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Distal Humerus Fractures For Postgraduate Orthopaedic Exams
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Distal Humerus Fractures For Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
So good evening, everyone, welcome to this teaching session, organized jointly by orthopedic Research UK and the orthopedic Academy.
The presenter this evening is Professor Mohammad EMOM. He is Professor and consultant, trauma and orthopedic surgeon at Bristol orthopedic center and the University of East London. He is a very keen researcher. He's published extensively and he's also very keen educator. He's been with us and his lectures and teachings are always very well received, so we're very pleased that he accepted our invitation to be with us tonight, and I'm sure we all will learn from a lot from him.
So my name Prasad, now I'll be moderating this session. And with us, we have Hannah and Imogen from the education team of our UK. So the session tonight will include a shoretel very focused lecture on distal humerus fractures. The focus of this lecture this evening is on the FRC exam, so that's the level we will be aiming at. The lecture will be followed by few questions.
This will be from the lecture, so please stay concentrated and you can answer the questions correctly. Following that, obviously, there will be an opportunity for you to ask you questions, so if you have any doubts or any questions you have in mind anything not clear. Please put your questions in the chat box and we will present these questions to prof. Emam at the end.
At the end, at the end of the session, there will be opportunity for those who are interested to take part in the hot seat waiver practice. This section will not be recorded and we encourage everyone who feels that they want to participate to let us through the chat box or raise their hands, or let myself or Hannah our emma-jane on.
Let know that you are interested in taking part in the Viva. So we have only three spaces, maximum three spaces available for that. We understand how the survivor and talk in front of people in this situation can be very stressful. We all been there and we will be as supportive to you as we can. So the aim is for this session overall to be an interactive session.
So please ask your questions and give us your feedback. And if you missed any part of the presentation, don't worry, it will be. It is. It's been recorded and it will be on the orthopedic Academy and on the UK website. Very Uh, shortly. Just a reminder before I hand over to profit, ma'am, that's the remainder of our courses.
So we have our. And mock exam course. The first of its kind in the UK, and we started that last year in September last year, and we are doing two more courses coming up one on the 4th of December and one those 20 second of January to book these courses. These are obviously these courses you. We simulate the real exam going through all the tables and clinical stations as if you are in the real exam all the time and you'll be given some feedback as well and results at the end.
So you could book these courses or UK website. We have other courses your case based discussions, courses on the 11th of December and 15th of January coming up, and these courses are for a very small group of people when you go through around 50 exam specific questions and we give you the answers and we will give you feedback and we give you detailed answers of this ideal answer, basically detailed explanation of the ideal answer.
So it's very useful for those who want to test their ability to answer a question, but they also want to improve their knowledge. OK and we do the same style for our basic sciences course of 29th of January but will be formally focused all day on basic sciences. So it's very good last minute revision. So these courses are on the Academy that code the GKE website.
So without further ado, I will leave you now with prof. Emam to start his teaching session. Over to you. Thank you very much for us, and thank you to the orthopedic Academy and all you for the kind invitation, and Thanks as well for the great work you're doing over a long time actually, which is a great aid for those undertaking the forces exam.
And Thanks for the great introduction. So actually, I'm going to end this presentation. I'm going to talk about distal humerus fractures. We know that distal humerus fractures are very common. They represent actually up to 6% of all other fractures and 10% of all elbow fractures and the court. The Robinson in 2003 is that have published. The number is actually increasing in frequency because the number of elderly individuals continue to grow.
Plus, it is actually now elderly individuals have more active lifestyles compared with before, so it is important for efforts as purposes to understand in trauma stations it is. It is crucial to talk about management and in-depth knowledge is expected in trauma survivors, especially compared with other survivor stations.
Also, to some extent in basic sciences, you need to know a bit more, but you can actually discuss a bit more superficial in the majority of Survivor stations. And actually for any fracture, it's good to understand the goals of any initial evaluation when you're managing and any fracture in real life and in exam scenarios, you have to understand the patterns, the geometry and actually understand the previous symptomatic pathology as well.
Because if you have someone with arthritis of the shoulder and having proximal humeral fracture, possibly the best treatment option would be a shoulder replacement. Also, the same someone elderly with a lot of resistant humerus fracture and arthritis and possibly a total replacement would be the best option. It's crucial to identify neurovascular injuries and soft tissue problems like open fractures.
And so, and for exam purposes, you can assume things. So if you see someone with a limb fracture, you can assume it's an isolated injury intact with intact neurovascular compromise because what you really need to appreciate in the exam is 4 and 1/2 minutes. It's not 5 because usually half a minute is wasted from the previous question or the next question. So this 4 and 1/2 minutes are crucial.
They are very precious minutes for you to utilize properly in order to identify the problem and address. Uh, address what the exam and what the examiners want you to talk about. So in order to understand the distal humerus we have, it is actually a complex structure where the distal end of the humerus is flatter, expanded, transversely and rounded at the end.
You have to understand also the distribution of the articular cartilage, where the posterior aspect of the capitellum has articular cartilage. There is a Downward projection of the cochlea, which is responsible about the carrying angle, which is increased in women. And that's important when you are reconstructing these injuries in real life. You have, we can see here you are.
Also, if you look at the distal humerus in cross section at the level of the fossa of the electron, the two columns on either side of the fossa are dense and strong and offers a good hold for screws. But with the elbow extension, the tip of the electron actually lodges in the olecranon fossa. So that's why when I'm doing this, I have to extend the elbow properly in order to make sure that it's not as the fossa is not blocked by a screw or a plate.
And finally, when you look at the humerus in flexion, you have to appreciate the movement and test it whenever you are addressing these injuries because it's a complex structure. The distal humerus and in the exam, you should highlight these aspects because it demonstrates lateral thinking and actually would enable will differentiate you among the crowd during the exam.
So here, if you look at the shape of the distant humerus, there is 94 to 98 degree angle between the axis of the humerus. It's a red line and the cochlea, which is the orange line, which if you can see it. And then if you look at the medial view of the distal humerus, the medial column, which is all and shear, makes around 10 degrees angulation to the longitudinal humerus and positioning that rocklea slightly in front of the humeral shaft, which is crucial when you are reconstructing these fractures.
And if you look at the lateral view, the lateral column makes around 30 degrees angulation to the humeral axis. Therefore, the capital is positioned in front of the hemodialysis, so both capital and rocklea are positioned anteriorly, which is important to understand. If there is significant communications and combination. Fractions of the distal humerus actually fall into two categories the simple metaphysical type A according to the Mayo and the partial articular type B epicondyle fractures and the former two types also sometimes are part of a more complex injury, such as the dislocation of the elbow.
