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You have that one already. Was that recording? Was it okay? So, welcome all to humeral shaft fractures. And thank you to Hussein and the E O E teaching committee SEB for setting up this session. Hopefully, we'll go through uh several cases together and you can teach me what I should have known before I became a consultant, uh upper limb surgeon at Addenbrooke's Hospital. So before we start, this is not going to be right now. This is gonna be at the end, but I'd like you all to uh point your phone's at the QR code or uh if you're on your phones to go to slide oh dot com and punch in that number double 395489, double 395489. And at the end, we'll see how much I actually effectively taught you. So of all the sharp fractures, apparently the human sharp fracture is the most benign. That was what bowler quoted in 1964. But why did he say that? Well, he thought that it was benign because they, the fractures have great tolerances. We don't normally walk on our arms and so we can accept a bit of a uh displacement and angulations and the pain isn't so bad. And uh so therefore, I don't need to rush into surgery uh in terms of the shoulder and elbow, having such a large range of motion, meaning that you can get away with quite a bit of um angulations when, whether it be in the AP plane or in the uh various valgus situation. And you can also tolerate quite a bit of shortening as well, which is something that you will might see later on in the presentation. So someone called till early strong um you may know him and I happened to work with him. He, he published this in 1998 before he became a consultant and show that the human sharp fractures occur over a bi modal peak. And I don't think anything has changed in the last 24 years or so. Um still um high energy young males usually and then low energy females uh more. So the classification pretty arbitrary. It's the A oh classification and depending on how much comminution it goes from a to see and then from a one to see three. So nothing really significant there. So what I need to do is put up the pole and actually, I should have asked my colleagues, can I get you to Hussein or Seb if you put up a poll? Number one? Uh Yeah, one second. What do I have to stop sharing? I think that should have put up the pole then uh we have some feedback because I can't see the whole necessarily. Right. So, yeah, I can see it. Great. What would you do in this situation? Do I need to scare my? So, hold on. So it should show the answers that everyone's put uh in the uh polls tab. So if I give you another 10 seconds, so this fracture is presented to you in any. Would you a just put it into a collar and cuff for gravity? Be put it into a sling for support? Uh huh. See, put it into an above elbow hanging cast deep into a cast brace, including the shoulder and elbow or e put it into a humeral brace. So that's what I want to know. What would you do? I don't care about what's right or wrong. It's just what would you do? So um should go back to number one poll one. Can you show us the results of that? What was that? I am. Let me work out how to do that. Um hmm uh So I mean, I can read it out basically like it's in the polls. Tab 17 response is 88% said e put in a human brace with 11% said puts into a cast brace, including the shoulder and elbow. Cool. Okay. All right. So you know, if there's not a right or wrong, it's just a case of what, what would you and your mates all do. So, the reason why is because you need to be able to consent your patient's and uh tell them exactly how long it's going to take. What's the rehab regimen in time? So, coal number two, could you put that up for a set? A so it's the same, same fracture and your dealing with the same patient. What are you gonna tell the patient this fracture heals in 95 great. 95% of people be this type of fracture heals in six weeks. See this type of fracture heals in four months. De we need to see you every week in clinic for six weeks or e physiotherapy is not going to help you. And when you think you've got the majority of results, if you could just uh shout out for us there. Uh Yep. So the uh let's move it again. Yeah. So, so far 66% are saying e physio will not help you. Uh I think some people aren't at this early prematurely for the other question. Uh All right. Doesn't make sense. But so far one person said this fracture heals in six weeks. The other said we need to see you in clinic every see you every week in clinic for six weeks. Hmm. Okay. All right. So my, my preferred answer to tell this patient would be that this type of fracture takes about four months to heal in a non operative situation. That's probably the closest to the truth out of those five options. Um And we'll come to some data about what percentage of these fractures heal uh and how long they take. So here we are an X ray of the same fracture that you've treated in the humeral brace. And this is at three months later. So just that it's good alignment just about healed. Six