Fractures around the elbow - Mr Peter Hallam
Summary
This on-demand teaching session will provide practical insight into dealing with distal humerus fractures, with a comprehensive run-through of investigations, pre-surgical management, surgical management, and patient positioning. We will discuss common problems that practitioners face, such as patient positioning for surgery and the necessary tools for effective treatment. The session encourages interaction and provides a realistic scenario where you, as a surgeon, have to decide on the position of the patient, choose the types of plates to use, and determine the approach to the fracture. Join us to learn more about handling distal humerus fractures, preparing for exams and sounding more like an orthopedic surgeon.
Learning objectives
- By the end of this session, participants should be able to identify the key anatomical structures involved in a distal humerus fracture.
- Participants will be able to explain the appropriate initial assessment and identification of distal humerus fractures using imaging techniques.
- Participants should be able to describe effective pre-surgical management strategies for patients with distal humerus fractures.
- Participants will gain knowledge on how to appropriately position a patient for surgical management of a distal humerus fracture.
- By the end of the session, participants should understand the steps involved in surgical intervention, including plate placement and post-operative care.
Speakers
Similar communities
Similar events and on demand videos
Computer generated transcript
Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.
OK, folks. So, um what I was gonna do, we're probably not gonna get through all of this. Uh because it's a big talker and Lee has covered some of it and Alex Mulligan is gonna cover approximate all the fractures, I think next week. So I think we'll probably end up staying mostly around the distal humerus. Um We talked a bit about radial head, quickly, might talk about um the cap. So here's going. So this is more of a practical tool, which is why I wanted to ask Leo's questions because it's all very well knowing about the theory sometimes, but it's hopeless knowing about the theory. If you don't know, actually know how to get to the particular bone you want to or how to position the patient. So I wanna make sure for the exam that you know that if you don't know some of the stuff that Lee is talking about, you think it's probably on balance, you get away with it. But the sort of stuff I'm telling you now you really have to know. Uh because as Lee says, you sound like an orthopedic surgeon, you can be one. So if you don't get this right. Then it's difficult to uh uh to, to, to, to convince the exam that you should pass. So we're gonna talk about the distal humerus of which you can have extra articular and intra articular. Uh Alex is gonna do the electron and I'll touch on that a little bit. Uh ra head neck. I see Lee talked about, I'll talk a bit about the cap, mostly terrible trial was done with leak. So immersive, we can, don't have to go through there again. Um, so for each fracture and this is how I approach this. If, um, someone comes in, I've got a case tomorrow and I'll be thinking about what investigations they need, um, the pre surgical management. So I've got a good idea in my head tomorrow, what we're gonna do tomorrow, um, the surgical management, um, patient position in my experience. This is where a lot of trainees really fall down. They can put all of the theory in, but you ask them to position the patient, they've got absolutely no idea. And at the end of the day, that's what the nurses and staff are more interested in. How are you going to position the patient? Um, and then obviously the approach is likely important as well. Um So we'll start off with the er, distal humeral fractures. It, this is a bit more, um, kind of low end. So we might go for, um, who's about SG three SG four in this room. OK. And it's name, right? So I don't know if you can see. It's the greatest of images. Cos I did look this one from the um the web actually. Can you tell us what's going on with this x-ray as far as I can see from here? And uh ap and a later view of uh um uh patients showing a discal you could all hear in folks. Yeah. Yes, we can hear. Yeah, just a uh fractures. Um um looks uh transverse on the ap view, bit of rotation on the lateral view. Um Either I'd like to get a scan, a CT scan to see a intraarticular extension. So you believe in your infinite wisdom that is extra articular, you don't run from the x-rays. Yeah. OK. So let's just say for simplicity. Um It is OK. Um So what investigations would you be arranging for this? Uh You said CT scan? I would agree. So you've got the x-ray, the CT scan uh confirms that it's an extra articular fracture of the distal humerus. Any other investigations? Radiologically, II wouldn't request an MRI scan or anything like this. But I would like to check obviously, the, the patient has had all her bloods and all that stuff. So, trick question, I think we'd be good to go on an X ray and ct everyone agree with that. Um But what about the uh pre surgical management? Then we'll talk, we'll, we can go back to that. So let's say you might have just seen it up, but you have no idea how to fix this fracture at all. Um But you know that someone in four or five days might be able to. So what are you gonna do? You're gonna phone that person up. I want you to come in tomorrow to do this. How are you gonna think about pre surgical management as a matter of urgency? I don't think it is urgent that needs to be done in a, so how long have you got them different? I'd say within a week, 10 days stops and um, I'd have the investigation of the CT and um, if I'm not able to do with someone else is able to, then I will discuss it with them. Well, forget open fractures would be slightly different, but I say it's a close fracture. So that's fine. I agree. You've probably got up to about two weeks of these things, but you wouldn't want to wait much more than two weeks. So what are you gonna do with the patient? You're gonna come in the hospital, you're gonna send them home. Um I send them home with a make sure they're in a uh back and make sure they're comfortable and you know. Ok. And so documenting. Yeah. So I think we've all concluded here that um, the patient is can wait for the surgery in and above elbow backslap, making sure that obviously neurovascular, nothing untoward is happening. So that's the, the pre surgical management. So I won't go forward because it will spoil it. So let's say you are the man, OK. It's Friday morning, it's your list. And thus far the patient's been in the back side. Um The patient is in the anesthetic room and you're doing the eight o'clock morning brief and the nursing staff say, how do you want the patient set up? So my preference would be s the d got from the other side so I can get his elbow out. So, um, and the tourniquet to be, apply the tourniquet and I'd, um, ask for them to have to give IV. And I checked the plates. I'd like to put two or so and try to get as much distal screws in. Ok. So that's good. So, uh, uh, anyone out there fairly junior? I can see Ben, unfortunately just staring at me, uh, Benjamin Davis, but who else have we got? That's a bit more, a few other others involved. Who else has ST three? Got? Uh, yeah, it's