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Ok. So, good evening everyone. My name is Go. I'm one of the teaching coordinators for Utah this year and hope everyone had a great New Year so far and welcome to the third Talk of our Deep Duck Specialty series. And today's topic is on elbow and wrist surgery. And today I'm proud to have Mr Andrew Duckworth who's a trauma and orthopedic surgeon at the Royal family of Edinburgh. And he's just gonna be talking us through the various elbow and wrist surgeries. So, uh, Mister Duckworth, whenever you're ready, you are. Thank you very much and, uh, thank you to you all for the invite to come and speak to you this evening. It's a real honor and a pleasure. So, as, um, already been said, I'm a, I'm a academic orthopedic trauma surgeon in, in Edinburgh. Uh, um, and they basically at the University of Edinburgh as well. Um, just important to put on my disclosures to see, you know, if I have any conflicts or anything like that. And obviously, our department receives a fair bit of funding and support from various implant companies often related to research and education, um, which are sort of relevant because you're gonna see some of the implants in this talk. Um But just to highlight as well, there's some pictures and some references made to these two really good um references for orthopedic surgery. So the a surgery reference and, and the m orthopedic trauma book, which is written by some of my colleagues in my department, very good colleagues. Um So just so you're aware of that more than anything. So the objectives of this evening um are really broken down to these four things. And the first was to understand the common injuries requiring elbow and wrist surgery. And I've really focused on trauma and injuries, firstly, because that's my main interest, but also in terms of just the time, I thought that was probably the most important thing to try and cover and give you some interest in and familiarizing yourself with some of the common surgical procedures that we use around the elbow and wrist for the injuries that we see there, predominantly focusing more on the elbow because that's sort of my major subspecialty interest area, but also touching on the wrist briefly as well. And I have tried to emphasize not only the surgical aspects of the management of these injuries, but also the current research and advancements and maybe future directions we're going in to a mix of the sort of surgical aspects when narrative treatment should be used and also some of the current literature and the upcoming research that's being done at the moment. Um, so I've broken it down to sort of four or five example, um, injuries and then talking through them and these are all relatively common injuries that we see in the upper limb. Er, and the first being humeral shaft fractures. So a humeral shaft fracture, um, is a relatively uncommon injury when you look at the grand scheme of things, but it is a long bone injury and what's unusual about it is a long bone injury. That is the only long bone injury that we have for historically treated non operatively. Uh And this is a common er, relatively common type of injury that you see with a transverse fracture, which is can often be related to high energy trauma, but also can be low energy trauma in um in an elderly population as well. And a lot of these fractures have that sort of type of distribution as you'll see. Um one of the main things that when we manage these injuries and uh I'm sure that you're aware is that we also worry about the any concomitant nerve injury. So, a radial nerve injury is not um uncommonly seen um after this type of injury and also any surgery to try and fix it just because as we know the anatomy of the radial nerve and where it runs, which we'll come on to. And one of the big parts of these type of injuries is a, is a very clear assessment and it's really important to assess the radial nerve in particular, obviously do a thorough assessment of the patient because like I said, it can be high in injuries, but it's really important to assess the radial nerve um thoroughly because obviously, if you're going to perform any intervention and even just putting a use lab on or a cast or a sling, um it's important to know if that has had any effect on the radial nerve and actually caused it to be injured. And obviously, as I'm sure you know, the assessing the radial nerve, the important thing is that sensation in the first dorsal web space and then uh wrist extension, thumb, extension, er and finger extension are key aspects of assessing that and that's really important that that's documented er when the patient first presents with these injuries. Um in terms of managing these, if we go down the surgical approach first. And the reason why I've done that is because obviously, that's one of the main key aspects of this talk and we'll talk about the normative management in a minute, but these can be really managed in two in approached in two ways, uh midshaft humerous fractures and either through an antra lateral approach, which is on the um sort of sudden into the Henry's approach, which is on moving on the lateral side of the, the biceps there, as you can see and patients have to be in a sine position that. Um But actually more commonly, certainly for myself and what I use for certainly mid shaft and distal third hum shaft fractures is a posterior approach to patients can be in a lateral position or arm over the front. Uh And it's really doing a split up that triceps as you can see there and that can extend down into the elbow if you want to into the lateral para approach and even the boy approach. Um sorry Doppler, but I think we're still seeing the assessment slide. Oh right. OK. It's definitely moved on here. Sorry. Has that changed at all? Now, it's not changing from my side. I'm not sure about the others. OK. So it was moving on fine but then just stopped it. Can everyone see the slides fine or it might just be me? Uh OK then OK. I think it's fine. OK, fine. I'll carry on if that's OK. Um Fine. Yeah, I think the chats saying that people are um saying it that's good. So um the posterior um er tricep split approach is often more commonly used, but the most important aspects of both of those approaches is really finding the radial nerve er and identifying that um er as it comes around that spiral groove um er um of the humerus um and then moves er into the from the posterior aspect of the arm, into the anterior down through it paces the lateral intramuscular septum and having a good knowledge of the path of the radial nerve and how you find it is essential part of this surgery. It's really the key part because once the radial nerve is found fixation of the fracture area is relatively straightforward. Uh But looking after that nerve is really important and it is a sensitive nerve and no part intended. But it's one of the ones where, for example, the ulnar nerve, as you can see there, which we see all the time during elbow surgery, that's a very robust nerve sits in an area where it often gets banged and bruised. But the radial nerve does not like to be um er disturbed. And