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You might still be able to see me. Um, but basically, II understand that you're expecting, um, a, a little, uh, uh, talk about supracondylar fractures. Um, and, um, I've try to cover all the basic topics that we should all really be discussing, but also trying to be going a little bit beyond to sort of a slightly higher level. Um, and hopefully that's what, that's what you, you're expecting too. Um, II think there's a lot to be said for sort of the adage of training hard and fighting easy and while I don't expect you to know everything about all of the papers that I might be talking about or, um, all of the, the, the osteotomies that I might be talking about if you at least have a basic understanding of them in that moment when you're under a bit of pressure, you can always sort of fall back on why we do certain things and, and, uh, what sort of osteotomy might be beneficial and how, how that would all work. But these are the basic things that I want you to go through. Um, I think there's nothing really sort of, um, you know, unusually than what I'm gonna go through. But uh, I'll, I'll hopefully touch on the, on the big main topics and uh, you'll be pleased to know I won't talk a huge amount about the post guidelines. I'll, I'll sort of expect you just to know them. Um, so John Gartland, he said that the tribulation with which men otherwise versed in the management of trauma approach, a fresh supracondylar fracture, um is, you know, clearly quite significant super chondria fractures by most people who aren't, who don't do peds are viewed with a, with a degree of fear. Um And I think it's very easy to get them wrong. They are associated with complications. There are lots of different things that have been published about how to reduce them and how to hold them. Um And they all carry various risks and whereas normally we say Children, as long as, as long as you roughly get them well aligned, they kind of heal themselves. Um You're just trying to, you know, you, you're babysitting them to make sure that they heal in, in a good position. Um You can really cock things up with this. Um And that's why people are sort of afraid of them. Um However, in the exam perspective and when you are approaching the exam, it is a gift. This is a um it's a really common uh topic, something that, you know, we've got both guidelines for it's expected of a day one consultant to be able to handle a supracondylar fracture on, on the, uh, on the trauma list. Um, and it, it's the, the, the explanations and the answers and the questions that you're gonna be asked are pretty predictable. So you can plan to do really well in this. Ok. So a really busy slide, I don't want you to concentrate too much on this, but just understand that, um, most elbow fractures are distal humeral. Uh and the majority of those are super Condy. This is a common injury. Um We know that extension type is the most common and that's what the vast majority of people see. Um And there and in the next slide, I'll go into a little bit more detail about that, that picture and talk a little bit about the augment laxity and how that's affected. Um And um just understand that that even in the exam setting, you're generally not gonna be asked about open fractures or, or flexion type of injuries, but just apply common sense to them. The, the principles are all the same trying to get reductions. And with an open fracture, you've effectively got an open reduction available to you because you've already got a an incision there. Uh And so you're gonna get the best reduction possible, hold it while it heals very, very simple and we'll go through that in a little bit more detail as well. Um So why do we get the super condylar fracture? Well, um the, the, the, the issue is this dumbbell shape and it's this dumbbell shape that um that we've got down here on this picture um where you've got the e electral fossa at the back and you've got the coronoid fossa at the front, which make this weak bit of bone. And if you combine that with an extent force so that the uh the elbow is fully straight, further extension will push the tip of the electron on into this um thinner sort of uh plate of bone. Um combine that with some ligamentous laxity, especially here at the front that allows that to happen. And you generate this, this fracture area and again, in that typical extension. Um and then as soon as you fit it up, you start to see the raised fat pads and, and the significance of those radiographically and everything else. But fundamentally, you've got this really strong lateral um column, really strong medial column. And then the, the articular bone here that is the weak point and that is the bit that fractures and the fractures propagate from there generally. Um I'm not gonna tell you where that dumbbell is. Um So when we come down the route of diagnosis, I mean, again, I a lot of this is really straightforward and you will know it from the, from the point of view of the history. If you know, if they're six, they've had a fall on an outstretched hand and they've got swelling and, um, uh, you know, this, this typical pattern of, of, um, distal sort of humor and elbow swelling, especially if it's, it's just above the elbow, then, you know, it, it's a pretty bar diagnosis at that stage straight away. Um, the, um, we know about the fat pads, we know how they're raised. Uh, and this is all stuff that, that you do routinely, um, remember that, that, that garland, one type of fracture that we'll talk about in a second in terms of the calcification. But that, that undisplaced pattern, you won't always necessarily see the, the break in the er in the anterior