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Um My name is Emma Griffiths. I'm one of the guys up at the north. No, and I've been asked to talk about radial head fractures and the terrible triad. Alright. So this is an outline of what we're gonna chat about for the next uh 40 minutes or so. We'll talk about the epidemiology, the anatomy of the radial head and the anatomy of the elbow function of the radial head. We'll talk quite a lot about isolated radial head fractures. Are you just managing the radial head? And then we'll talk about the radial head as part of a complex elbow injury, particularly the terrible triad. All. Um I'm assuming that uh Mr Mulligan has uh covered Monte fracture variations. So I won't talk about that too much. So, redhead fractures are common about three per 10,000 and represent about a third of all the elbow injuries we see below the age of 50. It's mainly men that get this problem and above the age of 50 it's mainly women, right? That's a function of um uh trauma in young, in young men and osteoporosis in old women. So we can't talk about the elbow without talking about the anatomy, particularly the ligaments. All right. So on the medial side, it's that anterior band that's important. Ok. And then on the lateral side, it's the lateral ulnar collateral, that's important, right? You can also see the annual ligament there which is just holding the radial head in. Right. Again, I'm assuming you've had discussions about ligaments already this elbow term. So what does the radio have do in terms of our, in terms of our elbow? All right. So the, the range of movement that we require for the elbow, for our activities of daily living, we need about 100 and 30 degrees of flexion and we don't need full extension. And actually, we only need a super pronation arc of about 50 degrees. Ok. And that's from an old paper from the forces across the elbow. Mainly it's valgus and the main and it's, it's mainly a valgus force because of the flexor muscle mass. And what that means is that the M cl the anterior band of the M CL is our primary stabilizer for valves. And the radiocapitellar articulation, the radial head that we'll be talking about in a minute is a secondary stabilizer. The various forces are, are rarer and the a the axial compression. Again, the radiocapitellar joint comes into its own with over half of the uh uh force across the elbow across the radiocapitellar joint. Right. And then right at the end there, you've got the intraosseous ligament to be aware of going forward. So function of the radial head, it's got two roles, isn't it? Ok. So it, as a as discussed in the previous slide, it resists, valves forces. OK. So particularly in external rotation, it resists Valvo force across the elbow. And then it's also important in the longitudinal transfer of load from the wrist to the elbow during your gripping activities. And again, that comes into its own when we start talking about long ai and instability of the forearm. So valgus elbows stability, we spoke about a couple of slides ago. So there are so the radial head is a secondary restraint to valgus forces. OK. And it actually functions by just shifting the center of the vera valgus rotation laterally. So the medial ligaments have to work less hard. And the radial head is an important stabilizer mainly when there's injuries to both the ligamentous structures and also the muscle tender across the elbow because obviously your um flexors and extensors act as dynamic stabilizers of your elbow, right. And then as we've said before, the longitudinal stability of the forearm is also related to the radial head. And the radial head acts in concert with intra six ligaments to provide longitudinal stability. And if you excise the radial head, that's when we can see proximal migration of the radius. OK. And so that's something to be aware of that causes the wrist pain. And then, and then the hand and wrist guys do a shortening osteotomy and it doesn't make any difference. So, classification of radial head fractures. This is something that you should be aware of. This is something you should be able to rattle out. I don't, I would expect this. Yeah, from almost everybody, particularly as you come up with the exam. So the original classifications from, from 1954 and that was just 12 and three and then that's been adjusted by all the people that you see down there on the bottom right over the course of the intervening uh 50 or 60 years to get where we are now. Alright. So now your type ones are undisplaced, there is no block to forearm rotation and the displacement of the fracture must be less than two millimeters. The type two fractures show a displaced radial head fracture, ok? With more than two levels of displacement or greater than 30% of the radial head involved. And then the most recent adjustment to that was re in 2010 and he spoke to you about stable versus unstable. Type three are displaced ones, they're severely comminuted and they uh are judged to be irrepairable, ok. So that's where your ra replacement starts coming into it. And then type four are then associated with elbow dislocations. So