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Examination of Shoulder and Elbow by Mr Amir Varasteh

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Summary

In this on-demand teaching session, ST3 registrar Amir leads a hands-on exploration of the complexities of shoulder and elbow examination. Tailored towards medical professionals seeking to refine their practical skills, Amir draws on rich anatomical knowledge, focusing on the structures critical to a sound examination - from rotator cuff muscles to ligaments. Equipped with an appreciation of the relevance and potential signs of underlying pathologies such as long head biceps tendon injuries and labral tears, you'll then delve into the details of carrying out patient examinations. From initial inspections for signs of atrophy and chronic supraspinatus tears, to more nuanced examinations of clavicle symmetry and scapula winging. Develop your curiosity for patient history, learning how to identify and code pain trends that may shapeshift diagnoses and treatment plans. The session also sheds light on key muscle grading systems to best record and track your examination findings. This deep dive is perfect for those looking to boost their confidence, competency, and compassion in common —yet crucial— clinical practice.
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Description

Examination of Shoulder and Elbow by Mr Amir Varasteh

Learning objectives

1. To explore and understand the anatomy of the shoulder and elbow joints, with a particular focus on the muscles and ligaments surrounding these areas. 2. To develop a strong understanding of the role of history taking in the diagnostic process, specifically gathering information about the nature and onset of the patient's pain. 3. To understand and identify common physical signs in patients with shoulder and elbow pathologies, such as atrophy, asymmetry, scapular winging, and the Popeye sign. 4. To familiarise with and execute a structured approach to examination of the shoulder and elbow joints, including inspection, palpation and movement testing. 5. To evaluate and interpret the results of a physical examination of the shoulder and elbow joints, linking clinical findings to potential diagnoses and treatment strategies.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

So we're live now. How do I see who's here? Mhm. Ansa Mohammed, Nicola Adams. Yeah, you can see. Ok, so we will start in two minutes. One. Excellent. So your perfect. So anyone who's not here? Can you guys hear me? Can you hear me now? Perfect. Excellent. So we shall start in a second kids. OK. How are you? Ok. Are you? And so I don't understand how you guys can do it, man. It repeatedly nonstop stress. It never ends as hard as you work. It doesn't end, does it? Yeah, it's like at least you have a list on my board. Finish it finished. Yeah, it's like we don't have a list of sitting around constant work. I liked the A&E until I figured that part off and I was like, right, I'm running for the hills. Brilliant. So guys, let's start this session today. My name is Amir. I'm one of the ST three registrars here in Worthing and I'll be talking to you about examining shoulders and elbows and we'll go through a little bit of some of the basic principles around elbow surgery. So kicking things off with a bit of anatomy. So the shoulder joint. The main things you have to appreciate is the rotator cuff muscles that are surrounding it cause that's really what we are examining. And that's what uh where the pathologies lie. And in your examination, you're trying to identify where the pathology is by, first of all, really good history taking, trying to figure out where, what, what activities causes the patient pain um and be very specific with the patient and try to get them to tell you about specific instances that cause them pain. And they will tell you when I do my hair, when I try to get my bra from the back, or when I try to lift my arm to get the cup from the top cupboard. And those things, history is really key in determining your focus of your examination. And also the nature of the pain is quite important. So it's really important to figure out. Does it come on with movement? Is it always there? Does it wake you up at night? Does it feel sharp in nature? Dull in nature? Because there's a lot of referred pain to the shoulder from other areas? So the history taking is quite key in sort of assessing where the pathology lies and then you focus your examination to try to sort of elicit signs to confirm what you're already suspecting. So the main muscles we need to talk about. Obviously, you've got your deltoid muscle overlying the whole thing supplied by the axillary nerve. And remember the deltoid has anterior medial and posterior sections that do different things. The rotator cuff specifically, you've got the supraspinatus in the supraspinous fossa attaching to the greater tuberosity of the superior aspect supplied by the suprascapular nerve. You've got the infraspinatus just below that also attaching to the greater tuberosity supplied by suprascapular nerve and terus minor. Below all of this