humerus, all the, the break in the hourglass that you see sort of up here. Um You'll just see the fat pads and they are still, you know, definite fractures and we treat them as fractures uh as such. Um Just a, a gentle reminder that it's probably wise to, to know all of the ossification centers. Uh because while the majority of these fractures tend to be uh s condylar distal hum fractures in the pediatric population, obviously have the lateral condyle fractures and other fractures as well. That is a good understanding of, of what the oscillation centers are, will stop you going or being led astray. Um So in terms of the classification, again, really busy, but I wanted you to have all that information on there so that when you come to revision, you understand where and how the modifications have come along. So we've got the classic three types, the 12 and three, the undisplaced fracture, er, the er displaced fracture of the intact posterior hinge uh and then the uh lack of the posterior each way it's completely displaced. And that was the original, one of classification. We know that Wilkins had modified that talking about his uh rotational deformity. So he, he uh subclassify er, the type two injuries into two A and two ba with er no rotation for uh and B with rotation and, and plus or M some angulation, uh bother then went on to talk about uh this uh medial column uh comminution uh and then the inability to reconstruct baer's angle. And again, we're gonna talk about that as a uh trying to sort of discuss the adequacy of of reduction. Um And I would also, while that a lot of that was talking about middle column comminution, think about passing defamation as well. Um If you've got a, a child who's got a super condylar fracture because of a fall into extension, but also combined with a little bit of varus, it's very easy to get some plastic deformation on that, on that medial column, which then makes the, the reconstruction with your distal fragment. When you try to reduce, it sort of starts to toggle a little bit, you have to make a decision as to which is the most accurate reconstruction or, or the most accurate um uh relocation. And that really, you can only do if you check the other side as well. So just be wary of, of, of the more combined fracture. Um And then, like she went on to talk about these type four fractures when actually there is no posterior hinge at all. Uh You've got no er periosteal sleeve to sort of work with how the distal fragment moves around fully, I guess really the, the, the, the point of these types of type four fractures is that they imply really severe defense of injury that are likely to be associated with multiple. Um you know, other injuries, think about floating elbow type injuries, think about um neurovascular injuries that are much more likely to, to, to be common. And this is a diagnosis that you only really make intraoperatively, you're not gonna be able to make that uh beforehand because you're not gonna be able to manipulate the elbow sufficiently. So the anterior humeral line, it's the, the standard measurement that we, we use between a third and two thirds of the capitellum. Um And um a really useful marker of the adequacy of your reduction um sometimes really difficult which he, there's a lot of combination posteriorly here in, in that right at the back there. Um But a really good marker of the, of how uh how far you need to come and, and, and uh and how adequate your reduction is in on a on a global sort of, er way. Um, I wanted to talk about Bowman's angle as well. So we, we, it's the effectively across the, um, the capita fis. Um, and the, the point is that we use it as a surrogate for the child's carrying angle. Um, and that if we reconstruct Bowman's angle, um, on, on the fractured side, the same as the, on the uninjured side that actually we will be reconstructing them anatomically in a sort of uh in a good way. Um And they will be symmetrical and actually that would, that's what's gonna prevent uh the uh the loss of position and the cus vus uh injury um or a def the cubitus varus deformity and, and complication. Um The um we, while they're not interchangeable, um it's useful to think of them as, as similar. So even if you don't X ray, the other side, if you see that there's quite a significant um uh carrying angle in, into, into Valgus, then you can use that when you're planning your um your uh reduction on, on the operated side and to make sure that you don't go into too much um into too much uh virus. And that's particularly the case when you've got classic defamation or combination on that media on the medial side. So the best guidelines, they're really straightforward. Um And um you just need to know them. Um I wouldn't necessarily, you know, remember them um by rote, but you need to know that they recommend two millimeter K Ys. You need to recommend that they recommend the neurovascular examination straight away. And after uh after the class, the plaster has been applied and then after any maneuvers and um you know, definitive treatment, uh they're really heavy on documentation of the neurovascular status. Um and that um that a pink well perfused hand is uh is uh acceptable uh without the requirement for exploration. Um And only if um a uh a reduced um sdy fracture that is not pink or well perfused um you know, requires a vascular sort of input. Um And I think that's probably where you need to be with that, but you need to sort of, you know, explain a plan of what you're gonna do. So if you, if you say that you're gonna do your vascular examination, you will say that you want to uh do a complete refill, check the, the distal pulses. Uh You want to check temperature, you may want