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Fractures of the Humerus for the FRCS
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Fractures of the Humerus for the FRCS
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Language: EN.
Segment:0 .
Good evening, everyone, and welcome to our teaching session on nothing funny about the humerus fractures, which is a combined session with OK. My name is Nikki Evans and I'll be co-hosting with Imogen and Hannah from OR UK and Joe, one of our mentors.
So this is the timetable for this evening. The presentation will be split into three parts, so the proximal part of the humerus, the shaft of the humerus and the distal part of the humerus. And we'll have space for two or three questions in between each segment. So if you write your questions in the chat box as soon as you want to, then Joe will keep an eye and ask those particular questions at the end of each segment will probably fit in about two or three questions for each segment.
OK, so we'll then move on to some polling and I think Mr. can do some polling throughout the lecture as well, which we'd like you all to participate in. Of course it's anonymous. Then we'll move on to this discussion and top tips for the Fox. We will be recording this lecture and the questions, so if you missed any part of it, don't panic.
It is recorded and it will be available on the Fox mentor YouTube channel and our UK websites in due course. If you would like to participate in one of the survivors, we ask that you get in touch with Hannah as soon as you decide that you want to so that we can schedule it will do as many as we have time for. We realized that this is quite intimidating putting yourself forward, but it's the best way to learn.
And you can rest assured that both Joe and I have been through this multiple times in your shoes. At this stage, I'd also say there's quite a few viable practice courses between ourselves and our UK, which you can find on the websites. As always, we recommend our study guide cancel orthopedic notes. This has been written by our mentors and our UK have is excellent books, which I used for my own exam.
Following the presentation this evening, imaging will be taught you regarding feedback and we really appreciate your input to help us improve these sessions. CPD certification is also available from our UK. If you contact with you. OK, so this evening, we're privileged to welcome Mr. Neil Kang, the consultant orthopedic surgeon at Cambridge University Hospitals NHS Foundation Trust.
Mr Kang combines his full time clinical work with educational activities and is a convener and faculty on multiple regional and national courses. He is keen on the clinical application of basic science and Orthopedics. As you all know, one of our mentors, one hinari, is also director of education for the East of England higher surgical training, rotation and trauma clinics, as well as associate lecturer for the School of clinical medicine in Cambridge and a member of the shoulder board.
I'm sure we're all going to learn a lot from this evening. So without further ado, I will pass you over to Mr. Neil King. Thank you. Thank you very much, KneeKG. I'm going to share my screen. Right so three parts to the talk today. First part, let's go for it, proximal humeral fractures, and hopefully you'll see that there are themes in common with all of today's talks.
Firstly, decisions and incisions. Secondly, pattern recognition. And thirdly, a few technical tips that will hopefully help you manage these better. Starting off with our proximal humeral fractures, what kind of decisions and decisions do we have to make? Well, here we have a class example of what presents at the beginning of COVID in lockdown 1 March 2020.
What would you do with this or what would you recommend for this patient? Well, because of COVID and the pandemic, much of our decision making was challenged and we had to use non operative methods and in fact, it did go on to heal. But as you can see, it didn't heal very well, and unsurprisingly, she didn't have a great result. So decision number one is always going to be.
Are you going to operate or not operate? And this is going to be multifactorial depending on the amount of displacement, the number of fragments and also the fitness for surgery of the patients. But ultimately, it will be a shared decision between you and the patient. So another example of pre-covid management, you can see here a three part fracture with the greater tuberosity and the neck.
And this one went on to do healed, just as you would expect and much better movement and less pain than the first example. So this play did give an idea of how well we're going to do. But if you are going to go for non operative, then I would recommend that you are aggressive with your physiotherapy and that you make sure that they do get good physiotherapy. There are some videos on the Cambridge University Hospital's website for and at different stages, as demonstrated here by my physiotherapist Laura.
And if you get the patients engage with those on, then the outcome usually is better. And that's what we probably found from the paper, which will come across later. So here's another example smashed up for Part proximal humeral fracture. In a '51 year old hair, this is a slightly older patient, 80 years old, completely displaced. And then a young person, 48, and you can see that the head is unsub coracoid, so quite a variety of scenarios that you could be presented with in the exam and in real life, which is more important, isn't it?