that is what we see in front of us now, ok. So 128 B3 and four and that should be something that is very familiar to you. So mason one versus Mason two, how do we assess the blocks of rotation? OK. And there are various ways we can do that. I'm a, I'm a relatively practical individual. And so for me, I just see my patients back after 10 days, two weeks and see and see if they can rotate. There is an argument and that actually is about what two thirds of shoulder surgeons in the UK do. OK. So that, so I'm in, I'm in the majority there. One about a third aspirate for hemarthrosis and then inject local aesthetic and then examine the patient. OK. That is uh that's a very good way of doing things if you need to have the answer straight away. And a very small percentage of people, presumably people who have uh more access to theater than other than, than most of us do um can just go straight to the UA and the theater. So take them in under the sea arm and just see if and just see if there is actually a B block to rotation and then how to assess displacement. We just, we you can assess it at the x-ray or um most of the time now we get it, we get three dimensional imaging in the form of act to, to have a look at that um in a bit more detail. So the Mason classification actually is relatively useful because it does actually govern what we end up doing. OK. And so, um mason ones, non op mason twos, if there are no, if there's no blocks in rotation and the injury and the fracture is a stable one, they get treated non surgically. If there is a block to rotation or the fracture is deemed to be unstable, they can have an operation. No normal fixation threes, fix or replace fours, fix or replace what we mean by non non operative management. So this is for our Mason ones and our stable mason twos, ok? You don't immobilize the elbow, right? So the key thing about any elbow injury is that from the very start, there needs to, the elbow needs to be moving as early as possible, right? And if the elbow doesn't move, then you need to find out why it's not and not not moving. So there's no form of immobilization sling only for comfort and you should begin your physio early within a couple of weeks. Again, there's some variation in practice in the UK. But um most will start within 1 to 2 weeks. And I would generally see my patients back at six weeks or, but they all come back earlier. If the pain is preventing immobilization, there is an argument to say you can discharge into physio. But um I like to II like to see mine at six weeks just to make sure there isn't any need for any other intervention. And just in bold there at the bottom. If the patient can't move the arm, look for other mischief. Right. And mischief is a global term that comes from the Van Rensburg Dictionary. Surgical management of radial head fractures. Ok. Now, I am unashamedly ageist when it comes to surgical management. All right, I will choose to fix radial heads in young patients even if they are quite smashed up. Um But I have a lower threshold to replace radio heads in older patients. There are, there are young patients whose radial heads are too smashed up and therefore need to be replaced. And I think if you've got, if you've got multiple fragments and you're gonna be left with only a partial radial head after you've fixed it, it's not unreasonable to replace it. Um And I think I have a lower threshold to replace the radial head if there's a fracture dislocation, and we'll discuss that a little bit more when we come to managing trials. And then right at the bottom in grade out is excision. The reason that's even in the talk is because it's still spoken about or it's still looked at in terms of, in terms of a lot of the literature, a lot of the websites and things like that do talk about excision of radial head. I think that most of the papers that relate to it are quite, are quite old and I don't think there is. Uh and I think you have to make sure that there's an isolated radial head injury without any um longitudinal injury to the forearm and indeed without much in the way of ligamentous injury either because I think that uh the radial head is an important stabilizer on the elbow. Um So this is the best survey that was done a couple of years ago, I think. Um so they just asked all the sure that all the members are best or the consultant members are best to um say what makes them replace Radiohead as opposed to fix things? Alright. Um And 71 out of the 160 respondents um said that aid was involved. Um 60 said that it was, it was in the complex fract location which of my two main indications and then they've got three or more fragments or when fixation is not possible, which are both reasonable things. But again, you're getting less and less and then absence of course, or contact, you know, in 27 regardless of what you do with your radial head, you have to make sure that you repair the lateral collateral structures on the way back out. And I think this is just surgical mass. You need to make sure you, if you, if you've opened the door to get in, you should make sure that you close the door on the way