on there. I know that. Yeah. Would you be able to say something? Are you happy? Uh, yeah, I'm, yeah. Yeah. Ok. Very good. Yeah. Nice to see you and hear you. So, we've just established. What position would you like? What could you think of another position that you'd like the patient to be operated in? Uh, did you hear what he said? Yeah. So he said um supine with the arm over um in like a gutter type thing or they could maybe be lateral. Um OK. So the nursing staff is fine lateral. I saw someone do that last year lateral. Um That's fine. The patient's lateral. What are you gonna do with the arm uh over like an elbow or one of those metal bars? So like hang flexor over? Yeah. OK. So I think it, it's fair to say that either of those are, is actually uh fine. Um So this is the one that I prefer, which is what you've just described, isn't it? Ok. Just uh I mean, maybe it's not so much teaching, but what's the disadvantage of doing it this way? Practically does anyone know? Yeah, it's a way to do the screening. Ok. Whereas I think with this approach here, why is the screening easier there because you can extend the arm out to get your ap Yeah. So on Wednesday we did one like this for approximate the fracture. Ok. That's good. That's good. So stay with it. Uh Yeah, don't go anywhere. Ok. So we just had a little bit of a discussion there um about the patient position. So the patient is now wheeled into the operating theater. Um And the nursing staff said that's fine. That's fine. You've got the position right now. Now, what plates do you want or do you want some K wires? Are you gonna replace the elbow. What are you gonna do? Um So it's extra articular. So it doesn't, the only thing that's thrown me is is it was quite a transverse fracture. Um So I don't really know how I would secure. II think you could plate it. Um So what uh what type of plating techniques would you, would you use one plate down the back? Uh one plate on the anterior side? How would you do it? Mm mm. So I think you you could have like um two plates like a double plating medium and later. Um Yeah. So when you, so let's have someone that's very good you had, that's excellent. So double plating is fine. So you can um you can relax now you're off the hook. OK. Um Who's neck slightly more senior than y out there in the ea? Oh dear. Ah so perfect. So we've got two plates. So it was actually said earlier but you're the surgeon, you choose what plates, where are you going to put your plates? We've established two plates. Yeah. So I would also go with dual plating and I'd go for medial and lateral. I know there's talk about orthogonal plating as well. But I think if you go medial lateral and you follow your principles of fixation of distal humerus, then you can achieve the same biomechanical stability. OK. So it will be very, very pedantic. So then when you say a lateral plate, do you know what, where are you going to go lateral, lateral or some other lateral way? So it's, it's more uh poster lateral, poster lateral anatomical plating. Yeah. OK. So I agree. So for me, it's a medial plate and a posterolateral plate. OK. Um And we've talked about the position. So can you see the slide I've got now? Yeah. OK. So I'm not here to, I've not got anything to do with skeletal dynamics, but we use skeletal dynamics plates here and you can see that they can, you see my cursor, you probably can't. No uh my cursor is coming down this lateral plate and you can see here it's on the posterolateral surface of the humerus. As my cursor comes laterally, it bends around onto the lateral side. So that's the perfect combination of it. It's both lateral at the top and bottom. Ok. So I agree with that. So, since you're here, sir, um we'll go to the room here in a second. That's fine. So the nurses have said that's fine. We've got all of that stuff for you. So, no problem. So they hand you the knife. OK. You've now got the knife. OK. How are you gonna get to that fracture? Um So with this one, I would do a posterior approach to the distal humerus. Um And then in terms of my distal extent, so I'd be working down the midline of the arm and then at the elbow, I would come um along the make a right, a lateral curve around the elbow and then from my distal extension down to the ulnar, I'd use a boys interval um to just extend over the elbow as well. Um And then I can create flap stacks as both medial and lateral um side of the elbow. Ok. So that's fine. So that, that's very specific and that's fine, that's good. So could you enlighten us as to generally? Ok. Because not everyone would be familiar with that. Have you worked with Lee? Yeah, and Mr Kang as well. Yeah. So let's just say others in this room have not been so fortunate to be able to work with the world expert just so the others explain the other potential approaches. Um So your other potential approaches um you can do um you can go medial lateral. OK. So medial and lateral windows. OK. We'll look at this in a minute. Everyone's nodding their head. That's one next one. Um And then you can also go triceps split. I agree with that. Who another ones tongue? That's three. Anyone else in the do two separate approaches in the skin? Uh not so much. No. Um So electron and osteotomy. Yes. Electron osteotomy. That's four. Why isn't electron osteo not necessary for this particular fracture? I mean, I don't, you don't have to access the central uh portion of the disc humerus is um yeah, you don't really get, you don't really need to get to the art surface on it. So you could probably get away with the other ones. The other one is actually I use it a bit. Is the triceps reflecting uh approach. Does anyone know that one? I'll explain in a minute. OK. Mhm. So those are the, the least five different approaches. Now, if your boy, you've got the six. OK. So if we just explore each of those a little bit. All right. So that's the ones that I thought of. Can you see that? OK. So you've talked about all those? Yeah, but I put the electron on o in brackets because I don't think you need it for this particular. Um So are you to change this to full screen your side? You can all see that, can you? Yeah. Yeah. Yeah. Yeah. OK. Um Good. You can't now. So that's fine set. That's fine. Um You've got your approach sorted out. We'll talk about these approaches in a bit more detail. Now, we're gonna go to the room now. So who have we got here? Um Yeah. How do you find the radial nerve? Now, what we're gonna do? We're gonna tricep split. We've decided that we're gonna plate this fracture for a tricep split. So we're gonna go right through the middle of triceps. OK. For good or for bad. But obviously you've got the radial nerve, haven't you? So where would the radial nerve be? Where does the radial nerve course in the humerus? Uh it causes uh medial goes in through the intermuscular septum and then a lateral uh around 15 centimeters above the radial head. I'm sorry, 50 millimeters. Ok. So all of this coursing from medial to lateral over the back of the humerus, isn't it? Yeah. Ok. We all got that and eventually it will dive down into the lateral intermuscular septum, but that's much more distance. So where you're gonna make your triceps split is uh you may have seen it here. So I'm afraid my eyesight is failing me, but this is the back of the humerus. Um We've got the medial epicondyle. I don't know if you can see my cursor but you