Because if you face these in real life and know how to deal with them in real life, then the exam will be a breeze. First, the paper that I want you to think about is this one from the Edinburgh group and Clement Gentile in the bone and Joint Journal in 2014. And basically the 10% mortality at one year. This is a sentinel fracture. Basically, it's another one of those fragility fractures that social the, you know, the patient is just at the tip of the iceberg and you have to treat these with care and understand their whole medical problems before jumping in and operating.
Next question will come up in the exams, probably classifications in the exams itself. Classification systems aren't required, but if you are going to classify it, what classification can we use for the proximal humerus? Everyone knows about nia's classification, the two three four part fractures and whether they are associated with the fracture dislocation or not.
Now, the mayor's paper talked about the degree of displacement, and it should be a centimeter and greater than 45 degrees of angulation if it is to be classified as a displaced part. And you got this awesome team from Imperial College and St Mary's hospital, Professor Roger Emory and Ralph Hertel, a famous shoulder surgeon from Switzerland, got together and they published a paper looking at the different classification systems and observe the variability between people reading the classification.
And guess what? They found that it was crap between everyone out, between all the classification systems. So even if you've got the fancy Hertel binary LEGO model, it doesn't really correlate to a good classification system. And so I would just stick to the simple nears two three four part fracture dislocation system. Next question what is the blood supply and which is the predominant blood supply to the humeral head?
We are all familiar with, we're all familiar with the anterior humoral so complex artery, and the archaeal artery climbs up the lateral edge of the bicep to groove with the longer the biceps. But that is not the predominant artery. Brooks Chris Brooks from when he was working at guy's and Tommy's, published this in 1993, and he found that the posterior branch posterior humerus complex was the predominant branch congenital thought, a similar or a similar thing that because Avorn is rare and the PHC is minimally disrupted in most fractures.
It is the predominant blood supply to the humeral head. If you need more evidence, there's a kind of studies using MRI and sico. Nearly 2/3 of the head was applied by the posterior humerus and artery. Next question that might come up in the Fox's how can you predict whether the humeral head will survive and/or will it go on to even? And so hurtle that surgeon and Swiss surgeon that I mentioned earlier with the classification system and the binary LEGO model?
Well, he did an intraoperatively study. So all those fractures that he was fixing, he drilled and then put on a Doppler ultrasound to check the blood flow and found that those patients that had a medial calcar segment less than 8 millimeters. So that's the head fragment. And if the cow calf fragment where I'm pointing my cursor is less than 8 millimeters or there was more than 2 millimeters of medial hinge disruption.
Then there was a higher rate of ischemia. However, his junior followed up those same patients and published the results of their fixation, and they found that although the ischemic heads were all the other, the heads were ischemic intraoperatively only 80 percent, 80% of them survived, so they deemed that fixation is worth considering, even if they've got the hurtles ischemic predictors.
So decision two, should we fix or should we replace? Can I ask Coldplay to help us with this? And if you are going to go for a fixation replacement, then which approach and that's decision 3 on the tree and to help you because common question for the exam is that what is the Delta to approach or maybe even the Delta in split?
These videos are both available for you to view after this course on Cambridge orthopedics YouTube channel, courtesy of my mate Lee. So if we're going to fix, should we fix? Well, proffer was is the largest randomized controlled trial in the world about fixation versus non operative treatment with aggressive physiotherapy.
Remember that aggressive physiotherapy because lots of patients get referred to physiotherapy and they don't do anything? And what was the outcome of proffer? Well, it basically demonstrated that there was no difference in the outcome, which the primary outcome was the Oxford Shoulder score at 112 months. So 24 months.
Once again. If you want a Fuller appraisal of the paper, one of the alumni from the East of England or the rotation arm and mosaddegh has designed a little video and it's on our website, which you can see at the bottom there. Eoa or. So in the paper, you can see that the vast majority were fixed, but there was a small percentage that went on to have hemiarthroplasty during the operation.
So it was a bit of a heterogeneous study and that's why it's called a pragmatic trial. And they found that the study of operative versus non operative treatment patients at all time points, including in this paper at 5 years, were pretty much the same. So this graph shows it all really. Look at the Oxford Shoulder score. Look at the different time points.
OK, non operative had a non statistically significant difference at six months by, but by one year, it was pretty much the same. And you can tell all your patients that if you fracture your proximal humerus that you'll continue to improve up to about four years after the injury, whether you have surgery or not. And then is there other evidence besides the proffer trial? Yes, definitely.
There's loads of trials in our own subspecialty journal Jesus in 2011 and general orthopedic trauma and showed no difference between whether it was an RF and non-op or hemi and non-op. so Basement Jaxx are asking, where's your header? What are you going to do with this case? That what approach are you going to take?
