you might have to, just as you say, Take it a big section of it. So So it's, uh we did exactly that. So we resected and then we put the stimulant and you can see there the block of stimulant in the whole to manage the dead space. That's really spoiled it. I manage the dead space, and then we use the fancy gun thing because we so the rep was wanting to use it. But what we would normally do is actually just use a chest drain, stick a chest drain all the way down, and then fill retrograde antegrade retrograde antegrade with with the slurry of stimulant from a bladder syringe of you. So yeah, we over reamed. We've gone from using standard reamers to rear too, uh, to use for those of you haven't seen ria. It's something that Cynthia's make is actually really fantastic tool in this situation. Um, rear to you can change the rema heads. You can change room heads on Rima one on rear one. But don't tell anyone. Um, you just need a decent pair of cockers and a certain degree of determination. That's not euphemism. Yeah, exactly, uh, but real to you can change the rema heads. What it does is sucks and washes at the same time. So you don't get that same septic shower that you'd expect when we're doing these, especially femurs were often more than the cyst that they can get sick when we start to ovary. And we found so far with rear to that we haven't seen that. And that's something we were talking to Cynthia's about actually looking at. It's interesting with Rhea that the one thing that was invented for is the thing it doesn't work. So really was invented to cool down the bone and reduce, you know, emboli and all that kind of stuff, and it doesn't do that. But what's great for is clear infection and taking bone graft, and that's pretty much what I use it for. My practice. Great Bone Graft Harvester. It's much better than Crest morbidity. It's massively lower. Good. So we're at a situation now, so we're in a decision making really a proximal femur. A proximal tibia story is a bit ropey. She's had locking screws in there big holes where they were, um, So we're thinking we have to bone transport now, but we're thinking about sites for Osteotomy. Does anyone know any one any particular ideas about that or not? Has anyone done any limb reconstruction? Go on. Why is that? No. Why? Why Why? Why does it regenerate faster? Why is it why is it regenerating more predictably? No, let's blitz supply. So if you think about blood supply to the bone, you've got endosteal periosteal. And then there's quite a rich supply, usually at the meta meta diaphyseal junction. Um so that's why we tend to go proximal, Because again, the regenerating the tibia is much more reliable. Are the river options for your osteotomy though? Yes, you You can actually do it anywhere. And I've got cases where we've done diaphyseal osteotomies and they still produce regenerate. It just happens in a slightly slower time frame, and it is slightly less predictable. So what do you think? Here. We're gonna go proximal distal. Yeah, And you saw the frame anyway, so that's exactly what we did. So this is just just before the docking site procedure. So this lost your to me retrograde transport. She's docked really nicely. So we tend to pre build my transport frames just because it's a little bit easier and you can make straight frame straight bone. Hopefully, um, and we always do docking site procedures. In Liverpool, we do quite a lot of bone transport. We do quite a lot of frames. Uh, we don't just do frames or hasten to add, but we found that docking sites take a long time to heal. If you don't go in and take the sort soon to pseudo meniscus out refresh. Everything can then put either their bone graft or something else and we tend not to use their bone graft. Now we tend to use induct us. Which is B M P three costs a lot of money, but it works very well. Any one. Any questions specifically about that? Do you nail them afterwards? Do we nail them afterwards? No. Um, we don't You just keeping me a favor. Keep in the frame. Well, you say that. I mean, I know that we've done that one before you say that you can do plates after length. I would prefer to do play after length thing in the nail. Yeah, there is a theoretical risk of, um intraneural infection converting X fix into into internal fixation. If you're Nottingham, you go through this process and very soon after the docking you get mailed. I'm not sure necessarily agree with that. So the other thing about that is the concept of periosteal rebound. But if you've heard of that, OK, so what happens with that is when you when you perform distraction, osteogenesis, okay, and you've lengthened something on average, it depends on the patient, the amount of length thing you double the time. And that's probably how long it'll take to solidify. So if you take the frame off, the reason that