should see the medial epicondyle there if you measure up 22 centimeters from there. So, and 15 cen centimeters up from the lateral of the condole, which is basically the radial head, isn't it? You see this green line? You can see that on the um diagram, your radial nerve should be somewhere in that territory. OK. And I normally draw that on and I have a centimeter above and a centimeter below. And that's where I know I'm gonna find the nerve causing from medial to lateral and I just dissect down through the muscle fibers until I feel it and see it. And that way I've got it and I can forget about it. So that's quite an important diagram as to where the radial nerve is. So, where do you find the ulnar nerve. Then I know me. Uh it's, it's in the medial compartment and uh it goes in the cubital tile. But so you can find, you can palpate it superficially around the medial epi. OK. So you can, now we're gonna do a little hands up now. OK. So let's just, you're doing the operation, you've s inside the skin, you split the triceps, fascia. Um But you're worried where the ulnar nerve is. So what I'm trying to work out is how you can identify that nerve before you even start splitting triceps. Cos I wanna know where that nerve is. So I can split triceps er with impunity. So hands up in this room, we can do it where you are now who would actually try and find the nerve at the cubital tunnel, who would find it somewhere else? We set it down. So my advice on that anyway, out there, uh you to trace it proximately near the um part of the triceps and then trace it distally. Yeah. So here you go. Can you see my slide here? So define the earth about eight to c 8 to 10 centimeters up from the media of the color. So you measure about 10 centimeters up from the meter and you'll find the nerve just on the medial border of the triceps tendon. OK? It I can't use the cursor here, but it's the, the sort of there's a little retractor in the left hand diagram and that's where you'll find the nerve. If you try and find the nerve around the medial epi conda on the cubital tunnel, you will not find it easily because these fractures distort the anatomy. So you must all wear the nerve proximately and work distally and it's easy. So, if I'm doing all nerve decompression on exactly the same thing, I find the medial dorset of the uh triceps, tendon and triceps muscle and it's always just sitting nicely there and then we can take it all the way down as far as we want. OK. Is that fairly clear to everyone? Good? All right. So this is the triceps split. What's the problem with the triceps split? Um You are destroying soft tissue if you don't need to. Yeah. So it's a few possibly you can extend into the tendon. Yeah. So it's a bit barbaric. You're right. It's very difficult to make the operation look um, elegant. I'll give you that. But remember the triceps is not an anti gravity muscle. So you can virtually destroy triceps and someone will be able to still straighten their elbow so that I wouldn't worry about that too much. It's just um what, what exposure does it limit you to getting distal and lateral needle as possible? Yeah. So you can see on the right hand diagram here. I wish I could um use my cursor. Does anyone know how I could put a cursor on there? Not easily No, you can see here on the right hand side, you can't really see the medial and lateral epicondyles very well can you? And that's the problem um with a load of effort you can get there. So what might be a better way of exposing it for this operation? This one? OK. So, very similar, you'd make your original incision. This was what you were describing, wasn't it se uh quite similar? Yeah. So on the left hand side, we've got the medial side exposed, haven't we? With a little um window there? On the right hand side, we've got the lateral side. So you can just pull the triceps back and forth to see where you are disadvantage of that difficult to see more approximately. Yeah. So actually difficult to see more approximately ironically. So if you've gotta put a long plate on, it's quite difficult. All right. But if it's just a short plate, you'll be fine. OK. That I'm just gonna come back a bit actually. Yeah. So those would be the most ones for your extra articular um fractures. So we'll call that one a day. Can I just er add? So when se you mentioned extending into the void interval just to er but not to confuse anyone so that the void is around the elbow. And if you want to end up seeing the radial head and like the radial capitellar joint, uh a approximal radiola joint, so you can extend some of these ones that you've done down the back then on into those approaches. That's what s was mentioning. So, but you wouldn't need to do that specifically for these extra articular fractures. But if you're coming into the, these different articular ones, then that's where sometimes that's, you know, when you need to see a bit more as an alternative to the electron osteotomy and things which you'll hear a bit about, I think in a minute. But that thinking, well, what about the boy? Well, I know the boy is more distal, but you can join the two together. Yeah. Good point. And that because when se did say that originally, that's why I wanted them to draw back and give us a bit more and sort of like, you know, conceptually slightly more sort of basic um approaches. Yeah. So I think we've got that. So we're gonna move on a lot of this is repetition. So we've now got the uh distal humerus intraarticular fracture. So, who wants to have a go at this one? Um He's been quite, quite. Yeah. No one really. Uh Will you go for this one? There you go. Yeah, go for it. So can you see it? Uh Let me come on, I'd hate, I'd hate everybody to not see much in. Um So OK. Yeah. So we've got a, so we've got a, a longitudinal sort of coronal split, haven't we? Um Can I just maximize the size of the imaging. How'd you do that on here? Well, don't sure if I can you do it on? Um, not sure. Actually that's what I was thinking. Um, ok. Anyway, so, yeah, so there's, there's importantly, it looks like there's an intraarticular spp the sleep, isn't it? Yeah. So you're gonna need, so I think you're likely to need plates on both sides. I can't see if there's um can't see from plain film imaging if there's a a transverse split on the lateral side as well. But I assume that they with this injury. Uh So I think all of those things, there are still true about um the amount of the preoperative management. So in terms of your imaging, exactly localization, that's very good. So even though this is an intraartic fracture, we've established that on the x rays, everything else would hold true for this. So you would want act scan and if the surgeon was in capable of doing the operation over the next few days, you would send the patient home in a back slap. Yeah. Yeah. And wait for the surgeon to do the operation. So let's fast forward. It's Friday morning. It's you doing it. Um um So how does this one differ from the extra articulate? So the ladies in fit or even the men in fit, it could be anyone in fit to say, well, how do you want to position this one next? Um So uh personally, I would have the um, patient in the lateral position rather than supine. Um, and, uh, I would want that because I think it's gonna be more difficult to reconstruct the articular block. So I don't want the, um, I don't want to be, er, fighting gravity so