to do a AAA um AAA refill or a Doppler. There isn't a huge amount of evidence for dopplers, but you know, at least that you're thinking about, you know, confirming that vascularity. And if you're gonna do AAA neurovascular exam, you need to say what you're gonna examine. Um And uh have some understanding of, of the like neurovascular injuries, which again, I'm not gonna, I'm not gonna ask you to tell me, but is, is you know, typically the Antero nerve. Um So a little bit of a fine anatomy in the context of we've, I've just told you the Antero nerve is the most likely nerve to be injured, however, or most likely nerve to um uh to present a as a, as a neurological injury in, in a supracondylar fracture. Um But if we look at this for the actual anatomy, the median nerve uh passes uh under FDA and the branch of the Antero is just under the ulnar head of the greater terriers, which is roughly at this level here. So we're talking about um the nerve that's being affected, being really distal to the um to the proposed fracture site that's causing the problem. And so it's useful to have an understanding of, of why that would be the cases, you know, cer certainly. Um while I wouldn't, I, I'd say that in the exam, they're not trying to catch you out. It is a little bit of a, of a, of a paradox and it's useful to have a bit of an understanding. So generally, this is probably the paper that I would use to, to sort of describe why that should be the case. Um And the, the thinking is that at the time of displacement, particularly with gland three fractures, um is that it's the axons at the back of the median nerve that are going to give rise down to interosseous nerve that are most likely to be pinched or damaged or uh certainly injured by the um the proximal fragment of the t condylar fracture. Um So that's one proposed mechanism. And the other is that we know that the anti interosseous nerve is really adherent to the intraosseous membrane uh at um once it's, it's come off the median nerve. So, whereas the median nerve will allow a certain amount of um forward displacement or anterior displacement. Um The Antero will be much more adherent. So there could be a traction element to that injury as well. Um So it's worth having a bit of a, a bit of a plan as to what you're gonna say for those. Um So assessing the vascular status a again, I would be really quick to, to sort of, to say exactly what you're going to work. Uh what you're going to measure as a means of um uh of calculating the uh of, of, of working out vascular status of the distal uh limb. Um You'll find these um sort of standard um um uh uh sort of performers or a standard protocol with how to assess on what to do at, at, at, at each stage. Um And there are, there are about two really that have been published and this is a version of one of those. Um by all means you can rely on it. Um You be feel free to look at the, the systematic review as well as that'll have more details and there are two, as I say, two other sort of big to talk about it as well. Um There is the essentially the, the really important ones are these first four, you will look for the arm, the pulse, there could be a refill temperature in the O2 SATS. There is obviously a Doppler can be used if you're struggling to find the pulses. Um However, the Doppler itself that if you can't feel the pulse being able to, um, to, um, hear, you know, a Doppler signal, you shouldn't be overly reassured by that as there's no evidence that that makes, you know, any difference to the outcome or the, or that, um, you know, that that implies better prognosis. Um, if you, if you're ticking the box for all, all four of those, then I think you're fine and I wouldn't worry too much about the Doppler. That's not part of the protocol and it's certainly not part of the both guidelines either. So, options for management. Well, um, effectively there are uh four main types. Er, so one is post reduction with an above elbow cast, er, and that is uh, a, a similar to sort of bouse technique and I'll show you a little bit about what that means and there's certainly a fair bit of, of stuff published about that, um, speed traction, which I was sort of trying to show you here and I'll come back to and then the closing, er, reduction or open reduction uh with fixation of different types of wires and, and uh whatnot. So, what I'm trying to show here is a, um this is called AAA Palmer um traction device or skeletal traction. You can see that it's really small and effectively with local anesthetic it's passed. Uh If you're a brave soul passed into the electron of a child and then held up and supported the important the thing which this is showing which this isn't showing when we're trying to represent Smith's fraction is that there's counter traction at the um in the upper arm. So the point is that we are not only are we achieving um traction across the fracture, we're also achieving the forearm being um the extension deformity being corrected as well. Um I mean, this is just, it's not really done anymore, it's certainly done um in other countries and where the burden perhaps might be a bit higher. Uh But it's not something that's routinely done in the, in the UK. And I don't think there's, there's, you know, there are very few scenarios I can imagine that would be needed. Um uh Maybe if there's a really high risk of modern anesthetic um or something else that's unpredictable in that sense. Um with regards uh Blount technique, uh so sorry, going back to the close reduction and the cast um really good uh description in John's book. Um And basically the, the, the point is that with a child in um with or traction, you're trying to disengage the um the