plating works is because you can put screws into the transport segment. Okay, If you nail it, you've actually just got transport segment. That's just gonna sitting there with nothing attached to it. And what can happen is if the regenerate hasn't hasn't fully healed, is that it can actually come back down again. Okay, so that can that can happen. I've seen it like three or four times now, certainly the first great times on fellowship. When I said that, that would put the frame on that and then 14 operations later when they had a frame on that. This is a classic ger fift. Yeah, there's a classic. Get it right. First time. Okay. It may or may not have been debrided properly. We don't know. Open fractures get infected, right? The best best treatment. Some of them still get infected, and that's fine. But this is a classic case for gift plastics consultants and orthopedics consultants. Present at the first to bribe mint, all infected tissue. And any dead bone at the fracture count comes out okay. And then definitive soft tissue government, 72 hours fixation of how you want it. If you look at how that nails done as has been pointed out, okay, spend some time getting the entry point, right? Okay. Get the entry point right. Get your guide wire center in the bottom of the tibia. Get the nail the right size. Okay. And then there's a lot of random locking screws going on there, and actually, you don't need to do that. I don't know if any. Has anyone been shown when they do a standard nail to put these really proximal transverse lock it? Sort of a leaky locking screws in So you don't need to do that. And actually the purchase on that because it's going through metaphyseal bone and because it's only that much bone at the front because the nails anterior is actually not as good. Those nails. Those screws are designed for people who want to nail very proximal fractures. Okay, if you've got a mid shaft fracture, use the medial collateral screws. Two screws, Medial collateral. Approximately two screws. Distally Make it easy. Don't make it complicated, and it will be fine. The other problem with those transverse screws is that they go, particularly the one that's going towards medial. Collateral is going straight towards the junction between the tibia and fibula. And when you go out the back there, what's sitting there? Oh, it's the traffic ation of the artery. Okay, so you don't need to use those screws. Okay? If you're doing a very distal fracture, you might want to put a third screw a toupee. If you're doing very proximal fractures, you probably just plate it. But for this fracture, you didn't need it. Okay, so that's that one. Anyone got any questions about that? Yes. So we'd open it up. Um, take it take any gristle we can get to, um, petal, the bone ends. Um, get it to make sure it's all bleeding nicely. Um, think in doctors comes on the membrane, and we tend to split it into three cigars. Try and get one around the back, one or two around the back and one down the down the lateral side, and that seems to work for us. When do we do it? Um, as around the time that we get to document tend to leave them a couple of mills shy so we can get in and take the gristle out and then compress it Interesting. No, no. Everyone can maybe do a little bit more. Usually it's fine. The other thing with that is, remember, you can go anywhere around the Tibby you want, so if you're if you've transported, you've got horrible soft tissue over the anterior part of the tibia and going back, it's actually quite a safe zone. To go in posterolaterally to TV, you can get at least three quarters of the way up it. Absolutely. You point about nailing. I mean, yeah, people do it. And as Steve said, it's not without complication, not without complication putting frames on, there's no doubt, and you know, there's various people who would say the tibia needs to be nailed and all the rest of it, and that's it's really, really good bravado, but you've got to think of. We've got a couple of slides at the start of this talk. The others were party, too. In certain scenarios went really high energy injury when the blood supply has been compromised that the fracture ends. You know the nail might be what you want to do, but actually, is it the right thing to do? So a good orthopedic surgeon can manage the bone. But Masturah orthopedic surgeon recognizes the soft tissues have been checked and the blood supply has been affected. So you might think that intramedullary named minimally invasive. But it isn't because you're having to ream the Intramedullary Canal and you haven't you're taking the industrial would supply away if you take the industrial blood supply, the periosteum at the fracture sites and even in this situation, which has been open, high energy injury is going to be affected. So you're rendering that bit of bone