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Uh Well, thank you very much for offering to teach Mister Rasheed. Um You're consultant down in Colchester now. Yeah, it's all going well. Yeah. Started in August exciting times. Marvelous, new brand new hub. Yeah, exactly. Starting next week and that'll be fine. When's your first list? Uh 20th, 20th of November. So, yeah. So just finish the whole week, seven days in a row. That's fun. That's very kind of you to offer to go through some things. We've had a brief introductory to some of the, some of the anatomy, some of the stabilizers, but we've kept pushing along. The more clinical stuff is going to come on a little bit. It's going to be a bit repetitive because trying to get your head around some of it for those who have a repetition is going to be a bit of the key. Um Yeah. And II have to say I um I did not understand this topic as a trainee, even as SDA even post Fr CSI did not really understand it. I thought I understood it and, and it was only really until I completed my first fellowship. That's when I had a better idea of what it was. And I think, um so I think what I'm gonna present today may be covered. I mean, you guys have Lee Van Rensburg in the area. He's probably the world authority on um elbow trauma. And so you're very fortunate to have the opportunity to potentially rotate through there and, and learn from him. And I've seen, you know, I watched a lot of his content on the Cambridge orthopedics youtube channel. Um And so a lot of that is take it from him, but actually most of my understanding of elbow instability comes from Adam Watts, who I spent some time with on fellowship in writing. Um and so I'm gonna be really rehashing a lot of um the sort of philosophy that he's developed, er, which has actually been developed on the back of many other elbow surgeons that came before him, people like Sean o'driscoll and, and what have you? Um So, yeah, so shall I get started, Charles? That would be great. Um Next week, Mr Van Renberg is going to be delving more into complex incident. So you're setting the scene for him. So I um if I say anything that he contradicts, go with whatever he says, like he's, he's, he's the guy. Don't, don't listen to me if I've said something that he disagrees with. Um OK, let's get started. So this is kind of, this is the talk that I wish I'd gotten at like ST 56 put it that way. Right. So that's what I've kind of put together. So we start, we start with anatomy. Um, you'll all be familiar with this. Just a shout out to Paul Goana who unfortunately passed away a few years ago. He was probably one of the greatest, er, anatomists, um, ever to, ever, ever lived and he had these incredible dissections. Um, so if you ever get the chance to read any of his papers, he didn't write that much. He, he headed up the, er, the University of Barcelona Anatomy, er, lab, but he wrote some unbelievable papers on the ankle anatomy and on the elbow anatomy. And I would highly recommend getting those. Um, and so in this comes from one of his papers and so he basically dissected out the, er, anatomy of the distal humerus, the radius and the ulnar. And there's a couple of things to say, I don't know whether this is gonna come across. Can you see my, my, right. Yeah. Ok. So, so obviously your distal humor is very irregular shaped, but essentially you've got your trochlea which articulates with the ulnar, the greatest thing, more notch. And then you've got your cella which articulates with the, er, radial head. Er, so this is just purely the burning anatomy, you can tell which is the medial side, aside from the fact that the radius looks like that the old looks like that because the medial epicondyle, er, protrudes further away from the midline of the um of the humerus. Um And on the posterior view, you can see the electron fossa which allows the electron tip to fall into. Um And you can see that one of the philosophies that Adam describes is this concept of the elbow having two halves to it and they, the osteology is incredibly different. So um on the medial half, it behaves like a hip joint. In other words, it has a significant amount of coverage. Um There's a significant amount of bony stability that comes from the ulnar humeral articulation, a bit like a hip. So if you had a hip and you excised the hip capsule and all the hip ligaments, it's unlikely that that hip will become stable, uh unstable, right? Because most of the stability is inferred by the fact that the ST li is deep and it's highly congruent to the femoral hip. So that's a bit like the medial side of the elbow. So that's the first concept to think of is the medial side of the elbow is a bit like a hip. In that most of its stability comes from bony anatomy, congruence, and depth of articulation on the lateral side of the hip. You can see that you've got a essentially two thirds of a sphere which is the cum which protrudes anteriorly from the distal humerus and that articulates with a reasonably shallow radial head which is elliptical er in nature and that radial head also articulates with the lesser sigmoid notch on the der Well, you can see how the regular head doesn't really cover much of the capitellum. So you can consider that like a shoulder, right shoulder is a very unstable joint, most dislocated joint of the body. And so the lateral side of the elbow can be considered from a bony stability standpoint, similar to that of the shoulder, large humeral head, tiny and shallow glenoid fossa. Therefore, the soft tissue um constraints to the lateral side are far more important for stability than the bony constraints. Co the bony constraints don't offer too much. If we look in more detail at the distal humerus, you can see that the trochlea extends very far distal er really er deepening