actually, you've got to be very careful with it. All the patients will end up with a palsy postoperatively as we described. And that can take several weeks to months to recover after months. So it's a really important aspect of this surgery. Um It is finding the radial nerve and really like I say, key to it and I think through that posterior er um triceps split splitting approach, it's a much easier structure to find because of the anatomical aspects of it. And it's very important to understand obviously the middle side of the arm, the left side of the arm cos it's at different levels as you progress um uh approximately and this is how they're often fixed and I'm sure many of you have seen this. So this is a, a plate and screws er construct that's been used to fix that transverse fracture, depending on the size of the patient. You can use a 3.5 or a 4.5 screws and plate, which is a small or large frag. And this has been fixed by compression because it's a transverse fracture. You can't lag it or put screws across it to hold it and then put a plate on to neutralize it's getting compression through that plate to allow it to heal. Um And you know, as a converse out, this is a distal third fracture, but again, a distal third heath fracture, but that's been, it has more of a spiral or a, a bleak component to it. It's been fixed er with some light screws across it as you can see there and a plate um that's almost acting like a neutralization plate over the postlateral aspect of it that runs down to the elbow to a slightly different er, precontour plate, but doing the same thing really and allowing the er, and the big thing about this is it allows the patients to move early, er, and they're not in a brace for a long period of time. And that sort of moves me nicely onto how these uh give you a bit of background about how these fractures were pre previously managed. So they were historically, historically that for many years and probably still now primarily managed with non operative management and that was in the form of a, a you lab often in A&E and then into a brace or a classical called a Sarmiento brace. And that's because of Sarmiento, as you can see here, who wrote a lot of the seminal papers talking about the, the effects of functional bracing of fractures of each after the humerus and an RD. I was once oh, a famous thing you, you, you were once taught was if, as long as the two ends of the humeral shaft fracture in the same room, they would heal and you didn't need to operate on them. Um And an analogy sort of was put forward, it was a bit like the clavicle where you can treat them all mo operatively and you just reserve fixation for when they go on to nonunion. But the, the successful results that he published haven't really been reproducible. And what you more see is something like this where you have there is a degree of success in managing non managing these fractures non operatively, but the non union rate is anything from 15 to 20% even. And that's a significantly high rate of non union for a long bone fracture, not something we would normally accept for a lot of treatment interventions that we use and has a huge impact, huge impact on the recovery of the patient. If you're waiting all that period of time for the fracture to heal, which can be up to, you know, six weeks 12 weeks, even up to six months, sometimes even other people say you should intervene before. Then that's a miserable period of time for the patient. When they're in a brace, they can't really do very much, they're in pain and that has significant impact on the patient. Um, and what we also know in from more recent surgery is if the patient goes on to a non union and then you do a non union surgery to fix the fracture and then it heals, they still are not as good as if it primarily healed in the first place, whether that be with non operative or operative management. And this has led a few including ourselves to, to perform some uh trying to obtain a level one data in this area. So randomized controlled trials of non operative versus operative management for closed displaced tumoral shaft fractions. And this is one of the biggest that has come out so far, the fish randomized controlled trial, which was published in Jama. And that we've also done a systematic review of bringing the current meta analysis together comparing non operative and operative management. And what's quite interesting about that is that operative fixation certainly does seem seem to offer superior early patient reported outcomes that that's sort of diminished by about 3 to 6 months and potentially a lower rate of non union and reintervention. So the patients are better, quicker and have less problems in the future. Um But there's no difference in a lot of other, a lot in other outcome scores. But in particular, there's no difference beyond six months. And so that the implications of that management are a little unclear at the moment in terms of offering primary surgery, surgical treatment to all patients. But there is just to highlight there's a growing body evidence in this area and there are more randomized controlled trials. Some maybe your centers are ongoing such as the hush trial, which is the Big Oxford trial run back through N hr but there's also the study, the SF study which is in Denmark, I believe and obviously fix trial, which we've just finished and hopefully soon to be published. But there is more level one data coming, I think where we will come with it is that it will be probably targeted fixation for those patients who are at risk of non union rather than a blanket policy of primary fixation. But I think it's a very interesting area, as I say, a AAA real real controversial area still in our, in our specialty. So if you mo move slightly down the humerus or distal humerus fractures, one of my most favorite injuries to manage and treat. Um So this is a sort of a classic picture that we see these days. These have become um they still do occur in younger patients uh with high energy injuries, but are more commonly occurring in elderly patients after a low energy uh fragility fracture, um uh explosion that is occurring in a large number of elderly patients growing and then the fractures they are sustaining is growing as well. Um And these can be rather challenging fractures, but in a good way to treat the vast majority though will be managed likely with fixation. And when you pose with um AFA fracture patent, like this vast majority of patients will have some form of surgery, whether it be fixation or ar plasty and will come on to that, there are a very small number that can undergo nor management. And again, I'll, I'll show you some of the evidence uh about that. Um, and what's interesting about this fracture is there's a variety of approaches that you can potentially use. Um, there's different types of fixation and the form of fixation which we'll go on to, er, and also what we do with the ulnar nerve co you'll see the ulnar nerve, as you remember from the previous slide, looking at the radial nerve is very close to where we were gonna, we do our surgery to fix these injuries right behind that medial upper