supplied by the axillary nerve around the front. You've got the um subscapularis muscle, which is innervated by the upper and lower subscapular nerve and attaches to the lesser tuberosity. And between them, you've got the bicipital groove here with the long head of biceps, which if you appreciate on this top diagram attaches onto the superior aspect of the labrum. So many times if you ever heard of thing called a slap tear, this is what we're talking about. So, anterior labral lesions and pathologies can involve the long head of biceps tendon and a lot of times the pain can come from here. And so on your examination, which we'll go through a little bit later. You need to be aware that the long head of biceps tendon goes in the joint and can cause pain sort of in the shoulder joint itself. So again, looking at its side view, you can see the muscles here, there is minor infraspinatus, supraspinatus biceps here and you've got your subscap at the front and you've got your glenoid here. It's also also important to sort of point out the ligaments um sort of between the coracoacromial and coracoclavicular ligaments. These are also key. So you do need to learn about these when we talk about the lateral clavicle fractures, but that's out of the scope of this talk today. So when we go to examine the shoulder, after we've taken our history, we kind of have an idea in our head. What we're sort of looking for things to look on inspection is generally your deltoid mass looking for any atrophy from the left to right side. Is there a problem? What can you see it? Yeah. Oh Yeah. Now you can see it now. Yeah. Fine. So, did you see this slide? Ok. Fine. So this isn't important. I'll go back through it again. So you've got your subscapularis around the front and that attaches here on to lesser tuberosity and you've got the long head of biceps that goes in the bicipital groove and attaches. No problem. Can you minimize it, minimize it? Does that solve the problem? Yeah. Yeah. So you can see it like that. OK. So, yeah, happy there. Yeah. You see it well enough. So long head of biceps goes and attaches to the top part of the labrum in the joint. So that's quite an important thing to note because a lot of superior labral tears will involve this tendon and that's when we call it a slap tear. So that's something to sort of think about when you're examining patients who you think have labral pathology, but subsequently sort of also examined to have a bicipital uh pathology. So this could be implicated here. And then the muscles we spoke about supraspinatus, infraspinatus and Teres minor coming around and attaching onto the greater tuberosity and the innervation I already told you about. So then when you go to see the patient things to look at is just a general muscle mass. So you're looking for any atrophy, any asymmetry between the left and right side, um any previous scars that might represent previous surgeries, and then you can start sort of having a look at atrophy of the supraspinous and infraspinous fossa. Again, suggesting of pathology, potentially a supraspinatus tear. If it's chronic, you will have atrophy with it. So if you notice atrophy, it can suggest tears. You have a look at the clavicle, see if there's any asymmetry between the clavicles. Cause again, you do, you've seen the patient in the elective clinic, you don't have x-rays. You don't necessarily know if this pain is coming from the clavicle or not. If they've had previous c clavicle fractures, et cetera, you also wanna look at the scapula around the back, initially, get them to just stand, normally have a look at it. Look for any asymmetry, then get them to stick their hands up onto the wall and look from behind and you'll sometimes find winging of the scapula again, that usually represents neurological pathology and it's something then you need to examine the scapula further and perhaps come get nerve conduction studies and MRI scans to assess this further. The biceps, you've got the Popeye sign and the reverse Popeye sign, which are the same thing, the Popeye sign, the deformity is slightly lower, the reverse Popeye sign, uh the bulge goes a bit more proximal and that's because the distal aspects of the biceps origin has to insertion have torn. So the whole biceps muscle has come up. It's not necessarily a significant thing where you need to sort of think oh, immediately. And this patient needs surgery. The patients who do need surgery or your younger patients with an acute tear, especially the other thing to think about electricians because there are people who do a lot of supination where they're tightening screws. So there are someone who you need to tell them about supination weakness. If you're gonna treat it conservatively, the other cohort of patients talk about the pop up signs specifically is bodybuilders because they often get bip care steroid use, et cetera and they come in and sometimes want to be managed conservatively. But you need to tell them you will have that deformity for life. So if they are aesthetic bodybuilder who goes to competitions, that may be a problem for them, so you need to have that counseling