It is easy to treat, and they are usually associated with good prognosis. Different classifications for the human race is not really sorry, distal humerus fractures is not really needed for the exam, but for extra articular type fractures, you just need to know that this is type and the partial articular type fractures. These are type B and type C are the complete articular fractures according to the molar classification or classification.
So it is actually we feel at from a prognostic point of view. It is more prudent to group fractures around the elbow and to those with good prognosis and those with poor prognosis, and to discuss each type separately, since each has its distinguishing features worthy of mention. Also, the compiler fractures and those with extension into the joint can be grouped together, and this is really important in the exam.
So if you are seeing a fracture with single intra articular extension, you can say it's an intra articular fracture. Are you understand the gravity I one patient about the long and short term sequelae of the fracture, but it might be of good association if you have an impacted fracture. This is also good to understand and we can classify them. According to shatzkin, two fractures with good prognosis and fractures with bad prognosis like an abortion injury would be good prognosis fractures intra articular fractures might be.
Some of them might be always good prognosis, while others might be of bad prognosis. And I didn't find these things initially in the exam demonstrates that you are a safe surgeon. You have mutual discussions with your patients before surgery. You understand your remit and you understand what you're offering to the patient. So you can definitely differentiate between good and bad prognostic factors.
When you are managing these types of injuries and the majority of intra articular fractures, you can actually highlight the gravity of the situation and that demonstrates your safe surgeon. Remember, in the exam you are a day one consultant. You're not a registrar or a fellow who actually says, oh, this is your graph showing so-and-so. You're someone who takes the initiative or demonstrate leadership.
And at any time point is the exam. You should demonstrate lateral thinking. Everything you mention in the exam, any question you ask is actually based on something you want to discuss treatment wise later on. So if you see a bad injury, say loud, it's bad injury. And if you say something that's wrong, retract it. Say sorry, I'd like to retract what I've just said. Actually, so-and-so never.
There is no wrong as there is no right answer, but there are wrong answers. So let's go through different fractions. You can see capitalism fracture, a colonial shared fracture. You can see here the double purple side, which involves the capital and the rocklea, or a combination of both. It is uncommon around maybe 6% of all this that human fractures and 1% of all elbow fractures, but they can be easily missed.
We've noticed recently a progressive increases their incidence. Maybe because we're picking them up now, maybe because we do more CT scans. However, the majority of this will be a follow on outstretched hand, with the elbow partially flexed and the forearm pronation. That's how you snap the capital and have a coronal fracture. So it can also happen if someone has a posterolateral rotator dislocation and you and then it is reducing back because the radial head will have an impact against the capital, as well as the rocklea and paranoid against the capital as the rocklea as well.
So well, I think a fractured only of the capital we actually initially we thought it is only a fraction of the only capital N then were classified, according to Brian Murray, and to these three types. And each of them has a mnemonic. But then Mackey made the modification, saying that actually, if the fraction, which is actually more common than what we used to think, I could only share fractions.
That includes both the capital level rocklea and, of course, four times 3. It will be a more nasty injury. It's that you need to address as well and identify. You don't really need to remember different names on different names for different fractions or different classifications. But if it is better to understand each and highlight that you understand the problem because that will dictate your management because.
Ringtail defined the articular fractions of the distal humerus, noting that these lesions not often not only are grown and shared and both the capital and the cochlea, but they involve as well as the lateral epicondyle or the lateral column. And that involves the posterior part of the truck and the medial epicondyle as well, because of the progression of trauma, doubly in 2006 proposed the name capital of Antioquia fractures because these are very common.
And then they identified a prognostic factor is the prognostic factors that differentiates the treatment. You usually access them. What I would do in the exam, if you have this, you access them through the lateral approach. You can use either the captain or the cooker approach based on the dissection done to you by the fracture itself during the traumatic incident itself. And then I use the lateral collateral ligament sparing approach you take to the bone left all up and then fix these fractures with the screws, Uh, headless screws or sometimes.
And of course, CT scan is mandatory to all these injuries to identify the problem and then which approach to use. That's actually something you can mention in the exam. I'll be sure to come see if I can fix through a cooker LCL preserving approach, but if there is extensive. Expansion of the fracture to the rocklea. You can discuss electron on the cooker tensile approach if it is worse and you can see in type C fractures here at the top image, you can use an ulnar claw osteotomy to manage this and this as you can identify with CT scan.
And if you demonstrate that in the exam you understand these things, you're scoring higher and higher. And as I said, you can fix it with screws like here or biodegradable screws, which is something I started to use myself, which you can mention in the exam, but stick to the standard, which would be the headless screws which you use. This is the type actually when you have an excess tensile capital and rocklea, including the column as well.
And then you can either use the screws, the headless screws to fix it, and which can be enough here, as you can see in this patient. And this is a patient where we fix with four forehead screws for biodegradable screws and reconstructed the ligament as well. There are advantages and disadvantages, but you know, I wouldn't go that far in the exam. Just stick to whatever you want.
This is becoming more and more common nowadays to fix these injuries. You can go through the approach, discuss different options. And of course, if you are worried, I'll always have a low threshold of fixing it with a plate as well. So what about the fractures with poor prognosis or type C fractures in order to prevent stiffness? We have to identify fractures with poor prognosis because.
In all, all very articulate and articular fractures required any active motion that's crucial. Prolonged blustery mobilization leads to irreversible joint stiffness, and that's cannot be fixed. We can we go and do our quick release. We do a bilateral kodom release or over-the-top media release. But still the best option for this patient is to reconstruct the fracture and correct the metaphysical and the physical deformity so that you reduce the stress of the articular cartilage.
Same to what we use in knees for tibial plateau structures can have published many years ago and the similar papers and actually before Chaska surgeon in 1961 said that's a perfect anatomic restoration and perfect freedom of joint movement can be obtained by internal fixations. And so we actually. Even if in the age where they couldn't fix all these fractures and they did have less toys compared with what we have today, they used to marry this by traction and elimination.
So we know for sure that for intra articular fractures, elimination is crucial. And actually, for example, purposes whenever you have an intra articular fraction, you should highlight that immobilization can cause joint stiffness. If you fix it and immobilize it, that actually is associated with worse stiffness. And if you have a depressed articular fragment, you and you cannot reduce by close manipulation, then you wouldn't be able to reduce by Closed means, so you have to open it and reduce it.
And actually, if you have a major depression, it wouldn't fill with fibrous cartilage and instability and displacement that can happen will be permanent. So that's why if these injuries you say my principles is to achieve an anatomic reduction, solid internal fixation that would enable me to achieve early, moderately mobilization and full range of motion.
And that applies to any particular fracture you see as exam. You have to restore the show incongruity. And if you have metaphysical defect, whether it's a proximal humerus, whether it's a temporary plateau or a distal humerus, you can mention that you can actually achieve it by bone grafting in whatever form of bone grafting. And we have to achieve address all displacements, either in the dialysis or the metaphysis in order to prevent the joint overload.