So you've already heard about the Delta petrol and the deltoid. Think about it, which one will give you better access to this and also. What other things do you have to contemplate? Well, if you look at that fracture, it's stuck under that coracoid. So my preference would be in a delta petrol approach from the front, obviously, and then you can perform a coracoid osteotomy because otherwise it's going to be nigh impossible to get that humeral head disengage from the anterior glenoid.
Then temporarily stabilize the humeral head to the glenoid. Use your bicep2 groove to line up the plate. Put in several screws and use sutures through the rotator cuff to grab hold of the tuberosity fragments and make sure that the plate is below the level of the greater tuberosity below the height of the Great tuberosity so that it doesn't impinge first. Screws should normally be the locking screw at the straight, a non locking screws to the shaft and then locking screws through the head, especially at the bottom for the raft and the calcar screws.
Make sure none of the screws penetrate the articular surface. And here's a quick summary of what we've just said. Decision for shall we go for a reverse or a hemi? Well, that's pretty much tribal, as Frankie Goes to Hollywood would tell us. And what happens if you do a hemi arthroplasty? Well, like the British weather, it is pretty unpredictable.
And despite using a vipers orgy of sutures, as you can see demonstrated here in this technique, there is still only a 75% tuberosity healing rate. Here's another example of a proximal human fracture that went on to a hemi arthroplasty, and you can see the tuberosity well reduced to the implant. But now, six months down the line, where's it gone? It's vanished, so people decided that reverse shoulders might be the way forward for trauma, given that you don't need to rely on the tuberosity.
And before the NJR reports were available, there were some equivocal evidence about using a reverse shoulder. And you can see from this recent NJR report that of 4,000 cases used for trauma. 2000 were for reverse shoulder compared to 1,100 with a human or hemi. So it's definitely in Vogue.
What are the revision rates for replacements following trauma? And we can see the blue line, which is trauma is rising and diverging away from the elective rates of revision. So that's a concerning feature. And here you can see the mortality figures. So pick your winners, is my suggestion to you. The purple line here is actually the acute trauma, and that shows that mortality rises significantly more than those that have shoulder replacements for elective care.
So do you take care in choosing your patients? So what are we going to do next? Well, you've heard about proffer there is proffer to ongoing. So if you're coming up to the exam, you would want to quote that we are looking at around the UK in another multicenter, randomized controlled trial at the use of hemiarthroplasty versus reverse hemiarthroplasty and also a cohort of nonsurgical patients in those patients aged 65 and over.
And for those of you who need to get an audit completed, don't miss out on famous C19, which is looking at retrospectively those patients that were treated with proximal humeral fractures back in the first lockdown. And that's another trial that's come out from York and am Rangan. And you can see the contact details there if you want to get involved.
So enough talking from me, I want to know what you think and learn from you. So I'm going to put up a poll and what I'd like you to do is tell me what you would do for these cases. Just trying to find the poll so. Would you a. No, not treat this, for part, displaced fracture.
And just move it, would you be? Fix with a plate C fix with a nail D replace with a hemi E replace with a reverse. So I'm going to end that poll now because we've got lots of polls and decisions coming up, and it's great to see so much activity. Just give you two more seconds. Good OK, so I'll share the results and the vast majority view 3/4 would like to replace this with the reverse.
OK and. A smaller majority would fix it with a plane, which is perfectly reasonable, but make sure you discuss the results with the air, discussed all options in a shared fashion with the patient. And hopefully that's what you will take away from this talk at all. All options are viable, but you need to share that discussion with the patient.
Next example. So 48-year-old fit and healthy patient who has sustained this four part fracture. And what are you going to do? So are you going to a fix it with a plate? That's right. A non operatively treat it and move it, be fix it with a plate C fix it with a nail D replace with a hemi E replace with a reverse.
So some rapid answers coming in, and I'm going to stop the poll there, and I'm going to share it. And once again, a 3/4 majority for fixing this with the plate and be replaced with a hemi, that's not a bad shell. And I'll show you why. So if you needed a CT scan to show you where the fragments were, then there it is.
So you can see that there's been lots of screws to fix that. And a coracoid osteotomy, you can see the fixation there and then what happened? Well, 18 months down the line, it all died away, so ischemic predictor. Definitely and maybe that hemi was a better shell straight off. Ironically, that patient actually, once they had metz-werke removed because he's not a manual labor.