the um the the socket if you like of the ulnar humeral joint, um you've got your epicondyles which have muscle attachments to them. We know that the uh extensors of the wrist um attach onto the lateral side and the flexors attach onto the medial side. And they're also important. We'll talk about those later. If we look at the radius and ulnar, we can see again, very deep articulation, which is highly congruent with a bare area in the middle, that's number seven. And that's your greatest sigmoid notch and then your lesser sigmoid notch has a place for the widest part of the um radial head to articulate between. And so this is also important because number 12 indicates where there is devoid cartilage in what's called the safe zone of the radial head. And that is the area that Lee Van Rosberg will exploit when he's putting a plate on the radial head. Um He's basically putting it over this area, not over where there's cartilage because that area does not rotate into the lesser sigmoid notch and therefore less likely to impinge. If you believe that is the case, you can see on this view just how deep the um greatest sigmoid notch is. So, the ulnar on the media side of the elbow really does resemble a hip joint. The talking about the soft tissue. Uh we're looking at the medial side of the elbow and you need to know some of these structures. So um 1617, 18, essentially collectively is the the medial ligamentous complex of the elbow. Um And we can see here that 16 is the anterior bundle and 18 is the posterior bundle. If you have someone with um elbow instability, simple elbows, nearly always, the injury begins at number 16, the anterior bundle of the medial collateral ligament which goes from the sublime cubicle, which is this ridge here, which is actually palpated in interrogatively. When you're doing a medial approach very easily. It really does feel like that like a very sharp, thin spike of er bone that protrudes from the um medial aspect of the elbow. And that attaches to the um medial epicondyle, that's probably the most important soft tissue structure on the medial side of the elbow, which we've already said is not as important as the bony anatomy and the bony anatomy, we've just labeled it all the humeral joint, but more specifically the coronoid and the trochlea. The number 18 is the posterior bundle of medial collateral ligament, which very rarely will cause problems and actually often is sacrificed in a tight elbow where you want to gain some extra elbow flexion in a degenerative or a posttraumatic arthritis situation. You can actually cut number 18 and you won't instigate any instability and you may actually deepen the flexion arc of that stiff elbow looking from the medial side over to the lateral side. Number 19 is the annual ligament which essentially wraps 270 degrees around the radial head, creating a nice envelope for it to rotate within a and that attaches um essentially from the er proximal ulnar and it goes all the way around and attaches to the posterolateral aspect of the ulnar. And this is what it looks like on pa glas dissection. Look how beautiful this is. You can see here's your, oh, let's go back. You can see here's your anterior bundle. Number three, your posterior bundle, number four, your transverse is really kind of or accessory er bundle is really not that important. It's just a condensation of the capsule. Er but really the most important structure here is number three, what you can see here. Number six is the annular ligament and then the radial tuberosity and the biceps tendon. That's number seven. So what we do are biceps, er distal biceps repair, we're essentially trying to recreate this footprint. But in elbow instability or just to summarize the medial side of the elbow, most of the stability comes from the bony anatomy with some er contribution from the anterior bundle of the M CL, which is nearly the always the first structure to injure itself when a patient dislocates or a simple elbow dislocation. Therefore, it can be important. So, on the lateral side, we can see just how that concept of bony osteology inferring stability plays out here because we can see the cellar which protrudes distally. Um If you, a lot of people will measure on a, on a lateral X ray, the um er the line that er dissects the capitellum from the anterior humeral line. And you can see just how far anterior the capitum projects. It's essentially you could say two thirds of a sphere and then just how shallow the the radial head is. But what I want to draw your attention to is the soft tissue anatomy of the lateral side of the elbow, which essentially is the lateral ulnar collateral ligament, the annular ligament and the accessory er ligament. Er but the most important structure here is number 14, which is the lateral ulnar collateral ligament. And can you see a couple of things I wanna highlight here. So together this is referred to as the lateral ligament is complex. But I wanna just point your attention to number 14, the lateral ulnar collateral ligament goes from the er lateral epicondyle to the sator crest of the proximal ulnar. But can you see how it kind of sits slightly posterior to the radial head? And and that's its function, it's function if you think about it is going here, it's actually posterior to the rail head. It just about traverses the most posterior aspect of the ra head and it really acts like a havoc. It acts like a hammock to prevent the redhead from drooping dorsally. Ok. That's his main function. And so when you have someone with very subtle er poster lateral rotator instability following a simple elbow investigation, one of the things that you'll notice is that the ra had sublux on the lateral view because that Hammock is no longer propping it up and to be in line and the ra captain are