fragments, bring it out to sufficient length that allows you to then manipulate those fragments. Um And um uh take the ligament, the ligament axis out so that you're able to then move the fragments before you then uh reemploy that lament axis to actually uh hold everything in place. You're reversing the forces that cause the um the fracture. So initially, that's the traction you then correct for various valgus and rotation. At the same time, making sure that the width of the media of the natural column on the proximal fragment lined up with the media, the natural um width of the distal fragment. So you should know that you corrected your deformity. Um and then with pressure over the electron on um and um forward uh uh flexion at the elbow, you, you try and bring everything back into place, lock it into as much flexion as possible. Um And then that's how you're trying to hold the um the reduction. You're far more likely to succeed in holding this reduction if you flex beyond 90 degrees. And that's part of um bringing the, the triceps forward so that you're um able to lock everything in place. But the more you bring it forward into flexion, um the greater the risk of compromising uh either the inflow, the arterial inflow er to the distal forearm or more likely the venous outflow, you're risking um Volker's ischemic contracture compartment syndrome, et cetera. So that being the case, the reduction part is usually to, to part of your er intra operative reduction where you're then gonna fix it and stabilize it more definitively, which then allows you to immobilize the arm in either 90 degrees or a little bit short of 90 degrees. Um This is bas technique in case you, you, you, you were ever asked uh and effectively, you can see that the arm is um brought out to the side uh held with um essentially vertical traction at about 60 degrees. What this positioning um allows for ice to be placed across, it allows to try and control some of the swelling. Um And um, and therefore hopefully make the, er, the trip to the theater a little bit easier and you can be in this position for, um, you know, for a day, for two days, three days, even longer if required before you end up, er, effectively, then going to theater. Um It allows the reduction uh to take place um with, on the, um uh on the, the, the mini sea arm. Um the anesthesia can be uh gas induction and then maintenance. So it's a much quicker anesthetic and a much quicker procedure. Um Overall, once you've got a reasonable reduction, you place it in a collar and cuff and as you can see above 90 degrees. So this is where some of that risk element comes in for um for uh compartment syndrome and uh contractures or s er ischemia. Um The argument for this is that it's very quick, very easy and in, in certain scenarios, uh you know, can be, can be very beneficial. Uh But um there is a strong emphasis on reducing the swelling and making sure that the swelling is controlled before you do the reduction. And the argument therefore is that with less swelling, you're less likely to, to get compromise of, of the vascular supply. Um, it's certainly, um, a relatively high risk uh, procedure in, in sort of western medicine. Um, and, and not be recommended but it's useful to, at least, you know about it as a means of trying to achieve, um, a reduction, um, for, uh, you know, prior to theater, if there's some reason why you can't take the child to theater, for example. So, um, I think it's probably useful to let you know what, what I do. Um, and, uh, of course, um, you know, other people will, will have different opinions but the way I, um, managed to, on the fracture is very much as per, er, man's paper from, er, 2001. Er, and basically this is a, this is, um, in a French institution and it's designed to be a protocol that's applicable, um, really across the whole institution. So it's whether there's a registrar on call overnight or whether there's a, you know, a, an upper limb consultant or a lower limb consultant. It should be really reproducible results. Um and effectively the, the, the child has um the standard neurovascular assessment and is uh take him to theater as soon as possible. Um He doesn't really talk about sort of overnight too much. Um But, you know, generally in a really displaced fracture, I but wouldn't want to take the child to theater at a reasonable time even in the evening. Um If, if that's gonna prevent and, and minimize some of the swelling. Um uh using a standard reduction technique as, as described as, as described by Charley. Uh And then once the fracture is reduced, um I pass two lateral wires and then I um the only prerequisite is that there is at least about a centimeter gap between them. II do tend to make them quite divergent. I know in the paper we talked about um parallel wires. Uh And again, I aim for two millimeters if I can. Um unless the child is, is, is uh you know, very young and very, very little uh bone. Um I will then screen it. So I will hold the uh proximal humerus, um full flexion, full extension. And I'm looking for any movement, especially rotation with um stupid or pronation. Um And if the distal fragment stays put with the two natural wires, um then I will hold uh the, the upper limb about uh 90 degrees or a little bit less. Um And uh apply a cast, uh check the um neuro access status again. Usually check with a, with a Doppler as well, clean off the FLUoxetine and check with a Doppler to the fingers to make sure that we've got uh not a Doppler a um sa probe uh to make sure that uh we haven't compromised the vascularity and I will run with that if at the time of checking the stability, I'm concerned about that. There is a little bit of extension and, and play