much. So for me. So for me lateral with the, with the elbow, anyone would, the, would anyone out, out of interest, would anyone else do this with the arm and a DHS? Trough? Hi, it's pine with, um, DHS. Yeah, I mean, Alex Mulligan, um, does it that way, er, did one the other day, uh with Rachel Fisher, she uses the same technique as well. So it's 5050. I tend to have it armed over a bar but you could go either way. Ok. So whichever way you want to do it, I find it easier for the arm down. Um, there are particular patterns that you would choose one over the other. It sounds like it's always deal. Yeah, I did, um, I fast forwarded over the classification for that reason because there might be different patterns. But I think, I think almost the different patterns are irrelevant because you're gonna do the same thing. Which is what, how in terms of uh technique with plates, what sort of plates are you gonna use? Er, as well? So, similar to the first one you want, you want medial and lateral, medial lateral plating, you want to interdigitate your screws. Um, but obviously here, the most important point is, is getting the articular surface good again. Yeah, very good. So, uh, I think we're all on track there. So, whoops. Sorry, what I can add in terms of when you might choose to have different positions, the reasons why, um, Ran Rensburg and, er, um, M Fisher and Mulligan as far as I understand, do Supine. It's partly because of the, the, the, the trauma units they've worked in. So it's, but when you're dealing with someone who's probably traumatized with these injuries and they're easier to be flat on their back for the operation. Maybe they've got spinal fractures, et cetera. So that's a bit harder to put them in the lateral position, then that's why they do them that way because that's what the units they've been in. However, most of the time these are isolated injuries in which case, putting them laterally doesn't really matter. And then therefore a lot of other people do, do them in the lateral position as well. But in terms of why you might pick one or the other, it might be because of the associated injuries, er, is when, why you want them to be? Ok? That's, that's a good point, Charlie. Thank you very much, sir. Nick. You take a seat. That's good. So, um, now, so we need someone a bit more senior now who's senior 56. Yes, that'll do. So I'll tell your name, sorry. And no, you, but of course. Yeah, I remember. Yeah. So Andy is gonna tell us um he's the man now he's been given the knife. So, uh what approach are you gonna use to? Andy? So I'd use a posterior approach um for this, I'm interested in the particular surface um and getting anatomical reduction. So I'd use an electron uh post um and be able to an reduce use and hold the K Ys and put my plates on the top. OK. Good. So he's, we've given it. So he's gonna, he says he's gonna use an electron on osteotomy and he says he's gonna try and restore the articular block first. He's gonna k wire it and then put these plates on. But um so that's all fine and dandy, that's good. But of course, doing the electron and osteotomy is not quite as straightforward as I think you might think. So, I just wanna, we'll come back to this in a minute that's called a ty beam. Uh But we'll come back to that. So, yeah. OK. So tell us more about the osteotomy. Yeah. Where are you gonna make it? So, you, it's a shown osteo in your leg. Um And it needs to be, I can't remember the exact measurement. So I think it's about four centimeters um away from the tip of the electrum with the um the point pointing distally um sent, right. So we'll stop there. So, in my opinion, um then four centimeters from the tip of the electron on process. I think you can see this slide on the right hand side. If you see where the tip of the electron on process is four centimeters would take you, I think a little bit too far distally. So the more discal you make that Chevron osteotomy, the more difficult it is to repair at the end. So if you take it much more distally, then you cannot repair it with a tension band wire because you effectively convert that into a distal electron fracture, which you'd have to play. So, and bearing in mind that you could normally see these fractures even through um tricep gutters, I would say you probably need a centimeter two centimeters max of uh ulna and it's a Chevron osteotomy. So I for what it's worth you can be no, at the end, what else could you do? So you've done the sy, how are you gonna fix your? So you could, we've got everything. So you could have. The classic one is the tension band wire. But remember, you can only do that if you've um not gone too distally. The other one is a screw. So when you're uh starting off, I predrill it and I sometimes use a large fragment screw which I just screw in, which normally works for young people, older people, they might not have regular purchase or the third one is to plate it. So if you make your osteotomy much more distal, then you will have to plate it, which we had to do with Rachel the other day actually. So you definitely don't. In my book, you don't want to include the um coronoid process to be more proximal to the coronoid process with Rachel's the other day. She took it this to the coronoid process and it was a quite a problem to get it reduced. Um Almost as difficult as the um fracture itself. Could you just turn that then under eye when you're doing it before? Yeah, plan it under eye if you want, it's very, very easy to go more distal. So I attempt you to put a green needle in to find the typical electron and then just make an, an incision about a centimeter and a half below that. But if you're unsure I iron, but that will be a nuisance II in it because remember you're over a bar and so that's another 15 minutes messing around before you even start the operation. So I think on some, she's got to go for it. If you take too little, it's not a disaster because you can do the operation without doing the job and you take too much, in my opinion, make matters worse. Um OK, so, well, I think we've labored that one. This is, that is the, your um sorry Andy was talking about the Chevron. It is, is the apex goes this way and then the Ao Mandator tell you to drill a hole at the apex so that you get a nice clean Chevron. All right. Cos that's quite difficult to do. Is that how do you make the Chevron? Do you use a, a saw? Do you use uh an oxygen to? Yeah, tend to use a So, yeah, it's much more uh controllable. And then we finish off, we live with the tension band you can see on this is that the piece of electro I taken as gastroectomy is small. Like I said, it's about a centimeter and a half, isn't it? Uh Now who? OK. Thanks very much. I will. Who knows the electron on the triceps reflecting technique? Can anyone talk about this anyone out there? Yeah. So this is I the reason I show you this is because most people don't do this. But actually, it's a perfectly good way of fixing intraarticular fractures. So I'm OK, I can't make the screen much bigger here. But um with this particular technique, my cursor is on the triceps tendon, you can see with a series of pictures that what you do is you take the triceps, insertion off the ulnar and reflect the whole of that mechanism from medial to lateral. OK. And you will see eventually as it goes all the way laterally on the third slide that you can see right down the