line to be I intact. Uh So that's really important in Montia fractures. This whole ligamentous complex may be intact but the radial head can come out of its pocket and sit anterior or posterior to that. So that's important to note, sorry, there's some beeping in my house going and I'm not sure what that is. I'm just gonna close this door. It might be the dishwasher. Sorry. Um This is the er P glands dissection of the lateral side of the elbow, you can see um it's never as clear as this, in my opinion. Um And actually, I'm not even sure that's truly where the ligament is, the ligament tends to go like. So, and it tends to extend er quite a way down. Um And that's really important for a number of reasons because not only is it slightly posterior to the radiocapitellar joint. If you're treating someone with a radial head fracture, without instability, you may want to preferentially make your deep incision anterior. So you may want to use something like a Kaplan's interval purely because there is a risk of IIC injury to the lateral ulnar collateral ligament. And that has been described by David Bloa in Chin, who's an elbow surgeon, fantastic elbow surgeon who does a beautiful dissections and some videos of me um that are worth watching. You'll see some of those a bit later. Um Here's another uh representation of the annual ligament in one, the, the distal biceps tendon in five. Um and essentially they red on neck and fall. Next is the muscles, the muscles are incredibly important um for dynamic stability of the elbow. The thing I want to bring your attention to is all of these muscle masses that originate in the forearm and insert um in the distal humerus, they cross the elbow. So if you imagine if these are attached to the distal humerus, as these muscles fire, they're essentially pulling the forearm onto the humerus. Um So on the, on the medial side, the medial epicondyle has this attachment of the er common flexor pronator mass. And on the lateral side along the er lateral column of the distal humerus, you have the um confluence of all the wrist extensors. Uh And so that's important, the dynamic stability comes from these muscles which may be injured in a simple allo dislocation. So, uh you can't really talk about elbow problems without talking about Sean o'driscoll, who er described this concept in the late nineties of the fortress of the elbow. Um And I used to, when I was in training, I used to think this was everything and I used to like draw this out and people get asked to draw this out in the Fr CS. Um And I remember thinking, oh yeah, I could definitely re recite this but I don't actually know what this means. And, and I actually think it's probably not as helpful as I used to think. Um mainly because what Sean o'driscoll essentially described was this fortress having um primary and secondary barriers to instability. Er And the primary essentially is the anti bundle of medial collateral ligament, the lateral ulnar collateral ligament and the ulnar humeral articulation. But that's not particularly helpful because in theory, if you disrupt the ulnar humeral articulation, but not the others, your fortress remains intact because your secondary um stabilizers are intact. But actually, that's not true in certain ways of disrupting your ulnar hum articulation, you can actually infer some instability of the elbow. So II don't really subscribe to this as a philosophy. I subscribe to er the Adam Watts philosophy on um elbows stability, which we're gonna talk about shortly. So if you, if you see a patient like this with a simple elbow dislocation and therefore no fracture, 95% uh unlike in the shoulder, 95% go posterior or posterolateral. And again, David Blonder described looking on the lateral dislocated x-ray if you get a reasonably good x-ray, if you draw a line along the axis of the radius, sorry the other, and you draw a line perpendicular that through the bare area, the deepest part of the greatest s one notch, if that does not touch any part of the humeral shaft, he believes that that is a marker of a high grade simple elbow injury. In other words, he believes that if it's gone that far posteriorly, you must have ripped everything off your distal humerus. And therefore, you may need to assess that patient more carefully because they may be at risk of recurrent instability. So 95% posterior or posterolateral like this one, no fractures seen. What are you gonna do? Well, you're gonna have to first appreciate what's injured. And Adam Watts described the, the ladder of er injuries and the kind of series of events that occur in a simple elbow dislocation and this really came out of a paper of 16 professional rugby players where he had the opportunity to get them an urgent MRI and he treated them privately. And he, and what he noticed was that all 100% of those pressure rugby players, er, sustained a medial ligament injury and then a, a smattering of others and essentially they decreased in severity, but with a large proportion of them, he's, he basically described um these series of injuries that occur in the simple elbow justifications. And so when you examine someone after you've reduced their elbow, it's actually nearly impossible to know which of these they're injured, right? People have looked at clinical signs. Um and it's not that reliable. So what uh Adam describes is getting an urgent MRI scan for all simple elbow dislocations to assess these structures, er radiologically as well as a clinical assessment. There's no substitute for that, but he always felt that um an urgent MRI would give you a lot more information. Uh Why are we doing this? You know, you may be told by a consultants that simple elbow medications are all stable after you reduce them and none of them need any treatment. It'll be great. That's