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This is kind of trying to summarize some of the stuff that hasn't really come up if you were at the face to face day last week. Um There's a couple, there's a bit of repetition because some of the stuff in this is I think more important than the nuances of different types of periarticular elbow fractures in terms of what you need to do on a day to day basis. So, um I'm going to go through a few different topics. There are a couple of audience participation sections and so if there's any volunteers who weren't at the face to face day, who want to just go through some cases, please, you'll need to kind of shout because I can't see you because of the way med all works. So first one we're going to go through is elect bursitis. So important points, basically, depending on your traps, this might go to medics. In which case, it's an absolute win. You don't need to deal with it, but in a lot of trust it doesn't. So what do you need to tell the patient? Does anybody have any kind of patter that they have for explaining to a patient. What electron bursitis is. Um, I mean, I just tell them it's a bit of an inflammation of the fluid filled sac around their elbow that's usually related to resting on it or rubbing on it for a prolonged period of time causing irritation. Um, often it can settle down by itself with some anti-inflammatories. But if there's signs of infection that we may need to treat this with some antibiotics, but typically we don't need to do any surgical. Well, almost the vast majority of the time, we don't need to do any surgical intervention for this and it will settle down with time. Lovely. So yeah, in of fluid and the potential space at the tip of your elbow. That's what I say. Sometimes it becomes inflamed and sometimes this can get infected. So yeah, exactly what he said. So what do you want to check with a patient who you think has electron bursitis? And I'm afraid said you've now nominated yourself for electron bursitis. Um I mean, so I always check, take a full clinical history as usual and examination, check to make sure they have no systemic signs of infection or duration recurrence, any precipitating factors that might have led to this. Um I think the main thing I usually need to know is whether they've been treated with any antibiotics yet or not because that'll give me an indication of how responsive they're going to be to just normal oral therapy. Whether they need admission for IVS. Um examination wise, the most important thing I need to know is what their range of movement is like. So I need to make sure there's no underlying septic joint. So their motion extension pronation, supination and then localizing the swelling. Is it just over the electron tip or is it actually the elbow itself, the elbow joint that's swollen or the fusion? Excellent. So, um I said what the bloods were, what your movement is and mark out any cellulitis. So you went into more detail than that. What and what are you gonna do about it? Um So based off their clinical findings, blood results, um systemic involvement, the vast majority of the time if their bloods aren't particularly exciting and they don't look infected some anti-inflammatories and then they can go home. No routine, follow up for them signs of infection antibiotics or a course of usually flu clocks. They've not been allergic. Um No routine follow up and then if they have been resistant to all therapy in the community, then admission for 24 48 hours IV antibiotics. And that's about it. Really repeat once in 48 hours. Great. So I said it elevate high dose antibiotics. And I said for 36 hours because if you say 24 hours, by the time they come in, they haven't, you know, they'll have had one dose, you'll see them in the morning. It all gets very confusing. So I essentially give them a day and a half and repeat their bloods after 24 hours. There's no point earlier than that explain that they might need a prolonged course and the swelling might not settle for months. The number of patients who come back to clinic can say, oh, I, um, had this and I thought it was gonna get better, but my elbow is still swollen and that's really, really common for patients to complain about that. So that's what I would recommend. And then, um, don't do an I and D the number of patients who say, oh my GP said that you'll stick a knife into it. Don't do that. They'll get a sinus. It won't help and then sometimes splinting and extension can help, but I rarely advocate it in the same way as if you listen to me a on before. I hate putting people with elbow injuries in plaster because it just gets stiff. So it's not something that I routinely do, but it is something that some people don't. Um, ok. Who wants to do cakes? He wasn't at the face to face thing that already done on. So I'm not gonna, I, I'll do one. All right that you were there. But Nick, do you wanna, do? You wanna, Nick was there? I'm here if Sly's not available. Yeah, but you were also at the face to face a a I wasn't there now. Ok. Uh, you nominate this. I know, I got very excited so you can phone a friend, you can do a 5050 or you can ask the audience if at any point you don't, you don't know what to do or you're worried about it. Ok? Don't do that again. Oh my God. It's like metal all over again. Ok. This is an 86 year old man who was referred from Ed. He's got 24 hour history of a painful right elbow and a restricted range of motion. He's generally unwell. Um His heart rate is 100 and 20. His BP is 100/70 his temperature is 38 too. And what are you, what are you gonna do? Um So, um so you need to manage this using um um So I'm just gonna go to a place where it's quieter one sec. Um Sorry, I'm just in the theater. Um So you're worried about this could be a septic patient. He's febrile, he's hypertensive and he's tachycardic. Um So I'd want to um ensure that