session. But if you see the Popeye sign, think biceps there and we spoke about scars before palpations. So in my head, I always start with a clavicle. I start with the medial end of the clavicle and work my way around to the A CJ and IW work my way back to the spinus process of the scapula. I have a feel of the um sort of la medial edge of the scapula, the lateral edge of the scapula, the supra and infraspinous um fossils I have ii palpate all of this to see if there's any tenderness there, then I come around, I palpate the humerus itself, the coracoid process and sort of the in the anterior shoulder, I try to palpate the bicipital groove which you can feel in younger skinnier patients. So again, if the tenderness is right in the bicipital groove, again, makes you think the pathology is bicipital in origin as opposed to directly from the shoulder itself, then we move on to movements. Again, these patients will that you're seeing will be in pain. They're not gonna be normal patients. So the best thing to do is ask them first of all to show you active movements. So you know where their limit is. So I ask the patients to sort of flex the shoulder first as high as they can. I mark what level that is. So if they can go up to 90 I say active 90 then I take their and I say, relax your hand into my hand, relax your arm completely. And then I take them further, telling them, let me know if it's painful and I will stop cause sometimes you will yank them up and they'll sort of get annoyed at you for causing them pain. So slowly, actively go up until they say it's painful or stiff. Here, mark them how much further you could go in the passive direction. Similarly, with abduction, external rotation, you mark sort of the degrees of movement both actively and passively for internal rotation, it's slightly different. So in this diagram, they just show going to the tummy, but actually the best way to do it is to get the patient to put their arm behind their back and see how far up in the spine they can go. Some people will go to the level of the belt, some people will go to the lumbar spine. Normal is to be able to reach your thoracic spine. So that's how I record my examination findings in on calls and clinics is as to what level of the spine they were able to take their hand through quick reminder, reminder of the MRC muscle grading system, again, you should be grading them uh based on 0 to 5 normal. Normally, these patients will be sort of 3 to 5 when you're seeing them in the elective clinic. But if you're seeing them in A&E they may be lower or below. So again, good to make sure that you are documenting your power grade accurately using this system. The other thing that people talk about when they speak about the shoulder is this painful arc where patients in the initial period don't have any pain above 60 to 100 and 20. They find it painful and then from 20 to 80 they again, don't find it painful. This is common for subacromial impingement and it is suggestive of impingement. Um So that's just something to think about. That's your basic shoulder examination and you can test the power of these muscles as well. So with flexion, you've got your deltoid mainly coming in the anterior part of the deltoid and your brachialis muscle with your um abduction. Again, it's deltoid with some infraspinati supraspinatus, getting involved a little bit of infraspinatus and then external rotation is your um infraspinatus Antero minor and um your internal rotation is your subscapularis. So, moving on further to special tests, we then have these weird and wonderful examinations for the shoulder that all have specific names, but they all kind of make sense. So once you've done your basic examination, you move on to thinking you now have a better idea of where the problem may be. So you want to do special test to clarify and confirm your suspicions. So to test for the A CJ, we have the scarf test which you ask the patient to flex their shoulder to about 90 bend their elbow a little bit and you ask them to reach for the other shoulder. A positive test is when doing this and it elicits pain in the A CJ. Cause if you think about it, when you're doing this, you're squeezing the A CJ together. So if the pain is coming from the A CJ, by doing this, you will elicit pain and you'll feel it over their A CJ. So that's sort of the scarf. That's easy one done. The subscapularis lift off test is how we describe internal rotation. Ask them to put their arm behind their back, check the level. Then what you do is you put your hand against their hand and you ask them to lift off normal examination, they should be able to push against your hand. But if they've got subscapular pathology, it will either be weak or will elicit pain. So that's the way you would assess if it's subscapular sort of pathology versus others. The sulcus sign is one that's rarely seen. It's usually seen in patients with sort of multidirectional instability of the shoulder. These are your recurrent shoulder dislocator who you guys see commonly in A&E coming week after week with shoulder dislocation. They are the patients you might see this on. What