at the fracture site. Uh Then I generally um use a mini open technique on the medial side to pass the cross K wires. The priority there is that I need to make sure that I get um uh holder bicortical hold to hold on any other cortex as well. Um And generally, um I will um take one of the er lateral wires out. So I'm left with just crossed wires but again, check um the er stability and then proceed in the same way. Um That is very much evidence based. Uh It's a nice study. Uh They used Flynn's criteria for sort of two years follow up just under two years, follow up. Um And it was uh and, you know, I think it, it's hard to argue against most of the logic there. Um We'll talk about sort of uh wire configurations and everything else in, in a little while, the controversies. Um So the first of some people talk about traction. It's not a big thing in, in the UK. Um, and some people, uh, talk about inline traction as a means of, of trying to, um, uh, hold, uh, the, uh, hold the, the, the, the fracture, uh with minimal chance of getting any, uh vascular compromise. Um, but the, the rates of, um, cuss vus are really, uh big, probably about, you know, 30% if not more. Um, and, um, it's not very popular in the UK. Um, I did there, there were a couple of American studies, um, but otherwise it was uh mostly sort of in the subcontinent and other places. Um, and it's not, it's not really the, the dumb thing. Um, in terms of patient positioning, I think everyone has their own sort of technique. Um, I, certainly, when I was in training I had um, someone who would, um, perform a reduction without any prep, um, once they were happy and they had a decent reduction, they would um supernate, er, the, er, sorry, they would pronate the forearm, um, hold the, um, elbow in maximal flexion, er, and then, um, use, er, tape to hold the hand down, go off and get scrubbed by which time they prep the elbow past the wires and then that would be then done. Um, I tend to think that if you can achieve a reduction that way, um, you can achieve a reduction. Um, you know, once, once the arm is prepped so yes, by all means, you can try your reduction before you get scrubbed and before you scrub the forearm. Um, but, um, you, you, you know, um, I like the idea of prepping the whole arm before you go down that route, but certainly they have good success with it as well. Um, and you have to be aware that particularly in a small child, you, you might want to apply the same technique for everyone, but it might be quite difficult to get, to be able to provide countertraction to your reduction, get X ray into the right position and an assistant and have a, have an arm board. You might find that you, that it's easier just to use the um image intensifier as a means of uh actually doing your work and getting your wires in and checking your reduction and it gives you a little bit of extra space, but it means that you've then got a, you know, be a bit more prepared when how you're holding wires and ma maintaining reductions and, and, and uh passing K wires and things. The timing of surgery is, is uh relatively uh controversial. Um There were, there was a, a flurry of papers probably about 10 to 15 years ago talking about um how leaving um darling three fractures overnight, increased the risk of er, needing an open reduction. Um and that, er therefore it was better to do them er, on an emergent basis. Um And then more recent meta analyses and um trials um have said that actually they, they, that that difference isn't um isn't seen. Um And they've, and the, the more recent meta analysis are using the same papers that we used previously plus newer evidence. Um And, you know, they're showing that the risk of needing a reduction. Um So certainly in this 2014 paper, uh was, was not increased by uh length of time. Um, since the fracture and therefore the amount of swelling from a personal perspective, I do think it is, um, you know, you do see more swelling the following day. There's no question. Um Now whether you, you're reducing the risk of, um, of uh an open reduction, uh because you're fresher, you're, you know, you've got, you know, a better theater team around you who's more able to support you, uh rather than using the emergency list or, um, you know, everyone being a little bit more jaded cos it's the end of the day. II couldn't tell you. Um, but I personally would, would probably take someone to theater of an evening, uh to try and, and reduce the, uh, the, the, the amount of swelling and the er, risk of needing to convert to open, um, out of uh, the, the following day. Once that swelling is a bit more established, the wire configuration remains controversial. People will still talk about um, in, um, in, er, models that the cross wire configuration is uh more stable than, er, two lateral wires. And I think that's difficult to argue against but whether that's clinically significant, um I'm, I'm not so sure as long as you follow, you know, the, the basic rules, so you're achieving bicortical hold. Um, and that, um, you have, uh, like I say, I prefer divergent wires and I think that that's really effective adding in a third wire in my experience probably doesn't make too much of a, of a difference. Um But you, you know, I think a as long as you're taking, as long as you're following the uh the both guidelines, which just say if you are gonna do a needle wire, you want to use a technique that, that minimizes the risk of the ulnar nerve. Um And uh generally, that would be a mini open technique and that you document your findings um afterwards and then the, the pink pulseless hand. Well, it's, it's something that, that um the, again, the, the, the, the both guidelines are, are, are