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OK. So there's a great thing about elbow instability is there is a big spectrum to the instability from the simple dislocation, which by technique uh definition is one that's a soft ish injury, but no bony injury to the complex dislocation where there's one with a bony injury. So if you see an X ray or a scan that shows you a bony injury to win, I win a chicken dinner, you can say it's a complex dislocation, but sometimes you'll get these severe soft tissue dislocations. So they've ripped the ligaments and the common extensor and common flex origins off that they're not stable and safe to move. Because we know with all elbow instability, the treatment for elbow instability is to move the elbow, the elbow becomes more stable as you move it as you get it going. Um And the trick is knowing which one of these is a simple soft tissue or which is a severe soft tissue. And my differentiator there is whether it's stable and congruent within the last 30 degrees. In other words, if you screen it on your lateral radiograph, if you can see that that elbow is stable in congruent within the last 30 degrees, you can simply get it moving because that's what elbows want, they want to move. Uh Ben, what is the Horry cycle? Are you there? He is there? Whether he can get his David? Oh, here he is. Ok. What? And we can't quite hear you at the minute, Ben. One minute he says, alright, David. David, what is the hole? Uh uh go on David um disruption of the elbow from uh lateral to medial uh that leads to elbow dislocation. Yeah. So we start on the lateral side and we end up with a posterolateral dislocation of the elbow. This is skater boy comes down, lands on his arm and he gets the dimpling laterally. So that elbow is dislocated, posterolateral classic posterolateral dislocation. Did that follow the Horry cycle? You David? Uh I think so I think slight disrupted first. You think the lateral side failed first? OK. OK. So uh no, no, he puts his hands out and he has a supinated hand and pure valgus on his elbow. I would suggest that the structures that come under tension first are the medial structures. So which are um so there's the medial lateral ligament. Mhm Complex. Um And what separates a simple dislocation from one of those severe soft tissue dislocations? In other words, which is one is safe to move and which is one that is not safe to move. Ba you're getting close to your microphone there. Keep it on. Yeah. Oh, that doesn't sound good. Then unfortunately, you close to your microphone. This is wrestler boy, watch him. He puts his hand out and down. It goes, it pops. You see it puts a valgus force across his elbow and injures the elbow. Now, classically, we taught the H cycle that everything starts on the lateral side, starts on the lateral collateral ligament comes across the ante capsule and then exits on the medial side. What we've seen in these two videos is that it's looks like it's starting on the medial side. And that's what Schreiber told us. He looked at like a 60 youtube videos of people dislocating their elbows and they were in valgus uh sorry in super, but most of them had a valgus force and they dislocated their elbows and the injury started on the medial side. But there, when I asked you, I've given you a bit of time to think about it. What separates a simple dislocation, simple soft tissue, one that's safe and stable to move from a severe soft tissue dislocation. One that's not potentially safe to move that one that you can't just get going. What normally differentiates the two um is it the involvement of the primary um or the primary and secondary stabilizers are all gone? Yes, the secondary stabilizers. So the primary stabilizers are the are bony congruent. So the bones, the radial head and the uh coronoid and the uh uh congruent elbow is. So, and then the ligaments are again part of our primary stabilizers. That's the middle collateral ligament and lateral collateral ligament complex. But when we start involving the secondary stabilizers, the common flex origin, the common stents origin, brachialis and biceps, then that's the one where the elbow is not stable and safe enough to move. That's the one that might just suddenly fall out. So when we talk about complex instability, which is what I'm gonna be talking about today is it's the sedition of this severe soft tissue injury. Um And that normally it means involving common sex origin, common extens origin. And although Sean first taught us the H cycle that everything starts on the lateral side and goes across to the medial side. Streiber in his online youtube video analysis and on his MRI studies showed us that actually most people who dislocate their elbows, it starts on the medial side, they pop their M cl they tear their common flex origin. They go across the anti capsule to the lateral side and complete it their classic posterolateral dislocation. G A nice day. Uh Yes, I'm here, he's there. He's not let you wrestler boy, but this is wrestler boy. Did you see the video of wrestler? Boy? Yeah, I did. Yeah. What position was the hand in? Uh it was uh uh I think it was pronated, wasn't it? You got to see the back of the hand to be super. You see the palm and his palm was in super. And what did he put his elbow? So he put a valgus force across his elbow. What do you think failed first? Uh With that, I think would, would have been the medial structures. Yeah. The anterior band of the M CL probably fail first. Oh, careful. Because normally it rips off the EK OK. Probably an band is probably the most important. Yeah, I like that. You're coming up to the exam. You want to show me that, you know, something that you know that there's the anti band and the poster