He was pretty pragmatic and doesn't want and hasn't wanted any surgery since. Next up, so this fracture going to show you the next slide as well. Because I think it will be helpful for you. And then let's get your thoughts on whether what you would like to do with this one. So would you a non operatively treat it and move it, be fix it with a plate c, fix it with a nail D replace with a hemi E replaced with reverse.
Cool OK. It's rather mixed bag this time. I'm going to share the results with you and. Just under 2/3 would fix it with a plate. And then, as I say, a bit of a mixture between non operatively treat it and replace with a hemi. But all options were used, really?
This one, I just want to highlight on the. The reason I showed you the CT is you can see that it's actually dislocated out the back. And so this required an open reduction and in my hands, a fixation. But you could have nailed it. You could have just reduced it open and see if there was much displacement, if there wasn't much displacement, then you could treat it without any metal work as well.
So all options are open. Another one. So let's see if proffer has had any bearing on your stance on the management of fractures. Here we go. So in this? Essentially, three part Vegas impacted fracture. Would you not optimally treat it and move it? Fix it with a plate, fix it with a nail, replace with a hemi or replace it with a reverse.
So it's. Looking good, it's going to end the poll there, give you share the results with you. So you all know what each other's is doing. And you can see a lot more of you would treat this non operatively. And I think that's a perfectly sensible suggestion. A few of you would fix this with the plate, which in a 65-year-old female is perhaps what Prosser was trying to say is the results are no better than non-operated treating it, and a few of you would also treat it with a hemiarthroplasty and couple with a reverse.
So let's see. What did I do? This was a few years ago before proffer, and you can see this is one I replaced with a hemiarthroplasty and the tuberosity did heal, so got a bit lucky there. So in summary, there's going to be an increasing burden of these humeral head fracture, proximal human fractures and 10% will be likely to die within a year.
Shared decision making is key, and non operative treatment is best for most. And if you are going to use non-addictive treatment, be aggressive and use the physiotherapy as the proper regimen. I'm going to stop there and ask if there's any questions. Hello yeah, thank you, Neal, for the proximal humeral token. Yeah, there is a couple of questions, so I think someone was a little bit, you know?
Is there any Black and white in either to fix versus to replace? It's this is that's the beauty of upper limb surgery. Yes, it's all about sharing all the, you know, all the evidence that you have your experience. It's as you will come across in the next couple of lectures. In cases, it's terrible what you've been brought up with, whether you use a nail or a plate, whether you use delta petrol approach, whether you use deltoid split approach, all these things.
There is no binary evidence that Black and white evidence that you should do whatever you whichever way. Sorry. OK. So you don't have, you know, like decision. What helps you in deciding whether either? Yeah so since there's something called the Hawthorne effect where when you've been observed, you change your practice, and that's certainly something that was observed during the profit trial.
And as a trainee myself, I was very keen to operate on everything and fix everything. But I didn't have the blessing of being able to look after those patients in the longer term. And now, as a consultant of nearly nine years, it's have that luxury that you can follow up your patients. And so everything is to talk to at length about the different options, and it's just what the patient wants, really.
You know, after discussion with yourself, you know, you have the experience, you have the knowledge, but what you don't have is what that patient wants. And that's so the take-home message is just take your time and make sure you discuss everything in detail with the patients. And that's the best way to get the outcome. Best outcome?
Thank you. And how to measure the medial Kessler or the hinge on the X-ray. So it was less than 8 millimeters. So if, Uh, is it from the articular surface, the medial articular surface? So actually, here you are. There is. Can you see on my screen now?
Yes, I'm sure you can see that there is a nice bit of calcar and actually that probably does measure about. Six to eight millimeters, so this would be quite borderline, but remember that they themselves published the results later down the line and showed that those ischemic predictors don't mean anything. Yes Yes. Yeah good.
Thank you very much. That concludes the questions for the proximal humerus. OK right? Less without further ado, get onto the shaft and. I mean, by the way, if anybody wants to send CBDS, I'm happy to fill those out as well. Not only do you get excellent training for your mock exams, but we can give you case based discussions as well to validate if you want to hear more sharp fractures.
So same pattern. It's all about the decisions and incisions and pattern recognition, with a few technical tips thrown in. So here was a throwaway comment by bola all the fractures of the long bones human skull fractures are the most benign. Well, let's have a look. Why are they benign? Well, because we can tolerate great disturbances of the alignment of the fractures.