Based on the shatzkin, theory and correction is crucial for joint stability and for their function. Immediate motion is a must and requires solid internal fixation, and that's actually why we are reading all about the mechanics of bone fixation. Different types of healing and that will then you will be able to help all your patients based on long and short their methods.
And that's actually would enable you to address any of these injuries at all time points. So for distal humerus, then what's specific about it in India also intra articular fracture? You can easily say there are factors dictating my decision, and these factors include the patient demographics, the fracture demographics, the degree of displacement as the degree of combination and joint involvement.
These are the four factors that influence all our decisions in any trauma setting. And actually, you can use that slide. In any case, you have what is there is a complex intra articular fracture in the exam. So applying that here, we have to understand again, I repeat there are no right decision in the exam, but there is definitely wrong decisions, wrong fixation missiles.
And that's actually important for the exam. And other important aspects that you need to be discussing in the exam is whether you're going to use parallel or perpendicular fracture construct when you are managing this distal humerus intra articular fractures because there are two different philosophies the orthogonal technique otherwise known as the 99 plating or perpendicular plating. And that's what the aorta supports, which which simply consists of placing two plates at 90 degrees angle to 1 another, with the lateral plate placed on the plate along the posterior aspect of the lateral column, and the medial plate applied to the medial ridge.
While the parallel plating was popularized by Sean O'Driscoll from Mayo clinic in 2005 and then Sanchez, who need to publish the who's also Mayo clinic in 2007. And they said that, you know, this is actually more biomechanical superior as each plate is actually rotated slightly, one towards the other in the sagittal plane and the angle between them is 150, 160 degrees. And the orientation would permit to limit soft tissue detachment of supposed to lateral side and insert by cortical screws from both sides, actually.
And the evidence has been contradictory, and there is different evidence supporting each of these two. But you can just stick to one way or another and support whatever you feel appropriate for me. I would opt for one of these two based on the fracture configuration some fractures. It's better to fix them using the principles the other ones would be based. It would be better to fix them through the parallel technique, and that's based on fracture geometry and morphology, as discussed earlier.
Whenever you are aiming to fix this, you have to achieve a commands. The first thing is you have to maximize it. This is actually more a clinical steps than exam wise. But if I'm here, I'm going to tell you this each screw should pass through the plate, which is crucial if you can. Of course, you can do screws outside the plate if you have to, but I would aim for that as much as I can.
I would aim to maximize the fixation in the distal fragment as much as I can, and the applied through compression as slap lesion Taylor level. Each screw you using should engage a fragment on the opposite side that's also fixed by the plate, which would be ideal. We're talking about ideal scenarios here, and adequate number of screws should be placed in the distance.
Fragment, as I said, and schools should be as long as possible, avoid screws, including the ulnar claw fossa. And they should lock together by Interdigital, creating a fixed angle structure and linking the columns together. This is also crucial. You have also the place should be applied. So that compression is achieved as the supercooled dialogue level for both columns and plates should be strong enough and by mechanically stiff enough to avoid breaking and bending.
And that's if you follow this. The chances of you having problems is actually low. And this was also mentioned before Sanchez to need to mention the shortening osteotomy, which you can achieve without a problem. This is a paper published in 2007, which this is another option. Also, one important thing you have to understand that if you have an elderly fracture with this problem, Makeda Allen 2009 highlighted a total elbow implant with substitution or a heavy plastic can be an excellent option and is associated with significant improvement.
And we started seeing a lot of not a lot, but more presentations like this where I showed a total elbow replacement is actually the best option. So that's something to keep in mind if you have a patient with this problem. A total and acute total elbow replacement is not a bad option for some elderly, low demand patients. And obviously, if you're mentioning that, you can mention the guest saying that this should be done in specific centers.
And gerth has highlighted these centers in each have identified these centers in each region. There are different constructs, different techniques in fixing these, but all what you need for the exam is to try to identify the biomechanical demands, identifies the biomechanical aspects of each of these and certain fractures. You have to identify if there is a super epicondyle fracture plus an intra articular fracture, and then you can address both problems because if you have a microfracture or supracondylar fracture and the fracture is large enough to allow for stable fixation, then you have to fix it.
And the exposure to European would be lateral with the fixation from posterior aspect or other ways. This is based on the presentation. There is newer, you know, now there is some trend into doing ascorbic assisted technique. I don't think you need to mention that in the exam unless it is a case, actually. Clearly the musc option colloid Canaanite fractions can be also addressed if you're doing arthroscopy and fix it, and you have to identify distal fractures in association with complex intra articular distal humerus fractures position when you are going through your technique.
You have to tell your approach as if you're telling a story. And every time I give a talk, I mention that because one of the most boring bits is actually telling approach. The way is intramural playing intra intramuscular plate. All that stuff. I'll positions the patients so and so I'll have the head away from the anesthetic machine. I'll have to see arm coming from the top.
I'll make sure there is a good access to the elbow before prepping and taping, because that's also the mistake lateral thinking and give the examiners the confidence that you are a surgeon who has done that before and you are a safe surgeon who knows what they are talking about. You will mention whether you're going to do an electron osteotomy for complex intra articular fractions.
You have to mention how you're going to do it and what's there and what you are going to do in advance, which will enable them to make sure you have a clear preoperative plan and you outline what you're going to do. I just got proposed and the sequence of fixing this many years ago. You can say whatever you would in this regards. You can also say you can make sure you have a plan whenever you are fixing this and converting multiple fragments into smaller number of fragments into two fragments and fix the joint first and then fix the distal fragment to the proximal fragment.
These are all technical bits you can mesh so that you can mention while doing the exam while. The exam always mentions you are going to identify the ulnar nerve first, and based on different classification, a different fracture presentations, you can actually identify your approach. And this is a very nice diagram that would enable you to have a good preoperative planning when you have one of these injuries and you're fixing it.
And Alek from osteotomy is something many would do. Although you have to warn the patients and the examiners that you are aware that they might not heal and can be symptomatic. Another good approach, which I prefer, is the trap approach in which I reflect the triceps and Cornelia's medical, and that actually enables me to have very good approach to the distal human and cells, and that would enable us to avoid the osteotomy problems.
Physiotherapy is crucial. Physiotherapy is mandatory for these, and early mobilization is not an option. It is actually. You have to aim for early mobilization at all times and these injuries. Thank you. Brilliant thank you very much, prof.
Imam, for this comprehensive and focused lecture on this dilemma structures. Thank you. It's very interesting how much is really how wide and big this topic is. And you could see how the exam question could go into so many different directions, isn't it? You know, so, so thank you very much for covering this for us. In terms of a point to remember for me which are related to the exam, I would like to comment about when you start seeing these fractures or indeed any other fracture in a trauma situation is good to mention what you said about it.