out. And there is a, there, there's a paper from the um JB GS American that says that repairing the LCL is important, which is maybe not surprising. This is the sign of excision. Ok. So these are old papers or Oldish papers um that say that it's ok. But all patients have reduced power and two thirds have ongoing pain with an a an average of 10 year follow up. Ok. And in fracture dislocations, they uh it causes significant wear to the remaining elbow. So ie excision is not part of my practice. So how do we deal with radial head injuries? All right. So if we're just doing things to the radial head, I would generally do it from, from the lateral side, right. So, lateral incision, deep dissection anterior to the LE CL, expose the anterior surface of the lateral like the condyle and then expose the radial neck by carefully elevating the super muscle with the arm pronated to protect the pin. All right fixation. You see some K wires provisionally and then headless compression screws and a tripod orientation. That's my mainstay. Uh There are surgeons who fix with um regular head locking plates which is not unreasonable, but we'll talk a little bit about that in a moment. And if we're going to be doing any metal work on the proximal radius, we have to remember the safe zone, which is now about 100 degrees centered on the equator of the neutral rotator for. So that runs between list as cheap and the ra right. So here we have an is radial hip fracture. You can see it's largely a two part fracture. OK. And there's no dislocation associated with it. OK. So this is your lateral approach. You mark you, you mark things up and make an incision over the top. So the elbow is flexed position on your right. Here is at the table. Then you make a lateral incision, skin incision down um to the common extensor origin, right? And then identify the um uh junction between an conia and EC U right. And then that allows us to see the upper edge of the capital and the radial head. So you've got the radiohead there and the cap just on the left side. And then this is a little bit of a closer view. You can see the fracturing a little bit more detail here. You can see the annular ligament running around the um around the radial neck. We've had to incise part of that as part of the capsule to see into where we are. And you can see the capitellum just winking there on the left hand side, don't go too far distally because there is, there is the pin there relatively close release things um mobilize things and then reduce them. OK. Which is what we're doing here. You can see that ra fracture being reduced and then hold it for the K wire and pro supinate to make sure you can see everything you need to see. You can see the fractures adequately reduced. And you can see that we're ready now to um treat things with a screw. And that's just a compression screw that's compressed nicely across that fracture line. And you can, if for this fracture, one screw is probably adequate. You can swap out for a second if you like. And then there's a POSTOP film that two part fracture being treated with a, with a compression screen. So again, so this is 1996. If you fix the radial heads, they had good, they they have good to excellent results. All those are simple fractures being treated with simple surgery and unsurprisingly it goes, all right. This is this, this is a, this is just a quick slide about your about your safe zone. Alright. So this is from a a study from to 97. Alright. And that's there's there's your safe zone there center. So between the rate of styloid and this is cheaper. Ok. Now, the, so the reason why um I in particular don't like um plating proximal radiuses is because um that safe zone is that, that reflects the part of the proximal radius that doesn't, that doesn't articulate. And that happens to be the place where the feeding vessel for the articular surface comes in. And so for me putting a plate over the top of the feeding vessel um in an intraarticular fracture where the blood supply is already quite tenuous is a hit too much for that. And my concern with plating these fractures is that, you know, I might be plating through the blood supply and therefore giving me a higher risk of non union or avascular necrosis. So that's why I don't like plating radial head and neck fractures. All right. But it is a recognized technique, um complications of fixation of radial heads. So, they're mainly related either cos the hardware's in the wrong place and causes impingement. Um Either the plate down down the radial shaft or the screw heads are a bit prominent. Um Because although they get sunk, you can get a little bit of uh resorption of the uh of, of, of, of the, of the chondral surface causing the metal work to become prominent. Ok. And so you, so you may sometimes have to go back in and either replace or excise the radial head to manage that risk of posterior osseous nerve injury if we go too far distally. Um And that to be treated with, uh assuming that it's um that it is a stretch injury that be treated with, with just a, a risk of splint. And obviously any elbow surgery is at significant risk of