you do is you ask the patient to sit upright, you pull down their arm and you have a feel in the sulcus above it. It's this basically, if you see this sort of sign could be being present once you pull the patients on, that's when you know they have likely got multidirectional instability and that's you have to sort of assess them further, potentially MRI S and think about what else we can do. The other thing is a lot of times in this, I saw many times last year in clinic patients come back and forth to clinic with shoulder pain. MRI S are normal, no one can get on top of the pain out or why it's causing the pain. And when you dig deeper, you find out actually that it's to do with rotation of the neck. Sometimes they say or sometimes they describe radiating pain into the shoulder or sharp pain in the shoulder. When these things happen, it should make you think is this coming from the spine as opposed to the shoulder. And I've seen this many times in clinic, you ask the patient to do the Spurling test. So what I tend to do is ask them to look in this corner of the room, bend their head a bit towards that way and apply axial load. I let you tell them this is gonna feel weird and press on the top of the head positive test. They will get radiating pain to their shoulder. If you notice that you get an MRI urgently many times they have multilevel disc disease, cervical myelopathy. And the treatment is with the neurosurgeon and not with us and people are injecting steroid into their shoulders thinking it's the oa in the shoulder. But actually, it's coming from the spine. So that's something to always consider when you're examining shoulders in the elective setting. The Hall Kings Kennedy test is a test for subacromial impingement as well. So you get the patient to flex their shoulder up to 90 degrees, you internally rotate their shou their shoulder and keep the elbow at 90 degrees. And with one arm stabilizing the elbow, one arm on the forearm, you get the patient to bend their arm downwards and you do this in multiple planes. So you have them fully extended, you try that and you move them in different directions and you keep pressing down and if they have subacromial impingement, they will find this movement painful. That's the Hawkins Kennedy test moving on, you have the nearest test which looks for labral or a CJ lesions. So in this case, you get the patients to flex their shoulders internally, rotate the arm and you hold on to their arm, ask them to relax and you quickly flex their shoulder up. And if they find pain over the anterior shoulder, that is suggestive of labral or a CJ lesions. And that's called the nearest test. Now o'brien's and Jobs test are essentially the same thing, but one of them is with the arm abducted, the other ones with the arm abducted. So with o'brien's test, you adduct the arm, you flex the shoulder, you adduct the arm to about 1015 degrees, you get them to internally, rotate their arm so that the thumb is pointing to the floor and you get them to flex their shoulders up against resistance. If that causes pain, that is suggestive of labral or a CJ lesions with the jobs test, we put them into sort of the scapular line we describe. So it's about 30 degrees of abduction and in that plane you apply the flexion in with resistance. And again, if that's painful, that's a positive test. So that's these two right here. So essentially the same thing just in different planes, more special test of the shoulder is for the biceps. So this is where you've examined your shoulder. Now, you're thinking this is all normal. I don't think this pain is coming from the rotator cuff, potentially it's coming from the biceps. So you go to do your speeds and yoga sense test the speeds test. Basically, you get them to flex the shoulder up externally, rotate a little bit full supination and you put your hand on their forearm and ask them to flex their arm up while holding it extended. And that's sort of testing your long head of biceps. And you will be, will tell you that it's painful in the anterior shoulder. And that's again, suggestive of bicipital bicipital pathology or lesions. Yergason's test is slightly different. It's testing the supination of the biceps tendon. So you ask the patient basically shake your hand, you stabilize their elbow next to their body make sure they are not using their shoulder to compensate. And you ask them to then supinate the arm against resistance and see if that causes pain. Again, if patients have by typical pathology, that will be testing positive and that will add the pain. The other thing we do is looking at special uh apprehension test. Again, this is a lot of it is theory in clinic, it's a bit difficult to do this examination for two reasons. One is theoretically, you need the patient lying down and many times you don't have a bed in the clinic room that's working. But if you have, ideally, you get the patient to lie down to do it. The other problem is it causes pain and patients who've got instability, they're not keen on you trying to dislocate their shoulder. So they, they don't really want this to be done. But if you have a chat with