band and the transverse transverse band. OK. What do you see on these radiographs? Uh So it's an ap radiograph of the elbow in a skeletally mature uh patient uh which shows uh well normal bony congruity uh of the radio capital and the ulnohumeral joints, no obvious fractures, but there is marked swelling of the soft tissues I can see on the radiograph and uh on the right side is a uh uh it's the radiograph helping you a little with the MRI, but I'm sticking to the radiograph. Yeah. OK. So we'd never get an X ray of when he's dislocated and that's what happened to wrestler. Boy, he popped it, he felt something pop his elbow wo he thought he dislocated it. But when he comes in, he has an X ray. It looks like this. Yeah. The injury has started on the medial side but not completed itself across to the lateral side. Ok. Yeah. Good, excellent. So what do you think has been injured? Um Soft tissues, I think it's got the medial collateral ligament complex is gone. Uh uh at the very least. Um And OK, and with that degree of swelling, I'm going to suggest to you that he's also ruptured common flex origin. OK. Looking at that MRI, what do you see? Uh it's an um it's, it's a, it's an actual uh slice of at two weighted image uh which shows um extensive signal change on uh I want to say the medial side. Um And also in the uh alacron fossa, there's a lot of fluid ie possibly a hematoma. Uh There's a lot of bruising in the muscles and the uh inter tissue planes on the medial side uh primarily absolutely looks like a bomb has gone off on the medial side. Yeah. So how do we then get some of our basic science? So Harry cycle started lateral and went, went medial. Um The reverse. Harry starts medial and goes lateral. Yeah. And so this injury has started where it started media and on and so what's been injured? Uh So um medial collateral ligament, possibly common flexor origin, not that common flexor origin. See all that edema in the common flexor on the medial side of his forearm. Yeah. Yeah. Like a bomb has gone off in his forearm, hasn't it? Yeah. Yeah. And then where did it get to. Uh so it's uh it's got to um um well, it's got to the mid for, I mean, it's got to the deep compartment of the forearm as well. Ok. I'm thinking more of that diagram of the hurry and the reverse hurry cycle of how it comes across. You know, do you remember that diagram of how it sort of comes across to the anterior capsule and then extends across onto lateral collateral ligament, common extensor origin. And so that's why this elbow will. A severe medial injury is probably stable and safe to move lateral collateral ligament and common extensor origin is still intact and there's no injury to his bones. And so we know the treatment of elbow instability is what? Um well, uh well, it could be um non operative or operative. Uh In this case, I would try uh uh management of non operative management first, immobilize him. Uh oh no, stop, stop, stop, stop, stop, stop. What did I say is the treatment of elbow instability? Um Yeah, you wanna, you wanna move them? Yeah, you don't need to immobilize them, you need to move it so that the fibroblasts know where the isometric points are. If you immobilize them, all they do is get stiff. Ok. So we we we in a brace, little, a clinical sound bite that you might use to tell patients, you know, a little bit about basic science. Yeah, tell me a sound bite. You know what uh ligaments that are gently stressed while they're healing will ultimately heal stronger. The fibroblasts will align in the forces in the direction of the forces. Yeah. And if you move it, the fibroblasts have a chance to find the isometric point. If you immobilize it in flection or if you mobilize it in extension, they don't have a chance. OK. And so, yes, generally moving. It is good moving. It is good for two reasons. It's good for the soft tissues. And the second reason is it actually makes your elbow more stable if you have those secondary stabilizers, if you've got a common extensor origin, if you've got common flex origin. OK. Um Just jump to this one. Uh It's still back then. Is your microphone been repaired yet? I know. Can you hear me? Yeah, I can hear you. Yeah. Good. OK. Switch to a different set of head. Um So this is an ap and lateral radiograph reverse leaking to a patient or a 55 year old patient that shows a um posterior lateral elbow dislocation. All right. Did, so did this go hurry or did this go reverse, hurry? Uh probably went reverse. H Yeah, probably or could have gone Horry. We don't know, you can't tell from the X rays because they will both end up sometimes with a poster lateral dislocation. And at the end of the day, that's a little bit of about exams and uh semantics because what we want to know is, is there a bony injury, is a complex, is there no bony injury? And then if there is no bony injury are the common flexor and common extensor involved? Ok, good. What do you think has been injured? Um So certainly the uh the medial um uh ligaments and probably common flexor origin on the medial side. Um and certainly part of the lateral complex of the annular ligament will have gone for the radio head to be out there. Um Oh, now you make me say so close, the annular ligament wraps around there. Yeah. And the ulnar actually is the ras is actually following the ulnar. Ok. So this is not annular ligament injury. This is lateral collateral ligament proper and uh medial collateral and and common extensor origin. Mm mm. No. So what are the lateral ligaments then? So lateral ligament is the lateral ulnar collateral ligament. Um The radial collateral ligament and the a the accessory uh lateral ligament and then the annular ligament. Yes. So uh annular ligament is wrapped around here. Yeah, that's