months later, you can definitely uh feel confident that it has healed. So it doesn't, he'll straightaway does take a long time. And rather than saying the arbitrary six weeks, that used to be a favorite number where I don't know where six weeks comes from for uh orthopedics, but I'd rather you say six months um really manage the patient's expectations. So you chose to put the Kocian in the brace. And the quick, the reason why you use a brace is because it affects the patient with hydrostatic pressure. Hence the uh the soundtrack there from uh David Bowie and Queen under pressure. That is what same enter used in 1977. And for 45 years, we've been using functional bracing for humeral shaft fractures to good effect. Lots of you chose to put it on immediately in the A and E and that is definitely a uh an acceptable method of treating these patient's and something that I do. Uh And we do in Cambridge University hospitals, we put them straight into the brace. Other centers may not they may put them into a cast, um uh for, you know, back slab for the time being until they get to the fracture clinic. So it isn't a right or wrong, but certainly you can go straight into the brace and it works by hydrostatic pressure. What are the contrary indications? Um Not much actually same into in his case series of 968 patient's actually used it in patient's with open fractures from gunshot wounds as well. So, and, and apparently many of them healed. Um but there are too many contraindications, you know, if it is an open fracture, I think nowadays we we do have to uh consider operations. So this patient presents to you. So the different patient with that midshaft humeral fracture, there you go, you put it into a humeral brace and this is uh the so same enters original paper, lots and lots of patient's took at least three months to heal, but a range from a month to six months, uh nearly on the uh on the side there. And there was a very small nonunion percentage in his series. Um and they're even in the open fractures, as I mentioned, you got no infections and only 6% were non unions. Um This was then re recently repeated and we looked at retrospectively at Cambridge are series of humor shaft fractures and what they came up with and uh come up with that uh bottom line from Van Rensburg and Tiddly strong's paper in the journal of shoulder and elbow surgery is that it matters where the fracture is the proximal third, only 75% healed. Middle, 3rd, 90% healed, distal 3rd, 85% healed. So when you say distal third, that's distort third, humeral shaft, all of these are humeral shaft fractures, not nec, not um articular fractures. Whole three, please. Could you put that up for us said uh is up? So you got this midshaft humeral fracture. Two part. Are you gonna a put it into a collar and cuff for gravity? Be put it into a sling for support? See, put it into an above elbow hanging cast. D put it into a cast brace, including the shoulder and elbow or E put it into a humeral brace. Any kind of change their seb joining? Tell us the results seb oh sep. Have I lost you? Sorry. Yeah, vast majority. 73% has put into a human brace. Seven. So we've changed. Yeah, teaching work, teachings work. Uh What was so 73% brace? And the what was the other uh 73% human brace? Uh Well, that's dropped 68% actually. So we've got 12% on B and 12% for see, I can't see those uh options uh link for support the N C. Uh 12%. Each one person looks like it's gone for collar and cuff for gravity. Okay. I'm gonna call it the uh I failed, I failed still more of the session today. So there are complications that can occur even in the brace. Uh You can see here that you can get blisters. Patient's have problems with axillary hygiene and also you can get skin reactions. And this patient actually uh started getting a rash due to the brace and uh couldn't tolerate the brace. And so he went from that position in the brace and then because of the uh the brace complications ended up like that. So this is three months later, what do you tell the patient? So obviously going to go for an operation, I guess at this stage, I hope. But which approach are you guys going to take? So said, Paul, please. Okay. What is the people's favorite approach then? Uh so at the moment, 60% going for posterior and 40% going for an trilateral. Yes, this is great. No, 50 50 now for both. Yeah. Okay. So post do an anti laterals basically are the the upshot and someone's jumped in with anterior now. Okay. All right, cool. I'm calling it there. So thank you. And this is what I did and I went for the anterior approach and you can see the plate sits on nicely on that uh anterior aspect of the humerus. And hopefully, what you can also see is that this wasn't some slim small fragment plate. This is a broad, large fragment plate which also has eight screws. So for either eight cord sees either side of the fracture on top of the, the lag screw as well. Uh It's a case of really, really try and make sure that you've got excellent purchase of your screws and uh