We don't need to walk on our arms, and our shoulder and elbows have a large range of motion that can compensate for those fractures that may be more United. My mate, Graham Tilley, strong in Edinburgh, once again, published this paper in 98 about the epidemiology of the human fractures, and you can see that pattern again. There's a low energy state that high energy in young adult males and low energy fragility fractures in females, we choose a theme of humor or sharp humor practically.
So let's get you engaged straight away. Paul Warren here's a fracture that's been referred to you whilst you're in A&E. What are you going to do? Are you going to a put this patient into a collar and cuff for gravity, B put it into a sling for support? C put it into an above elbow hanging cast. D put it into a class brace, including the shoulder and elbow, or E put it into a humerus brace straight away.
So we've got a few. Lots of answers coming in. And slowing down now, so I'm going to end the poll, share the results with you. And you can see 50% would put this straight into a human race. A few would put it into a cast brace, including the shoulder and elbow, and others would put it into a collar and cuff for gravity.
So what would I do this one? I definitely would put into a humoral brace in. And what am I going to tell them? Well, I'm going to tell them that it's going to take about three to four months for that fracture to heal. Not that typical six weeks, the arbitrary unit of time in orthopedics. And I'm going to tell them that they may have a stiff shoulder and may have a stiff elbow as well because of the time spent within when the humoral brace.
We can put them in that brace straightaway. As I say, just going back to that mid shaft humoral fracture, three parts minimally displaced. What would you tell them about the healing? That's right. So going to relaunch, let's go back. We launch a poll.
This type of fracture heals in 90 greater than 95% B, this type of fracture heals in six weeks. See, this type of fracture heals in four months. D we need to see you every week in clinic for six weeks. E! physiotherapy will not help you. So get it in the poll there.
And you can see 60% going for c, and that's the one correct answer that I would give here that this type of fracture heals within about four months. That's what I would tell my patients or the others are not what I would tell my patients. And you can see here that first example I gave you even at three months later, it's still not quite healed. It's got some bridging callus there.
And then by 6 months, though, it's healed suddenly. Although it's a bit undulated, it's not causing them any problems. So the bracing regimen, you can brace them immediately. You should then see them in shoulder fracture clinic to or whichever fracture clinic to teach them and their friends or next of kin about brace hygiene demonstrate the exercises for hand, wrist, elbow and shoulder and see them again, if they've decided on non operative treatment.
Following a discussion with you and a shared decision, then they should be prepared to be in this for about three months. And it's probably not worthwhile bringing them back every week for an X-ray. And then you can see here it may take up to six months for them to have an X-ray that shows that it has completely healed. So next question from the farces examiner how does the brace work?
Well, Thanks to queen, it's remember that it was under pressure. Is hydrostatic pressure compressing the muscles around the fractured bones, helping to align them? When is a brace contraindicated? If there's massive soft tissue loss, if it's an unreliable patient and if there's a big fracture gap because there's an increased risk nonunion here, we have an example of when we might use it under pressure.
Sarmiento published his results of 900 patients used that had to brace used, but only 565 actually had follow up radiograph, so quite a high dropout rate and the mean to union, you can see that was about three months, but quite a range up to 22 weeks. And he also used it in open fracture, so gunshot wounds as well. And he reckoned there were no infections and quite a high union rate of 94% What about modern day studies looking at that?
Because that was the one man band of sarmiento? Well, my friends into the strong and Lee Van rensburg at Cambridge published this paper in 2015, and they found that anatomy matters that if you're trying to heal a proximal, you're more proximal third humeral shaft fracture that 3/4 will heal in a brace. 90% will heal an abrasive. It's the middle third, and if it's the distal third.
85% will heal. So these are quite useful figures for you to discuss with your patients. So toll to is the hair of the radiographs a very healthy non-smoker? And what would you do for this? Just bring it up in the poll. Would you put them into a collar and cuff for gravity?
Would you put it into a sling for support? Would you put them into an above elbow hanging cast? A cast brace, including shoulder and elbow or into a humeral brace. Just give you 5 more seconds. Quite a few still flying in. OK, let's share the results and mixed back, so.
Mixture, probably between putting it in an above elbow hanging cast and humeral brace. So a third of you human race slightly less than last time. And let's see what we did. US being Cambridge, we put a brace. And you can see even braces can have complications. This guy had a problem with the reaction to the brace.