back of the back of the humerus. So without having to do an electron osteotomy, so it avoids having to do an electron ostomy because everyone hates that. You do. The operation takes two hours, you're tired, shattered and then you have to do another operation to fix it. There's a nice little um bear with me here. I hope you can all see that it doesn't show up brilliantly. But this is from the surgical technique for Konrad moray elbow replacement. And this a bit more elegantly shows that approach in the bottom, right? You can see the whole of that tricep mechanism has been reflected um laterally. So it's gone from medial to lateral and you can see the whole of the bottom of the humerus. How much exposure do you need to me uh to lateralize it quite a bit. So you need to take the triceps off the ulnar perio and you need to take it right off laterally as well, almost off the media condyle. But you're left with a very good view, you have to put it back and normally there's, if you leave a cuff, you can get it back or you just make some drill holes into or attach it that way, but it all just flops back normally. So I recommend that to people who do not want to do an electron osteotomy. OK. So just it, what is uh again, I don't really use this technique very much, but Rachel was using it the other day, Rachel Fisher here. What is er this, who knows what the tie beam is, it comes back to what Nick was saying, what is the most important thing? Where's um not really, I don't think no. Who said it's a compression evidence on both sides and a compression force? You? That's right. So if someone said the most important step, what is the, who's here, Jose, can you hear me? Yes, I can. Yeah. What's the first step of this operation? First step is uh it depends, I mean, as part of the approach, you should try and isolate the nerve. But if you just got down to the bone, the bone would be to try and convert the intraarticular fracture into a simple fragment. Very good. So how is that done? How could you do that? How do you do that? Um um So the, the, the split you try and um try and compress that maybe with um bone reduction forceps and then shave into fragmentary compression can be done with screws good man. Um or holding it initially with K wires and then screws very good. So that's exactly what I do. I get it reduced with some forceps. If I can first pass some K wires and then put a partially Fred screw in to compress that articular block together. Yeah. And then you just put your plates on the tie beam is where you get compression across the articular block through the bottom end of the plate. Does that make sense? So if you look at this this particular device um is held at the bottom of each plate and then with a slightly complicated rather, do you wanna message on, hold home to the hospital and home to the families that we serve? We currently have done 60 missions we've been to, that's better that that beam is outside. Um sort of attaching on like uh periodically. Yes. And then the beam then itself helps with the compression. Yeah, that's right. So you get compression of the fracture through the distal end of the plates. Correct Charlie? Yeah. And that's also just, you know, that's forming a fixed triangle almost if that makes sense. So it, it is making it pretty solid uh connecting these plates up together, but you also can get compression through that together. Yeah. So it's just a level of that sort of solid angle. And you've got, you know, in the humerus, you've got that uh medial column, later column and then the articular block. And so that is helping to reconstruct and hold all that together. Ok. And I will disappear off it very shortly. But uh it's all going very well. That's fine. I think we're gonna do cap and call it a day, probably uh carry on. You've got till five o'clock. I think it's all good stuff. I don't think they'll be alive at five. but um, yeah, we'll see how we go, but thank you. Ok. Uh Mr Hallam, is this, could you not just achieve the same thing. Just applying a, a large periarticular clamp to your plates. Cos this one you have to drill through the distal humerus looks like to pass this. Oh, it does. This, this stays in. Yeah. Yeah. Yeah, it stays in. So I've only seen this in action once when I, um, came in to help Rachel out of her case the other day actually. And she used it, I wasn't particularly impressed with it, but that's probably cos I've not used it before. I thought it was a bit clunky. But I agree. I think you can get exactly the same done with, um, the partially Fred screw at the beginning and then if needs be with your fracture reduction forceps. Yes. But I think it's a, it's, it's, it's not a sort of elegant way of doing it but it, it didn't all line up very well and it, it just made the operation, in my opinion about 1520 minutes longer, but I just put it there because everyone's talking about it at the moment. Yeah, you don't have to. This is, um, specific for, um, the, on this, on the SCN, like a piece of kit and stuff that you have as a, as an option. But for, for how that actually work for these guys, there's a, you know, male and female bit you can see in the middle bit. So, like they, as you tighten it, that compresses the lot together and then, and then you can lock it into the place as well. So it's just an option. But it's uh you know, when you talk about all these things in an exam situation, you wanna be talking about from principles and what you're using to achieve your goals and that these are options. But you wouldn't be saying like, you know, I will use a DHS, you'll be saying, oh, this is an extra capsular fracture that you're gonna be, um, you know, fixing and, and from the stability options are, you know, if you were then talking about implants, all that as such, you don't just straight away say, well, are you gonna use this particular name to brand an implant? Does that make sense? So you've got to get into the habit of just talking principles and, and, and whatever kit you're using, you're using that to achieve those principles or achieve those goals. All right. Yeah, that's good, Charlie. Thanks very much. Goodbye. Um, so, yeah, that's why I've done it this way. Um, you know, investigations, er, approach called surgical because that's how it will be in the exam. Um That's how you, so, um, I think we've done that one. That's good. I this, this is a tricky operation. Electron osteotomy. It really is and it makes the operation. I find that more difficult than the actual fixation of the fracture. Obviously, it, it can be very tiresome. Um, I think Lee's done electron on and Alex is doing electron next week. So I will not labor on that one. I think this one is worth 10 minutes off though because these are not actually uh that rare and I just wanted to. Uh huh OK. Fine. So who's next? Who's not, who hasn't had a really good go here? Yes, sir. And it's um a, a come up and have a look at this, so have a look. Yeah, so speak up. Um So this is a lateral radiograph of an elbow which shows a fracture of the Capello. It's a trans which is displaced and the radiocapitellar joint is no longer congruent. Very good. Yeah. So for five gold star, if you're working in mcdonald's, can you give me the classification of these fractures? I think it classifications. I'm not particularly keen on myself because it's either undisplaced, quite displaced or smashed. It doesn't