likely intact and attaching to annular ligament is your lateral collateral ligament, you know the flare part and then you have your lateral ulnar collateral ligament that comes to your ulnar and so injured in this one is probably lateral collateral ligament proper and lateral ulnar collateral ligament. Yeah. Do you understand that? Yeah. Yeah. Yeah. Ok. Great treatment. Um Yeah. So AAA key treatment would be uh reduction of the, of the joint itself. Um And then you want to assess, well, you want to assess the stability of it. So, um, initially you mobilize them, probably not in a cast but in a splint just for, to rest them and then see them to assess what's intact and how stable it is. Whether it's, as you said, complex or simple dislocation to see whether they can get the arm straight close to straight. I think it's unlikely in this case because of the amount of uh injury they've had done. Um Yeah, I think I would agree with you. Um I bulldoze you, I bulldoze you for a number of reasons. One because you can't be and you're good enough. Um But when you come into the exam, don't let them get flustered you. So when you have a dislocated joint, what do you say first? What are you gonna do? So, it's probably a high energy injury. So you want to say at LS and make sure it's a closed isolated neurovascular intact injury. Uh There we go. I assess, I'd like to assess the neurological and vascular status of the limb prior to it. I would like to reduce it. And then once I've reduced it, I'll once again, assess the neurological and vascular status of the limb. Ok. So that's what they did and they wrote down nothing had been injured. And what do you see? Um So this is presumably the same elbow. Uh, now in a, in a cast, it, it's difficult to see from the X rays, whether it's reduced or not, it doesn't look like it really is. Um, it does feel that doesn't, doesn't look like it looks like the radiohead's not pointing in the right direction. Yeah. Postcode is the distal humerus. The distal humerus is somewhere and the regular head is off to the side and if this is me lipi condyle, it's still, it's still dislocated. Ok. And so now it makes you start thinking that this is one of those severe dislocations, either they never, never reduced it or they reduced it and it dropped back. And when you take it to theater, you can see it's like a bomb has gone off in the SB what's been injured. So um yeah, the medial, medial collateral ligament and then part of the and probably the common flexor origin as well. And then part of the part of the lateral um collateral lateral ligament complex. So the lateral ulnar collateral ligament um and and the uh radial collateral, lateral, lateral collateral ligament proper um yeah, lateral collateral ligament complex, medial collateral ligament, common flexor origin. And for the regular head to be that far away from the humerus also likely have to common extensor, common extension. And so what we're seeing here is the involvement of the primary stabilizers, the ligaments and the secondary stabilizers, the common ele origin, common extensor origin and what we want to know is just this elbow stable in congruent within the last 30 degrees of extension. And it's not stable in congruent within the last 30 degrees of extension, which means it's not safe to move because we know the treatment of elbow instability is movement, active movement, active, dynamic, congruity. And so what we need to do is repair something um to make it safe to move. And generally we do uh lateral side first and then medial side. Um on this occasion, they required everything repairing because that was the b distal humerus. When you see that much distraction, just on your ap radiograph, you're never gonna get away without having to repair everything in that elbow. And I'll often uh if I can repair the ligaments, just repair them directly. If I can't repair the ligaments, then I will internally brace them. So the internal brace was a concept popularized by Arthrex for the lateral ankle. But if you can apply it to any joint, and for me, an internal brace is a high density polyethylene suture or take between the origin and the insertion of the ligament. And so here we see on this medial side, the origin being the anti infra condyle, the insertion being the subli cubicle. And so I've used the sutures from that to repair whatever ligament or soft tissue I can find I've used those sutures to repair common origin because that brings the dynamic stabilizers. But then I've tied one set of those sutures together to create an internal brace to make it stable. I can do the same on the lateral side except on the lateral side here. I've used an anchor into the center of the capitellum. I can repair my lateral collateral ligament, lul common extensor origin here. But I can also bring one set of my sutures from there down to the supernate crest and through the super crest. And that then becomes an internal brace with a Transosseous suture. So depending on your soft tissues, you don't always have to add the internal brace. Uh You only need to add the internal brace. Um If it's not stable, once you've repaired it, I'm gonna get back into the room. So that is just the, the severe soft tissue sort of spectrum. Uh Anyone got any questions so far? Uh Yeah, I have a question if that's OK. Yeah, fine. You mentioned uh early movement. So say we see somebody in A&E with a simple dislocation and it's reduced and it's seemingly stable. Would you then tell them just move straight away or would you just immobilize for a few days? Yeah. So we made that jump. So the jump was then, well, let's not put them into the back in the first instance. Um I'm not sure the front door really has the subtlety of uh there's