condyle. So how we position these er, patients in theater if you ever see this surgery? So they, uh, they can be either in the lateral position with their arm over a support like this, often with a tourniquet on, with he shat fractures before we often do put a tourniquet on tourniquet use though. Again, is becoming controversial. Well, more of an area of debate, more and more people are not using a tourniquet, er, for, er, upper limb surgery or even lower limb surgery. So that is again debated. Um, but you can also be on the supine, supine, on their front. So it's lying as I am, you know, front now and their, their arm is supported over their front and you can do it sort of upside down. Er, because the approach is a a posterior approach to the elbow either way. And we sort of do this posterior midline incision and most commonly, um now we use a lateral para electron on approach, which goes into the tricep split. So it's very similar to what we've just seen with the humeral shaft. Um and then a medial window via the ulnar nerve. But there are other ways that you can do this, you can do parasite tricipital. Um and also you can do an osteotomy where we break the bone, the electron to gain access to the distal humerus. And that gives you a very good view of the distal humerus. But really with the approaches that we have now that certainly in my practice and I know others that's becoming relatively rare and it's certainly a good thing to avoid if you can, because obviously you're giving the patient something else that's another fracture or a fracture you've made that has to heal. Mar really the most important thing is you have to be able to see this fracture well, to fix it and sort it. Um, and in terms of the plating, there's a, there's an idea, there's various advocates for either what's known as orthogonal or parallel plates. You can see from those two pictures where the plates go on the side of the bone or one plate on the side of the bone and another on the postural act aspect of the bone. And there's arguments, er, either way, I think the most important thing is that the orientation of your plates is often related to your fracture pattern and you have to adapt to that. This is often what happens in terms of, you know, fractures are the fractures held reduced often with K wires and the plates are placed into position. After you've done your posterior approach, the ulnar nerves protected on the side there, as you can see with that blue, um, tie there. Um, and then you use the plates and screws to, to, to secure everything in a good position and the Ky is removed and that's the standard sort of surgery that we go through, er, for, for these injuries. Um Go just go back briefly, the ulnar nerve. Most people leave that in the position, it's in, you just have to be careful, it doesn't irritate the, er, isn't irritated by, on the metal work. Some people transpose it and what that means is bringing it around the front slightly of the elbow to try and prevent any irritation there. The general evidence though probably says that it can just be left where it is. So, um, what about elbow arthroplasty? So you can see here these are uh, pictures of a distal humerus fractures that have been managed either with a, er, an elbow hemi arthroplasty where we replace the broken part of the joint. But the, the, um, the proximal forearm is, is native or you can do a total elbow replacement. Er, and er, for, for some time, that's really been based on the fact that if you can fix the fracture, you should fix it. Uh And if you can't fix the fracture and the patient's active, then you should because of due to comminution or the severity of the fracture, the elbow needs replaced. Um And there's been more and more work in this area looking at comparing this particularly in older patients. So in older patients with sort of lower functional demands, maybe but certainly older patients is the out the outcome better with elbow arthroplasty than or if, because there was this complication profile with or if um and fixation uh in terms of particularly in terms of reoperation. Um and some have suggested and there's a slow growing body of literature suggesting maybe arthroplasty, we should consider more primarily for these patients rather than just in those non salvageable cases. And to date, there's only one randomized controlled trial which is compared the two that was from the cox group who are prolific, um and also publishers in, in orthopedic trauma trials. Um but a relatively small trial, but that actually showed some potential benefit in terms of patient report and outcome measures favoring total elbow replacement. Uh But it's a relatively small trial and can't sort of definitively answer that. But even in the longer term, the reoperation rate was a lot lower with total elbow replacement. But that can obviously be biased by the fact that once you have a total elbow replacement, there isn't much we can do after that. And I think that what's important to say as with a lot of things. Um, er, although there are problems with fixation and you can have problems with, um, you know, needing further surgery, if something goes wrong with an alb arthroplasty, in particular infection, it is an unmitigated disaster for both the patient and for you as a treating surgeon, it is a very difficult thing to sort. And so that is why there's that slight resonance about giving everyone a to replacement versus, or if I'm really, what I'm really talking about here for a replacement or if these are in the older patients, we would always try and fix the fracture no matter what in younger patients. And this is where we're at with this sort of a versus elbow arthroplasty in this elderly population and what we're trying to weigh up these risks and we're just about to start a big I hr trial myself and my colleague, Ben all over in Nottingham. Um And it will be a multi center trial comparing this and trying to answer this very question of whether fixation or Arth Plasty is the better option. And that's really the main thrust of research at the moment. Certainly here in the UK that we're aiming for distal humor fractures at the moment before we move on to the next injury. Though, I just wanted to mention non operative management. Um I think it's, it, it, it does have a role in some patients. There's some studies that you see here from Canada and a bit closer to home in, in, in Glasgow um where it's called the. So it's been well, it's been termed the bag of bones technique where you just put the patient in a cast for a variable period of time. Some people say a couple of weeks, some people say six weeks and you just let the fracture try and heal in that position. Uh It is a very reasonable option in patients who would not survive surgery or surgery is not an option, um or patients who even decline surgery, er, but it is for low demand patients. And I think it is for patients where um they um require or, or can cope with minimal function in their elbow because if the fracture goes on to heal, uh they will have a very stiff stiff elbow, which will have limited function. And the other problem with this is there is a notable non