probably bloodless, potentially for somewhere between eight and 12 weeks, depending on which animals good as you look at. So you have to be really careful. And that's where minimally invasive techniques can you plate it minimally invasively. Can you put a frame on what you do? So it's the art of trauma. Surgery isn't just banging a nail down. It's actually making the right decision based in. And that's what gift is for these scenarios. And there's a lot of bravado about it, isn't there? Even within this society, and especially in terms of some people who work in the Southwest about how they manage these and you know they're welcome to that. But in my in my hands, you know, I'm sorry to upset anyone who works in North Bristol, but in my hands, that's what we're doing. He says he's sorry, but yeah, but equally Steve. Steve Mitchell is a very good friend of mine, and I've seen some of the things that he's had to do. I'm based on the retention of bone and all the rest of it. So anyway, we got time for one more or, um, what do you think give it? Uh, Okay, well, we'll do one more and then we'll wrap up. How much do you want it to be like? I want to go to the pub. Stop it, Steve. Uh, well, let's take that one and take that one to heart then. So can we go to 107 thinking about it? Uh, we're just dwelling on how good that one. Right. So there's a couple of things on this slide. Um, You wanna nail talk me through this? This is Warren, um, late twenties. Used to play a bit of football for Manchester United's reserve team or something like that. Upset someone When, um, he was walking across the road in Stockport and got run over, um, by the said person who turned around, came back and ran him over. So high or low? Low energy, high allergy. Yeah. What? You're expecting the soft tissues to be, like, terrible. Yeah. What do you think of the X weeks? Horrible needs to be bridging bridging over the nurses segmental to be on fibula factor approximately. Yeah. I mean, that pins got it. Gone somewhere that it shouldn't have gone. I mean, you think if you're going to do that, you may as well just go all the way through the back just to find out what? Just so you can see the other end, you know? Look, there's no infection on it. So, technically, a few issues. What do people filling think about these pink plants? What do you think? I think yeah. So, So dry. And, uh um does a lot of work with Ortho fix prior to his retirement. So galaxy, um he basically says he we hate these pink lamps in Liverpool and we would tend to avoid using them all the time. But he said when he was designing galaxy with Ortho fix that they they insisted they had to put pin clamps on because it was commercially. That's what people wanted. Uh, but they don't let you get near near far. Far fixation, Jimmy. So the whole thing about an ex fixes in the near far, far and what people will do, particularly in distal tibial fractures, is put two pins almost right up at the tibial tuberosity and then build a delta like that. Actually that really unstable. And you may as well put a quad frame on. If you're gonna do that, it's been going for a long time Everyone says you're near far, far, blah, blah. Yeah, because they don't get taught properly in certain places. How many experts is you have to do before you can C c t five now, is it? But your head, it seems easier. All right. Well, what an event shows you exactly. How far could the next minute it seems easier. Do it without it. It's really easy. Kind of just It's a lot of things deciding you, and this will be breed. You're in the frame. Mhm. So if you work in that, you need Yeah, you probably are using for six. Kind of. Yeah, I I I don't know. I mean, so I I do use them for ankles. So if you're putting a standard spanning and that's kind of what they're for, right, if you're putting a standard spanning expects across an ankle, you've got that on. You can put the two pins down to the den and pin, and that's fine. But I don't really see why you would use them anywhere else. Uh, probably. Yeah. Thanks very much. Like the French guy gets the most unstated ankle to be produced, held very few someone else put the bars. And, uh, did you get to use those little different things from different treatments? I've It has. You're So what's to specialize in One way? If you want to do it properly, try and avoid using those prints. Then you can always go back to it after because it's an easier technique. Stable vestry definitely. Did you get to count those little finger frames that the hand surgeons do for your ex fixes as well? Awesome. I thought you said that was like, What? What? Suzuki? Yeah. So going on, Oliver. What you're thinking. What? What? You What? You made your concerns here about your next next move. So I want to make sure he's new vascular intact. No reversal intact. Uh, so, yeah, make