For some reason, lots of people have problems with hygiene in the armpit and auxiliary issues. But this guy was particularly allergic and he didn't comply very well with the brace. And you can see there's quite a fracture gap that appeared now and then. Three months later, you can see that he's been abducting his shoulder because it's now angular. So are you going to change your plan now?
What are you going to say to the patient? You can imagine that I had the full Frank discussion, went through the options with him and decided in a shared fashion to go with an operation. But which approach would you take if you were going to operate on this patient? So option a, would you use a posterior approach? Option b, would you use a lateral c, a D extended deltopectoral E and trilateral?
And I'm assuming that we're plating and not nailing. So give you another couple of seconds, and it looks like most of you. Finish answering, and you can see that. 41% of you would go for a posterior approach. That's cool. That's a very generalized universal approach to this fracture.
And I personally go for an anterior approach, and there's no right or wrong for whichever you use, because what we will find is that this friend, the radial nerve, will be wherever, whichever approach that we choose. And you just have to be comfortable finding that approach that you can be safe with the radial nerve. If you are using the anterior or Antrel lateral approach, a little tip on how to find that radial nerve is was given by an elbow surgeon called Stanley from Sheffield.
And if you put the patient's Hand's breadth above the lateral epicondyle, then the nerve is usually there, coming out between breaking loose and breaking radiators. So here we have another example a slightly more complicated and a more proximal third fracture. So what would you do for this patient? Are you going to put them into a collar and cuff for gravity into a sling for support above elbow hanging cast?
Cast, brace or humor or brace? OK, I'm going to end the poll that far more of you would put them into a human race straight off, and I think that's fair enough. And then. What are you going to have a discussion with these in the clinic? Well, you remember at that paper from Cambridge, which showed that 75% of fractures healed if they were in the proximal third within the human race.
And then the patient decides, OK, I'm not going to take that. I want to have an operation. So which approach are you going to take for that proximal third fracture? Are you going to stick with the posterior and a.? Are you going to go lateral with b? You're going to go with CD an extended delta petrol E an anterolateral.
We've got a consensus here. I'm going to end the poll on that consensus, nearly 70% would do option d, which is an extended delta petrol. I think that's a very sensible. All of these. Approaches, you need to be aware of the radial nerve, and that's the extended delta petrol approach that I used. Note that there are lots of separate lag screws to help share the strain of the fracture.
Otherwise, you may get on go on to a nonunion the next. Another common question for the folks what do we do with a humeral shaft fracture with a risk drop or a radial nerve palsy? And here we have options a which is. Recommend a brace for six weeks, so this happened at the time of the fracture. Brace for six weeks and see if the nerve recovers. B offer immediate operation, quickly nailing C. C in the clinic in three weeks and check tonsils and imgs D offer immediate operation plating be put into a humoral brace.
This one's causing it a bit more consternation, I can see that on the poll and. OK, we go. I'm going to end the poll. Going to share the results with you, and you can see that some of you. Nearly a third would watch and wait, basically, which is perfectly acceptable, and nearly half of you would offer an immediate operation with plating.
So what should we do? Well, first and foremost is that shared decision making. Whatever you do, you need to talk it through with the patient and find out what they want to do as well. It's not just it's not just about what you feel the evidence shows and showing you nudists have published on this in the bone and Joint Journal. And there is a variability of the rates of rate or nerve injuries, according to different publications.
This was a case that we had before was a primary example of radial nerve injury, secondary ones occur later, either during operative treatment or on application of the brace or plaster, and management is like everything else in upper limb, controversial. Do you notice in their systematic review showed that spontaneous recovery occurred in 90% and even secondary policies have a high rate of spontaneous recovery?
Imgs aren't useful until about three weeks down the line, so if it's before three weeks, don't get an EMG. If there is no recovery, tendon transfer can be utilized and are very reliable. So in 2005, they published their paper. They found that the indications for surgery in most of the papers, including in their review, were for open fractures. The secondary policy's high energy trauma or patient choices, we keep saying, and they've even come up with this decision algorithm for whether there is an indication for an RF following a radial nerve palsy.
And I would say that it's pretty. Uh, difficult to follow this, but essentially if it's a high energy injury, if it's an open injury, if it's something that's likely to have occurred after surgery, then that's when I would operate. And or if the patient is extremely keen to have an operation, then I would. I'm going to skip over this one, we've done quite a few polls.
If you do want to see a video of the anterior approach, then once again on it's available on the Cambridge orthopedics YouTube channel and hopefully the easiest ABC method will help you remember it. And that was the last example. You can see a long plate there with lots of lag screws. So treatment options, non operative that is operative. Lots of different non operative treatments, lots of different operative treatments, indications for surgery, really only open fractures, possibly polytrauma is still a relative indication.