union rate with it. So the fractures do not go on to heal. Uh and once that occurs, you're often quite limited in what could be provided, an elbow replacement might be the only option. Now, if the patient isn't suitable fixation, it's certainly unlikely gonna be suitable for an elbow arthroplasty. So non operative management can be used but very cautiously and in a very small select patient group. So moving a bit further down their arm to the er Alacron, again, a very er, a relatively common injury in the proximal forearm, but the second most after the radial head, er, and again, er, an injury which is often treated with surgery but not universally and we get come on to that. So this is the classic sort of image that we look at. It's the, you know, there's an ap often that's an important view but also the lateral view of the elbow where you just see this displaced electron fracture and the important things we're looking at here are we're looking at not only the displacement of this, this bit of bone here, we're looking, if there's any commu around the elbow here, sorry around the joint, any er um er articular depression. So the the, the articular surface is depressed down. And also we're looking very subtly here at the radiocapitellar alignment and in which we have what's called an anterior v sign. So what that means is that the proximal forearm bones are being able to translate relative to the distal humerus. So the elbow is unstable. And the reason why all these things are important is they determine how you're going to treat that fracture. Uh This is a, you know, a relatively straightforward displaced leg fracture with no evidence of instability. And once you know that it then guides management and this is roughly how we treat these injuries. I'm I'm sure this is a pediatric. It doesn't have some of the, the moving sides on there. But, but what's known as a mayo type one fracture is an undisplaced fracture. We usually classify that as under two millimeters of displacement and we usually treat this with a period of immobilization very short period and then get people moving. These type two A fractures can be often treated in uh uh three ways and it's probably where the controversy most exi exists about how we treat these where they're displaced, there's no comminution and it's, and it's a stable elbow joint and that's either retention man wiring, which is probably still the most commonly used somehow advocate plate fixation, which you can see below and the final which is suture fixation, which I'll come onto and discuss in a bit more detail. Um The type two B fractures, which is where they have comminution. You know, the articular surfaces are a bit depressed and more importantly, there's evidence of subluxation. So that radiocapitellar alignment I was talking about, you can see there's a little subtle anterior V sign just there where the cursor is that would be usually more mo most of these fractures are almost all are treated with AAA plate fixation of some sort, cos it gives you that stability that you need. Um So in theater, we set these off the off the they're getting in the lateral position, arm over a bolster, but you can do an arm over the front, supported by a mayo table as well, er er or supported by um some towels. So a variety of positions can be used for this. So you can get the eye machine in and do what you need to do. And we often one of my mentors used to say and often the of and a lot of people say the front door to the elbow is at the back. So the vast majority of the elbow approach, which is as in with the distal humerus is a posterior midline incision. We don't usually curve uh the incision as it is. There just usually go over the top and it's a relatively straightforward incision that goes down the middle and then through the eu and ec U interval. Um So a relatively straightforward approach to get to the proximal ulnar, just being very wary of the ulnar nerve being not too far away. Uh And that gives you very good access to the fracture. So you can reduce it and then put K wires and a tension band wire in. So this is a tension band wire figure of eight construct as you can see here, uh which is probably still the garden variety way to treat the simple two a fractures. So those simple displaced fractures that don't show any evidence of elbow instability. And the tension by wire construct is this idea that it converts a tensile force into a compressive force at the fracture side. And you can see this very nicely from this diagram here, which is referenced and that's how the tension by wire works. And as the elbow gets moving, er and that tensile force is then converted into a compressive force. And it's the same when it's used in the patella as well. Um But there are alternatives now and the alternative for these more simple fractures. And I, and I think that's an important thing to differentiate. We had the type one fractures which were undisplaced or, and the type two Bs and three A s which are either commuted and or unstable the two A fractures where it's as simple as face fracture. There is this option of suture fixation. So it's using the concept of the tension band wire sort of um but using sutures to repair it rather than wires. And there's um my colleague in R and Adam w just an ex paper with his colleagues and joy. How about how you do this, um this fixation and it's something that we have started to do more and more for these injuries. Um And this is sort of the image, you get a simple type two, a fracture that has then been suture fixed and then has gone on to heal in a very satisfactory position. Slightly strange because you don't see any metal work there and it's a bit of an odd feeling that um but it's a very good technique and does work in the right with the right indications and there's various nuances into it as well. And why that's become a an option is really related to this. One of the big problems with tension band wiring or plate fixation, but particularly tension band wiring is where it is if you imagine where your electron is and it's very prominent um over the bone, the bone is very prominent right underneath the skin. The metal work also is very prominent and it, it can irritate patients, it can cause wound breakdown. And so the necessity for a further operation is not uncommon with these. So anything up to 30 to 50% even intention by wiring, anything from 9, 1020 to 20% in pla fixation. And so quite a variety there, but it is definitely documented there in the literature. And that is a that is a problem because obviously that's a further surgery for the patient. It's another further risk for the patient. And more importantly, it's cost related as well, isn't it? And, and well as important, but just as important, um, it's cost because actually going back to theater is an immensely costly thing for the health service, which is already strained as it is. And so to try and avoid that is the best thing possible. And as you can see there, the rate of having to go back to surgery to remove the um the suture for pro pro is, is, is negligible if not zero. Well, that doesn't mean it's without complication, but because