a bit more in assessing whether you a simple or simple complex. OK. Um I don't know if I won't go too much of that because I've already used up half now of my time. But no, I'll put them into a back slab, but don't make the back slab too heavy. So there was a randomized controlled trial of simple dislocation ie no bony injury, uh, back slab or no back slab. Those that had a back slab for a week, uh were more comfortable and there was no increase in instability. But what you don't want to do is put a big fat, heavy back slab on it because that adds weight to the arm and then distracts your arm maybe more joint and makes you more likely to dislocate it. So yes, just AAA finished back slab uh for comfort. See them at a week and then you look at initial radiographs, you look at the soft tissues, you look at the size of the elbow. Do you remember that x-ray that we saw where they did the MRI? They did the MRI to see if a bomb had gone off in the elbow because they looked at the elbow and they thought shit, it looks like there's a bomb going off in that elbow. You don't need the MRI to tell you that. Just look at the elbow, but it's much more impressive when you see the T two like glowing in the dark. Oh shit. A bomb's gone off. Ok. When you bomb, where did I get up to? So, they come at a week, you look at the soft tissues, you see how much pain they've got. Um And you look at the initial radiographs, the amount of initial displacement I'll go back to my thumbnails in a moment and highlight that your postreduction films. Is there a drop sign? Is it, is it just dropping out just a little? Is it because there's no tone in the muscles or is it because they've gone complete hurry or normally complete reverse hurry. That's like a great skater boy move, but a complete reverse hurry to everything on the medial side, across capsule, torn everything on the lateral side and it's just hanging in there with a little bit of brachialis. Yes, Pete had a hand out. Yeah. Good. Very, very good, Lee. Um the only thing on a practical point of view. So that theoretically is fantastic. My question is, how do you get to all those structures? So when you repaired the lateral collateral, uh you repaired, I think the mioc collateral, you did some crazy stuff going on to the sublime tubercle of the ulnar. How are you gonna get there? Yeah. Yes. Good. Great question. So, um most times when we, well, when I was taught elbow surgery, I knew the er approach, I knew the leg on osteotomy and I didn't learn anything more because I was taught by world famous shoulder surgeons and let's face it. They know a lot about the shoulder. But this, this being recorded, by the way, we can, we can trim out whatever you like whenever we have to. But do you know where I'm going with that? I was taught a lot about the shoulder. That's all I'm saying. Say nothing to me. Um So there are lots of windows to get to the elbow. So you need to get to the lateral side and most times in the elbow dislocations, the common extensor origin, the lateral collateral has just been torn off like a bomb. And so you just need to get to the lateral condo. Now, you can get to that from a lateral approach. Uh EDC split or a cocker or a captain slightly more anterior or for me, I do void because I can do everything I need to do through a void when it comes to the medial side. Again, it's normally the bomb has gone off and the dissection has been made for you. You open up the elbow, you get to the middle side, you find down the nerve to make sure that you don't injure it. You push your finger towards the common fix origin and it's all just string. And so actually, the dissection has been made for you in these uh horrendous soft tissue injuries. And then you grab what you think is common extensor or lateral colla ligament and let the capitellum and repair it on the medial side. Your isometric point for your AMC L the most important part to instability in a simple dislocation um is an infer lipid condyle. And so again, you put an anchor in there, but the problem with the M cl, the M cl obvious often shreds itself. And that's why you then put another little anchor into the sublime cubicle because you know that's your origin and insertion and you use your sutures to stitch as much soft tissue as you can and then create an internal brace. I was just about to show you me. Um I don't think on. Oh no. So uh boy, terrible Triad narrated. There we go. That's the one le Van Rensburg. But there are lots of, all right. My mistake. It's OK. Am I screen sharing it? No, not in a minute. OK. I'm gonna come to that. You just Charlie, what is it? Oh no, that was me uh by you. Sure. Yeah, it's OK. Just prompt me if I'm, you know, going way off. But what I was gonna say is you've got a few other other people you can ask, you can ask uh who already already spoke up? Oscar. Josh Oscar. Yeah, I think uh these people can wake up and then they can ask a few things too as well. Anything else? Uh Josh and panels panels. OK. So let's share again. Uh home screen. There we go. I can see your screen now. Yeah. So you see the video. Yes, I don't know why. It's a little bit small, um the middle, it's just there we go. This is full screen. So this is the approach I use most times for my complex elbow instability. This is called the void approach. Um And so what I've done is I've come down the back of the elbow, down the side of the elbow um between anus and the ulnar and I feel the annular ligament and L UC, which is a search on the supinated crest of the supinated crest there it is. So here you'll see the radial head and you just see where the knife is now, that is the condensation of L UCL and annular ligament. And you can peel that just off the super crest. Uh just