really make much difference often what you do. But this one is just quite interesting how we, I see there would be an AO classification as there is an AO one, but there's a more eponymous one. Anyone there fitting uh inspired. You don't know the eponymous ones. No, not Milch. Uh There is one actually which has got that and then we will come to a minute. Anyone else for the, the common too? No. OK. That's good. That's good. So that's why it's worth coming to this session. Uh So here we go. Now, I again, can you see that? So the type one is, uh that's what he said. Ah, no, I call it a different. Um, so the type one I call, which is a large osseous piece of cafe is the Heinz Stand. Ok. That's type one. Type two is when you just have an eggshell of capita cartilage which is a couple of Lorenz. And the third one is the one that I, yeah, the one I thought you mentioned was type three. I mentioned the name of the classification. I didn't mention the names. Oh, sorry, sorry, sorry. So the classification you were, I apologize. I take that back. I thought you were trying to tell me which ones was. So yes, the classification is personally classify that you are correct. And type one, type two and type three. So this the example that um Abra gave us. What type is that? So that would be a type one. Yeah, type one. So type two and type three very, very difficult to fix and probably not much you could do in all honesty. So type three at the bottom of that CT scan is completely smashed and there's probably nothing you can do apart from bring, you know, take the pieces out a core, which is the egg shell. Do you know what age group? Get that? Fortunate for you old, normally old. So they don't need anything doing anyway. But, but he stand full unfortunately for you with the younger population have sheer fracture. Ok. So let's just say uh that it is that we're gonna treat this. Um Hi. Stand for fracture, which is this one here? Keep going. I think you're doing a very good job. So how are you gonna w what's your pre surgical management? Um So you arrange act scan. Good. Yeah. Um and exactly the same surgeon's not here. You can leave at two weeks. We flash fast forward to the um meet eight o'clock in the morning. A what position do you want to put this patient in to do this fracture? So again, the same position. So lateral with a team lateral with a Yeah. Yeah. No, that's a perfectly safe for way of doing it. That would be one way of doing it. That's a good way of doing it. So you could do it that way if they say I'm really sorry, but there's no way on earth we can do that. Um The nieces might say you're gonna have to do it in a different way. We can't put this person laterally because I don't know, they've got some tumor of their pelvis or something. I don't know, whatever it might be. Yeah. Um With a DH that would that be an option would be more difficult? Yeah. So just with exactly with the arm, with the arm on arm. So if that were the case, which was my preference for this one, What approach would you use then. Yeah. Cocker. Good. OK, so we'll talk about that in a second. What else could you, you could use the Yeah, the other one is but boy, boy, ok, so cocker or boy, I think would be the for my two for these anyway, the other ones exist but I don't really use them. So you, but I think cocking cannot go wrong. So who is unfortunate to mention cocker? So what is the, what is the, so what's the Cocker approach then? Let's do it, right? And then it's between the EC U and the very good. So between ec U and anconis and just a little bit of a tip here in relation to the lateral epicondyle is that interval above, below, anterior, posterior. Yes. So it's quite a posterior approach to the coup. I see people trying to make a direct lateral which is fine but then you're gonna be too far forward. So the copper approach is actually quite er because it's between anus and EC U and there should be a little fast strip between the two often. Isn't you go through that and then what's next? So you've, you've split ANAs off Cocker, you've got your little interval there. What's next? You need to extend it? Proximate? Yeah. How do you explain it? How do you extend it approximately? Especially for the cap, correct? So you're gonna take thick flaps and usually care for a lot to injure those here. Yeah, you can take those here and flap and yeah, what I do is just take the soft tissues off the supra condylar ridge and just get a diaphragm and they'll probably just collapse back down onto it. So, but you do need to get a much more proximal approach with cos you're going for the cap, not the radial head. Um You will need to extend it distally as well. So distally what you have to go through. So you're gonna, you're gonna be, so you're gonna be down in the joint. I mean, the ligaments are just thickenings in the capsule already, aren't they? So basically, you're going through the capsule and probably a tiny bit of an ligament. I think Lee's correct. II was pleased. He said that I don't be too worried about um taking the annual ligament even if it's Christ, I mustn't touch the annal ligament. You can also repair it. Um It's not great, but if you, if you know it, probably it's not a big deal, it's better to get your uh exposure. So Boyd, we talked about earlier, gave a beautiful video of that. Didn't, it would be equally as good. So that's your Cocker approach. OK. So I think we'll just go through here. So this is your fascia, that's, that's um EC U, this is an K uh just more of it and then basically down. So it's not very difficult if you're worried about where you are, what I do is tend to put my thumb on the radial head and twist the forearm and then that will at least tell me where the radial head is. Cos if again, these can be quite swollen. Uh You've got obese patients, muscular patients, so that's fine. So you've finally managed to get down to the um capitum, who's next? Who wants anyone out there wanna do this? How are you gonna fix the capitellum? Josh, any idea I can see your name there? That's the trouble. Yeah, that's fine. Um ok, so you got your approach. You, you've um approached the cabin, I try and reduce and fix with uh head to small factors. OK. Cool. I like it. Ok. So you want, you're gonna go front to back head with screws. Mhm. And just in terms of actually the exam, I might wanna know this. It's a good start. You're gonna, you're gonna reduce the fracture first, aren't you? Yeah. So, so you, you're gonna push it down, pin it down to where it is. You're gonna use the II if you use the Supine position arm on the table II is very easy. Um How are you gonna hold the reduction? Cos as soon as you let go of the Capone, it's gonna pop up again, isn't it? And of course I get um some um K wires um perhaps to hold up initially. Well, for you screws with them. Yeah. So yeah, so the screws are you use the Ky to reduce it. And then um if the reductions held, it looks acceptable on II, use your um small fag headless compression screws. Yeah. OK. So that's using the headless screws. And I think these days I tend to go for that. When I started off about 22 years ago, there was, um, there weren't very many good headless screws on the market. So what can you use if you don't want to use headless screws alternative techniques? Uh I suppose you could bury the C head. That would be, you could do that and a push. I feel as if we'd let the