elbow stiffness. One of the reasons we operate on these is to get things moving. Um And the best way of stopping getting stiff is getting moving, but even with that, it's very common to lose that 20 or 30 degrees of extension. So overall outcomes. Ok. So surgical management ra head fractures best results in type two as per the previous paper, they all do reasonably well. OK. And type three and four do progressively worse. Best outcome is screw fixation, which is why the majority of people use um headless compression screws in a sort of tripod type formation. And then partial excision, soy, elastic implants and plating are the things that do worse according to that study. So here is a um tripod technique for a um proximal radial fracture. And you can see a metal anchor has been, has been put in to reconstruct the LCL. So those are a transfers right hip replacement. OK. So this, so this is for those really smashed up pro and rads uh where the um fragments are deemed too small to fix again. What you've deemed too small to fix may be related to the patient's age and bone quality. Um or may also be related to other injuries arou around the elbow right, mostly now uncemented um or most primary radial head replacements are uncemented. Um There are some revision stents that do get cemented in but primary is generally uncemented because uh there was a, a study again about 15 or 20 years ago that, that, that suggested that uncemented implants had a lower complication rate and lower reoperation rate compared to cemented implants. So the process of this, we take out all the bits and we put the radial head roughly back together to decide how big it is. OK. That gives us the size of the radial head replacement disc. OK. We then prepare the proximal radial stem, the, the broad rads to accept the stem. So we size that up and then size the gap in between times to make sure that we don't over stuff. The joints, right? The easiest thing to do with a rail replacement is put one in, that's too big. OK? And if you do that, they do badly, they have increased pain and they have increased wear and that is what we need to avoid. So better to better to underst stuff and over stuff. And the way you judge radial, the the the the height of your radial head prosthesis, you can do it after X rays and on direct vision. Alright. So you assess um where your radial head is articulated with a signal notch both on the vision and under x- and you remember that, that, that, that, that the proximal radius moves moves approximately when you pronate the arm. Ok. So all the peas, so you pronate the arm and that's, that's the furthest the proximal radius moves. So that's the position where you should be assessing whether you've overstuffed or not, right hip replacements. Um Yeah, do. All right. Um with a mean patient with a mean outcome of 12, I mean 5 to 12 years. Um And so yeah, 12 excellent, four good and then four less good. Alright. Um which is probably about right for this, for this type of injury. Um This is why I'm quite ageist about radial head replacements. Ok. So there is a significant complication rate. OK. So I think you get, as I as II tell my patients you get, you get between seven and 10 years out of a radial head. This paper would suggest about one in five require, require further surgery within eight years and you'll see the main, the main complications there, 10% loosening uh about a quarter will get some radio lucency. So some proximal resorption, about 50% get degenerative change on the other side of the joint and about 40% will have some classification. OK. So I think that II try to reserve radial heads for further down the journey rather than doing them straight up. So as a breast, the lesion, this is your longitudinal um instability of the forearm. OK. So this is a a approximate radial injury associated with destruction of the intraosseous ligament. So that means that the um that the longitude muscle of the forearm that's helped by the radial head is II is now on the radial head until that until that intraosseous membrane um reconstitutes. So it's difficult to see this, it's difficult to diagnose this right now. You can see it um on the dynamic ultrasound. So you can pop an ultrasound on the forearm and, and watch the um muscles bulge through what should be the intraop membrane. OK. Or you can do an in optive radial pull on the image intensifier. And if you manage to distract things by more than three millimeters, you are. Um there, there is probably an intraosseous ligament injury. Ok. So it's important to be aware of this and it's important to expect this with your app proximal radial injuries because you need to, you need to restore the stability of the long aud of those of the forearm by managing the radial head properly and then assessing the distal radioulnar joint to see if that needs some temporary stabilization as well. Because the key thing is if you are considering doing a radio head excision or indeed, you're going to worry about how tenuous the fixation of your radial head is. This is not the injury to do it in. Alright. So if you're worried about those things, you