turn your knife upside down. The full narrated video is on me. Um If you're just on V me, leave Van Rensburg work and put on a group chat or someone's group chat, the uh the QR code. Um but the beau beauty of boys interval is that it gives you a beautiful view of most of the things that you need to deal with when you're dealing with complex instability, particularly if it's involving the radial head. And so you can sublux the elbow like it was subluxed or dislocated at one stage and you can now fix or replace the radial head. So increasingly I will use tripod screws and I can get to all the craters of the radial head. But more importantly, if I can't fix it, but I need to replace it. I can see the lateral aspect of the coronoid so that my radial head height is perfectly. I can see beautifully how my radial head is tracking the lesser sigmoid notch, the, the PR UJ. Um And I can also, once I've reduced it, I can see how my own humor joint is tracking and I can see how my radiocapitellar joint is tracking and so that I know everything is stable. So here, um P MRI and then just having a look into the side of the ulnohumeral joint. Um and you can get a really good strong repair of your annular ligament. L UCL with these holes in the complex in the context of the complex soft tissues. There, you see how I've now peeled everything lateral on the collateral ligament, the lateral collateral ligament proper, that would insert into annular ligament and common extensor origin of the lateral epicondyle, the so called bale lateral epicondyle. And that's what you would find in the severe soft tissue or the terrible triad where they've had a dislocation, a coronary fracture and a regular hip fracture. And once you've released it, well that you find this injury is done for you, you can simply put an anchor into the center of the lateral epicondyle and then weave that the sutures from that anchor into your lateral ulnar collateral ligament, lateral collateral ligament complex proper. You can push them through into the fascia of your common extensor origin and repair your common extensor origin down. And now you can repair your void and the void is done there. The sutures are into the annular ligament and I can repair my void normally. But if my elbow is still unstable or if this tissue here and your ligament, lateral collateral ligament isn't very good. I still have this set of sutures which is attached to my anchor. Remember that that's at the center of the lateral epicondyle. And so if I pass that along the path of the L UCL, lateral ulnar collateral ligament, I can pull it out at the supinator crest and I can now reverse shuttle that through the drill holes that I've made in the super crest. And so now I've repaired all my ligaments. So if the tissue is good, that's all you need. If the tissue is not good, then you need to uh protect the ligaments while you move it because, you know, ligaments that are gently stressed while they are healing will ultimately heal stronger. And I've now created an internal brace between the origin and the insertion of the L UCL. And it's the lul that really keeps you stable. Everything else is repaired. And so if they don't stress it, it'll heal, I can add a few more sutures into the side of the ULN. If I wanted to, I don't always, only if it's really bad. Instability. Normally with that, we can then get an elbow stable and stop. Um Not sure. So you don't see too many. And so that Boyd's interval that's on view may be much longer. It's about a 15 minute uh uh uh narrated video on how you can go through Boyd's interval to get to your radial head and still repair L UCL common extensor origin. I do make a double injury in my lateral colla ligament is complex because I do release it off the annular ligament of the super breast. But if you can cock up or if you can void, you're still cutting annular ligaments somewhere. You know, you have to get to it somehow if you wanna get to radial head. Mm Any questions on that. So I'm gonna lose my la last 20 minutes on a subject which I don't think will be covered with the other topics that you've got. And that's with the P MRI or posteromedial rotatory instability. One that I think probably is the most confusing um part in discussion and takes a little bit of thinking kind of screen share uh in. OK. Can you see my screen? OK. Charlie, we can indeed. Thank you. All right. So we'll go back on the spectrum of elbow instability. You've got simple and complex complex. The one easy. If there is a bony injury, it's complex. If you've totally ripped the soft tissues, notably the secondary stabilizer, common extensin, common flex arg off and that elbow is not safe to move. You have to operate to get it moving. Then it becomes a complex severe soft tissue. All right, the common pathway for all forms of elbow instability is movement. You want to move it so that the elbow gets your optimal function. So they can get back to life and work as they can in the group of complex instabilities. We've got the posterior elbow dislocations with the elbow fracture and the radial hip fracture. And that combination dislocation, coronoid and radial head is called the terrible triad. And that normally gets covered when you do radial heads. Because at the end of the day to turn a complex dislocation into a simple dislocation, you deal with the primary stabilizers, whether that's the ligaments, the soft tissues, which I've just talked about or whether it's the bones. And so in the radial head, it means replacing or fixing the radial head, dealing with the coronoid. If it's a big enough piece, if it's a significant piece, if it's a knife, that's my crocodile DB. Quote. You know, that's not a knife, a tiny little piece off isn't a