A&E have uh arranged for an X ray, uh ensure that he's um um had fluids start a septic screen, but I would advise him to hold off antibiotics until I've seen him. Um And then I would go and review the patient. Awesome. So you go, they do that. They get this X ray. Is there anything on this X ray that worries you or is it normal? Um Looks like, he may have mild arthritic changes, possible loss of joint space. Um, but I know that looks and he's got massive swelling. Yeah, he's got massive infusion. He's got arthritis. Yeah. And see some uh change to the um, the radiocapitellar joint. You can see some change in the, on the humeral joint. But you can also see that there's a little bit of a space here which looks abnormal. So there is a faint anterior fat pad, but there's also this distraction of the joint which can represent a whole host of different things about elbow instability. But it could also just be an effusion in the joint. So yeah, it's worth kind of mentioning that one. Ok. So what are you going to do? Um So assess him to take a a focused history, establish um when his symptoms started whether he's had any um fevers systemically how he's doing. Um look for any other potential causes that um any other systems that may be involved. So just do a general make sure his chest urine et cetera is clear. Yeah. Um and then it would be important to do an exam, uh a examination um establish his range of movements, see whether there is any obvious effusion, any surrounding erythema, uh whether it's hot to touch, what investigations are you going to do? Um So we'd like to do blood tests. So get a FBC CRP uh check his uh kidney function. Um He can do ESR as well, but my main part of concern would be to rule out septic arthritis in this elbow. Um, um, how do you do that? Um, so it would be a combination of history examination. Yeah. So the only way you could rule out it is, um, if you're, if there's higher suspicion then you need to do an aspiration of the joint. Oh, so you've got his blood, his white cell count is 17. His CRP is 230. He's got essentially fairly normal for an 86 year old. His urate on the high end of normal and you've sent some pouches and then you aspirate the joint and that kind of led you into where you're going to go. Where do you aspirate an elbow? Um So normally it depends if there is, if you're happy that there's no erythema, it's normally a soft spot. So it's like a triangle. So um later on the radial head um and the electron tip and just going in the middle of the, and that's what a showed us to do as well and good might have seen it before. And so you aspirate it and that's what you get out of his elbow. It's just horrible mucky yellow stuff. Where are you, what are you gonna send it for? Um send it off for um Graham bone um and then send it off for culture and sensitivity and if you have enough, you can send it off for um histology as well. Uh Yeah. So cytology and so um SM CNS crystals and then you can sell it, send it for a cell count depending on where you work. That might be in a bottle that they just do on the initial brown stain or it might be, you need to send it in a red blood cell bottle. OK. So we can do a cell count if you do that, just make sure you write on it that it's not blood, it's synovial fluid. Otherwise they get very confused. Um ok. Cool. What next? Um So the appearance of it looks to be very viscous and thick, almost like pus, it looks like pus. Um So, so you want to, this is a septic elbow. So this would be an emergency. So um I would start the leg work in preparing this patient for a to take him to theater for a washout. It's me you can was it out? I'll be around? What incision are you going to make? How are you going to get into this man elbow? Um So you've got options either to do this arthroscopically or do an open wash out? Yeah. Um washout. Have you done? I haven't done one but I would imagine you could probably use the same um entry as where you went with your aspiration. Yeah, that wouldn't be unreasonable, but I would suggest that maybe doing an elbow for a septic elbow when you haven't done an elbow was a little bit scary. And, uh how would you set the patient up to do that? Um So you could put, so elbow, so you could probably put them, um, supine with a DHS trough. I know elbows like that, but not this one, this one, you have an elbow, you need to be able to move their elbow. It's much harder to do that when they're over. So you fell into the obvious crack of something and not knowing how to do it. But don't worry, how would you do it as an open procedure as a, as an open procedure? Um So, so would you would there be, so could you do a um uh incision? So a lateral incision to get in um similar to when you, what you need to do for a radial head? Oh, like the one we did the other weekend? Yeah. Yeah. Do you remember what the intervals were? Yeah, it was a ec uh C interval. Is that right? Um Yeah. No. Get worried. And remember you can bring your friend or you can, you can you not in this all? Um II might ask uh one of the other registrars and who, who can tell us about the act approaches to the elbow? Mhm. And I know there are people on here who we talked through this last week, so it's nothing hard I can do. Ok, do it. Um So um the later approaches there are um main three intervals. Um The starting from more posterior is the boil which is between the ulna and, and Conus and um a little bit more anterior which is the copper interval between the anconia and the um PCU prescribed by a nurse. And uh moving more lateral uh is the interval um which is either EBC split or between the interval of EBC and um um the other one is yes lovely. So I wouldn't normally count the void approach as being a lateral approach to the elbow. I would kind of count that more posterior. But yes, you can definitely talk about doing a void approach into the elbow if you want