This structure has a good prognosis or poor prognosis. And I think intra articular comminuted fractures, you could just tell exam straightaway. These fractures carry poor prognosis. And I think that will show the higher order thinking that we should examine that, that you only took the patient from the outset. You're going to explain to them there were the poor prognosis of their injuries and they will be well informed you managing the patient expectations from the outset.
And that's very, very important to the exam. More important than a lot of other, you know, more important, I would say for me, if I'm examiners to know that the candidate is able to tell that the patient is more important than classifications for. And also another point I picked up from you is about, which also shows the higher order thinking is how you explain when you explain your approach.
And if you're saying the surgical plane. You will follow the surgical plane that's been dissected by the fracture. And, you know, you're not just going to use that approach, you know, cooker approach of exactly what you know, if you open up and you find the fracture have dissected another plane for you, then you have that flexibility of moving your approach. Up to that one, and that's also shows the examiner who's done this operation.
You've been there and you're not just regurgitating knowledge, you've actually from the book, you have actually been there. And I think this very, very important point to give you higher marks in the exam. So I keep learning from you every time you know that I'm listening to you. You know, you have all that before, but actually, I think also for those that are not, you know, it's basically it is actually also a reflection of you as a good surgeon because you're doing this exam to demonstrate your surgeon.
So actually, this is real life scenarios. You know, if I break my elbow and I come to any of the candidates hospitals, you know, it's actually in trauma scenarios. You are the one who's going to be doing it. I mean, you a candidate. And you know, like, why would you do? And that's what I'm going to do in my practice if I have a similar injury and we have a lot of these injuries nowadays, so I would always dissect using the same approach is the approach done to me by the trauma itself because it is already done to you.
I've done for you. Absolutely a very good point for us. Excellent point. So we have a question here from Italy is asking if the fracture results in a metaphyseal bone loss in one column. So what would you do with you graft that area or would you shorten the other column to achieve equal columns?
Very, very good point. And I think, you know, it's also based on the four factors I've mentioned fracture geometry, fracture demographics and patient demographics. So you have both options. They lead, you know, in proximal humerus, I tend to do grafting or even bone void fillers, stuff like that, but in distal humerus. In my experience, we don't need to do a lot of this grafting.
If there is metaphysical loss, but what you can do is actually have a longer plate and try to reconstruct it. But if you need, you have also to have plan B in hand and plan C as well. So for any elbow fracture dislocation I have, I'm going to fix. I have an external fixator, which we have on the shelf because I can fix everything at the elbow would be unstable, so I'll take an external fixator in as well.
And also for the Sanchez to lead to 2037 published very good results for the short leg osteotomy. And in this paper, I can share with everyone if needed, but I think it's also have a good indication for when to do that. Also, it's not very common, but you can use that mainly in markedly shorter fractures and especially in open fractures where you are worried about the bone as well quality as a fracture site.
Thank you for explaining that. I think that's all the questions we have, so we can move on to the next section now, which is the secure part. So I will be sharing the polls now. Can you ever imagine, maybe. Do you mind sharing the poll for us? Good, great.
Thank you. So, guys, we have three questions. All the answers are I don't know. I encourage each one of you to attempt. You're not missing anything. Prof Emmanuel at the end go through the answers and explanation as well, so you will have 1 minute. Better question.
That's what actually get in the real exam, I think you get to 1 minute, 10 seconds or so. Um, so please. Answer as soon as you can. And that's just what we're waiting here. Just a reminder that if anyone is interested in taking part in the next section of this teaching session, which is the Viva, please send us a message sent to Hannah or to myself or right on the chat box that you are interested only we have three maximum of three available slots.
They're very useful. We highly, highly recommend that you take part. It's worth It. You get feedback and. You get into the mode of the exam. I know that exam is not until February, but it's good to get ready early.
And she talked to previous candidates who did the exams with regular attenders with us. They found these very useful. So only one more minute to go, guys, so. And start as soon as you can.
So now we have two candidates for the Viva, so only one slot left. If anyone interested, please expressed the interest as soon as you can. So 72% of you guys have attempted to answer, and it's been now 3 and 1/2 minutes. So I think if anyone wants to quickly attempt, please do now, now, otherwise we will end the poll and go to the answers.
OK, we'll end the poll now. It's four minutes. And we'll share the results. Right and we imagine able to share. Yeah here are the results. Can you see the results? Yes, that is great. So do you mind going through the questions and answers, please?
So for first question, the majority has got they have got the right of production, thermal fixation with plating and legs screws through the plate. So there was a couple of biomechanical studies one by corner and one by Stoffel, and they both popularized the concept that, you know, if you use screws or wires and isolation or third floor plates, this is insufficient to allow a active range of motion. And so you cannot really achieve good outcomes with this.
And they actually more biomechanical people have demonstrated that if you do go for parallel plating the good way or the Mayo Clinic way, it might be more stable. Although Zara Baker has been published as well to be by mechanically superior, but more and more are actually in favor of the metal plating. So the best construct here would be if you go for plating and the lag screws through the plate so that you have the columnar support, as well as the leg compression for the second screw.
Also, 38% got it right. So the most common mechanism of injury here is, well, the stress on an extended elbow is the forearm supine, and that's how you are going to fracture the lateral condyle in children presenting with this, and 38% have got this right for the last question. The majority also has got it right where although there was some, Uh, mentioning any other ligament.
So it is really important to have to have full understanding of the lateral collateral ligament as complex because B LCL is the right answer as opposed to lateral collateral ligament is actually not part of it doesn't exist. The other four structures comprise the lateral collateral ligament complex. And if you want to add in some ways, they're also dynamic lateral collateral support, which is provided by the extensor carpi analysis on the supine nature tendons, which provides a secondary dynamic stability and mainly recessed support to the lateral rotators stability there.
So well done, everyone. The majority, you know. So the first question you had 58% got it right and then the second to only 35.38 got it right. Well, well done, everyone. Yeah, good effort, and I think it's an exam as well, there are always two or three answers who are very, very close, and that's not the real exam as well, and that's what we had feedback as well.
So for those who done or going to execute, so it's going to always start, there are two options that are always very close. You have to decide which one is the best or the better answer or the best answer. There could be more than one correct answer. But you have to decide which one is the best. And that's why they're called single best answer, isn't it, because they could be more than one correct answer in, they're lovely, so.
Well done, everyone. Thank you to everyone who attempted to answer this question. Thank you, professor, for going through this and for writing these questions for us. Very, very useful. My pleasure. Lovely thank you very much. Now we move on to the next section of this session, which is the vital components of that.
So we have the first candidate is Mitt Romney, and we have here the pleasure of having Mr Abdul Waheed. Hello All right. Yeah, it's good to see you. Thank you for joining us. Thank you very much. It's a pleasure to have you here.