sure there's no signs of a compartment syndrome. Know compartment syndrome. Uh, compartments are surprisingly. Stuff is swollen doing their own bits. Compartments are surprisingly stuff. The next stability of the construct. I'd want to bridging knee fixator when you say bridge. What do you mean? So we'd have to bridge the joint above and below. They probably don't actually. So they've tried to do something which is reasonable, so they if you again. We mentioned it next door. So if you if you want to put stable experts on, you need to know, um, safe corridors. Um, whether that be, if you're doing an fancy Elizabeth frame or you're doing a simple mono lateral frame say simple my lateral frame. So there's a good paper by Darren again, um, 2007, in strategies of trauma and then reconstruction, where he splits the bone into the segment one, which is from joint line to tibial tuberosity. Essentially, uh, the midshaft and then the bottom bit. So those two convergent pins in the top, uh, remedial to posterior lateral will give you actually surprisingly good hold, which means that you don't necessarily need to have to go cross knee. So if you ever see, um, on the Ortho fix lRS there's something called t gosh, which is essentially how that wants you to put your pins. All right, so that's not that's not a but you can improve the stability by but But take expects aside, what's your plan in terms of surgical fixation? Hear what you're gonna do next? I think I think this would, um no, we probably. But the problem was He was taken to some of ST elsewhere first and then referred to us. Um, because they felt they couldn't manage it, so probably wouldn't have xx if I mean, if it was okay, the they did. And we sort of said you put an x on, but do it like this. They didn't do that. And then, um, I think it's difficult to say without seeing the preoperative films because particularly if you look at that, I think that you know, the mid shaft. But when you look at that shearing force up the top there, you might find that just leaving that in the cast actually creates quite a bit of shortening and may threaten this office is I don't think I don't think decision to put an X fix on an unreasonable one. And you had to come 50 miles to obviously yeah, to have that swapped out. I like downs, but I would hate him. Can you nail that? What are your concerns about nailing that concerns Maybe the segmental nature, particularly the end also the fracture line through the middle facil point as well? Yes. So the inter calorie segments got a break in it. But what is the other issue that makes that bear in mind? It's segmental. Even if they didn't have the distal fracture, what's the issue with the proximal fracture? It's not just that there's not a lot of room. What's pulling on that from the top? What's pulling on the other? Yeah, so? So let's put it another way. If you didn't have the distal fracture and just the proximal fracture, did you nail it? Why bloody hard, difficult that that that that that proximal is really difficult to know. And you could if you were honestly, if you were extreme, Naylor. You could definitely do this. You could do it. You probably maybe do what? Yeah, maybe. But this goes back to what we're talking about about the first case with the neck shaft and having two separate fracture in two separate ones. It's actually very difficult to treat these two fractures with single device. Yeah, because invariably what happens is you'll get one really good and the other one we shit. And so that's That's my experience of these anyway. And I really tend to agree with that. So, having tried to do these with nails, try to do them with plates. Try to do them with frames. You always get one looking really nice and you get another which just if only we've done that, and they're really difficult to treat with straight. All is rough frames. You need lots of hinges. You need lots of chronical washers, etcetera, etcetera and probably talking about things that some of you've never even contemplated. But that's gets really difficult. So what device do you think? If we're not gonna nail it, you could nail it. You could nail it. But if we're not gonna nail it, what? We're going to use a plate you could use. But the again, the soft tissues are a bit so you could do, um, IPO plate with expects assisted. But that's that's difficult in this situation, especially to get both fractures, and you're probably gonna need to at least two plates. So you're gonna do a lot of soft tissue dissection circular frame. But I've said to you a straight liver is not going to be easy. So yes, a hex pod, because that's that's the thing with the frame, you can actually have a frame that is to separate frames that are treating two separate fractures. So that's the advantage of doing that. Absolutely. And this is and that's