knife. So in the group of the complex dislocations, we've got this terrible triad which often happen as a form of PL ri poster lateral rotatory instability. It's where the forearm hyper supernate and the radial head goes off the back of the capitellum, then you break a tiny little piece of the front of the coronoid, the elbow jumps back and the elbow dislocates. The next group of elbow instability is this P MRI posteromedial rotator instability. Um And that's where the forearm hyperpronate and gradually fails. And then you also have an axial load where the cochlear drives itself into the coronoid. OK. And then the last group uh angry, not angry, Alex Mulligan, there's a proximal fracture dislocation um edit that. Yeah Charlie approximation. Now they are beautiful. That's a great subset. They are really, really interesting. Um So I'm gonna leave those to him and I'm gonna be talking about P MRI cost me rotatory instability. Now, you don't always have an elbow that's dislocated X ray, but the patient feels a pop. They just doesn't quite feel right. So who are we going to Oscar? Are you there? Yep, I'm here. Can you hear me? Yeah, I can hear you fine. It's brought it home to me. This guy brought it home to me. It was about 2006. I just been made a consultant. I knew about the and the and osteotomy. I knew all about the la and all that shoulder instability. I knew nothing about elbows and I saw this guy. What do you see uh ap and lateral radiograph of an elbow? 55 year old chap. Um It looks like the elbow is not congruent uh at the uh ulnohumeral joint. Um OK, you're coming up to exam time, you know, if you sound like an orthopedic surgeon. You can be an orthopedic surgeon. You don't sound like you kind of sound like an orthopedic surgeon. What's the do linger word? What's the, sorry that tells me that the elbow is not perfectly concrete, dislocated, more subluxed. We say like a 15 year old. We speaking French say subluxed. Yes, that is a much better word. Yeah. If you sound like an orthopedic surgeon, you can be an orthopedic surgeon. I see not the best of ap and lateral radiographs of the elbow. And the most striking abnormality is that the elbow is sub subluxed. Yeah, it's not perfectly congruent. Ok. Now, what else do you see? Mhm On the AP radiograph, it looks like the radial head um is not uh uh conquered with the cat. Yeah, there's a, there's a large, yeah, I I'm not entirely sure how to say it, but there's a, it, it looks to me like it's opening up laterally. Yeah, I would say that the lateral joint space is widened. Oh man, I sound like an orthopedic surgeon because I've been playing this game trying to fool people but just sounding like an orthopedic surgeon for the last 20 odd years. So I see widening of the lateral component to the elbow. The radiocapitellar joint is a little widened. Ok. Good. Yeah. What do I see on the lateral vertebra? When we see this only human destruction distraction where we see that the, when you see my, my camera, you see how the arm just drops out. The, this is the ulnar, this is the humerus, it just drops out. Yeah. What do we call that? The drop sign? Have you heard of the drop sign? Yeah. Yeah. It's just a little bit of ulnar humor. Distraction. It's not perfectly congruently, subluxed and that was it. I looked at these X rays and I thought, hm, it just doesn't look right in retrospect. Now, I know why it doesn't look right because it, it wasn't right. Ok. I don't know why that one doesn't wanna the race. Then we might have to be left with a little red dot I did act scan and in those days they didn't do, the scanners weren't that good. And all I could see was that the elbow just wasn't quite right. It was subluxed and that's all I can say. And so now I'm screening him. And what do you see? Well, you can see that there's still, it still looks like the joint is not perfectly conduit. There's almost a drop sign or it's po posteriorly subluxed. Yes. The older hip joint. Yeah, I love that. He's sliding backwards, isn't he? So we're opening up here at the back? Ok. And we know that the most important ligament in the elbow probably is the AMC L mm. So what ligament might be injured to allow your humerus to slide back like that. Sometimes the anterior capsule may be compromised, potentially no anterior capsule will actually be no, not sure. May maybe a little poster band of the MCL. Yeah, it's when you start seeing um uh P MRI poster rotatory instability, the ligamentous pattern that gets injured is lateral collateral ligament or L UCL and mostly post to a band of the M CL. OK. What? Ok. Well, just bear that in mind because the anti band of the M CL is attached to subli cubicle. Mm. And in these, here here is subli cubicle, there is anti inframedial condyle. This is anti band of M CL, anti band is intact. And what happens is the trochlear drives itself in into the ulnar and blows out this anti coronoid fragment. This is not, you will not get a better, I cannot better P MRI than this. OK. And so now I screened the elbow and I'm placing a Elvis horse. Um it opens a little but that subli tubercle is not going very far. All right, I place a various force. And what do you um So that's a blind tule display significantly. Um OK. Yes. So the property drove itself into the blind tubule and, and, and la la laterally, it's also opening up um with the radio uh capitella joint widening of the implying what implying there's uh lateral collateral ligament uh injury also. Mm OK. If you had used the word complex, I would have let you get away with it. It's complex. Very strong Ok. So what are the ligaments on the lateral side? So la the lateral or on the cholesterol ligament? Lateral ulnar collateral ligament. Yes. Yeah. Lateral collateral