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Segment:0 .
So good evening, everyone, welcome to this teaching session, organized jointly by orthopedic Research UK and the orthopedic Academy.
The presenter this evening is Professor Mohammad EMOM. He is Professor and consultant, trauma and orthopedic surgeon at Bristol orthopedic center and the University of East London. He is a very keen researcher. He's published extensively and he's also very keen educator. He's been with us and his lectures and teachings are always very well received, so we're very pleased that he accepted our invitation to be with us tonight, and I'm sure we all will learn from a lot from him.
So my name Prasad, now I'll be moderating this session. And with us, we have Hannah and Imogen from the education team of our UK. So the session tonight will include a shoretel very focused lecture on distal humerus fractures. The focus of this lecture this evening is on the FRC exam, so that's the level we will be aiming at. The lecture will be followed by few questions.
This will be from the lecture, so please stay concentrated and you can answer the questions correctly. Following that, obviously, there will be an opportunity for you to ask you questions, so if you have any doubts or any questions you have in mind anything not clear. Please put your questions in the chat box and we will present these questions to prof. Emam at the end.
At the end, at the end of the session, there will be opportunity for those who are interested to take part in the hot seat waiver practice. This section will not be recorded and we encourage everyone who feels that they want to participate to let us through the chat box or raise their hands, or let myself or Hannah our emma-jane on.
Let know that you are interested in taking part in the Viva. So we have only three spaces, maximum three spaces available for that. We understand how the survivor and talk in front of people in this situation can be very stressful. We all been there and we will be as supportive to you as we can. So the aim is for this session overall to be an interactive session.
So please ask your questions and give us your feedback. And if you missed any part of the presentation, don't worry, it will be. It is. It's been recorded and it will be on the orthopedic Academy and on the UK website. Very Uh, shortly. Just a reminder before I hand over to profit, ma'am, that's the remainder of our courses.
So we have our. And mock exam course. The first of its kind in the UK, and we started that last year in September last year, and we are doing two more courses coming up one on the 4th of December and one those 20 second of January to book these courses. These are obviously these courses you. We simulate the real exam going through all the tables and clinical stations as if you are in the real exam all the time and you'll be given some feedback as well and results at the end.
So you could book these courses or UK website. We have other courses your case based discussions, courses on the 11th of December and 15th of January coming up, and these courses are for a very small group of people when you go through around 50 exam specific questions and we give you the answers and we will give you feedback and we give you detailed answers of this ideal answer, basically detailed explanation of the ideal answer.
So it's very useful for those who want to test their ability to answer a question, but they also want to improve their knowledge. OK and we do the same style for our basic sciences course of 29th of January but will be formally focused all day on basic sciences. So it's very good last minute revision. So these courses are on the Academy that code the GKE website.
So without further ado, I will leave you now with prof. Emam to start his teaching session. Over to you. Thank you very much for us, and thank you to the orthopedic Academy and all you for the kind invitation, and Thanks as well for the great work you're doing over a long time actually, which is a great aid for those undertaking the forces exam.
And Thanks for the great introduction. So actually, I'm going to end this presentation. I'm going to talk about distal humerus fractures. We know that distal humerus fractures are very common. They represent actually up to 6% of all other fractures and 10% of all elbow fractures and the court. The Robinson in 2003 is that have published. The number is actually increasing in frequency because the number of elderly individuals continue to grow.
Plus, it is actually now elderly individuals have more active lifestyles compared with before, so it is important for efforts as purposes to understand in trauma stations it is. It is crucial to talk about management and in-depth knowledge is expected in trauma survivors, especially compared with other survivor stations.
Also, to some extent in basic sciences, you need to know a bit more, but you can actually discuss a bit more superficial in the majority of Survivor stations. And actually for any fracture, it's good to understand the goals of any initial evaluation when you're managing and any fracture in real life and in exam scenarios, you have to understand the patterns, the geometry and actually understand the previous symptomatic pathology as well.
Because if you have someone with arthritis of the shoulder and having proximal humeral fracture, possibly the best treatment option would be a shoulder replacement. Also, the same someone elderly with a lot of resistant humerus fracture and arthritis and possibly a total replacement would be the best option. It's crucial to identify neurovascular injuries and soft tissue problems like open fractures.
And so, and for exam purposes, you can assume things. So if you see someone with a limb fracture, you can assume it's an isolated injury intact with intact neurovascular compromise because what you really need to appreciate in the exam is 4 and 1/2 minutes. It's not 5 because usually half a minute is wasted from the previous question or the next question. So this 4 and 1/2 minutes are crucial.
They are very precious minutes for you to utilize properly in order to identify the problem and address. Uh, address what the exam and what the examiners want you to talk about. So in order to understand the distal humerus we have, it is actually a complex structure where the distal end of the humerus is flatter, expanded, transversely and rounded at the end.
You have to understand also the distribution of the articular cartilage, where the posterior aspect of the capitellum has articular cartilage. There is a Downward projection of the cochlea, which is responsible about the carrying angle, which is increased in women. And that's important when you are reconstructing these injuries in real life. You have, we can see here you are.
Also, if you look at the distal humerus in cross section at the level of the fossa of the electron, the two columns on either side of the fossa are dense and strong and offers a good hold for screws. But with the elbow extension, the tip of the electron actually lodges in the olecranon fossa. So that's why when I'm doing this, I have to extend the elbow properly in order to make sure that it's not as the fossa is not blocked by a screw or a plate.
And finally, when you look at the humerus in flexion, you have to appreciate the movement and test it whenever you are addressing these injuries because it's a complex structure. The distal humerus and in the exam, you should highlight these aspects because it demonstrates lateral thinking and actually would enable will differentiate you among the crowd during the exam.
So here, if you look at the shape of the distant humerus, there is 94 to 98 degree angle between the axis of the humerus. It's a red line and the cochlea, which is the orange line, which if you can see it. And then if you look at the medial view of the distal humerus, the medial column, which is all and shear, makes around 10 degrees angulation to the longitudinal humerus and positioning that rocklea slightly in front of the humeral shaft, which is crucial when you are reconstructing these fractures.
And if you look at the lateral view, the lateral column makes around 30 degrees angulation to the humeral axis. Therefore, the capital is positioned in front of the hemodialysis, so both capital and rocklea are positioned anteriorly, which is important to understand. If there is significant communications and combination. Fractions of the distal humerus actually fall into two categories the simple metaphysical type A according to the Mayo and the partial articular type B epicondyle fractures and the former two types also sometimes are part of a more complex injury, such as the dislocation of the elbow.
It is easy to treat, and they are usually associated with good prognosis. Different classifications for the human race is not really sorry, distal humerus fractures is not really needed for the exam, but for extra articular type fractures, you just need to know that this is type and the partial articular type fractures. These are type B and type C are the complete articular fractures according to the molar classification or classification.