quite explicit about it. They're really helpful. Um You, the people who argue that you, what you really want is a pulsed hand talk about the fact that you can, you can have um an occluded uh brachial artery um that, that you end up developing a collateral supply from. Um But actually, you know, you'll still get complications for that. One of that's called intolerance, a leg compartment syndrome or growth discrepancies. Um, and therefore you, what you really want is that you don't want an brachial artery and that you should be exploring more frequently. Um, as I say, that is a, it's a view, it's not part of the most guidelines, it's not what we do. Um, and I think the, the risk from, um, you know, a secondary vascular injury from, er, exploration is probably higher than accepting the lateral circulation will fall. Um, the, and the converse of that argument is that even if you, if you know that you've got a thrombosed artery that you are ignoring, because you've got a good collateral supply. If you examine the circumference, the strength uh and pain scores on either hand, uh, or either um, arm. Um, they are equivalent. So actually if you do have an occluded, uh brachial artery, as long as your hands are still warm and well perfused, it really doesn't, it doesn't matter. Um, and the point about doctors and angiography and all of these things is there is no evidence to support their use. Um, and really, um any evidence trying to, to, er, or any, uh, trial, trying to, to see if it's a useful adjunct probably will fail because all it's gonna do is is add delay, er, to the treatment of, uh, of a, um, of an emergency situation, basically. So if we think about some of the complications that I really just wanted to talk about people varus and and, and about of skin contracture. Um We've heard of that expression of a gun stock deformity. And this is trying to show what, what this is, uh why that that comes about. And you can see that carrying angle that's, you know, really changed from, you know, in, in this case, quite a, you know, various angle perhaps of, of about 10 or 15 degrees to, to, well, probably neutral, about five degrees of varus. Uh and again, from a neutral to, to some varus here. Um The what we really want to sort of know ideally, especially in a young child is, is this cerus deformity static. Uh In which case, we can just observe it and think about and plan something for the future if it causes problems, otherwise we can leave it or is it progressive? Is there involvement of the growth plate and we perhaps might need to do, you know, multiple osteotomies to make sure that we, we don't end up with a, with a further problem. Um We know that obesity increases the risk and that's probably to do with, you know, trying to achieve a grow reduction and, and the uh sort of the soft tissue that that, that goes there uh that will interfere with your ability to, to achieve a reduction and hold it. And there are various osteotomies described for this, I mean, in this picture, um the osteotomy has been completed and then held uh with, you know, two plates. So a really sort of, uh, you know, in invasive procedure here that I, I'm gonna have to probably remove these plates, uh, as well at some point. Um So that's much more invasive than what we would normally do. Um And we can do these in, in a number of ways, um, which I'm gonna sort of talk about in the next slide. The, the lateral closing wedge ostomy, the French osteotomy was the first one described and I'll, and I'll show you what, what that involves and you can, then it's been modified multiple times in different ways. You can do an opening, we osteotomy domes step cuts, uh the pento osteotomy, which I'll, I'll, I've got a, a picture of, er, for you as well. Um And just when you, uh you know, when you're trying to do osteotomies, and I'll show you a picture in a second to explain a bit more when, where in the metaphyseal segment of bone where uh if you try and do the easy osteotomy, that's to say, try to do an osteotomy parallel to the joint line, you end up with one part of the ostomy that's really long and then the other part of the osteotomy that's relatively short. So when you bring them together, you end up with a, with a real sort of step and an offset. So if you, or by just by lifting up the osteotomy, so that the mid point of the osteotomy is parallel 90 degrees to the surface that you're, that you're closing the wedge on. If that makes sense. Uh then you end up with both sides of the osteotomy being roughly the same length. When you bring them together, you've got a nice smooth section of bone uh to either put a plate on or just to stop it, impinging too much on the soft tissues on that side, which will be far better tolerated. Um So this is the French Osteotomy with the original description. Um and effectively, he's looking to address the um the uh the 3d nature of the abnormality. So one is the obvious the, the virus. And so that's why you, you, you do this, the, the wedge cut coming from um the lateral side to then restore the, the joint line and balance angle. Um But also you will see that he puts the screws offset to correct some of the rotational deformity that's also um contributed to the virus. And so when you put your um your wire around the screws and you start to tighten it, you're correcting both the rotational deformity and the er and the virus, um this is uh oh let's bring that back up. Um So this is your step cut. Um You can see that there's a little bit of a, of a, of a step that's made there. I have never seen this being done. Um And I and II, it's not something II think I would use. This is probably the more modern version of a of a French osteotomy