of that main complication being implant removal, it's a very appealing aspect and there's been a, a variety of retrospective data. So data looking back um approving this and also with data that's been compiled together in the systematic review and meta analysis, looking at those various implant irritation and reoperation rates. And it fairly comes out in the literature that with suture fixation, it's very low, which has led to the soft trial which we've just completed. This has been led by my colleague, Aam Watson in writing them and we were coop and on it here in that has completed and is due to publish very soon, the findings of suture fixation versus 10. And that will be an important paper, a very important paper from this trial looking at if there is a benefit to that in terms of um particularly that return to, to surgery, return to theater to remove prominent metalwork. And that's one of the big areas that people are looking at at the moment and let her on fracture fixation. Um But I think it's also important not to forget the role of non operative management. I really, um we've done a lot of work here in Edinburgh based on this, in terms of the role of anor management. When you have a displaced fracture, it can be commun or not. Um but you have a stable elbow joint and that is key, you must make sure that the elbow joint is stable. You don't have this anterior translation that we talked about. And in elderly patients, we have often said low demand, but I question that more and more whether it's just elderly patients who um um er cope with this or even maybe younger patients could as well, but they seem to do incredibly well er with non operative management of these patients. And, and you get this classic scenario of, of these patients being seen six weeks, three months, six months down the line, they're doing lots of things with their elbow. Er, they have a good functional arc and they have a little, little complaints and gradually over time. There's been this build up of evidence from retrospective studies, there's been AAA small RCT as well and all these retrospective studies have shown that the patient outcomes are very good and the reintervention rate for a painful non union is negligible. Um And there we have recently done a study with a team in Stanford trying to combine all this together as part of a systematic review and meta analysis and shows actually the DS scores are even better in the narrative of management and this is elderly, lower demand patients, er when no management is used compared to plate fixation tension by wiring and the reintervention rate is negligible and that includes some data from our very small prospective randomized controlled trial. Er And there is a third one that's come out called um I believe Sophie, it's called, which has come out from Australia, which has corroborated that and that was in the JB GS just this month. Er And so there is certainly a role for management much broader than with distal humerus fractures for these injuries. And that generally there, as you can see is our general algorithm. We publish this algorithm in the B JJ about how we manage the electron fractures. And, and one of the key aspects, as you can see there is making sure the on the humeral joint, the elbow joint is stable and there's no anterior translation and then determined on the fragmentation, determining on the um the level of um er the activity of the patient. Um We then determine what management is required. So we've done the humeral shaft, we've done, we've done the distal humerus and we've done the electron and just going on to a slightly less common, but M and a very briefly, more complex injuries around the elbow just to give you a flavor of the type of injuries that we do treat around the elbow. And then I'll finish off with a distal radius, the terrible triad injury. This is um uh probably the one of the more common complex injuries if that makes sense. Uh This involves a posterior dislocation of the elbow, um and a radial head fracture and a coronoid fracture. Um So it's a classic injury pattern that we see an unstable injury frat with which the vast vast majority are treated with surgery. It's very important when doing any elbow surgery to have a very clear understanding of the anatomy of the elbow really essential for these type of injuries because the injuries I'm about to talk about these next to they are a AAA complex fracture of the elbow. They involve both bony bony injury and soft tissue injury. And that's a really important concept. So I thought I just very briefly touch upon the anatomy that's important in terms of the radial head has a very distinct shape, elliptical shape. It forms a radial capitellar joint. It's really important to understand where it sits, particularly relative to the sigmoid notch as you can just see there on the top, right. Um um And that's important particularly when we're not repairing, but more importantly, replacing the radial head as part of this injury. Cos we mustn't overstuff the joint. And that's when you make the radial head too tall, almost for a better word in this joint. And it opens up the other side and causes problems with wear and d and discomfort. It's also important to know where, where you can place any metalwork to try and make sure it doesn't um irritate the proximal radial ulnar joint as you can see there. So, moving on to the coronoid, the coronoid is, is the key to any er intraarticular fracture of the elbow. It's this structure, as you can see here as part of the proximal ulnar. And these days, often a lot of us break it down into three columns which relate to their rights and classification with the radiocapitellar joint being one column, the intralateral facet of the coronoid being the middle and the antra media facet being the medial column. But the coronoid is absolutely key to regaining elbow stability and regaining stability of the ulnar humeral joint. And it's something that we will always chase very hard in terms of how we fix these, we sort out these injuries um er particularly and then it's also understanding the soft tissues in terms of the lateral ligamentous complex, the medial ligamentous complex as well as the secondary stabilizers that occur, er that are, are part of the elbow, including the common extensor and flexor or origins. So, the muscles that cross the elbow because what you're really chasing with these injuries is you're chasing stability, you need to get stability so the elbow can be moving, so you can prevent stiffness. That's the key to most elbow injuries to be fair. Um And there are various ways that we can classify them or often in relation to the radial head. I, I'm going to talk about these two here. I'm going to talk about terrible trial and the proximal fracture with the radial head fracture or fracture dislocations. Um But there are other variants. And um for those of you who are really interested there is this classification system that's been published in the bone and joint journal by, again, by my colleague, Adam Watts. And I think this provides a very good template for these more complex injuries and how we manage them. Um So these