ligament. Which annular ligament? Yeah. So what's been injured? No, I expect the m the most lateral which is the lateral or later collateral ligament proper. Yeah, annular ligament is still intact. Yes. And what else might be injured? Uh Could be the common extensor could also be injured potentially. Yes, common extensor origins. And so P MRI is not the same mischief of developing instability. You don't really see dislocated elbows, but you see these subluxed elbows and the problem with the P MRI is that the elbow rides up onto the broken bits of the coronoid and then becomes tic. And so you see them getting arthritis, um you know, they're OK, they feel crunchiness for a year or two and then they've got medial compartment arthritis. And if you get medial compartment of your ulnar humor joint, you can't offload it. If you get radiocapitellar arthritis like a bad radial head and it doesn't heal well, you can offload it by lifting up a cup, lifting up a jug doing something. You're always putting a various force across your elbow, you offload your radiocapitellar joint unless you do pushups, unless you do bench press and you very quickly learn to stop doing those. Whereas if you've got medial compartment arthritis with day to day activities, you can't offload your medial compartment for most activities. And so they cry and there's no great solution to them if they're young. And so what has happened here is the coronoid has been repaired. This is an old school coronoid plate. So you won't see that much anymore. That's a G two anchor which has been there to repair the lateral collateral ligament, common extensor origin. Um and that's classic sort of uh P MRI. And here we see another one, a 40 five-year-old slips playing football feels a pop and we don't see the dislocation. The important thing with these injuries is mostly the radial head is intact. That's why it's not a terrible triad on the lateral. We just see a tiny little piece of the coronoid. Here we see on the ap that it's involving the sub cubicle fragment, but actually, this is not in any way subluxed as bad as those other injuries. And so we get a CT scan on him. And on the sagittal view, we see how the radiocapitellar joint is beautifully reduced, not beautifully, there's nothing wrong really. And we see the ulnar humor joint and actually the ulnar humor joint looks reasonably congruent. We see this coronoid fracture which starts on the lateral side. And the significance of this one is it extends all the way across to the medial side. It's this involvement of the medial part of the coronoid, which is the crus. But his cross sectional imaging is actually congruent. Now, uh don't wanna get too much into the fine detail of the P MRI s. But uh you could make an argument for treating him nonoperatively putting him in a cast for three months. But the consequences of missing it and him developing arthritis are so bad in a 45 year old um that I'm gonna take you to theater because although on nearly all the imaging, this elbow is congruent. This is as good of an intermeal ent fragment as you are gonna get. And the problem is, is here just uh come on, Lee just this point here where your native cartilage of the trochlea runs on the coronoid and then they get arthritic. OK. So, although he is stable and ent while he's flexed in his cast, if we take him to theater, we place a V force. We see injury to the lateral ligament is complex, likely lateral collateral ligament proper. And L UCL of the humerus, that's most times where it gets injured. It's not opening up a centimeter or two. So, common extensor origin may be intact when I put a valgus force across the elbow, my conoid doesn't run away. It's not incompetence of the medial side, which is what we expect. Uh The uh anti band of M CL is still attached to this piece, but this is the money shot how the elbow sublux as it comes into extension. So when he flexes it up and has it, every x-ray taken in clinic is congruent. But then when he goes home and gets it moving, he extends it and he slips and grinds the way the cartilage from the medial compartment of his elbow and he gets arthritis. And that's why we go down the deep dark tunnel past the ulnar nerve to get to the sublime cubicle and the uh an intermeal coronoid to stop him from subluxing. And now, once I've got his bones right? Because he had one big solid piece of bone. And so if I get my primary stabilizers right, the congruence of my elbow is a very constrained joint. I don't then often have to worry too much about the soft tissues. OK? And so I haven in him repaired his lateral collateral ligament complex because once I've done the medial side, I get him moving with avoidance of various stress. I don't stress his various uh elbow um and allow the lateral collateral ligament, lateral ulnar col electral ligament to find itself how I think wanted to ask a quick question there. Same question. I'm afraid just getting that plate onto the, what approach did you use for that? I can see some of the guys thinking I'm generally going to go with what's called an a an extended medial elbow approach. Um So when you're approaching the chrono on the middle side of your elbow, you've got three windows. The first window is between the ulnar and the common flex origin or FC U and that window is called Talar sha The next window you've got is between the two heads of FC U or the FC U split. And then the third window you've got is the Hotchkiss approach. And that's where you split the flexor pronator muscle mass at a varying place. So you can split, split it high or you can split it just above FC U between FC U and Palmaris longus. And a lot of the time, it really depends on what part of the corners you're trying to get to, whether you