should, you should be replacing the radial head for this type of issue. So that's our simple radial head fractures. We're now gonna talk a little bit about the terrible triad. Ok. A lot of what we said about the radial head will come into this as well, but there's a couple of of other bits that need to be uh covered when we talk about the triad. So what is it? It is an elbow dislocation associated with a radial head or neck fracture, a coronoid and a coronoid fracture. So what it actually is is a postero lateral fracture location of the elbow and the structures fail from the lateral side first. OK. So LCL anterior capsule and then possibly all the way around into M CL. OK. Other bits of anatomy, we spoke about the radial head, a nausea. So um we'll talk about the other bits. So the coronoid process is the anterior buttress to posterior subluxation. OK. It's got median and left off the sets. OK. And often in this injury, we'll have anterior capsule attached to it. So that is our anterior stabilizer, the lateral collateral ligament going back to that second or third slide. This is our main restraint to postlateral rotational instability. And if we think this is a postlateral um dislocation, our, our LCL is probably pretty important to reconstruct, nearly always comes up on the humoral side and has those four different components. But the L UCL is the most important of those. In reality, we just do a sort of mass repair of those in and then the medial collateral ligament, as I've said already is that anterior bo that's most important. OK. And that inserts on the supplied tubercle, which is the anteromedial facet of the corona. OK. And that's why sometimes your CT scan of the corona where we get those slices through that just show that it off is quite important. Management of the trial is mainly surgical. OK. One of the reasons it's called terrible trial is because uh the outcomes are not so good. All right. So non-operating management of terrible trials has been associated with pretty poor outcomes. And so we have to have a very strict criteria for it. And so for me, it needs to be no criteria whatsoever for exactly. If one bit of it needs to be fixed, then the whole lot of it needs to be fixed. So the regular head needs to be undisplaced. The corridor needs to be undisplaced and tiny and needs to be able to get that elbow moving by one week. Again, it flips back, it flips back to our overarching rules about elbow trauma. If it, if you need to get it moving, whether that's with surgery or without it needs to get moved. So the surgical plan, ok. So as opposed to our radial head injuries, which we managed by the lateral, I manage by the lateral side, I know the knee doesn't, but I manage by the lateral side for this type of injury. I do it is sensible to do it from the back. Alright. So we use a universe a poster approach by a pos interval. Alright. And the order of fixation is is as shown on this slide, right? So you fix the corridor first, fix will replace the radial head, repair, the lateral collateral ligament and then examine and check the M CL, right? And this is this is a sort of well established link been going for 20 odd years. And there's and there's various uh there's various papers that look into this and show that. It's, it is an effective way of managing this management of coronal fractures. So nearly always in these circumstances, it's a, it's, it's a relatively small corridor piece, ok? And so most of these will be fixed with sutures, ok? Even, even the twos, you can get your sutures round, um, and tie down and if you're from the back, it's very easy. You're seeing all quite nicely. You can, you can pop your drill arms through, pass your suture and tie them all back down. Because what you're trying to do is we're trying to reconstruct the anterior capsule almost as much as you are or anything else. I mean, like AAA type one coronary fracture, there's almost no bony stability from that little bit is there, right? So, so it's the capsule that you're trying to reconstruct and that's nearly always possible with suture fixation if you've got a proper basic basic coral, um A type three and those, those will often need metal work to fix them. There are various little locking plates you can put in and that and they generally go from the medial side just via the bed of the ulnar nerve or just in front or, or just in front of FC. All right, radial head management. The reason we spent so long talk about radial heads in the first part is because I can then put this slide in and just say as per radial head fracture. Alright. So all the stuff we spoke about in the first half of the talk is relevant here. But as I say, it's a lower threshold for arthroplasty. And that's because the overall injury to the elbow is that much, is that much larger? There, there is much more instability associated with it. And with that in mind, what I want is I want mine is I want my radial col to be restored robustly so that I can load through it early to allow the elbow to move. And for that reason, it may be that you have a lower threshold for replacing the radial head because you get