actually not true. Um So 95 to 98% of them probably will never have recurrent instability. But if you're an elbow surgeon, you will see some patients with postlateral rotator instability, months or years after a simple elbow dislocation that were just neglected cos they were told you're stable, you're fine. And, and the reason why we picked those up is because they tend to be young people who can develop arthritis very quickly. So, um the take home message here is you, you can't really assess which of these structures are torn on clinical exam. Er, you could argue and what Levan Rensburg argues is that maybe we should be doing a lot of eu A s and if it's deemed to be unstable or opening up on an eu A then proceed to fixing it again, I always had issues with that. Cos I felt like certainly as a fellow and as a senior trainee, you, you take these people, you give them a G A, you do an EU A and it's like, oh, is that 10 degrees or is it nine degrees? Is it 11 degrees opening up? I don't know if you end up just opening it anyway and fixing it. Um So Adam's philosophy was very much to get an urgent MRI to um to assess that and then decide thereafter. So he basically said that nearly everyone gets a medial ligament tear and that's probably ok. But if the MRI shows they've got muscle avulsions from the distal humerus where the partial or incomplete or complete, that person may not have a happy elbow after the simple herbal dislocation and they may need surgery um where it's a bit unclear as if they have a, a lateral or the collateral ligament is unclear which patients compensate with their dynamic stabilizers that are intact. And which ones don't. Obviously, once you see someone with an elbow instability, you need to document and examine for the el nerve, the median nerve, the radial nerve and the radial pulses and you need to document all of those again. Er after you reduce the elbow, you reduce the elbow in a number of different ways. This is a two person technique where essentially you've got traction counts, traction and disinfection with the left arm. Uh This is another way my preferred method of just palpating for the electron on and trying to milk that over the distal humerus uh from a posterior position to a AAA reduced position. And FIFA actually describes this on their website, er, if you're gonna do it pitch side er to do it over a bench or over a chair. Um with a single person technique, it doesn't really matter how you do it as long as you reduce it. Um And then what you'll often see is A&E will put these patients in a plaster. Um Anyone agree with that Charlie, what do you think you? Should, we put them in a plaster? No, no. OK. Don't put, don't put your face in the plaster for several reasons. OK. Number one, if you put someone in the plastic with a simple investigation, the weight of the plaster wants to pull the ulna away from the distal humerus. So you're making them more unstable. You think you're helping the patient, you're making them more unstable because now they're trying really hard to keep their ulnar attached to their humerus and they're having to cancel out the added weight that they've put on that you, that they've put on with the plaster. That's the first issue, right? The second issue is you immobilize the dynamic stabilizers. So the patient often will feel more unstable after the backsliders put on than before. Ok. So you've, if they haven't torn their dynamic stabilizers, their muscles, you're now taking them out of the equation by putting them in a plaster cos it often includes the wrist. Ok? So don't do that. Do not put simple elbow dislocations, post reduction into a plaster. You may feel like you're doing the patient a favor. Oh, they're in pain. It, it hurt, it hurts, they feel better. You're making them worse. You're making them more unstable. Another thing that you'll often see and certainly I saw as a trainee on rotations is these fancy hinged elbow braces. Um Should we be putting these on? Absolutely not, I've yet to see one applied and remains applied in the correct manner. You can see the hinges here, right? But the hinge of the, the center of rotation of the elbow is up here. Nearly always. These things slide down is a bit like the hinge knee brace. But this is worse because you're giving a patient a device that is intended for dynamic motion, but it's not applied correctly, it can never be applied correctly, even if you put it on correctly. In the first instance, gravity will always pull it down to a more distal position. So as this patient flexes and extends the brace is actually creating a translatory traction force across the elbow, making them feel even more unstable, er, which is kind of bizarre, right? Because if you think about it, the sense of rotation is the red star and when it needs to be on the green star, so every time the patient flexes and extends in this brace, they're actually distracting their ulnar away from their humor. So don't use these hinged elbow braces, they're not helpful. Most simple ations will be stable um in high a high flexion position. And if you wanna tell the patient to rest their, their, er, palm of their hand on their chest that puts them into pro a slight pronation or neutral rotation and that tends to be the most stable position. Um, that's for most people, most people, the posterior postlateral. So that's all they need a, a simple collaring cough or I prefer a broad arm sling and, and a nice high position. And you explain to the patient, this is likely to feel unstable in extension and supination. So that's really the thing you want to try and avoid in the early phases until we see you back in the clinic. So you see them back in the clinic. You do you, you take your history, you do your examination. One of the things that's important to look