want to just get to the front, the anti part or whether you want to get to that sublime cubicle part. And the problem with going through the FC U split, it gets you to the blind cubicle part. Um but you'll find it difficult to get across to this anterior part to the more lateral part of that elbow. Uh With this guy, the one that I've just shown you, where is he there? I needed to get to sublime cubicle and anterior part. And so you could have gone any route there, that view from the side. But for him, I would have gone above the FC US. This is nice. So that's why I left the soft tissues on. So well, windows are through the FC. So we can't see your screen at the minute. Ok. Thank you. This part um chest pain, I really should just try the window thing, but I'm not gonna mess with it too much. Now. Yeah. Now we can OK. So, in this coronoid, I need to get to the sublime cubicle fragment. Um that part there and I need to get to the front part. And so I could either come through my, along the path of my ulnar nerve, my FC split, but then I'm gonna struggle a little bit to see the stuff at the front. Oh Running there there. It's my hum head of FC. And so now I can split it just above the human head of FC. So you come down the medial supracondylar ridge and you come down there into the gap between FC U and and then I can elevate everything off the front and that's called the the extended medial elbow approach. That's excellently. And so you've mentioned in my experience that is a quite unnerving, deep dark tunnel, whichever way you do it. Yeah, it is a deep do panel and but you got to solidify yourself to do it because if you don't, you'll find x-rays like these 46 year old female with an arthritic elbow of the medial compartment. Can you still see my screen? No, it jumped back to the uh unfortunately, part of the thing. So let me just share present. Now, sharing to ask me you just, just while you're getting that up. I mean, I kind of know the answer. So you would not be able to get to that bit of approximate through your void approach, no side is also the left side. Yeah. So just for the sake of the people room next to me, that was the missing link, which is why I wanted to describe that. So to get to the medial side, you've got to do something you've just told us about. But for the lateral side, you could go void so you can't void, I'll go lateral. Uh Yeah, if I get my radial head, I'll go void. Now in the terrible triad, the piece of the crown that's broken is often the top lateral piece. Um and that you can get to quite nicely through void. Uh There is a video on the Cambridge orthopedics website. Um but that's only the very typical. Yeah, I'll, I'll, I'll get you to that debate for those of you who want to know more. There's about a 30 minute video on the coronoid. Yeah, I think, I think you have to go through it or find someone who can go through it is if you don't, you will see X rays like this. And so this lady has got medial compartment arthritis in her elbow at the age of 46. And when you've got me compartment arthritis like that at the age of 46 there's no great solution. Um you know, sure another one, 61 4 weeks since injury. And you can see there's no medial joint arthritis. And when you look at her MRI scans, you'll see how unhappy she is on that medial side of the elbow. And once you've started grinding, once you're there, you see how this trochlea has slid forward, we see that open air at the back of the Quinon like we saw on the screening films, uh interruptive screening films, lateral side looks pretty good. Um But that's the danger of P MRI. Now there's not gonna be lots of these, it's not that they're gonna be there every day, every week. Um But yeah, you, you need to look out for them because if you see a anal coronoid to the point that if I saw a small piece of coronoid on my lateral radiograph, a small little piece like that, I will ct every elbow to see exactly where that coronoid fragment is broken. Um OK with orthopedics. Um it's a little of a chunky, this little, isn't it? It's a little, it's OK. We can work around it, we can work around and so on the Cambridge orthopedics, youtube channel. Um There is a, I don't know, half an hour video uh on tips on the coronoid and how to get to the coronoid. It's the tips on the coronoid that you wanna watch. Um There you go, that video there. Uh And it tells you how to get to different parts of the coronoid because there are in essence 11 different ways to get to the coronoid. It sounds like you don't. Ok. Um P MRI post meal rotation stability is a various injury to the elbow, injuring your lateral collateral ligament, your anti meal coronoid and the poster band of the M CL. And you need to fix variably sometimes all three. most times you would go for the winner if you've got a nice big solid bony component, uh I think I'll stop there because we're coming up to three o'clock rabbit it on a little bit about elbow instability. And if elbows aren't your thing, I can appreciate, you might not be there really useful. Thank you, Mister. And hopefully that's all. Although, so last week we did cover some of the anatomy and all those structures, but you can see that everyone is trying, you know, to get their head around it and be able to then talk through it. So, so that's why repetition, repetition about some of this stuff. And uh those who are coming to the practical day will get to reinforce some of this again, uh to sort of make it then and hopefully you'll get an understanding around it. Yeah, that's very, very good. Thank you very much. That was a subject. Seem vaguely understandable. Any, any questions, anyone great. Have a good day. All right. Thank you very much. See you next week. See you next week.