to. Like we talked about last week, that's quite an invasive thing to do and you need to be right around the back. So I wouldn't start with that one. But when you're talking about natural approaches to the elbow, you've got Cockers, Caplans in the EDC split. Um Clockers is round at the back. Um And cats is round at the front and then A DC is obviously just splitting the muscle in the middle. And the problem with uh a big swollen infected elbow is that you don't often or it's very difficult to determine what's what. And so just look for the middle, something that looks like it's a nice wide expanse, probably EC and just split that and that will take you into the joint. Um And that's probably the safest way to get into the elbow if you're not used to getting in the elbows. Um, or even if you are in a, in a trauma situation, it's the easiest thing to do so well done on it. Um And then uh with arthroscopy, it's not an easy thing to do. I still struggle with what weighs up and what weighs down. So it's probably not the best thing to do in the first instance for a um septic elbow. Ok. Radial head fractures. I know we went through at great length earlier on, but they're often missed, but they're also over managed depending on um you know, if they come from, we don't need to see every radial head fracture that they seem to like to send them to us. Ones that need to be seen by us are displayed fractures and people with the bony block in rotation. What do you want to check? You want to check their range of motion? But be aware that there will be stiffness due to the swelling. It doesn't mean that they can't move because of the radial head fracture. There might be pain in rotation. But if you can't rotate them at all, you've got to have a bit of a worry that there is a bony block and they're the ones that need to be looked at in more detail as to whether we need to do something about it. What to do, get your CT scan, it will delineate things a lot closer if you're worried and then you want to work out if it's reconstructable and you're gonna do that with an R if, whether you use a tripod configuration, whether you need to address the articular surface, whether you're gonna plate and what your safe corridors are gonna be, whether they need a replacement or whether they need excision. And so that's just like a little overview about radial head fractures. OK. Number two. So you wanted to do a case, this one's a different one so you can do it if you want. Really? Yeah. Yeah. So, but you still at 5050 you still got phone a friend and you've still got ask the audience. Oh no, here we go. Sh So 27 year old girl, have I stopped them? She technologically 27 year old girl, she was referred from A&E she fell on a horse and then the horse stood on her arm and what are you gonna do? So um assuming this is an isolated injury at less principles, making sure that all lifethreatening injuries are dealt with this. Um I want to examine history, examination and investigation. So in history, um time of injury mechanism, I know that there's a crush injury. So I'm worried about uh sweating and possible compartment syndrome. Um I wanna make sure that it's not an open fracture, there's no nerve vessel involvement and then imaging. I want an X ray ap and not of the forearm, I'll make sure I as clinically assess the um elbow and the wrist and ensure that there are radiographs of that as well. Ok. So this is her x-ray um and her radial nerve function is intact at this point. How are you gonna manage this? So this is a um transverse fracture, midshaft humerus without any nerve or vessel involvement closed. So the principle here would be to, to um to aim for secondary healing with uh callus formation. And I would want to uh plan for a bridge plate at best. The second option would be non operative, but that would depend on two things. Uh what the uh what the x-ray looks like after it's been in a sling and the fracture pattern. I, if I look at it really closely, I can see that it is a transverse fracture. So I don't think it's going to be less stable. And thus, I would rather do the first option, which is the operative. OK. Um When you said about conservative management and put them in a sling, would you put them in a sling or would you put them in something different? Waiting question price. Yeah. Brace it. So there we go. She gets put in a brace. Sorry, sorry. I thought we weren't supposed to put them in a brace. That was the conclusion that it's, I forgot which lesson it was or which teaching session it was that we're not supposed to put them in a brace because it's bad for the skin or is that like, uh you can put them in a brace? You can have. Absolutely. There is a reason to put patients in a brace and putting her in a sling isn't going to stabilize her fracture in any way, shape or form. So, a brace for a midshaft humerus fracture is a reasonable thing to do. You just need to make sure that those patients are followed up and managed appropriately with regular skin checks and follow up in clinic. And it depends on where you work as to how that happens. And we know that in the trust that we work in, that's a little bit more tricky. Um But some places have it set up wonderfully that Peterborough, for instance, are really, really good at managing their humoral race patients. But this lady goes on to then develop a radial nerve palsy when she's put in that brace. Um So what are you gonna do now? So I'm thinking about uh first assessing uh the palsy. So I want to know um the sensory component and I'm thinking, is this, is this a, is this a crush or is it transection? I think this is a crush and then I'll apply those guidelines for peripheral nerve injury. Um Essentially, I want to ask the actions that I'm gonna take next would be to um to tell my consultant about this and then we would have to possibly take the patients theater. Do, does the fact