for is the pattern of bruising, again, sensitive but not that specific. Um Where is the pattern of bruising? Is it all medial, is it medial or lateral? You can see on the left side, it's all medial bruising. This patient we know will have an anterior bundle of M cl tear. But as long as the ulnar humeral anatomy is not disrupted. And as long as they have got some muscle attachments to the distal humerus, this patient will likely you have a stable elbow after this simple elbow. The patient on the right, you can see has got a tourniquet on and is about to have surgery. So, you know, they're gonna be unstable because they're having surgery and you can see their er bruising is extensive across both the medial and the lateral side. So this patient had essentially extensive detachment of their common flexor and common extensor origin as well as anterior bo LCL and lateral ulnar collateral ligament injury. So you can see, even though they have a simple elbow dislocation, that patient needs to be stabilized because they have, they have little chance of, of creating stability cos they've got no structures remaining attached across the elbow. Um Joe deep fadness doesn't use urgent MRI for everyone. Um Even though he's trained by Adam. Er, he feels that it he can a a adequately assess who is potentially unstable in the clinic using the post lateral draw test, which is uh this is David Blonder in one of his videos showing you how to do it. So the patient's supine, they er forward, flex their shoulder and flex their elbow. And essentially you're using um your index finger on the volar aspect of the proximal radius um and to stabilize the humerus. And essentially, you're trying to bring the er radial head to sublux posture. And he's basically he demonstrating that er in this er in this cadaveric demonstration. So that's the post draw test. Joe Deep and Brighton will do this for everyone within a couple of weeks of their simple education. And if they feel that this is positive, he will then go and, and stabilize them. I have to say in my practice, I get an urgent MRI. I work in Colchester. It's a DGA. So that's quite busy for trauma. But I've yet to have any radiologist, give me a hard time about getting an urgent MRI and you have to appreciate most hospitals will see probably five simple verifications in a year. So you're not gonna be flooding the, the radiology department with a bunch of MRI elbows. Um And so for me, II, feel like this adds a lot of value er where it becomes difficult is when they, they report, get reported as partial, er, carboflex origin colon extensor origin tears. So I look at all the, er, sequences myself and, and then assess them with a postlateral draw. So it's kind of a, a hybrid assessment of all of the things that I've been taught by, er, masters of elbow surgery. And then after you do your examination you're gonna send them for an image. And what I would recommend is if the patient cannot abduct their shoulder to get a lateral view of the elbow, which is normally how they do it in the department. Um You can ask for a horizontal beam lateral a bit like how they do for hip fractures. So essentially they rest their elbow down on the platform on the couch. They have a foam triangle under the wrist and the X ray beam is horizontal and parallel to the floor and they do a horizontal beam lateral. What you really want is a really good true lateral of the ulnohumeral articulation of the radiocapitellar articulation. Because what you're trying to assess is this radiocapitellar line if the patient is not immobilized, and they've got a simple application that's now reduced. And you do an X ray a couple of weeks in the clinic and you get a really good picture, you will know if that radial head is subluxed posteriorly that not only do they have instability, but they have the lack of dynamic stability from their muscles. So what this really tells me in the acute scenario. The first post post dislocation visit in the fracture clinic is that this patient not only has they torn the anterior bundle M cl their lateral and the collateral ligament, but they've done enough damage to their dynamic stabilizers for them not to be able to keep their radial head centered on the capitella, which to me may not necessarily mean they definitely need an operation but will definitely push me more towards that. Uh That, that way of thinking. So you can see here, I if it is sub locked poster, the, the L UCL is incompetent, but more importantly, the dynamic stabilizers cannot compensate for that subtle instability and it's very subtle because if the patient won't have dislocated, they'll just be subluxed. OK, I'm gonna stop there and just take some quick questions and then we can move on to a little bit of complex elbow instability but not very much a very basic introduction. Cos I'm sure Lee's gonna give do a better job of describing that to you guys. Does is everything uh has everything that I've said made sense. Does anyone want me to uh clarify any of those points? Um I had a question. Um Yes, please, if you, if like I've seen someone who had a uh let's say uh a fracture, dislocation of their elbow. So you have uh let's say the coronoid and the radial head fracture as well. And when you're thinking about surgical management how do you know, uh because they're gonna be tender examination, why it's gonna be challenging? How do you know whether to fix the medial side um or not? Great question. That's, that's the second half of the talk. So f justifications second half of the talk, simple notifications. Any questions on that? V Hi. Can I ask a question? Hi. Oh, yeah, of course. Hello. Hi. Hi. I'm sorry. Uh, what's the, at what stage do you do? The pl ri testing? And do you grade them? Is it possible to grade them to compare the opposite