So it is actually we feel at from a prognostic point of view. It is more prudent to group fractures around the elbow and to those with good prognosis and those with poor prognosis, and to discuss each type separately, since each has its distinguishing features worthy of mention. Also, the compiler fractures and those with extension into the joint can be grouped together, and this is really important in the exam.
So if you are seeing a fracture with single intra articular extension, you can say it's an intra articular fracture. Are you understand the gravity I one patient about the long and short term sequelae of the fracture, but it might be of good association if you have an impacted fracture. This is also good to understand and we can classify them. According to shatzkin, two fractures with good prognosis and fractures with bad prognosis like an abortion injury would be good prognosis fractures intra articular fractures might be.
Some of them might be always good prognosis, while others might be of bad prognosis. And I didn't find these things initially in the exam demonstrates that you are a safe surgeon. You have mutual discussions with your patients before surgery. You understand your remit and you understand what you're offering to the patient. So you can definitely differentiate between good and bad prognostic factors.
When you are managing these types of injuries and the majority of intra articular fractures, you can actually highlight the gravity of the situation and that demonstrates your safe surgeon. Remember, in the exam you are a day one consultant. You're not a registrar or a fellow who actually says, oh, this is your graph showing so-and-so. You're someone who takes the initiative or demonstrate leadership.
And at any time point is the exam. You should demonstrate lateral thinking. Everything you mention in the exam, any question you ask is actually based on something you want to discuss treatment wise later on. So if you see a bad injury, say loud, it's bad injury. And if you say something that's wrong, retract it. Say sorry, I'd like to retract what I've just said. Actually, so-and-so never.
There is no wrong as there is no right answer, but there are wrong answers. So let's go through different fractions. You can see capitalism fracture, a colonial shared fracture. You can see here the double purple side, which involves the capital and the rocklea, or a combination of both. It is uncommon around maybe 6% of all this that human fractures and 1% of all elbow fractures, but they can be easily missed.
We've noticed recently a progressive increases their incidence. Maybe because we're picking them up now, maybe because we do more CT scans. However, the majority of this will be a follow on outstretched hand, with the elbow partially flexed and the forearm pronation. That's how you snap the capital and have a coronal fracture. So it can also happen if someone has a posterolateral rotator dislocation and you and then it is reducing back because the radial head will have an impact against the capital, as well as the rocklea and paranoid against the capital as the rocklea as well.
So well, I think a fractured only of the capital we actually initially we thought it is only a fraction of the only capital N then were classified, according to Brian Murray, and to these three types. And each of them has a mnemonic. But then Mackey made the modification, saying that actually, if the fraction, which is actually more common than what we used to think, I could only share fractions.
That includes both the capital level rocklea and, of course, four times 3. It will be a more nasty injury. It's that you need to address as well and identify. You don't really need to remember different names on different names for different fractions or different classifications. But if it is better to understand each and highlight that you understand the problem because that will dictate your management because.
Ringtail defined the articular fractions of the distal humerus, noting that these lesions not often not only are grown and shared and both the capital and the cochlea, but they involve as well as the lateral epicondyle or the lateral column. And that involves the posterior part of the truck and the medial epicondyle as well, because of the progression of trauma, doubly in 2006 proposed the name capital of Antioquia fractures because these are very common.
And then they identified a prognostic factor is the prognostic factors that differentiates the treatment. You usually access them. What I would do in the exam, if you have this, you access them through the lateral approach. You can use either the captain or the cooker approach based on the dissection done to you by the fracture itself during the traumatic incident itself. And then I use the lateral collateral ligament sparing approach you take to the bone left all up and then fix these fractures with the screws, Uh, headless screws or sometimes.
And of course, CT scan is mandatory to all these injuries to identify the problem and then which approach to use. That's actually something you can mention in the exam. I'll be sure to come see if I can fix through a cooker LCL preserving approach, but if there is extensive. Expansion of the fracture to the rocklea. You can discuss electron on the cooker tensile approach if it is worse and you can see in type C fractures here at the top image, you can use an ulnar claw osteotomy to manage this and this as you can identify with CT scan.
And if you demonstrate that in the exam you understand these things, you're scoring higher and higher. And as I said, you can fix it with screws like here or biodegradable screws, which is something I started to use myself, which you can mention in the exam, but stick to the standard, which would be the headless screws which you use. This is the type actually when you have an excess tensile capital and rocklea, including the column as well.
And then you can either use the screws, the headless screws to fix it, and which can be enough here, as you can see in this patient. And this is a patient where we fix with four forehead screws for biodegradable screws and reconstructed the ligament as well. There are advantages and disadvantages, but you know, I wouldn't go that far in the exam. Just stick to whatever you want.
This is becoming more and more common nowadays to fix these injuries. You can go through the approach, discuss different options. And of course, if you are worried, I'll always have a low threshold of fixing it with a plate as well. So what about the fractures with poor prognosis or type C fractures in order to prevent stiffness? We have to identify fractures with poor prognosis because.
In all, all very articulate and articular fractures required any active motion that's crucial. Prolonged blustery mobilization leads to irreversible joint stiffness, and that's cannot be fixed. We can we go and do our quick release. We do a bilateral kodom release or over-the-top media release. But still the best option for this patient is to reconstruct the fracture and correct the metaphysical and the physical deformity so that you reduce the stress of the articular cartilage.
Same to what we use in knees for tibial plateau structures can have published many years ago and the similar papers and actually before Chaska surgeon in 1961 said that's a perfect anatomic restoration and perfect freedom of joint movement can be obtained by internal fixations. And so we actually. Even if in the age where they couldn't fix all these fractures and they did have less toys compared with what we have today, they used to marry this by traction and elimination.
So we know for sure that for intra articular fractures, elimination is crucial. And actually, for example, purposes whenever you have an intra articular fraction, you should highlight that immobilization can cause joint stiffness. If you fix it and immobilize it, that actually is associated with worse stiffness. And if you have a depressed articular fragment, you and you cannot reduce by close manipulation, then you wouldn't be able to reduce by Closed means, so you have to open it and reduce it.
And actually, if you have a major depression, it wouldn't fill with fibrous cartilage and instability and displacement that can happen will be permanent. So that's why if these injuries you say my principles is to achieve an anatomic reduction, solid internal fixation that would enable me to achieve early, moderately mobilization and full range of motion.
And that applies to any particular fracture you see as exam. You have to restore the show incongruity. And if you have metaphysical defect, whether it's a proximal humerus, whether it's a temporary plateau or a distal humerus, you can mention that you can actually achieve it by bone grafting in whatever form of bone grafting. And we have to achieve address all displacements, either in the dialysis or the metaphysis in order to prevent the joint overload.