are often um when we're in theater, managing these er terrible injuries, often supine with an arm and an arm board. Um It's often a er you either do a posterior incision but a postural lateral approach er either through what's known as the cocker, which is an E and K syndrome or the cap cap, which is uh as you can see here, slightly more anterior um um from it, but often you're using the incision, the patient gives you. And what that means is there's often trauma, the trauma associated with it is disrupted these soft tissues. Um and the lateral ligament repair is a very important part of these terrible triad injuries you can often also use the void approaches, which is coming in the back, er, which is very useful as well. And so there are a variety of ways we can get to these injuries and deal with them and it's very much surgeon preference and this is how these injuries are classically treated. So you end up with a, uh you either fix or replace the radial head often with a terrible triad and it's a very distinct injury pattern. We don't, you often there's advocates now for not having to fix the coronoid, it's a very small, an interlateral tip that's not important. But generally, people will have suggested fix the coronoid fix or replace the radial head and then you repair the lateral ligament complex and you can see there's just a, a faint hole you can see there, which is where we put our suture anchor to repair that ligament back on. Um, and the most important thing with these injuries is getting the elbow moving because stiffness is a huge, huge problem, er, for these injuries and, er, and, er, and after the surgery as well and I think that's what most of the patients always have to be warned for. And then I'm gonna just touch very briefly on the complex fracture dislocations. These are probably the most malignant injuries we deal with around the elbow where there's an involvement of both sides of the elbow or, or, or a complex injury around the proximal ulnar around the coronoid. Uh And these are really challenging, really challenging injuries to treat. As you can see here, complex coronoid fracture, there's approximate all the fractures, there's a complex radial head fracture as well. Um And there's instability of the elbow and this has the full gambit of issues that we have um um in terms of injuries around the elbow and we often set these up with an arm over the front. Uh and er having the ability to put the arm on the armboard. Cos multiple approaches can be required to try and fix these injuries as you can imagine. Er, and usually we come in the gap the back again, the posterior midline incision, er, and we go down through this interval um and then we can access everything through the off the proximal and the fracture and also the radial head through the boy approach all around the side. Uh but it's, it's a very complex injury pattern um to, to manage, often we can get to the coronoid which is often involved through the proximal. We can have a look at it and reduce it and decide whether we're going to try and fix it through the plate or whether we're going to need to do a separate incision where we come around the side of the elbow and do a medial approach to the elbow, which is a bit different. And it's common to use where we have to plate the coronoid from the front. So multiple various options that may be required for these injuries. And this is generally how we manage these injuries. As you can see here in terms of fix or replacing the radial head, you fix the proximal ulnar and the coronoid and the um as you require and then repair the cla movements as needed. And these are very challenging injuries to treat, they have very complex outcomes or, or guarded prognosis is probably a better term and you have to be very cautious with these injuries. Um, um, er, in terms of when counseling the patients, but um a, a real challenge to treat, but I thought I'd just mention those because those last two are rare but they are, they're very much more complex surgical um, er, injuries that we manage, er, around the elbow. So touching finally, I was gonna be for about 40 45 minutes to take any questions, but for the last 5 to 10 minutes, I'm gonna talk about distal radius fractures. So, moving down to the wrist, um, er, the, what I did think about speaking about other injuries such as a forward, but, you know, they are a lot less common and less commonly operated on as well and I think disor fractures are, are really, they are most common injury. Uh, there's a lot of complexity in how we manage them which I hopefully will um, go through, er, and, and, and, and maybe shine some light in a few important papers in this area. This is a very common situation that we're presenting with in our in orthopedics in our clinics. You know, a, a um a, a postmenopausal woman is a very common in and is the name of the index fracture postmenopause and then lead into potential into fragility fractures and osteoporosis. Um And um they've got a dorsally displaced fracture off the back uh from a low energy fall. Um and they have some comorbidities and this is the very, very classical pa pattern and that these injuries and type of people and patients that these injuries occur. Um So just briefly going over the assessment of these injuries as we did with the humor a because it's just really important to assess obviously as with all of these injuries, a neurovascular assessment um assessing for an open injury. Um but in, in particular for the, there's a rate as well as assessing the median nerve. So assessing for carpal tunnel syndrome. So understanding those radial 3.5 digits, if there's any reduced sensation there, it's very often difficult to assess for power because the patients are really sore. But that's a really key part of the assessment of these injuries and having a very clear understanding of the anatomy of the radius. Um in terms of the normal angles that we're looking at on a normal X ray and how they differ from a fractured, a fractured wrist So, in terms of the normal volar tilt of approximately 10 to 11 degrees, you know, the radial inflammation, um the understanding of the scaphoid and lunate facets and the aspects of that. Um and also understanding, looking for things such as the ulnar variant. So the radius is normally ahead or in line with the ulnar. Um but often with fractures, it's more prominent as you can see on that original lecture where it's broken. So the ulnar is taking more of the uh of the load and the um articulation than it should be. Um And then looking at overall and the lateral of the carpal alignment and what we mean by that is a line running through the carpus and the radio station intersect uh in this area here. And this is a, for example, a fracture that's come off the front that's gone in a var direction compared to um the dorsal direction which we just saw the dorsal or a colleagues fracture often is, it says is a lot more common than the var displaced fractures. And those are the important aspects that we look at every day with just the radius fractures. Um And what we are looking at as um and trying to determine how the patient needs to