the patient, explain it's gonna feel uncomfortable and why you're doing it. They will then let you do it. But you need to be aware that you're gonna cause some discomfort. And if you tell your patient that this is gonna feel weird and it might be uncomfortable and we need to tell you. So what you do is you get the patient laying down so that their scapula is lying flat on the table and it's eliminated from rotating you flex the shoulder to 90 degrees, you externally rotate them upwards like this and see if this causes sort of the feeling that the shoulder is gonna dislocate. If that's the case, you apply anterior pressure and try again. And if it feels better now with you applying anterior pressure, it's again, suggestive of instability. And this is someone you need to work up further, potentially offer them surgery. If there is labor of pathologies that need a dressing, that's the sort of um apprehension test and you can do it standing up. But again, it's more uncomfortable and it's more difficult to do it correctly. The other thing you need to think about when you've got patients coming to your clinic or A&E with multiple dislocations in the past is hypermobility disorders, connective tissue disorders and that we use the baton score to assess for that. So the baton score is nine points looking at specific areas of hypermobility. So you look at the little finger, whether you can flex it beyond 90 degrees, extend it beyond 90 degrees. You look at whether you can bring the thumb to touch the radius down here, you see whether the elbow hyperextends beyond 10 degrees, same with the knees, whether they hyperextend beyond 10 degrees and active flexion with the leg hold held straight, you ask them to bend over and if they can touch their toes without having to bend their knees, these are all positive findings and a score of 4 to 9 suggest hyperlaxity. So in those patients, they need to think of family history of connective tissue disorders, et cetera cause those patients will have hyperlaxity and you need to be a bit more careful when offering them surgery and counseling them for surgery as they'll have a higher risk of failure and repeated dislocations. So that's the sort of summary of shoulder examinations. Now, moving on to elbow examinations, there is not that much to examine in terms of sort of just your basic examination. So you've got your flexion extension pronation and supination. And you basically, you want to measure the degree in which they can extend from 0 to 100 and 60 supination pronation, whether they can get all the way to full supination and pronation. That's sort of the basics of it. The more complex aspects about the shoulder is uh the elbow is about the instability and the ligaments um sort of, and that's where the more in depth examinations come into. And a lot of times these are done under a general anesthetic with an ee weight. So I thought I'll introduce you guys today to the sort of concepts of elbow instability, the ligaments and the stabilizers in the elbow, as well as a few basic principles of surgery regarding the elbow cause I thought it would be quite a nice introduction for you guys to sort of see why we worry about ligaments of the elbow. So you've got your lateral and medial collateral ligament complexes. They're not one ligament there are multiple ligaments on both sides. So, on the lateral side, you've got your uh lateral ulnar collateral ligament, you've got your radial collateral ligament and the annular ligament, they all begin at the isometric point in the epicondyle. The lateral ulnar collateral ligament is the main one and it attaches to what's called a sna crest. Over here, the radial collateral attaches onto the annular ligament and the annular ligament goes all around the radial head. The main one is the lateral ulnar collateral ligament that provides the stability and the lateral side is providing v stability. So if those are torn, you get varus instability, meaning the elbow will go inward talking about the medial side. Again, you've got the anterior part, you've got the transverse and the posterior bundle, the anterior bundle is your main one that supplies the stability on the medial side. And it's, and it's stopping against the valgus stress. So, again, going outwards, the elbow coming in the arms going outwards. And it's this anterior bundle that's important which attaches to a place called the sublime tubercle over here. And that's the main thing. The anterior bundle is divided into the anterior band and posterior band. And if the anterior band is the main part that provides stability in less than 90 degrees of flexion, the posterior band provides the stability in more than 90 degrees of flexion. So when your arm is fully bent, the stability is coming from the posterior band when the arm is less bent, it's coming from the anterior band. And these are the ligaments that we worry about when we talk about instability. And the reason for it is this thing here, o'driscoll's fortress of stability. So this diagram describes what provides the stability to an elbow. So you've got your primary stabilizers, which is the outside