A floating elbow and then anything that may involve extensive nerve injury. And then metastases, that's something that I won't cover in today's book because it's too much to cover and plating versus non operative treatment. There's another trial that's been set up randomized controlled trial.
It's called the hush trial humeral shaft fracture trial, which has only just started recruiting. So the results won't be available for your exams, but you can talk about it in the exam because what it means is that if there's a randomized controlled trial, no one knows the answer. Has the distal third fracture, you can do equally well in a splint or if you are going to operate, then I would recommend using this J shape plate and you can see the forceps they're pointing at the radial nerve document where that crosses.
And this is a posterior approach for that there is a video or will be a video one or both. Cambridge orthopedics. And you can see it take a long time. Once again, eight months later, for that to heal. So whether we use nails or plates, as Frankie says, it's tribal. In summary, it's all about the shared decision making, if you are going to brace, then know about the hygiene and how long it's going to take the fracture to heal.
And I'm going to stop there. Any questions on human skull fractures? Yes, just a couple. So does it take longer to unite the human factor compared to lower limb fractures? Well, good, good. I don't think it does, actually. So once it's this fragility issue, and I have lots of patients who are in Cambridge.
We are blessed with some of the greatest longevity in the country, especially South cambridgeshire, and we, you know, they choose to go for non treatment and they can be in a plaster for several months and longer than a humeral fracture. But what you've discovered, probably as a consultant as well, it's never six weeks, and it's all about setting those expectations.
If we in A&E are telling the patients that, Oh yeah, six weeks it'll all be healed, you'll be moving your arm fine. We're on to a difficult situation, aren't we really? And it's always going to be difficult to please those patients. But if we get them right at the beginning and say, yeah, it's going to take three four months, but your outcome will be as good as if you had an operation, then it does.
It does actually really make a difference. And is there any worries from fixing human fracture after three months other than maybe the second the regular? Anything else? Yeah, Yeah. So is that radial nerve, isn't it? And you know, the calluses there usually is quite a bit of callus and fibrous tissue around that. And in fact, because of covid, lots of patients were choosing to not have an operation, and we've been having to do delayed open reduction internal fixations.
And it does take a lot longer and in terms of finding that site. But actually, the outcomes are just as good because if the beauty of a human skull fracture compared to a delayed union and/or nonunion if compared to lower limb is that you can shorten it, can't you? You can. You don't need to take graft. You can just shorten it and get fresh bleeding bone.
So that's one of the nice, nice things. When are you deciding hanging costs for the patients? A don't rather OK. A brace? We all brace in Cambridge. So unfortunately, yeah, we'll stop questions for the middle third now and go for the distal third. Yeah, the distal third is the quickest you'll be glad to know, but you'll have a full appreciation of the humerus by the end of this, I hope.
So with the help of my friend Bono, who has experienced this injury himself, he's going to help us make the right decisions and decisions to have a beautiful day. You've got it, it's all about those decisions, it's all about the pattern recognition and a few technical tips. Oh, look, where is this from? It's from Robinson in Edinburgh, the epidemiology.
And guess what? There is a high energy male preponderance and bimodal distribution with the female fragility fractures of distal himor fractures. They come in whole sizes and shapes. Here's an example that's X-ray. The next example is intra articular, and then it's getting a little bit more displaced. And then boom, you've got a bomb gone off in that one, haven't you?
So exam time classifications, no one really expects you to have a classification. But in clinical cases, what would I use? I wouldn't use the eoe classification. I find it too hard. Instead, I would recommend Jesse Jupiter's classification system in terms of describing it as a T or a y or a lambda into a Lateral medial aspects.
Bono, once again, inspiring us orthopedic surgeons, you'd think he was an orthopedic surgeon with this quote about hammering the world into shape and. This is what you need to think about. Is it a superconductor or intra articular if it's interacting? It doesn't matter, you can still treat it non operatively and/or should you be replacing it or lifting it? And if it's superconductor, you still got that tricky decision of non operative versus RF.
So decision two, if you are going to treat it, not optimally. Are you going to move it like this lady on the left? Or are you going to keep it fixed in that decision? If you do right? The non operative outcomes in a very small paper, a small case series described by batten showed that compared to total elbow arthroplasty were actually very similar in terms of low pain levels at rest and activity, and the Oxford elbow score was statistically superior.