to load those um more quickly without worrying so much about uh the metal LCL reconstruction. OK. So as I said, the, the, the, the, the, the lateral ligament comes off at insertion. Alright. And so what we need is to put an anchor at the isometric point and then repair the lateral collateral structures to it and then do a mass repair of everything else over the top. So a mass repair of your, of your common sense, I open the top and the way you find your isometric point, it's a circle that fits the curvature of capitellum. So you look at the capitellum and drop an out into the middle of it. OK? And then tie everything onto that complications. So the the the complications of your trial, persistent instability, that's why you need to make sure that you f that that you do something about that an of instability. So that's so that's why we fix those little dinky coronoid fractures, which don't look like enough failure of metalwork in radial head. That's why I have a lower threshold for arthroplasty because you're loading it earlier. It's more likely to do, it's more likely to fail. And again, watch out for plates around these stiffness or operating on elbow, it's gonna get stiff, it's gonna get op ossification. All we can do is uh mitigate that by getting the movement early and then degenerative change. This is a horrible in, in, in intraarticular fracture, the joint is never quite the same. And so you have to, so you have to warn the patient about early degenerative change outcomes. So this is um this is a sort of uh approximation of several papers, one of them's down there. But essentially, if you get you, you would expect an acceptable range of movement. So 100 and 20 degrees of flexion extension arc, OK. And about 100 and 50 degrees of your protos arc. So not a normal range of movement but one that is normal function. All right. But you have to warn patients that their elbow score is likely to be lower compared to an age match and it's gonna remain lower. OK. So they are. So this is, this is a terrible trial. This is this, this is gonna cause mischief in the medium and long term for these patients, they're never gonna have a normal outbow. So, here we have a case. So this is one, for about a year ago, actually, 48 year old, um, tripped and fell, her hand, complained of pain around the elbow, neurovascular intact, closed injury. So, these are the original films. What, um, you can see that the radial head is, uh, smashed. You get the impression that there's, uh, a coronary fracture as well. All right. So we see here and you can see on the CT scan that you've got a smashed up radial head, um several pieces there. If you look at the image on the left and the image on the right, several pieces of that radial head, right. And then that middle image is just showing us that little coronoid fracture. Alright. So minimally displaced coronary fracture. So um this was associated with dislocations tri. So it was taken to the theater and was treated with uh r replacement and lateral ligament reconstruction. You can see that the coronoid has been treated with um sutures. You can see on the uh on, on, on the bottom, right picture there. You can see your drill holes from where we've done our Transosseous uh management of it there. And you can see that that ra head is sitting nicely in terms of um it's not over standard. So summary for you, I say radial head fractures, that's our approach. Alright. You um ones and stable twos nonop everything else gets surgery or can be offered surgery. Ok. And I fix my radial heads through a lateral approach with headless screws and a tripod. All right, I have a highish threshold to replace. And I, and the key thing is if you're doing a replacement, make sure you don't make the damn thing too big. The trial, it's about that systemic order approach to the injury. Alright. Fix the coronoid saw the radial head, repair the lateral collateral and then possibly repair the media collateral if they're still um opening on that side after you've done everything else. Any questions, I don't, I have to have to get a question. Any questions do you ever, do you ever give in the medicine or anything for the really complex injuries where you know, there's a Yeah, so that, so I don't is the answer to that. Um I sort of, so I do occasionally um ask for updates in terms of ossification from my uh pelvic surgeons and trauma surgeons. Um but I tend not to is the short answer. My understanding was II believe I read something about two or three years ago that suggested that Indomethacin didn't help with um heals around the elbow and was associated with um gastric problems. So it caused more problems than it solved. Um I'm I'm pretty certain I read that in one of the journals a couple of years ago. Um and that's kind of my practice since then. II admit I haven't, I haven't looked at anything since then. Um I think, I think my understanding is that radiation does help with ossification. But again, your risk balance is probably in favor of just getting it moving and not getting ification that way. Cool. Thanks very much. Um There's also a question on the chat from Salim