fortress and then you've got your secondary stabilizers. So the main stabilizers is your ulnohumeral joint and then your anteria anterior bundle of the medial collateral and the lateral ulnar collateral ligament. So the two I just described to you those ligaments and the ulnar humeral joint itself, that's the main, those three provide the main stability to the elbow. On top of that. You've got then your secondary stabilizers, which is your radiohumeral articulation, your common flexor and common extensor origins. As you can imagine one being here, one being there right around your ligaments. They all provide stability to the elbow. But these outside ones are your main ones. And then if you notice the whole thing on by the outside is covered by the capsule. So the capsule is another stabilizer of the elbow um just to think about, but the main three is your ulnar humor articulation, the anterior band of your medial collateral ligament and the lateral ulnar collateral ligament. There are other stabilizers such as your radiocapitellar articulation, um your flexor and extensor mass we spoke about and these we've spoken about. So then the next thing to think about is when we talk about elbow fractures, we often talk about the coronoid process and whether that's involved or not. And that helping us decide whether we need to do surgery or not. There's lots of different classification and sort of um algorithms of treatment for this kind of injury. The one I seem to understand more and sort of makes sense in my head is called the writing classification. There's a good paper on this, we can review, I've taken some diagrams from it and I'll introduce the basic principle today. So this is the electron looking at it from the back side. So you've got your electron on here. This is your coronoid process. This is the subline tubercle where the anterior band of medial collateral attaches to. And this is then split into the anteromedial and anterolateral facet of the coronoid. And the reason why that's important is this. So when we talk about the elbow, in terms of its stability and fractures, you, the bright classifications suggest that there is a fulcrum and that fulcrum is between your anterial and your an lateral facet. So right here in the middle, the sort of main things that provide the stability are your lateral column and your medial column, the actual lateral facet is not as important because if it's the only thing that's injured, you still have your radial head and the lateral ulnar collateral ligament providing the stability on the lateral side, as long as your medial column, which is your intramedial tubercle and medial collateral ligaments are intact. So this is where the CT scans are important to assess where the fracture is to determine whether it's likely to be unstable and whether it needs surgery or not. So for example, if your radial head is intact, but your antral lateral facet is fractured, it's still gonna be stable because your radial head and lateral collateral ligaments are providing the stability for it. Whereas on this side, if you fracture your intramedial facet, you have instability cause there's nothing else on this side to block, to stop the block. The problems occur. When this goes, the radial head goes, your trilateral facet is still there, but it still causes instability. So that's when you have to address these things. So it's a little introduction. I would suggest you guys read this paper if you're interested in elbows and it goes into a lot more depth of fracture configurations, classify as A to D and specifically tells you if the fracture is here and there, how you should treat it here and there, how you treat it. So it's a little bit more in depth for that's not required for today's talk. But I thought I'll give you a little introduction into this sort of fulcrum idea. The other thing I wanted to sort of talk to you guys about is the tension band principle because this is something that you and you want to do orthopedics. This is will be asked in your ST three interview and it will be asked for me and my FR CS examination. This is a big topic, tension band wiring principles in general. So the idea is best described by this thing called an I beam. So this is like, you know, the eye beam, the metal rod that is used for construction that's sort of looking at it head on. Now, any time you get a transverse fracture where you've got load being applied to it, you get a compressive side and a tensile side, the progressive side and this is around the center of rotation always. So fractures want to rotate around that center of rotation on the compression side and the tensive tension side wants to widen. So what the tension band does, main thing is that so it converts tensile forces into compressive forces. But the way it does that is by moving the center of rotation to the tension band fixation. So without the tension band fixation, if you apply load up here into the eye beam and you've got a fracture going there, your center of rotation is here. So you're gonna get compression on this side and tension on that side and your fracture will collapse. Now, if we apply