side or is it just, I mean, ii always go on the opposite side. So the patient knows I'm not gonna try and rip their arm off. And so it's very gentle, it's very subtle and they'll say to you, you know, they, they'll be apprehensive. It's only one of the many things that I do on the clinical exam. You got your, you look, feel move, you wanna assess for bruising. And I tend to get to them, uh, between one and two weeks after their dislocation, uh, in, in, in our system, in our, in our fracture clinic. One of the other things that I think is important that I didn't touch on is, um, whether the patient can extend within 30 degrees of full extension. If they can do within that 30 degree arc of full extension, then they probably have a stable elbow post, simple elbow dislocations. The ones that are apprehensive. They say I can't go any further than this. That's what I'm doing. The postlateral draw just to prove that this is probably unstable. I'm gonna confirm that with the X ray, I'm gonna get an MRI and all of that is pointing me towards potentially stabilizing that simple elbow muation acutely, which is very important. Cos most people don't talk about this, they just say you, you read all the bullets and everything else online, simple identifications, all stable afterwards, just, just reduce them and get them going. That's definitely not true. It's, you know, 2 to 2 to 5% in most series will have problems. Um And, and that needs to be picked up. And so the best way you pick it up is through a multimodal approach of clinical history examination, imaging um and so forth. One more question is uh when you put them into the po sling and you put them in high flexion, what is the advice that you give them? Do you ask them to keep it in that position for one whole week and then start to move the arm out of the whole or just start moving it when they feel comfortable? Yeah. So II say to them wear the polish sling until you come to see us in the clinic. Um But I would strongly encourage them to start mobilizing. And the way that I ask them to mobilize is to do what we call Supine dart throwing exercises. So I show them, you lie down flat, you pretend you're holding a dart or a pen and you're supine and you're trying to throw darts at the ceiling. And the reason why that's beneficial is because in that position, the weight of your forearm is pushing it onto your distal humerus. Number one, right? As you throw a dart like this, you're in pronation, which is more stable for most of these posterior postlateral dislocations. And then the third thing is I get them moving and biceps is actually helping me now because it's not really firing excessively because I'm using gravity to get my flexion whilst in the, in the sitting position as biceps fires to f er flex the elbow, it wants to pull on the radius and that may be ok. But th this is a much easier position to get. But in, in all, honestly, if they're not moving that much in the first week or two, I'm not that concerned. I'm more concerned at the second POSTOP visit where they come in, still wearing a sling, even though I told them to get rid of it and they haven't done any of their flexion exercises in the super position. Then I'm worried because um instability, I can easily deal with stiffness is less of a problem and so more of a problem and takes longer to recover from. So I strongly encourage them if I'm, if I'm confident that this is stable on the imaging, on the clinical exam and everything else. I really try and push them and I refer them to physio. And I specifically say please only do you supine er flexion extension. And the only thing I want the physios to avoid is passive supination. So often they'll be stiff and pro supination. And what you don't want is passive supination because that's essentially levering out your radial head poster laterally. So they can do active as much as they want. But I don't want the physio to go. Oh, it's a bit stiff. Let's try and get you a bit more. That's not helpful. Ok. Sure. Thank you. No worries. No worries. Um OK. So sorry. Could you once again explain the reason for uh using a sling sling as against a plaster following a simple, let's go back. Oh, hold on one second. Ok. So we said that and a simple elbow dislocation, you almost always damage your anterior bundle of M CL, which is not that important because your coronoid and your trochlea is intact cos there's no fracture on the lateral side. You rely heavily on your soft tissue structures and principally the lateral ulnar collateral ligament is the most important static stabilizer of the lateral side of the elbow. It acts like a hammock to keep the um the radial head in line with the capsular in a plaster scenario, you've added weight to the arm. So there's extra weight trying to pull the ulnar away from the distal humerus. Number one and number two, you've immobilized the dynamic stabilizers of the elbow, the common flexor origin and the common extensor origin. So they cannot assist in giving you dynamic stability of the elbow. So what often happens? And, and II ha I did have a case of this which I didn't include in the slide. A simple elation gets put in a plaster and you speak to the patient and they say it feels worse in the plaster. They don't say it feels better. They say it feels worse than plaster. And I had one case of my registrar during the clinic and I got called into the theater. So he saw a patient who took the plaster off, put them in a hinged elbow brace. This is my first month as a consultant. So he didn't know about my peculiarities around elbow instability. Um put them in a hinged elbow brace, took an x-ray, the radial capella joint is sublux and I brought the patient back immediately did a horizontal being lateral. It's still sublux. She ended up having surgery. But