Based on the shatzkin, theory and correction is crucial for joint stability and for their function. Immediate motion is a must and requires solid internal fixation, and that's actually why we are reading all about the mechanics of bone fixation. Different types of healing and that will then you will be able to help all your patients based on long and short their methods.
And that's actually would enable you to address any of these injuries at all time points. So for distal humerus, then what's specific about it in India also intra articular fracture? You can easily say there are factors dictating my decision, and these factors include the patient demographics, the fracture demographics, the degree of displacement as the degree of combination and joint involvement.
These are the four factors that influence all our decisions in any trauma setting. And actually, you can use that slide. In any case, you have what is there is a complex intra articular fracture in the exam. So applying that here, we have to understand again, I repeat there are no right decision in the exam, but there is definitely wrong decisions, wrong fixation missiles.
And that's actually important for the exam. And other important aspects that you need to be discussing in the exam is whether you're going to use parallel or perpendicular fracture construct when you are managing this distal humerus intra articular fractures because there are two different philosophies the orthogonal technique otherwise known as the 99 plating or perpendicular plating. And that's what the aorta supports, which which simply consists of placing two plates at 90 degrees angle to 1 another, with the lateral plate placed on the plate along the posterior aspect of the lateral column, and the medial plate applied to the medial ridge.
While the parallel plating was popularized by Sean O'Driscoll from Mayo clinic in 2005 and then Sanchez, who need to publish the who's also Mayo clinic in 2007. And they said that, you know, this is actually more biomechanical superior as each plate is actually rotated slightly, one towards the other in the sagittal plane and the angle between them is 150, 160 degrees. And the orientation would permit to limit soft tissue detachment of supposed to lateral side and insert by cortical screws from both sides, actually.
And the evidence has been contradictory, and there is different evidence supporting each of these two. But you can just stick to one way or another and support whatever you feel appropriate for me. I would opt for one of these two based on the fracture configuration some fractures. It's better to fix them using the principles the other ones would be based. It would be better to fix them through the parallel technique, and that's based on fracture geometry and morphology, as discussed earlier.
Whenever you are aiming to fix this, you have to achieve a commands. The first thing is you have to maximize it. This is actually more a clinical steps than exam wise. But if I'm here, I'm going to tell you this each screw should pass through the plate, which is crucial if you can. Of course, you can do screws outside the plate if you have to, but I would aim for that as much as I can.
I would aim to maximize the fixation in the distal fragment as much as I can, and the applied through compression as slap lesion Taylor level. Each screw you using should engage a fragment on the opposite side that's also fixed by the plate, which would be ideal. We're talking about ideal scenarios here, and adequate number of screws should be placed in the distance.
Fragment, as I said, and schools should be as long as possible, avoid screws, including the ulnar claw fossa. And they should lock together by Interdigital, creating a fixed angle structure and linking the columns together. This is also crucial. You have also the place should be applied. So that compression is achieved as the supercooled dialogue level for both columns and plates should be strong enough and by mechanically stiff enough to avoid breaking and bending.
And that's if you follow this. The chances of you having problems is actually low. And this was also mentioned before Sanchez to need to mention the shortening osteotomy, which you can achieve without a problem. This is a paper published in 2007, which this is another option. Also, one important thing you have to understand that if you have an elderly fracture with this problem, Makeda Allen 2009 highlighted a total elbow implant with substitution or a heavy plastic can be an excellent option and is associated with significant improvement.
And we started seeing a lot of not a lot, but more presentations like this where I showed a total elbow replacement is actually the best option. So that's something to keep in mind if you have a patient with this problem. A total and acute total elbow replacement is not a bad option for some elderly, low demand patients. And obviously, if you're mentioning that, you can mention the guest saying that this should be done in specific centers.
And gerth has highlighted these centers in each have identified these centers in each region. There are different constructs, different techniques in fixing these, but all what you need for the exam is to try to identify the biomechanical demands, identifies the biomechanical aspects of each of these and certain fractures. You have to identify if there is a super epicondyle fracture plus an intra articular fracture, and then you can address both problems because if you have a microfracture or supracondylar fracture and the fracture is large enough to allow for stable fixation, then you have to fix it.
And the exposure to European would be lateral with the fixation from posterior aspect or other ways. This is based on the presentation. There is newer, you know, now there is some trend into doing ascorbic assisted technique. I don't think you need to mention that in the exam unless it is a case, actually. Clearly the musc option colloid Canaanite fractions can be also addressed if you're doing arthroscopy and fix it, and you have to identify distal fractures in association with complex intra articular distal humerus fractures position when you are going through your technique.
You have to tell your approach as if you're telling a story. And every time I give a talk, I mention that because one of the most boring bits is actually telling approach. The way is intramural playing intra intramuscular plate. All that stuff. I'll positions the patients so and so I'll have the head away from the anesthetic machine. I'll have to see arm coming from the top.
I'll make sure there is a good access to the elbow before prepping and taping, because that's also the mistake lateral thinking and give the examiners the confidence that you are a surgeon who has done that before and you are a safe surgeon who knows what they are talking about. You will mention whether you're going to do an electron osteotomy for complex intra articular fractions.
You have to mention how you're going to do it and what's there and what you are going to do in advance, which will enable them to make sure you have a clear preoperative plan and you outline what you're going to do. I just got proposed and the sequence of fixing this many years ago. You can say whatever you would in this regards. You can also say you can make sure you have a plan whenever you are fixing this and converting multiple fragments into smaller number of fragments into two fragments and fix the joint first and then fix the distal fragment to the proximal fragment.
These are all technical bits you can mesh so that you can mention while doing the exam while. The exam always mentions you are going to identify the ulnar nerve first, and based on different classification, a different fracture presentations, you can actually identify your approach. And this is a very nice diagram that would enable you to have a good preoperative planning when you have one of these injuries and you're fixing it.
And Alek from osteotomy is something many would do. Although you have to warn the patients and the examiners that you are aware that they might not heal and can be symptomatic. Another good approach, which I prefer, is the trap approach in which I reflect the triceps and Cornelia's medical, and that actually enables me to have very good approach to the distal human and cells, and that would enable us to avoid the osteotomy problems.
Physiotherapy is crucial. Physiotherapy is mandatory for these, and early mobilization is not an option. It is actually. You have to aim for early mobilization at all times and these injuries. Thank you. Brilliant thank you very much, prof.
Imam, for this comprehensive and focused lecture on this dilemma structures. Thank you. It's very interesting how much is really how wide and big this topic is. And you could see how the exam question could go into so many different directions, isn't it? You know, so, so thank you very much for covering this for us. In terms of a point to remember for me which are related to the exam, I would like to comment about when you start seeing these fractures or indeed any other fracture in a trauma situation is good to mention what you said about it.