about how you do the radial head full test. Um So essentially what you're looking for is longitudinal instability of the forearm. OK. So you choose a bit where you can see it, the wrist is absolutely fine. You look where the radial height is and then you pull things out and if you've got more than three mils worth of translation, then that is, then, then that, then that sort of on, on longitudinal traction on the forearm, then that would imply that the um ligament connecting the radius is not working. Mr Griffith have a question. Yeah, of course, I can't see, I see you can see me. I can't see anybody. I don't know, I don't know which icon on Rachel's laptop to click on. I'm a proper old man. No. And we talk about in the, sorry, when you talk about terrible injuries. Is it always the usually the an media facet of coronoid where the anti band attaches is that the one that's torn? Usually I just get injury because we're trying to post your later. It later, isn't it? So it's more likely to be the whole of it or I suppose you might, you might get the lateral facet off, but the lateral facet, we tend not to go chasing. Ok. If we're doing something on the radio, I wouldn't necessarily chase, chase the lateral facet. But most of the time what you've done is, um, it's a post lap for this and it's just, and it nearly always, it, it is, it is the whole of the tip that goes rather than just one of the. OK. OK. Sure. And II from Bromfield, um thanks very much for this. Do so just a quick question. Um uh When you do the terrible thread through the boy posterior approach, um how, how do you um grab the coronoid fracture to the intra sutures posteriorly? Do you do another incision anteriorly? No. So you, you do it all from within. So you've um you've got a, you've got a view down the back, OK. You've got your smashed up radial head, OK. It's much easier to do your coronoid if you replace your radial head. So that's another reason why you might have a lower threshold to replace your radial head in, in a, in a trial injury where you want to fix the car. Because if you take your radial head out, you get a beautiful view of, of, of, of, of, of, of the front of the elbow and you can pass your, you, you and so you pass your two, your, your your drill holes from the back through the bed and then you can take that suture out and then just pass it through the, through the um coronoid tip, through the well through the capsule associated with the Coronoid tip and tie that back down that way. If the railheads intact, it's a little bit more prickle to do that, but it's still possible. No, not a separate incision. Thank you very much. Thank you. So, Mr Griffith, you just getting back to that if you think about because that's the very first thing you do. So the elbows all unstable, you've not tied anything together at that point. So you've, you've got much more play in the elbow than you would normally if you see me because because you haven't repaired any ligaments, everything's off. So it's much more easy to get access to the front at the start, which is why you're doing it at the start. Mm And if there is an through media chrono large fragment with post media instability injury, how um how do you put the uh plate or how do you fix the anthro medial large fragment of the chrono? Would you use the the same just to go medium if it's just? So it depends an awful, so it depends an awful lot on what the fracture pattern is and which other bits need to be fixed? Ok. So um if it's a, if it's a, a postmedial dislocation of the elbow All right. And the, and the, and the, and the, and the fracture that you're treating is just the coronoid. Then I might be tempted to do that from the medial side, depending on what bony work or what ligamentous work I need to do on the other side, I may open up the sides for that one. If I don't need to get so unlikely, I don't do all my radial heads from the back. So, um if I'm, if I'm fixing the um medial side, then I would aim for just the medial side. And if it's a big bit that I need a plate and I don't, I don't need to put a plate on, then I probably would open up the medial side. And as I say, you can either go through the bed of the nerve or actually, it's quite nice to go over the top border of uh of, of FC U and get in that way. Yeah. And then, and then, and then, but the plates that go on are only dinky little things. You only get a couple of screws in them and they, and they're contoured to sit on that, on that sort of anal part of the, of the arm. Yeah, but the thing is a lot of the time when you're fixing big coronoid fragments, you're also looking, there's also other fractures around. So you're looking at, you're looking at fractures, locations of the elbow where you've gone through the, through the electron and stuff like that and in those circumstances you might go from the back. It's quite, it's, it's, uh, unfortunately there isn't really a, um, uh, a one size fits all for a lot of elbow trauma. It depends a lot on what you're trying to achieve. Yeah. Does that make sense? Yes. Absolutely. Yeah. Thank you very much for that. Thank you. Thanks a lot.