compression of the fracture with a sturdy construct. So why, what do we see here? You can see an interrupted picture of the uh the patient's fixation where there's the lag screw just there with my mouse is and then on the anterior surface is the plate. The broad fragment LCP and not far away between break your radialis and brachialis is the radial nerve. A hands breath above the patient's uh lateral epicondyle to. So if you look at your a oh um Atlas at that point, you can see here is breaky Alice, I'm just outlining it with my cursor and then just lateral is coming out between brachialis and raid brachialis and brachioradialis. More over better overview there. And you can see if you put the patient's hand breath above the lateral epicondyle. You can see that it often x it's higher than you expect, right? What are you guys going to do for this one? So, poll number five, I think it is, is it uh yeah, you're on um five is running. So a bit more commune Utian on this one, you know, at least three parts, it spirals up to the uh we the proximal humerus uh to the neck almost. Are you gonna in the immediate setting? Going to put it into a collar and cuff? Are you going to put it into a sling above elbow hanging, cast d into a cast brace, including shoulder elbow or E put it into a humeral brace? So we did have 100% for human brace, but someone's just jumped in with a cast brace. Very chilled, an alibi. Okay, fair enough. Uh, I think it'll be uh pretty good in the uh humoral brace. Um And you can see that I'm thinking probably going to go for an operation more likely because of a couple of factors. We know that the combination is going to lead to a longer rate of healing. Uh And also we know that the more proximal fractures, there's a higher nonunion rate from Van Rensburg antilles stronger 25% nonunion rate for proximal mid approximal to midshaft fractures. So, using Montgomery principles, make sure that you discussed the options with them and if they choose to go for an operation, which they did in this case, what approach would you use for this one? So Poll six, please use pole six running. Hey, are you gonna go posterior, bi lateral, maybe I'll bring up the uh the X rays again. So bi lateral, see anterior D extended delta, petrol e anterolateral. There's the X rays again, they're the options. What are they saying? So it's quite a bit of a spread actually. So uh 43% went for an trilateral, 18% for extended delta peck. Uh 25% went posterior and 12% went anterior. Okay. Cool. I like it. So whatever approach you decide to take, whether it's anterolateral anterior posterior, that radial nerve is always at risk. But this is what I chose to do. So it was a long Phylis plate which was put in via combination of the anterior approach and then um more approximately through the delta petrol, get up on my feet. Next case, what are you going to do a poll again, please? Uh running. Mm So distal third, are you gonna put him in a plaster with a wrist-drop? Are you gonna offer an immediate operation? Nail it are you going to see them in clinic in three weeks and check Tinel's and E M GS. So to qualify the the wrist drop was there when they came to you? Because I know some of you clever people will say uh was it, did the wrist drop happened before or after you any manipulation? No, it's at the time they presented to you the offer an immediate operation plate. It e put into your humeral brace. What are the, what are the crowds saying? Said? So at the moment, 85% say immediate operation with plating and then 87%. And then then I think one person for put into human brace and one for seeing clinic in three weeks, check two nails in the MGS. So vast majority, immediate plating. Okay. All right. So what would we tend to do? Uh, my practice is that if it happens before any manipulation at the time of injury, it's most likely that it's actually gonna recover and it happens quite a lot. You can see there, the variable incidents reported of from 2 to 24% of sharp fractures. Primary care's primarily, it occurs at a time of injury. Um rarely it occurs later when we're trying to treat it. Uh controversial management, but it is a F R C S exam question but also a real life quandary. And because most of them actually recover, especially if it's happened at the time of injury. Um The primary palsies have a high spontaneous recovery rate. Uh So the probably the correct answer would be see, see them in clinic and three in three weeks time and check Tinel's and the MGS, but I just realized that E put them into humeral brace is also what we should be doing as well. So either um put him into a humeral brace and then see making sure that they're getting some E MGS at the three week mark and also checking that tunnels from this door two proximal in the exam. That's how you would assess to nails. Um This was reported on in uh in the Joan Bone and joint journal in 2005 by Xiao and Genoud is, you might have heard of Januvia is Professor JIA Notice from Leeds and they showed that there was a spontaneous recovery