where um effectively you're using K wires to mark your where the osteotomy is gonna be. You provisionally put in your uh K wires in the distal fragment. So that when you take out your um wedge of birth, you're able to bring these two together um and then pin everything with your two K wires and then usually add a third for a bit of extra security. And then these wires can be taken out quite easily. And that more often than not, that's more than enough. Um This is the um the ostectomy itself is the bit that's done through the bigger incision um on the lateral side. Um And then these K wires can all be percutaneous as well. So you can have a much smaller incision than, than otherwise. Um the fine. Uh And then this is just trying to explain what I mean by the offset osteotomy. If you do AAA wedge, if you take a wedge of bone from a metaphyseal area and then close everything down, you'll have a bit of a step. Unfortunately, that's not formatted particularly well. Uh Day osteotomies, your step card osteotomy. Um That's probably why it, it's on two slides rather than one. And again, the, the aim of the day Mastectomies is to effectively bring everything back into line your sacrifice and translation uh for a really nice healing surface, uh and you're leaving a lot of overhang in certain area here. So, you know, here in your, you're um obviously bringing some soft tissues into the osteotomy as well. Um And then this was again, um, something that I've not seen before, but it, it is beautifully elegant for the really complex. Um, you know, and horrible c of those various deformities, you end up with um a uh effectively no steps. Um You end up with a surface once this bit of bone is excised, that you can literally lag across to bring the, the ostomy together and then just hold it with ak wire as well. No overhang and, and bear in mind that initial deformity, I think this would be really difficult to try and manage with the standard um closing wedge osteotomy and just in terms of variation things that, that you can see um this is a uh closing wedge osteotomy that has been um held with um a tension band wire. So a lot of variation on how you can hold, there's lots of modifications of the original uh French ostomy as well. And then I just wanted to mention Volkmanns er ischemic contracture. Uh it's effectively the death of the muscle usually and, and most severely in the deeper volar forearm compartment. Um And um if identified early, um you know, you should, you should be prepared uh to um decompress the forearm. Um And uh if you did need to explore the, uh the, the um brachial artery. Um We know about the, the, about the er sm in the antecubital fossa, your incision coming across. Um And often you'll find that the proximal fragment has already gone through your brachialis muscle and it's sitting right on top of the artery in the nerve. Um and the, the button holding through the, the, the, the biceps. Um and then you, that's what's uh generally sitting directly on top of the artery of the nerve which you of often find together uh with a little sort of sling of muscle underneath. Um And the um indications for this are, are, are as per the, the most guidelines are pretty rare. Um And I wouldn't really entertain doing this uh unless I'd already spoken to the vascular surgeon and there was no other alternative in which case, uh it becomes a sort of living saving procedure, which is uh more straightforward. Uh But we, you know, most hospitals have vascular uh service available here even out of hours to some degree. Um II appreciate this is all a bit of a whistle stop tour and that we've got um a fair bit beyond sort of the routine knowledge that I expect for Fr CS. Um And my expectation is that you can use these slides for uh revision uh if you're interested in any of those uh papers that all the references are in there so that they can act as a as, um, sort of further clarification if you like, um, and the, this adage of, uh, perhaps knowing more than you need to know. Uh, so that you map out your knowledge means that even if you only really access to certain bits that you need for your exam, um, at, at least you've got that, er, those principles and that map that is in your head that you can refer to, um, for, for answering those, those trickier questions that they might, er, pose in the exam. You don't have any questions. When would you automatically go for a, a medial wire and electral wire rather than uh two electro parallel wires? I think if I felt that it was a really unstable, er, construct from, from right at the beginning. Um And if I felt that there was a, uh you know, there was a, a lot of comminution and that I was predicting that I would need cross K wires, II might go and do that uh sort of the first off. And the only other time where I would probably do that is if I was, if I had to do an open reduction. Um and I already had um the uh e essentially the fragments and the fracture in front of me. Um, then I could really safely pass a wire on the medial side, then fine, then, then I'd probably do that only because it's there and in front of me and I know the ulnar nerve is safe and protected and the incision is already made and the morbidity of that's gonna cause has already been inflicted. So, um, my threshold would be lower, but otherwise, II would, I'd try and, and, uh, do lateral wise first if I could. Um, hi Mr Blanco. It's pretty here. I just wondered if I could ask you a couple of questions if that's all right. Um Thanks for the presentation. So the first question was, um, I've reduced a few in theater, the extension type fractures, but I've yet to do a flexion type that I can recall anyway, and with regards to reduction