that's That's what we went for here. So approximately a good ring with we've managed to get three wires and a half pit, uh, and that we've used one of those, uh, anterior Meador to posterolateral pins bone in mind Exactly what Steve say in terms of you got to be really careful where you're putting your drill because there's some nasty clockwork at the back of it. I would tend to with a proximal fracture, actually use what we call slavering. So you have a working when it's got all your fixation on, and then a slavering, which allows you to attract you attach your struts. But this was getting really complicated, and we want to avoid that, and we use the half been because I try to avoid half pins. They changed the even in hex a pot to try and avoid half pins because they changed the biomechanics of your frame quite significantly and the ice, a trophy and all the rest of it. But that's a that's a different talk, so we were able to get that one into that position and you need a bit of tweaking. And it's always the proximal ones that are really difficult to get to a line. And it's always those ones that are going to give you any problems in the future. Whereas the distal one, we managed to sort of click with the struts and then drop um, threaded Robson. So we had. It was essentially a double start tax apart, and we could have kept it double stat. But we might try to make it less complicated by doing acute reduction of one of them, which we managed to achieve. Have you done anything different? No, I think I don't. I think that the one thing that I've found with and I think those threaded rods are really vital to get into that hip fracture because if you look at the heck spot, so if you ever seen a TSF when it moves, it kind of does that. Okay, and with that fracture, it's gonna sheer it, so I would get it reduced and potentially put some threaded rods in with some chronicle washes as soon as possible, or let it heal a little bit. And then you could put that you. Actually, once the soft tissues have all settled, then you can augment that with some percutaneous screws across the public, witty of the fracture. Allah, Mr. Handley, Um, but you may not need to do that. So that's what we ended up with a couple of weeks down the line. So we've managed to reduce it really quite nicely in both sagittal and Corona planes. We would tend to take out as Steve's intimated. We tend to take out the struts on the bit that we're using that spot off and change them out for Fred Rods fairly soon, or even just dropped to threaded rubs in to make it a lot different. I do that because I'm lazy. Yeah, I can't be bothered taking all the struts off. And also it's cheaper because you can just put two struts in and you've already spent, like, you know what, 3, 300 quid a pop for the struts? Yeah, not quite that 100 quid. I mean, that's an expensive frame their way. Yeah, but it's cheaper than treating an infected malunion nonunion case. Yeah, very much so. And that's where he ended up. Yeah, and he's back to exercise, and he's doing all the things he wants to do. And you know, it's a whole thing about the left and making those correct decisions early. And if we just finish off with 131 what active? Something a bit like that, but not quite like that. So we said conversion pins, something to hold it and then a couple of pins in the difficult bit. If you actually look at the position of the pins apart from the one that's right through the back position of the pins are actually okay. It's just everything else. So you could probably have if you wanted to. You could have just taken all the all the everything off, left the pins in and put a new frame on. Just made it better. It just needed it. Essentially needed some soft tissue tension that it just hadn't been. There wasn't enough distraction if I go so for those of you aren't from Liverpool, there's none of you. So there is a swear word in this. You might not necessarily pick up local vernacular. Obviously, this is this is Hannibal Smith, but Steve stung coz on Twitter, and he produces a little tip talks, essentially taking the piss in scales. Um, so it's fucking boss. When a plan comes together, my success. But ultimately, when you go into these situations, you got to go with Plan A You got to go with Plan B. You got to go with plan. See, um, if you get to the end of plan A and everything sorted, then happy days. But, you know, it's the whole six piece scenario. So prior preparation prevents piss, poor performance. So you've got to think about these, uh, things and you've got to just try and get a plan together. You can't go into these cold. And don't be afraid to phone a friend. You think it needs a frame and you will do frames call. Somebody does. Uh huh. Any questions? Sports desires? Yeah, I think so. So thanks. Thank you very much. Thank you. Very well,