in their systematic review. Uh but it could take up to seven weeks. The reason why I say getty MGS about three weeks down the line is because that's the earliest you can expect to see any changes on the MGS before that, that you will not see any changes necessarily and you may get a false positive or false negative reassurance. So, indications for surgery when you have a wrist drop or a radial nerve palsy is an open fracture. Or if you've developed it secondarily to a manipulation or even worse. If you've developed it after a surgery, if it's high energy trauma, more likely to have a radial nerve uh accident to missus or neuroma to missus rather than a neuropraxia. And then there's also the patient choice if they are suitably concerned. Despite your reassurances that 90% will hear recover spontaneously. There is a algorithm busy one that was produced by that paper in that paper in uh shower ingenue this and they even talked about ultrasound as well to look at it. But I, I think that's all, all a little bit too uh busy and too much really, it's clinical acumen. And if they've got pain at the fracture site that corresponds to a radial nerve injury, and if there's a Tinel's over it, which positive Tinel's, then it's more likely to be an injured nerve. And so you should intervene, brother pole for you. Okay. So this patient is 50 years old and they want to have surgery with this three part. Let's see if uh you've changed your minds about what approach you might use for this one. So midshaft, but does extend quite proximal. You can see that there's an undisplaced spiral, spiral fracture there. Um I don't have any more poles on here that won't let me rerun it. There were uh don't worry, we'll just, we'll just uh God. So basically, I would advocate that anterior approach which you can all find on Cambridge orthopedics, youtube channel. Uh And you can see that you have to log in because it is age restricted. That's purely because of the blood and nothing else. I promise. Um I think, and then you can see lots and lots of screws to take the strain off the fixation and a long plate. So you might ask me, why didn't I nail it? You know, if I'm going to use that. And the reason being um nailing, obviously, we have to consider the rotator cuff patient's have a considerable degree of shoulder pain. Uh If we nail it, there are more modern day systems that um have produced some literature that say that their shoulder, I am nailing doesn't cause so much rotator cuff pain, but I still think it's quite a brutal procedure to go through. And then if I go back to the actual original x rays. I do worry that I'm not going to get a very good reduction. And the more distal the fracture is the less room there is for that nail to work. So there wouldn't be much room working length for the nail in this particular fracture. That's why I opted for the, the long plate and you can see that. Yeah, try to put as many screws through the plate as um both sides of the fracture, as well as lots of lag screws to try and prevent the obvious problem of nonunion because there is a lot of torsion or force going through the humerus. So, indication of surgery, open fractures, polyp traumas, floating elbow and then if there's a nerve injury and muscle damage prosthesis or pathological fractures, maybe touch on that if I have some time and then if failure of clothes treatment, I nonunion plating different approaches that you've perhaps experienced lots of, you like to go for the posterior approach. Uh I saw at the beginning um uh some of you mentioned the anterolateral approach between break your radialis and brachial lists. You can see that this is a lateral position plate through the anterolateral approach. What are the concerns? Well, how much soft tissue do you have to dissect through? And then it's that radial nerve really? We don't know what the right answer is for these human sharp fractures. As I've mentioned, it can take months um within the humeral brace for the patient's fracture to heal. So, what are the complications of having spent months in the human race? I mentioned already about the uh possibility of the brace causing hygiene issues as well as uh skin problems, but patient's will get shoulder stiffness and elbow stiffness if they are in a brace for over three months or so. Uh And so that's something that can be uh avoided by an earlier operation. And then you saw that depending on where the fracture is. If it's proximal third, middle third, or distal third, there are variable rates of non union. And if it's a proximal third fracture of the shaft, then you may have up to 25% that don't heal in the brace. Uh But there's no good long term studies about all this. And so at the moment, still recruiting is the hush trial. And so if you're coming up to the exam, you would be mentioning this. And by the time most of you are actually doing the exam, hopefully we'll have some answers from the hush trial. And I don't think it's going to be like previous upper limb trials where we thought that oh yeah. Uh