when you ask her, you say, what did it feel like in the hinged elbow brace? She actually says it felt even worse. It felt like my arm was no longer attached, right? So, and when you take everything off, she goes, oh thank you. That feels better because these things we put them on this paraphernalia of elbow instability thinking we're helping the patient, but we're not. So to answer your question, 22 main elements. Number one, you're adding weight to distract the elbow away from the humerus which you want to avoid. And number two, you're taking out dynamic stabilizers, which if they're intact will be having a preferential beneficial effect. Cos it crosses the elbow joint and therefore when those muscles fire, it wants to pull the ulnar onto the humerus to some degree. Thank you. OK. So no worries. So um complex elbow stability, but just very brief introduction. Um So essentially this is one of the things that you need to be aware of. This is in Adam Watt's paper. Again, I think this was, we invited him when he, when I was a pot trainee, we invited him to the pot meeting one year and he gave this amazing talk on Fran applications and he, he was really hashing out this concept at that time. This was several years ago now and it was probably the best lecture I've ever seen on elbow trauma. Um And, and this is what he basically said. He says, if you think of um the elbow for fracture investigations like a a temple or with pillars, there are three essentially three columns, the lateral column, the middle column and the medial column and the fulcrum is in between the middle and the medial columns. And essentially the principle of all of this is um when you break bones around the elbow and you have a dis an instability, which bits you break can be uh essentially recognized in patterns, but it can also um infer which needs to be um fixed in order to restore stability. So the medial column is the anteromedial facet of the coronoid as well as the um er capitella, sorry, the trochlea um aside from that, you've got the anterior bundle of medial collateral ligament, which we talked about, which is attached to the anteromedial facet via the um sublime tubercle. The middle column is the anterolateral facet of the coronoid. And the lateral column is the radial capitellar articulation, specifically the radial head and the lateral ligament is complex, which essentially is the lateral ulnar collateral ligament plus the others. And so Adam described this classification system which is really informative because even though it's a bit daunting, you don't have to memorize this. But if you just look at it from left to right, there are some key things to, to to bring your attention to. So whenever you see the anteromedial facet of coronoid involved in any of these diagrams, you'll always see fixed coronoid, right. Number one, number two, whenever the anterolateral facet of coronoid is involved, you don't always see fixed coronoid. So it's less important whenever you see um uh essentially some injury to the er lateral column, you will always see something to do with the lateral ligamentous complex. OK. So that's I don't want you to memorize this, but I want you to appreciate why this is important. So, a type A is a anteromedial coronoid fracture. If we go back to what I said before, the medial side of the elbow is like a hip, this is like in my mind, like a large posterior wall of acetabulum fracture. If you see those post dislocation, they get fixed, right, you send them to Adam Brooks, er a pelvic and as the surgeon gets to them, they fix them and if they're young, they hope for the best. If they're old, they may get a total hip as well. So this is a very important structure. A terrible triad is essentially a type C OK. Terrible trial is a dislocation, a ral head fracture and a coronoid fracture, but the coronoid fracture tends to be the anterolateral facet. And if we go, if we bring back our um our er diagram of these columns, you've essentially broke your radial head. So you need to fix that or replace that to restore the lateral column and your anteromedial facet is intact. So you don't have to do anything to that. So if you ignore the middle column, the roof will remain on top of that temple, right? Cos you've got the medial column and now you've fixed or er restored the lateral column. So a lot of the time in terrible triads, you do not need to fix the coronoid, the final thing I want to mention about this is you can see with this 3d uh ct of the elbow, there is no such thing as tip of coronoid. That is a radiographic phenomenon. There is no tip of coronoid. The the coronoid is a fan shaped structure, there is no tip. OK. There's either anteromedial facet, anterolateral facet and that's as much as you need to know as trainees. There is also an intermediate ridge which lee talks about. But that is not that important. What you essentially want to know when you see a coronoid fracture on an X ray is which facet of the coronoid is fractured. So what I want you guys to take away just like the ankle surgeons have made you all believe that a ct of the ankle is necessary. Whenever you see a fleck of posterior amount, you need to think the same. When there's a fleck of coronoid, you see a fleck of cor anywhere on the X ray, you get them act co what you don't know on those two D radiographic projections, whether it's the anterolateral facet or the anteromedial facet. Now, luckily for you, the anteromedial facet is more important and that actually is quite well imaged on an ap radiograph. So you can often see them. But I would just say, just say to you, if you think there's a suspicion of a coronoid in a fragile location of the elbow, just get them act it, it'll save you a lot of headache. OK. So here's um x-rays of uh patients with a fracture