be treated. Um But if we come back to this case here, the most important thing to consider always is the patient and we'll come on to that by our definitive of managing them but a lot of these injuries, wherever they're treated, uh, often undergo a manipulation. Now, in here in Edinburgh, we use a, a beer box surface so they use it done in the A&E department under a, a region anesthetic. We're using a bear boxer and we often use a reduction technique that you describe there to pull them back into a good position and they get casted and then they come back to clinic, er a week to 10 days to determine if that, if that position has been held. So have they lost position going back to their original patient after these original, like after its original reduction? Er and then you often get them coming back to clinic at this stage and you what you either see it's holding position or you worry that this is coming off the back end, you see this is going into that er dorsal displacement again and carpal malalignment. And that's a really important reason why we see these injuries relatively soon after their reduction and then how we definitively manage them is often down to the patient. Now, there are young people with these fractures, there can be complex injuries, high knee injuries and they are a different, a different category. But the the garden variety of just the radius fractures occurs in elderly patients or older patients, we should say and actually how you treat them varies because they all have different functional demands, different and different expectations and So that's the most important thing when you determine how best to treat these injuries. But and one important aspect of that is um is malunion. So the distal radius will almost always heal and if it heals in the wrong position. So a malun position off the back, the effect that has on the patient is a little unknown. But what we do know is there is a relatively poor correlation between the final position of your wrist on a X ray. And the patient reported outcome measures that we collect as part of our studies. They don't often correlate particularly in older patients. And that is not ii think just due to the functional demands of the patient, there's something the way the risk compensates as we get older that we don't really understand, I think um and that's why there's a huge amount of interest. And a lot of the research in the past maybe decade in these injuries has been looking at non operative versus operative management in older patients with these injuries. And there's just a smattering of the big randomized controlled trials and we're doing our own trial e force which is um ongoing in I think that's one of the key areas that has developed more and more literature in this area and certainly something to be aware of. But the other studies to be aware of are obviously the draft studies. So there's the draft one and two studies that have been published by our colleague, Costa and his colleagues in Oxford and throughout the UK, big N HR trials, um, and they've looked at, um, not only plates versus KWS, they've also looked at KWS versus just manipulation. And these are really important studies to know about and have various implications about how we manage these injuries. And I think there's certainly something to be aware of. Um, and I think what's interesting about the draft two study is obviously that there was a subtle difference between, you know, mu A and K wires were slightly more costly. Er, and er, but, but, but K wire and K is unlikely to be cost effective in these older patients or adult patients and these were actually in all comers. Um but there was a re intervention rate. So if you don't put the K Ys in or fix it with something it does, it does fall off in a number of patients. There are other techniques you can use, you can do plate fixation. As we've said K wires, there's um er, er, non bridging X fix, there's bridging X fixes. There's a variety of techniques we can use. Often it comes down to K wires or fixation. Obviously, the drafts study looked at those and um there was no difference in the draft trial between the, the fixation or plates. But what the one caveat is that it's only applicable to in fractures, which you can reduce clothes, which in some of the intraarticular fractures, you can't um and when you look at that in systematic review, they're overall relatively comparable. What? But what is important about that is in patients where you have reasonable bone and you can reduce it close. K Ys are cheaper and seem to give you an equivalent outcome. So if we are gonna fix these often with a um a plate and screws, if we can't reduce them close, then for more complex injuries, we use something what the modified Henry's approach is probably one of the most common approaches, er um that you'll basically see in trauma theater as you go through um your undergraduate and post work if you're interested in orthopedics. Um and something that's often a part of an exam question that um all the way through your, your training, if, if truth be told. Um and this is, uses an incision, which is based on um in line with the F cr the F cr tendon and you come through the better of scr, you move FP out the way and then you're down to what's known as pronator quadratus as you can see here, being very cautious of the, the median nerve, the, the palane branch of the nerve and the radial artery being either side of you and then you take off pronator quadratus and that will expose your distal radius. And when using plate fixation, er, in this way, it's very important that your plate is um positioned in the right way. These are, er, locking plates. What that means that these distal screws are locked. So they're holding that surface up from a dorsally displaced fracture. Um, and the position of these plates are really important because if they're positioned poorly, er, they can lead to problems, er, with, um, er, irritation, metalwork, irritation, um, and irritating, the, the pelvis can irritate the tendons at the front of the wrist. And that's a really important concept. You'll see when we're placing these plates is make sure they're, they're, they're not too distal or past what's known as the watershed line there. So they don't irritate the tendons cos if they do that can be a real disaster and that's what we're sort of looking for some fixation. And if you want to critique this, you could say that plate is slightly prominent and you also would worry potentially that these screws are not penetrating through the back, the do aspect of the wrist. And I and I pick these liberate cos you want to pick and make sure that when you do your final x rays in theater, that you, that those screws are not proper on the dorsal surface of the wrist because they, again, they can rotate the extensor tendons on that side and the plate can in the flexor tendons in this size. And there's various views you need to do in the theater um, rather than the standard ap and lateral to try and make sure that you um our screws are positioned correctly. They're not going to allow fracture collapse, but also they're not going to irritate