the tension band, which is right here, we move that center of rotation from here to there. Now what happens is when you apply the load the forces want to go this way. But because the center of rotation has been moved, we're not gonna get equal compression around the fracture site. So the whole thing wants to tilt. But because our center of rotation is here, it will provide compression at the fracture site. So that's the tension band principle and that's why we do it. So it's a, it's not just saying compression, inter tension, but it's about moving that center of the patient around. So I just interject there just completely, that's brilliant explanation. You, you explained it more clearly than I could have. One of the things is like um talking about the articular surface. So let's say this is a, this is where you see the X on the left hand side is the joint surface. OK? You actually get if you do what he's describing and put the tension band on the majority of your compression is occurring there. So you get slightly less compression here and it's increasing amount of compression, the more towards the articular surface you get. So that's why we use it really for articular fractures where we want to compress at the articular surface and we use them anatomically where it doesn't work is when the articular surface is comminuted. OK. So it's in bits and pieces, you need a stable uh area to fit the two bits of bone back together because then if you do a 10 right, it's gonna crumble in because the compressive forces are too much on that side and it will fail. So I exactly, no, perfectly. Exactly the same, the same, the same. Exactly. So you need that bone on bone contact. Otherwise it's just all gonna collapse around itself. So this is a, in any exact situation, you can always draw this eye beam. And literally the main things they wanna hear is compression, tension into compression and we move the center of her patient. Those are the key principles of it. Now, the other thing I wanted to sort of go through was this tension suture, tension band suture fixation instead of the metal work. This is a new technique that we're using more often in TNL surgery for electron on tension banding. And Mister Fatness has published this paper that goes through um his limited case series, which is now superseded by the soft trial, but it inside it, he describes the entire surgical procedure and pearls and pitfalls which we'll go through. So with this procedure similar to electron tension band wiring, you do a posterior approach, you expose your electron on you find your fracture, you reduce it, you put a clamp on it to keep it in compression. And that's when normally you'd begin your tension band wire fixation where you start putting K wires in and then passing your main wire around the K wires. But this is slightly different. So what we do is we cause the compression with plants then what you do is you make this tunnel using a drill. It has to be distal to the fracture site and it has to be a centimeter deep from the border of the ulnar to make sure that the tunnel you're breaking doesn't rip out. You make your tunnel, then you take your synthetic nonabsorbable sutures, you pass them from the lateral side to the medial side. You take a bite of the triceps, tendon, avoiding the ulnar nerve. You need to know where the ulnar nerve is. So that you avoid biting into that you go close to the bone as possible to get maximum grip into that tendon. You go back through the hole on the lateral side. Now similarly take a big bite of that triceps, tendon down to bone and you tie your knot on the lateral side to show why are we tying our knots on the lateral side and not the media side? Exactly. So you don't want your knots on the medial side cause your all the nerve is passing down. It will irritate that nerve. Then what you do is you take another suture, you go in from the lateral side again, but instead of biting the medial side, this time, you come out the medial, you go back to lateral, you bite the triceps on the lateral, come back to medial through your hole and then the other side. And t again here. So first one in, out in out you get your sort of U shaped suture next you come and do your figure of eight. OK. And the key thing is that these sutures need to be tight because this is what's providing your stability and your compression. So you need to make sure that this is done with the arm extended clamp is aren't creating the compression and that these have meticulous knot tying. You need to hold the knot down the, the what's it called the glavan so that it doesn't come out and everything needs to be super tight. So some of the things that Mister fat has highlighted in his paper sort of using a nonabsorbable graded suture. So similar strength and fatigue properties to steel wire. So they don't sort of elongate after some time compress the fracture using a uh pointed reduction clamp. The other thing I've seen people do is with the arm extended, they put a meal table there so that it can hold the arm extended for you while you're timing or not 10 millimeters between your bone and where you're drilling