This structure has a good prognosis or poor prognosis. And I think intra articular comminuted fractures, you could just tell exam straightaway. These fractures carry poor prognosis. And I think that will show the higher order thinking that we should examine that, that you only took the patient from the outset. You're going to explain to them there were the poor prognosis of their injuries and they will be well informed you managing the patient expectations from the outset.
And that's very, very important to the exam. More important than a lot of other, you know, more important, I would say for me, if I'm examiners to know that the candidate is able to tell that the patient is more important than classifications for. And also another point I picked up from you is about, which also shows the higher order thinking is how you explain when you explain your approach.
And if you're saying the surgical plane. You will follow the surgical plane that's been dissected by the fracture. And, you know, you're not just going to use that approach, you know, cooker approach of exactly what you know, if you open up and you find the fracture have dissected another plane for you, then you have that flexibility of moving your approach. Up to that one, and that's also shows the examiner who's done this operation.
You've been there and you're not just regurgitating knowledge, you've actually from the book, you have actually been there. And I think this very, very important point to give you higher marks in the exam. So I keep learning from you every time you know that I'm listening to you. You know, you have all that before, but actually, I think also for those that are not, you know, it's basically it is actually also a reflection of you as a good surgeon because you're doing this exam to demonstrate your surgeon.
So actually, this is real life scenarios. You know, if I break my elbow and I come to any of the candidates hospitals, you know, it's actually in trauma scenarios. You are the one who's going to be doing it. I mean, you a candidate. And you know, like, why would you do? And that's what I'm going to do in my practice if I have a similar injury and we have a lot of these injuries nowadays, so I would always dissect using the same approach is the approach done to me by the trauma itself because it is already done to you.
I've done for you. Absolutely a very good point for us. Excellent point. So we have a question here from Italy is asking if the fracture results in a metaphyseal bone loss in one column. So what would you do with you graft that area or would you shorten the other column to achieve equal columns?
Very, very good point. And I think, you know, it's also based on the four factors I've mentioned fracture geometry, fracture demographics and patient demographics. So you have both options. They lead, you know, in proximal humerus, I tend to do grafting or even bone void fillers, stuff like that, but in distal humerus. In my experience, we don't need to do a lot of this grafting.
If there is metaphysical loss, but what you can do is actually have a longer plate and try to reconstruct it. But if you need, you have also to have plan B in hand and plan C as well. So for any elbow fracture dislocation I have, I'm going to fix. I have an external fixator, which we have on the shelf because I can fix everything at the elbow would be unstable, so I'll take an external fixator in as well.
And also for the Sanchez to lead to 2037 published very good results for the short leg osteotomy. And in this paper, I can share with everyone if needed, but I think it's also have a good indication for when to do that. Also, it's not very common, but you can use that mainly in markedly shorter fractures and especially in open fractures where you are worried about the bone as well quality as a fracture site.
Thank you for explaining that. I think that's all the questions we have, so we can move on to the next section now, which is the secure part. So I will be sharing the polls now. Can you ever imagine, maybe. Do you mind sharing the poll for us? Good, great.
Thank you. So, guys, we have three questions. All the answers are I don't know. I encourage each one of you to attempt. You're not missing anything. Prof Emmanuel at the end go through the answers and explanation as well, so you will have 1 minute. Better question.
That's what actually get in the real exam, I think you get to 1 minute, 10 seconds or so. Um, so please. Answer as soon as you can. And that's just what we're waiting here. Just a reminder that if anyone is interested in taking part in the next section of this teaching session, which is the Viva, please send us a message sent to Hannah or to myself or right on the chat box that you are interested only we have three maximum of three available slots.
They're very useful. We highly, highly recommend that you take part. It's worth It. You get feedback and. You get into the mode of the exam. I know that exam is not until February, but it's good to get ready early.
And she talked to previous candidates who did the exams with regular attenders with us. They found these very useful. So only one more minute to go, guys, so. And start as soon as you can.
So now we have two candidates for the Viva, so only one slot left. If anyone interested, please expressed the interest as soon as you can. So 72% of you guys have attempted to answer, and it's been now 3 and 1/2 minutes. So I think if anyone wants to quickly attempt, please do now, now, otherwise we will end the poll and go to the answers.
OK, we'll end the poll now. It's four minutes. And we'll share the results. Right and we imagine able to share. Yeah here are the results. Can you see the results? Yes, that is great. So do you mind going through the questions and answers, please?
So for first question, the majority has got they have got the right of production, thermal fixation with plating and legs screws through the plate. So there was a couple of biomechanical studies one by corner and one by Stoffel, and they both popularized the concept that, you know, if you use screws or wires and isolation or third floor plates, this is insufficient to allow a active range of motion. And so you cannot really achieve good outcomes with this.
And they actually more biomechanical people have demonstrated that if you do go for parallel plating the good way or the Mayo Clinic way, it might be more stable. Although Zara Baker has been published as well to be by mechanically superior, but more and more are actually in favor of the metal plating. So the best construct here would be if you go for plating and the lag screws through the plate so that you have the columnar support, as well as the leg compression for the second screw.
Also, 38% got it right. So the most common mechanism of injury here is, well, the stress on an extended elbow is the forearm supine, and that's how you are going to fracture the lateral condyle in children presenting with this, and 38% have got this right for the last question. The majority also has got it right where although there was some, Uh, mentioning any other ligament.
So it is really important to have to have full understanding of the lateral collateral ligament as complex because B LCL is the right answer as opposed to lateral collateral ligament is actually not part of it doesn't exist. The other four structures comprise the lateral collateral ligament complex. And if you want to add in some ways, they're also dynamic lateral collateral support, which is provided by the extensor carpi analysis on the supine nature tendons, which provides a secondary dynamic stability and mainly recessed support to the lateral rotators stability there.
So well done, everyone. The majority, you know. So the first question you had 58% got it right and then the second to only 35.38 got it right. Well, well done, everyone. Yeah, good effort, and I think it's an exam as well, there are always two or three answers who are very, very close, and that's not the real exam as well, and that's what we had feedback as well.
So for those who done or going to execute, so it's going to always start, there are two options that are always very close. You have to decide which one is the best or the better answer or the best answer. There could be more than one correct answer. But you have to decide which one is the best. And that's why they're called single best answer, isn't it, because they could be more than one correct answer in, they're lovely, so.
Well done, everyone. Thank you to everyone who attempted to answer this question. Thank you, professor, for going through this and for writing these questions for us. Very, very useful. My pleasure. Lovely thank you very much. Now we move on to the next section of this session, which is the vital components of that.
So we have the first candidate is Mitt Romney, and we have here the pleasure of having Mr Abdul Waheed. Hello All right. Yeah, it's good to see you. Thank you for joining us. Thank you very much. It's a pleasure to have you here.
But
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The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
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Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
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