patient down a bit, but you could do that bury it. That's good. The other one could you come from a different angle rather than an anterior, posterior, you come at a angle of the joint. Yeah, that's right. So we're all saying here as well. So uh you go from back to front. So what you would do is you'd open up the cap with the cocker or the boy approach. You'd use Joss technique with a Ky to reduce it and then through a small split at the back through triceps, you would then put your screws from back to front, partially Fred screws f like doing a posterior Mario old styling from back to front, but you would need to make an incision through the back. So whoever said, lateral position, who said lateral position, that's the one advantage there if you're gonna go back to front, it's easier to get to the back. Cos otherwise your, the armboard here is just more difficult to get them up for it. So back to front is number. But I think most people would use headless screws. Now, George, since you were unlucky enough to mention headless screws, how, how is a headless screw? Cos you want compression of the fracture, don't you? Yes. So how does the head of the screw produce compression? Your sort of, if you had a sort of 19 year old daughter or something, they might say. Well, that's crazy. How can you get done? Whatever it is, the general knowledge, how can a headless screw cause it's to do with the thread pitch and the size of the, um, you say it's headless but it's actually the diameter of the, um, pro sorry, my dog's barking away the battle, um, the, er, where they had to be on the screw, the, um, damage that is larger than the, um, the tip or the, um, on the square. And the, the uh, does that help you the pitch size as they approach the top large? Uh Yeah, so I don't know if you can see that on the screen, but that's basically where it's the, basically, in simple terms, it's the pitch diameter. So the, because the pitch of the screws is a different diameter as it engages a two part of bone, the screw moves further through one piece of bone than it does or another for one half turn of the screw, isn't it? So that's how you get your compression. Um So is it like L by design? Another version of L by design? Yes. Yeah. It's a different way of a L screw, but you can't get a lot of compression with it. But if in this type of thing, I'm not wanting a huge amount of compression because you've probably got it reduced pretty well. But it's um if you can't compress it, it's not the end of the world, but the headless screw gives you the opportunity to bury the screw and cause compression, not only as a teenage girl, but as a middle age man, I still don't entirely get how the differential screw pitch actually doesn't destroy all of your previous threads because you've still got the same core and thread diameters and your, the, the cutting FLS, the cutting edge of the screw is going through, it's still going through the same vein. Yeah. So I always, the reason I mentioned teenage daughters, I've got two teenage daughters. You might wonder why I said that because they ask awkward questions, you said. So um that's a sort of awkward question they would ask um if I was giving a talk. So basically, you can see here that it's thick at this end and it's thin at that end. So as you put this screw in, uh yeah, it it doesn't engage fully until you're at the foremost at the end of applying this screw. So, you haven't ruined it this end because that's a thinner end because your, your, your, your, the, the screw you're putting is fatter this end than the other. You've got twice as many on the, the screw. So it's gonna go through. So, yeah. Does that make sense? Yeah, it is a bit of a funny one. But that's how it works. Cool. And I think the diameter of the re makes a bit of a difference, but it is not just that, but it's a variable pitch. So it's gripping more on one side of the bone for every half turn you make than the other and therefore it compresses. Ok. Um And how would you, so that's when you've done this operation, you've made very sure that you close the cock of um interval correctly. What would be your POSTOP management be? Uh, well on this one. So in general, with upper limb and elbow, we like to put um patients uh to a short period of immobilization to help the wound more than anything. Um But to get the elbow moving, um as early as possible. So, put them into a uh a back stab um for 10 to 14 days, bring them back to clinic if the w uh wounds all healed, get them moving straight away and uh sort of no loading of the arm for six weeks. Ok. Any difference is there? Of opinion, we'll increase those things. Ok. Yeah. So you're saying move straight away, basically, I think I'd probably be more on the side of that. We'll also, if you've gone to the effort of going in to reduce this rich thing, assuming your head of screw technique has worked, then I would get the patient moving straight away. I think they would be the same about getting the elbow movement. So it is tempting when you first start off in Christ, I just want to wait a couple of weeks for it all to settle. But probably you're dealing with patient at this service, probably a couple of weeks. That makes much difference. So get them moving straight away because they'll get stiff very quickly. As soon as you touch the elbow, it gets stiff, particularly if you've vil the annual ligament and so forth. So in general, get them moving, if there is a specific need to keep them in a sling, because you've been very concerned about your fixation then short, but otherwise get them go. Um The other thing here is on this side here, uh obviously in any approach, on the lateral side to uh the elbow, you've got the er radial nerve in the way, haven't you? So I think the side has stolen my thumb. But, but so then you will know what you can do to make sure the radial nerve is not. So obvious. Right. Yeah. So if you pronate it'll take the nerve further away from you. Ok. Just makes it much more out here. So that's quite useful. Um, I think we're there. We're an hour and 10 minutes in, aren't we? Um, fortunately for you, I think the rest of it is just about being covered. Ok. Um, because I was gonna do a terrible trial which lee sort of touched Alex is gonna do proximal ulnar and the radial header le touched a bit. The only thing about the radial head, um they would be exactly the same for the radio head, Boyd and cocker. But bear in mind that you've got a different, you can use a plate. OK? I thought I had some uh slides of this. If you weren't gonna use pla use three screws like three headless screws, there's a sort of tripod that you put in there. Um And that's just as effective. In fact, that's what I tend to know because the, what's the advantage of that over a plate to get moving fixation? And you don't get the uh the, the plate doesn't get. Yeah, that's what the platelet pinch. You probably get more anatomical fixation because you can put the screws across the fracture pains at the right angle. What is we talk about the radial nerve? What is the get irritated? You get irritated. Yeah. Or worse. Where is, where is the poster intra nerve? Yeah. So if you did a radial tuberosity, haven't you? Yeah. So you've got the radial head, ra neck, uh radial tuberosity. If you start going towards the radial tuberosity with your this end of your heart, excuse me, you might hit the uh posterior