that she had a radial nerve palsy post application of the brace for management compared to if she had a radial nerve palsy at the time of injury? Yes, because um one thing I didn't mention earlier was that we can take the brace off and see if it, if it gets better. So you, that's the insult that happened. So we'd remove that um with the, with having the palsy prior to seeing us or at the time of injury, that could be more serious ie transection as I was talking about transection versus crush. Yeah. So it, it would probably be a different mechanism of injury and a different underlying pathology that this is probably like you said, a crash type situation, but she has displaced her fracture quite significantly. So you don't know, it's kind of in the territory of where you expect radial nerve to be. So it might be that just by translating that sharp edges caught it and something happened. So once you've intervened and you can't rectify the situation, you've basically caused this injury. So you have a duty to explore it. So um she goes to the theater, um it's explored radial nerves intact. It now lies over the fourth most proximal hole in the plate, always document where you put it. Um How would you set the patient up to do this? This is in a beach chat position. Uh So you could, it would be more tricky to get round the back, then it would be the, the adjust, you can pretty much be if I'm doing something to the shoulder and what approach would you take if you're going to explore the nerve? Um I, I'm thinking triceps splitting, but that's just something that's coming to my head. I'm not sure. That's right. So you need to go around the back. Whereabouts can you find the radial nerve in the spiral groove, midshaft? Um How you actually gonna find that cos all you can see is muscle. When you open up the back of the arm, anybody want to have, you can use a patient's patient's own hand span above their trans epicondylar line. Um And then you can also look for the change in direction of the um aponeurosis of the triceps where it curves and the radial nerve runs roughly in that directly deep to the or around 1.5 centimeter just above the tricipital aponeurosis as well. Yeah, where it starts. I think, I think that that description of where's talking about where the aponeurosis curves that is about, it's about one centimeter above where the uh confluence of the head of triceps is approximately. And so you can do a split down to bone and you can almost always feel it within a centimeter of where that confluence is and that's finding it approximately and then distally it's about a hand's bread. But it's normally about 10 centimeters above the lateral condyle. You can see it coming through the inter around the side there. Um So depending on where your fracture is, those are the two kind of constant places to find it. All right. Um Pediatric elbow injuries really quickly. They're confusing and X rays don't always help because there's vasal injuries, there's invisible ossification centers, there's easy to miss injuries. Um, and they've just are pretty magical children's elbows. I like to tell Children, I can tell how old they are based on their X ray because they're like a tree and with the circles, but their ossification centers tell me how old they are, they quite like that. Um So what do you want to check? Do you want to check range of motion? And that's the most important thing. Um, any concern of the incongruency of the joints or any restriction or block to their range means that you need to do some further investigations. And the question is whether you do that with further imaging in the form of an MRI because we don't want to ct Children unless we really have to or whether we're going to take them to the, to do an arthrogram. And then we're going to have a dynamic test that allows us to then fix whatever we find the best way to, I find to get Children to check their range of motion is to play head shoulders, knees and toes with them because they need to touch their heads. So their arms are going up in the air, their shoulders need to flex their el elbow, more knees. They need to start to extend it and then toes, they've got to fully extend, um, their elbows. So I think that's a really useful tool and you get to play a little game. Um, elbow dislocations in under three year olds are not elbow dislocations unless proved otherwise. It's a high rate of a non accidental injury of a five seal separation. Um And that's quoted as being 50% of those cases. It's where the distal humerus fiss is weaker than the bone ligament interface. So in the same way that when Children get hit by cars, they don't break bones, they get soft tissue injuries. The fal separation is because the B is really weak compared to the rest of the bone. So if you see an elbow dislocation or are referred to an elbow dislocation in an under three year old, you've got to be concerned that it's actually a five separation and therefore your spine sensors need to be up for risk of. And so my, my four things I want you to have taken away from the other bits of uh elbow trauma is never ever, ever unless you have to put someone in a cast for an elbow injury. POSTOP. The whole point of fixing an elbow injury is to get their elbow moving. Um be nervous about the nerves because they are scary but know where they are, where to find them, how to protect them and you'll be fine. Um, the pediatric elbows are hard for the exam and for just succeeding in life, know where your ossification centers are and always have a high index of suspicion if something doesn't look right because it probably isn't. And if in doubt, phone a friend and there are lots of friends around the region which hopefully this um term has shown you. There are lots of very nice a in surgeons who will help you out if you have issues with them. Ok. Now Mister White has sent, I do have his email now.