maneuver, like what would you recommend? And um, obviously, I'm guessing you still keep the prolonged traction that you do initially with when you're doing extension type. Um, but in terms of trying to get that nicely reduced, are there any tips and tricks that you can kind of recommend for a flexion type fracture? So I, so I in, in my vast experience of one? Um, no, I don't think I have anything particularly clever, I think, whereas we often talk about uh brachialis and um nerve and muscle in, you know, getting caught in the, er, in the fracture site with the extension site with the extension type osteotomies. There, there isn't quite so much that can get stuck in with a, with a, a flexion type, perhaps a little sort of sliver of periosteum. Um But otherwise it it tends to come quite nicely. Um uh And I think if it, if it really isn't, y you know, coming back then it's probably because you've got something in there like a bit of periosteum. I don't have a low threshold for uh um and, and in that scenario, perhaps doing a um uh sort of AAA postero um medial sort of incision that allows you to get to flick something out of the, of the fracture site. And at the same time allows you to visualize the ulnar nerve so that, you know, it's gonna be safe. Um And therefore you can put your, your uh medial wire as well. But I'm guessing in those cases, obviously, you're not kind of hyperflexing for your reduction because obviously, it's already the distal fragments already flexed at all. Um And you can, and you just, you bring it back into the, yeah. And the second one being um you know, just you're on the, the, the um flexion type. Yeah, sorry, I'm just uh interfere. You'll generally find that they are absolute pigs, you know, if you found a flexion type because so yeah, you can get it back. Uh You can reduce it as in it will go past it and then it will go all the way across. So flexion type, it's extension type. Um And exactly as I was Franco saying, um with those ones and have to have them extended. So um you're trying to fix them extended, which means um swinging the eye, I rather than keeping the eye static and moving the arm because the minute that you rotate the arm, the whole thing will rotate off. So it's not usually the reduction is actually trying to hold it there so you can put the pin across. And it is really a lesson in misery. And II think generally it's really hard to come across. You know, the leach was talking about these type four calcification where, you know, there's no periostal, um, you know, hinge at all. I, you know, I think generally there must, there usually is a periosteal hinge. Um, and I wonder how much of it is iatrogenic where we've over forced it. We've tried to bring it too far into place and then we, oh, we, oh, it looks more like affection type but now I let, push it back the other way and then all of a sudden you've lost your hinge which then becomes a whole world of pain. Um, so, yeah, a lot of this has to be with a little bit of salt. Don't, don't over these things. It, it comes back into a nice position or it doesn't, in which case, your next attempt, you just put a little bit more force in and you gradually build it up, but you don't necessarily have to go he for the first time. Yeah. Yeah, because I think recently we did one. Well, it wasn't, it was an extension type. But even that I remember that we kind of restored the lateral column, put a wire in and then tried to get the sagittal plane reduced after putting a wire in, which is something I hadn't kind of done before, but it seemed to work. So I guess, like you're saying, you could put a wire in with it slightly extended and then try and achieve your reduction once you've got it a little bit more stable. Um Is that right? Would that make sense or are you, are you jo sticking it? So it's the wire just in the distal fragment to miss with the wire and the distal into the pros and it's well described, isn't it? You pop the, the wires and then just use that to try to hold it on. And then also about some people talk about locking it in supernational pronation. Um Does that, do you feel that it actually makes a difference like clinically because um the last few times I've kind of done it to see whichever way it looks good and then fixed it, but I don't know whether I should be locking it in supernational pronation for certain types of injuries. So there is so I have to say in my experience, I don't think it makes any difference. Um I do nearly always lock it in um pronation. Um because once you've got that acceler rotation, you're, you're, you're, you're locking the um the the uh the ligament axis on the medial side. Um And there is, there are people who talk about the uh trying to bring the periosteum under tension on whichever side the periost is still intact and that holding things in place. But when I try and predict so, if I've got a, a fracture that's in um in various the logic is that you've still got an intact periosteum on the medial side. So if you bring it across until your intention and look it that way that that provides more stability, I'm not convinced that I can feel the difference in my hands um in, in the same way that if you've got a valgus deformity, the um the logic is that you've got an intact periosteum on the lateral side. So if you bring everything across and you hold it in super nation, you're providing more tension on the lateral side to support what you know, your, your wires and to support your reduction. Er and therefore that will provide more stability. And again, II don't feel that I can tell the difference, but that, that is a theory that he's spoken about. Yeah. OK. All right. Thank you so much. Thank you. Thanks.