non operative treatment is as good or not inferior to um uh to uh surgical treatment. I think we might find that because of the length of time it takes for the human sharp fractures to heal that an operation may, may actually be better, but I'm looking forward to the results. So this is a distal third fracture. I don't think it's gonna be easily controlled in that humor or brace, but you could still try it in the humeral brace. However, because it's so low, the brace isn't always effective. And you may want to actually include the elbow in a uh bespoke kind of removable cast, uh which can, can be fabricated for the patient's in your plaster room. And remember you can tolerate quite a bit of angulations and A P uh ambulation. But what will happen is that patient's will get a elbow fixed flexion deformity if they are kept in that cast for too long. So if you were to operate on it, then you can get them moving quicker and you have uh less liable, less liable to get elbow stiffness. But obviously, you have the risks of the radio nerve again. And uh you can get loss of fixation unless you're using a fracture specific plate. So you may have come across this, the J shaped plate uh from Cynthia's. There are other companies that now make a similar J shaped plate, but you can see that uh it's actually a small fragment plate with 3.5 screws uh but locking into the distal Postrel lateral surface of the humerus and then your standard combi holes more proximately into the shaft, got a couple of videos to show you the set up for the a distal humeral fracture. You can see well at Cambridge because we have patience with polytrauma. We like to set them up in supine position and then bring their arm across the chest in a DHS trough. This is quite a brutal operation if I don't say uh say so myself, you can see triceps split in this case. Um And I know that the app in your osis of the triceps is where the radial nerve will be coming out post eerily. So as long as I'm away from there, then it's okay. You can see the, the an example of this J shaped plate and how it fits on once you've reduced the fracture and then it's your standard AO principles for fracture treatment. You can see you can get the X ray in from the side and good coverage once you've repaired the triceps, but you could do that without splitting the triceps. And that's through this approach called the Gurwin Hodgkiss approach, where you avoid damaging the triceps. You can see there's a thickened fascia that forms pretty quickly even within a couple of weeks. If you uh have to add a long wait till surgery, then you come down on that poster lateral surface of the humerus and then is the radial nerve coming just between break your alias and break your radialis and brachialis. And I think we're going to see. So this is the fracture reduced without splitting the triceps at all. And then here is the radio nerve. So where the forceps are now that it's just above the radio nerve just showing there, it is, there's the radio nerve coming between, break your radialis and brachialis and there's the radial nerve at the app you neurosis of the large and long heads of the triceps. So the confluence of the large and long heads of triceps and you can see how to get your X ray in parallel to the bed and slightly oblique and pulling the arm out and then repair without having damaged the radio nerve or the triceps. So that's the Gurwin Hodgkiss approach and you can see it still takes a long time and it's several months. So it's not something that the patient's are able to go back and lifting within six weeks. Still, it's uh you know, minimum three months before they can do any lifting. And that's what you have to consent them prior to the operation that this was a case that has been uh my, my, one of my albatrosses, as you say, might say. So patient comes 55 year old smoker and you can see it's a midshaft humeral fracture. So remember till early strong and Van Rensburg paper said that 85% would heal in the humeral brace. So we put her in the humeral brace and then three months later, this is what you see uh well established nonunion and from that to that. So you decide to uh operate on her and fix it surgically. You can see that there is a an anterior plate again, but one year later or within under a year, you can see the plate and the fixation is falling apart. And so what would you do? Looking back to theater and you can see the screw holes. The from that anterior approach, massive cavitation means there was no evidence of infection or the uh microbiology came back negative. So it took deep samples. You can see here on the left hand picture, there's a little bit of bone that's a fibula allograft used and basically almost like a kebab really put it up the middle of the proximal construct and then slid it into the uh distal uh element. You can see that I've actually shaved the and shortened the humerus to bleeding back to bleeding bone and then put in my favorite long uh fi loss plate and try to compress it as much as they can. And