the soft tissue structures. So that's me. I think in terms of um er our objectives, I think, I hope I've given you an oversight of some of the common injuries that we treat around the elbow and wrist and the surgeries that we do and how we do them. Um uh and the the common surgical procedures that we use for these injuries. Um There is so much more we could potentially talk about, but obviously in the trying for 45 50 minutes, um I thought these was the best things to cover the common injuries as well and the exciting injuries to see. Er but also I really do hope I've given you a flavor of um the research in this area and the current advancements and how one thing I love about orthopedics as with medicine is it's constantly evolving. There's always new potential techniques and innovations and trials and research to try and determine what are the best options for our patients, what gives them the best and the most optimal outcome uh and also, which is important to all of these studies and some of these big NIH R trials that I've mentioned already, a key aspect of those, those studies is the health economic analysis. So actually are what we doing not only effective and good for our patients, but also is it um cost effective? And that is such a hugely important aspect, excuse me of how we treat our patients, er, particularly in a health service such as ours, which is, which is resource depleted, resource, resource restricted. So it's a really important aspect that you know, we should be doing the best for the patient but also the most cost effective thing for the patient as well. Uh That's me. Thank you very much. I hope um I've really enjoyed it and if there's any questions, I'm very happy to take. Thank you, Mister Duckworth for the great talk. So I think we'll have some time for questions. If anyone wants to ask any or alternatively, if you have a question you like to ask more in private, we have an option in our feedback form, ok? You can just fill up and there's an option at the end for you to ask any questions you want and we can forward them to dow and we'll be able to forward them on to you. Of course. Yeah, I'm very happy to do that. Yeah, but in the meantime, if you guys have any more questions, feel free to ask away. So in the meantime, while if you guys are talking about any questions, we do have our fourth talk which will be hosted on the visit of Aberdeen's Trauma Orthoped Society page. It'll be on for that ankle surgery and Mr sent a trauma or surgery from Aberdeen will be talking about that as well. I'm just gonna put the link in the chat. So do sign up for that as well. Thanks for the question, Brendan. I'm just really is now. Um, yeah, that, that's a good, a good question. Um, generally not. So for the terrible triad injuries because of the nature of you've, obviously with those, you've got a very small coronary fracture. Er, you've got, er, obviously a radial head fracture and an elbow instability. Er, so generally not, you can often provide um enough stability and fixation um through your soft tissue and bony repairs that an elbow arth plasty is not indicated. However, um it's not something that, you know, something that always may be in the future for the patient, hopefully unlikely. The, the great thing again, the advances that have been made in the management of these injuries has been, has been such that actually, although they are guarded prognosis in terms of stiffness, they generally do quite well as long as you regain stability to the elbow, um they generally don't require um any arthroplasty at all, but it's an important question, but it's the elbow arthroplasty in the, in the aspects of trauma is predominantly predominantly in the, in the situation of a distal humus fracture in the elderly patient. Uh And I think the most important thing else I should have pointed out is that the thing with an elbow arthroplasty, I think a third level. A a plasty is it does have restriction on the pa on the patient. Potentially, there are restrictions and potentially what they can lift. And so it really is for a uh the lower demand potentially patient um with more complex, with more complex injury. Um Yeah, I just looking at your for Electromed treatment in the NHS um very few. So, e electro bursitis is a um a thing that we very rarely see now admitted. Um, they can sometimes be infected so they require IV antibodies. But our indication for aspiration or any surgery is very, very limited. Indeed. Uh, the main reason for being that is that actually you can potentially make things worse if, if you, um, are, are you do surgical drainage of it problems with the wound ever healing, which is a real issue, er, and the same, when you aspirate it, you can cause skin breakdown, but very, occasionally we do need to do that in refractory cases where it doesn't settle down. Um, and, you know, you have to take the bursa out at a later stage once, er, if it's becoming across irritable, um, once the infection settle down, but it's not in the certainly in the infective stage, which is what we often see. It's very rarely indicated. Um, I really, I think I've met a few patient, the patient patient, you've talked about surgery for not, not helping but not, not really. Yeah, that, that's, that's true. Yeah. No, I think that is true. And I think electro bursitis is one of these things which is slightly difficult because it is very problematic for the patient. But there really isn't a very good surgical solution to it. Um, and aspirations do occasionally work but they often reaccumulate. Um And what you're really trying to prevent is that recurrent infection you see there. But it, it's something I personally very, very, very rarely operate on if, if, is there any more questions, but if not, is, is there anything else you want me to cover? Hm. No, that's pretty much it. So I think you just end the talk there. Thank you, Mr Duckworth for having for the great talk. 00, sorry, I've just, there's another, ok. What's your thoughts on repairing PQ? Oh, brilliant question. Very good question. Um I don't repair PQ. Um Some people do. So that's the question is about when you take the pronated quadrati off and just arrange fractures, whether you repair it. Um um I don't cos er, there is to my knowledge, no evidence that it improves the outcome of the patient. Some people believe in putting PQ back, laying it back down on the plate, which I think is a reasonable thing to do to try and protect the overlying tendons. Um But to my knowledge, there is no evidence that suggests that the patients have a superior outcome. If you repair PQ, I may be wrong but I think there is a randomized controlled trial that compared repair of PQ versus no repair. And I think actually, ironically the pronation was worse in the patients who had their PQ repaired. So, um, uh, I may just quing that Beth, and that's true, but it's not something we routinely do. Just no problem. Ok. So I think if there's any further questions, you guys can just put on the feedback for, we'll forward it on to you, Mr. Ok. So thank you everyone for joining and hope you guys have a great evening. Ok? Thanks very much. Take care.