dislocation. Ok. Um You can see here, there is some fragment here. Sorry. These aren't projected very well. I'm not sure why. Um But you can see this is your answer me facet. Look at this. Yes, it's intact. Yeah. All the hero carer articulation nice and congruent here. You can see the radial head is dislocated posteriorly. There's some fractures here and again here. Ok. So coronoid is definitely fractured here. You need to get act. So I call this a little bit spicy. OK. This this is a lot more going on here than, than meets the eye. So what this patient has is essentially a terrible triad. They've injured the radial head, they've fractured that they've fractured their antri lateral facet. So how do you restore this patient's stability of their elbow? You fix or replace the radial head? If the lateral ligamentous complex is injured at the same time, you do a lateral approach to the elbow, you can fix that, but you do not necessarily need to fix the coronoid if it's truly an an interlateral facet, because the fulcrums in the middle here, this is intact. You've restored this column, the roof will remain on the temple and not fall over. Ok. What about this one ap lateral of a fracture er of an elbow that was previously dislocated. You can see this is what I was talking about the antra lateral, an intermedial facet of the coronoid is quite well imaged on an ap radiograph of the elbow. Whenever you see this, just get them act. What you don't know is whether this is an an intermedial facet coronoid only or whether it extends across and is bi basal. But if you think about how this patient sustained this injury, they've loaded this side in compression, which means they've loaded this side in tension, which means they've probably injured. Their lateral ligament is complex and they've destroyed their all the humeral congruent. Therefore, this is going to be unstable. This does not pass go, this gets act and surgery. Ok. And how are you gonna stabilize this person's elbow? You can either start medially and you fix the coronoid, you can fix it with a screw. If it's big enough, you can fix it with a, a plate if it's comminuted or small. And if you, if it is very comminuted but fixable, you can often put the plate extra articular, you can put the, the plate on top of the anterior capsule and it kind of buttresses everything back down to create that um er bony congruence and then you won't be done because you probably need to go laterally to fix the lateral ligamentous complex. You can see here if you draw a line through the radial er shaft axis, it's sitting slightly posterior to the capita, very subtle. But if you ever see an interim medial facet of coronoid do not, do not sit on these patients. They will develop arthritis within six months of this injury. If it's not treated. We had a patient, I worked at an N TC before coming down to Colchester. We had an 18 year old polytrauma had multiple operations, lost half his bowel was, was in bed for four months and at and at five weeks, I was doing a ward round and I picked up he had a, a missed an medial facet coronoid fracture. I ct ed him, I discussed him with all the professors of elbow surgery around the world and there was no consensus. So we, we examined him, he had no pain, he had full range of motion, no crepitus. So we decided just to watch it, he came, he, he, he kind of got lost. He went through the polytrauma thing, er, went to the intestinal failure unit. Anyway, he came back to my clinic three months after his injury and he started to develop arthritis and he feels like he's unstable when he tries to pick himself up and pull himself up to do his rehab. He feels like he's falling into that uh medial space left by the um Antra media facet of Coronoid, it healed, but it healed in a non anti position and that patient has instability. So he ended up needing um er surgery to correct that which becomes very difficult whilst the thing has already healed. So an intermedial facet coronoid there is one chap in er, in a, in the, in Milan, I believe Palo Arone. I think he advocates doing a, a back slab and act to see if the ulnar humeral joint is congruent and treating them non operatively in some situations. But that is not mainstream in the UK. If you see an intramed facet or coronary fracture that needs surgery to stabilize it. Ok. Uh OK. So yeah, I go, this is pretty spicy. This needs to be fixed. So this is a, an illustrative representation of what that injury is. They've got anteromedial facet of coronoid fracture. They've also probably injured the lateral ulnar collateral ligament, you can see the fulcrum is here. So therefore, the roof of this temple will fall down if you do not restore the medial column. And the only way you can restore the medial column, unlike on the lateral column where you can replace the radial head, there is no coronoid replacement, you've gotta fix it. So you've gotta pick them up acutely and fix it. So that's it that these are my take home messages. When the anti bundle M cl is torn, then the anti medial facet is incredibly important. If fractured, it needs an operation, the muscles that cross the elbow, the common flexor, the common extensor muscles are very helpful, post instability and a simple elbow justification. They give you dynamic stability a lot of the time. So if someone has a simple elbow justification. Do not put them in a plaster and immobilize those muscles. They are, they are helpful if you suspect a fractured coronoid get act just like the posterior amount of an ankle for all dislocations. You're gonna document the neurovascular status, pre and post reduction and in complex fractionations. Think about restoring the columns, just think of it in terms of columns. That's probably the easiest way. Okey doke, I'll stop that. Any questions.