this is immediately after the operation, you can see lots of screws approximately for distantly and you can guess what's going to happen next. If you look very carefully at the distal screws, there is a breakage in one of the screws. And so it's starting to fall apart again rather than risk that massive capitation that she had previously got in there as quickly as possible, put her on a trauma list. And this time, if you look very carefully. There is an anterior plate as well to compress the fracture. So took out some of the, took out the screws distantly compressed it with another plate anteriorly or anterolaterally and then put in several screws distantly to compress again as well as some I'll Yeah, crest bone graft because the bone graph that I put in previously was dead bone. It was just a structural uh allograft. It wasn't actually osteo inductive or even osteo even better osteo conduct conductive. Um And so using her iliac crest bone graft, I was able to provide her with some osteo conductive uh osteo induct serie osteo inductive and osteo progenitors, potential. Sorry, that's what I meant osteo progenitor. Let's before we go to the slide. Oh But a another example because I'm doing quite well for a time, I think um what do you think of this? So pathological fracture uh looks moth eaten the cortices. All right, a lytic and it looks like it's expanding into the soft tissue preoperatively. You can see from the CT scan that um this was a renal cell met. So we knew that that's why we got the angio. And what it showed was that there was this uh and nasty Massie's that we're forming new neovascularization to the tumor. And so in the old days, we were uh kind of had it drummed into us too embolize these preoperatively within a day or two of the operation. However, now our radiology department have pulled out this review which showed that actually, there was no difference if you pre optically embolized or didn't in terms of hematoma formation transfusion rates and complications for these uh long bone metastases. So I didn't do that, did nail it because it's a long segment and there was enough working length to fix the fracture. However, patient died within four months. So that was a little bit of a lesson on terms in terms of liaising with the multidisciplinary team. So let's get you back into the game. And if you all go to slide oh dot com, if you haven't already used your phone and snap the QR code there or if you're on your phone, go to split oh dot com. Hashtag number 3395489. And if you go now I'm going to stop share ing this. Uh Mr came, it was just a quick question from Karim. I think it was for that patient who had the plate that was pretty much from the top of their humor's to the bottom. How are the functional outcomes with such a big plate and extensive soft tissue manipulation? They're really good. So as long as you, so as long as you don't damage the radial nerve, um then in terms of splitting. So if you look at the video on, on or Cambridge orthopedics, youtube about the anterior approach, you split brachialis down the middle, so you risk the uh the uh the radial nerve less by going that way. Um, there's no problems with their elbow movement. You can get them moving straight away in terms of their elbow, um, shoulder movement. It's probably better than if they were in a humeral brace for even a month or even, even less, maybe even 2 to 3 weeks of being in a humeral brace really stiffens up the patient. But because they can move their shoulder and elbow straight away, they have really good, um, function. Uh, and it, the movement isn't really a problem. It's a question of whether the fracture is going to heal. So good question, Kareem. Uh, another one I, I had just for that, for the, you know, that patient who underwent 10,000 operations on their humorous, yeah, they said there were 55 really said smoker. Did they stop smoking at all during that entire episode? They kept going? Good question. Yes. So, smoking cessation advice was given from the beginning and they did try their best and they did reduce and cut down. Uh, and also they actually went to vaping, uh, by the end of that, by the third up up, but vaping is the same, isn't it? It's nicotine. And so, um, yeah, you know, it's, it's hard, isn't it? You know, do you wait until they stop smoking or do you, uh, you know, get on before it becomes too, too difficult to do anything? Um, you could see the huge gravitation is that were occurring. Um, you know, one time we got in there and it would have been just so much more difficult to come back through that. Um, and Nick just was asking whether you'd be able to put that slide up with the blue table back on again from your Sure. Sure. Okay. Right. Like the country. That's right. Play boat to do. Was it the approaches one, do you think? uh, let me that one? Is that a thumbs up from Nick? I'll stop sharing. Uh, do you want me to keep the recording going for the slide apart or should I pause the recording? Uh, pause the recording. Yeah. Pause the recording.