the hole. Otherwise, it will just rip through that tunnel you created. And the whole thing will fail, grasping bites of the triceps and ensure you get sort of as close to the bone as possible. Pick up some periosteum as much as you can so that it doesn't rip out through the triceps tendon. And the other things is two separate sutures, two separate knots, less likely to fall apart, um tighten it with everything extended and put all your knots on the lateral side so that you're not affecting the ulnar nerve. That's it for today. What do you guys think? Any thing that doesn't quite make sense? Anything you'd like me to explore more of uh really well presented, well done. Thank you. Very, very good, very clear. Lots of things that I didn't particularly the um calcification of the hormon fracture. Interesting concept of the um it Rebecca is that the classification you use for um when you decide something stable or not at the elbow, maybe she done. It seems to make sense, more structures on the lateral side in your hand and your ligaments as well as the that help stabilize your. So the full thing is this, so they specify exactly where your fracture is and that determines sort of how you fix it. So the idea starts with that fulcrum, but they've subspecialized it in a lot more details. If you're interested, there's a whole paper on it and it goes through everything in quite a lot of detail. I read it a few times. I still don't fully get it because it comes to you. I went and saw him at the American Academy. I wasn't even interested in it at that time. He gave such a brilliant lecture that made it very clear uh about over breakfast, but just clarifies the whole thing. I like it. Um Yeah, that's all right. That's all stuff on that as well is online. I can't talk with this stuff. No idea how to use this. Ok, perfect. Um, good. All right. Well done. Any other questions about any of those? Has everyone managed to tell the attention on the other side. We've got a lot of people online. It's r is going to relieve me from the. So. Ok, so, yeah, so hopefully you're all registered on the app. If you want to get exactly. Once you send your feedback in for today's session, then you'll get your feedback certificate coming through with your name on it and add that on. And yeah, we'll see you this week, next week, this time. Is it all working for you guys so far? It's only been like two of the new. Yeah. Yeah. Anything we can change anything that make a difference? I think it's, I think it's much, much better. Yeah. How has it been doing because of the app? And we have some rights so everyone can log in and cert moving. Yeah, tender. Yeah, that's, that's, there is a way we can do it where people online can also chat with us, but we've not figured that out yet. So for next week, hopefully we'll figure how to do that. Next week. Next week. Teaching is Michelle. And what are you teaching on? Good, brilliant. If there's any other topics anyone likes us to cover, please send myself or Arnab, an email, just tell us what you would like us to cover and we're more than happy to add that for in, for one of the sessions or put it to the end of the one of the sessions. So anything at all anyone's interested in, wanna talk about it more, just tell us and we'll put a session on it. Ok, great. I didn't say organizing anymore. So night out dinner, right? The next one is Michelle. When is the Arthrex lab coming? So 31st of July, we are having a cadaveric lab brought down from Arthrex for 24 hours here where we'll have a sign up email sent out to you guys. You'll have 45 minute sessions where you can sign up for specific parts of the body. We'll have consultants and registrars and fellows available to go through the things with you, but there'll be fresh cadavers, lots of anatomy dissecting. There'll be arthritic plates and things like that, but it'll be Absolutely. Yeah. No, wants to do orthopedics. This is very, very rare that they come and bring our mobile. I was shocked when they tell me they're gonna do. So it's just gonna be a brilliant session. I wanna make sure I can get there. Um So we'll send emails out. Please make sure you email us if you want to come because we can't have too many people in at the same time. So it'll be time slots first come first serve. So please just email us if you're interested. Of course, from both sides, but the van will be over here, be here and worthy, but it'll be well worth coming over for. Um, and I think I can make it. I'll be done 31st. Yeah, 31st. Is it? What time is the coming? I think it's here in the morning, isn't it? Michel? Do you have to get leave in the morning? I was planning to take study leave the whole day and help facilitate the session. Yeah. Yeah. No, that's great. Yeah, I would encourage you to take study leave as much as you can if you can only get sun leave for, for the, if you can't get it for the morning, you should have the afternoon. Yeah. And I think Zs planning a few activities for the evening, there will be some recreational activities. Be well worth it. Well done. Thanks everyone. Awesome. Thanks everyone for attending. Have a nice afternoon.