intraosseous nerve as it wraps around uh the proximal radius. So, with the plating technique, you've got to violate the whole of the ligament, which you probably have to go away for the screws to be honest, but you are in danger of uh injuring the poster intros nerve. And if you injure the poster intros nerve, what palsy do they get? Yeah. So I probably wouldn't put a plate in these days with the tripod technique because the head with screws are better. So um just that's the position with the arm just on an arm table and that's very easy to actually. OK, folks, I think an hour and 10 is probably enough. Um Are there any questions with radio head when you, when you replace? Oh OK. We've got a question here. Head fixation. Um Head replace. Yeah. Yeah. OK. You got no chance of fix it because I see that all the time. OK. OK. Let's just uh let's spend five minutes doing that then bear with me any other questions while we're getting that up? Uh Sorry, sorry Mr Halem in an A six la presse type of um injuries. Uh when would you um repair the er interosseous membrane? OK. You mean at the um level of the elbow or the wrist. Um I mean, we normally the central band, isn't it? Which is more in the middle. I mean, would you ever, um, crikey, you might be. So, I, the other press the lesion I know is that this one, you get a distal radial ulnar joint dislocation, um which is a, um associated with a uh g and fracture. Um, I mean, I mean, if you've addressed the wrist and the uh uh radial head, oh, I see. Got you. Would you? Yes. Yes. Yes. Yes. Yes. Yes. Yes, I see you now. Yeah. So I would not personally bother with that. If you fix the radial head or replace the radial head, then I have never fixed the intraosseous membrane or stitched it. So if you get the radial head right and reduce the joint, then that will look after itself, right. Thank you. But you are correct. If you don't fix the radial head or you don't replace the radial head, then you will end up with um problems of the essex suppressor because the er ulnar can move relative to the radius. But it's provide you fixed or replaced the radial head. You don't need to repair the membrane itself. OK. No problem. Uh uh So the, we've got a little slide here. Actually, there we go. That answers this question. I think. So I tend to be, again, it's just personal choice. I tend to um be fairly ni when it comes to the radial head. There are occasions when Lee I was mentioning earlier when you must do something for the radial head because the radiohead is a secondary stabilizer of the other. Isn't it not a primary stabilizer? So I will tend to be a little bit cavalier of the radial head um and remove fragments and sometimes leave people with just a radial head excision. But if you can't do that and you need to do something, um then you can either uh replace it or fix it. Replacing is difficult because you've gotta get the thing right? And you doesn't overstuff it. If you overstuff it, then the patient won't like you because it just grinds down their capitella. So in general, I think this slide saws it. So if the fracture involves less than 40% of the articular surface, then in general, I think you could try and fix it. Ok. Using a head of a screw or plate. If there is greater than 40% of articular surface loss, then that is when you would have to replace it. Ok. Conversely, if it's only a very small portion of the radio head that's fractured less than 25% I would just remove the fragments and leave what's left of the radial head because the natural radio head is gonna be much, much better than a replacement and probably better than your fixation. But if you've got a particular fracture dislocation pattern, which is uh dependent on stability for radial head. Uh Then you have got to do one of the two. But I would say as long as only about 40% of it's gone, I'll fix it rather than replace it. So only replace it if you seriously have to. It's a very difficult operation to get. Right. Does that help at all? They seem to like asking this in part one to come up in a couple of ones that I've seen and they say if it's three or so, if it's three fragments or less, you can fix it. If it's more than three fragments, then you have to replace it. Yeah, that would be another, that's what the book says, sort of thing. Yeah. So that probably comes to, yes, that's fine. So, if you've got a 40% greater, 43 big chunks, then I would fix it more than three chunks. Yeah, along those sort of lines. So, unless it is completely smashed, fix it, that would be my advice. All right, because then you'll get the height right? And then you won't get the sly of the Essex Press Le Lesion that I was brought up earlier because your anatomy that the patient started off with is gonna be much more accurate than your attempt at getting the length right of the radial head. Yeah. Since we there almost finished, Lee made the point as well that if you're gonna replace the radial head, it is much easier to do it through a void approach because you're passing the radio head down the trajectory of the radius. If you do the cocker approach, you're having to, you're coming in through the side to put something down the radius which is 90 degrees to it. So a radial head replacement is much easier for the boy approach. But there are replacements now which are side loaded. So you put the stem of the head on and then it you sub load the head onto that, which makes it a lot easier, which actually is another skeletal dynamics. Um innovation which um I've not got shares in skeletal dynamics, but their distal humor set is very, very good and has all of the stuff that you need. I think I've got a picture of it. Um somewhere here, maybe not, maybe not just bear with me. I think I did put one in. So if you're going through the cocker approach, definitely use the um skeletal dynamic one there it is top left. Do you see that the stem is in the hum er in the radius? And then the head is side loaded on the top. OK. Any more questions? Uh Sorry miss a one last one. In my Viber recently II got asked uh about radial head blood supply and its clinical significance. Oh my God. Um They like four or five different vessels that supply. II don't, do you know anything. Which, which, which, um, which fiber was this? This was, uh, sorry, this was, uh, part two, part two last week. Really? No, I'm afraid I can't help you though. I'm very sorry. That's ok. I don't think that's ever. Radio head is fine. Yeah, everyone's saying that you must have done for a while. I don't know that, I don't think in the I, II didn't, no, I think I've been an orthopedic surgeon since about the age of 25 ish 26. And I don't think I've ever known that or needed to know. No worries. Thank you. Ok. So, um, but you can educate us next time. I don't know the answer. I'm afraid. Does it necro in particular? I don't, you see, I don't think it does because the reason I tend to be fairly ne with the right of head is that actually it could be quite badly broken. Um, and you can just remove everything, but if you do fix it, it does normally join up. So I would think that avascular necrosis is not a big deal, but I might be wrong there. It's being recorded. So, um, we'll see if someone has able to give the answer to that somewhere. All right. Ok. I think that's it fol you've done well. It's 20 past four. Take care. Thank you. Thank you. Thank you. Thank you. Thank you.