However, there wasn't. The minimal clinical difference was superior, but there wasn't a statistically significant margin of error, no complications. So although there are complications in the non operative treatment group, they are mainly bony and nonunion. Whereas with the internal fixation and arthroplasty, they are a wide variety of nerve injuries, wound deficits and mechanical failure of the implants.
So I'm going to put up a decision about a no. A better comminuted fracture in a young person, and I think there is no it's a no brainer that you would counsel this patient to have an operation. What what approach are you going to use for it? That's the next decision. So you're in theater, are you going to use a Tricep split and power electron on? Are you going to do the electron osteotomy?
Are you going to use power approach? Well, if this was your patient and they had decided with shared decision making to go to the theatre, what would you approach? Would you take on this extra articular test or human fracture? Would you go a not opportunity and move it be try to see an electron osteotomy D a Tricep split with the parallel electron or e?
Another approach? Well, it's pretty 50-50, actually quite a wide distribution, actually. I'm going to end the poll there. Share that with you. And 40% would go with paratransit spittle. A few of you at nearly a third would go with electron osteotomy and then a few would go with a Tricep split and power electron.
Let's go into what I did, and I used a parrot tricep tool, so like the vast majority of you. And let's move on to the next case. All right. What approach are you going to use for this one? So it's slightly more complicated because it's intra articular. And are you going to use or are you going to treat it non operatively and just get it moving?
Are you going to use this power tricep tool like you did in the last case? You're going to use an electron on osteotomy or you're going to use a Tricep split with a parallel approach? Or have you got another trick up your sleeve? I end the poll there because there's quite a unanimous 3/4 of you would do an electron osteotomy and then a complete split between paratriathlon and a parallel approach.
So let's see what did I do in this one? Well, it's a parallel chronology and see from these intraoperatively photographs how what a view you can get. And so this is through the boyed interval and extending it back through into the disk into the lateral third middle third junction of the triceps. And if you want to see a video on this, you can see that approach on Cambridge orthopedics YouTube channel again.
And you can see this is the result that we got from that. Now, once again, a little bit more complicated, but pretty similar. So I'm just going to jump to what I did. And like a lot of you, an electron osteotomy. But can you see on this right hand picture the mischief that can occur from using a plate? There's an abortion almost fracture of the electron there that can occur.
So I always supplement it with a suture fixation through the tendon. This one, I'm confident most of you will go with an electron osteotomy to visualize the joint, and it looks like that there hasn't been an osteotomy. That's because this gentleman went on to have serious stiffness of the elbow, as you can imagine, and has had an arthritis and removal of the electron plate.
But as you can see, I didn't remove the remainder of the metal work because there's still this nonunion on the lateral condyle and. So he's still ongoing under my care. But this one was used, we used an electronic osteotomy again, but this time using a suture technique that was described by Adam watts for simple olecranon fractures.
Decision for. What are you going to do with the nerves? So you're definitely going to decompress the nerve, but transposition is selective. So if you're asked about that, what you're going to do with this fracture. And how you going to deal with it operatively in the exam or even life, you're going to say I'm a selective trans.
And that's because I'm going to check if there's subluxation after I've decompressed it and if there's any contact with the metalwork. The radial nerve should also be seen to be not under the plate. The lateral plate more proximally. I remember that tip about where the radial nerve is. And it's the patient's Hand's breadth above the lateral epicondyle decision, 5 Watt plating technique.
Are you going to use. So you've decided on, you're going to do an rf, you've decided that you've going to use your approach. You decided that you're going to selectively transpose the nerve. Then you've got to make a decision on which plating technique. And there's two different plating techniques. Whether you use a parallel plating, that's the Black line or you use the 90 90 degree plating, which is the dotted line.
You can see from this paper in 2013 that there is no difference in the outcomes. Same with the complications. And so in summary, for grief of an artist or human fracture, use the ABC description for the exam a for attaching the articular fragments again. B for bridging the articular block to the shaft with epicondyle and plates.
Whether it's parallel or orthogonal and see for compressing the condyles through the plates. Remember that case? I showed you where there was a nonunion of the epicondyle. Tips and tricks use a threaded wire if you can. They act for the reduction of the articular surface, they can be left temporarily or take the left permanently cut in situ if you want and it's on, I use a particular set.
You don't need to use that set. But if you are going to use this equipment plating system, by the way, I get no royalties from them, then I would recommend in the majority of cases to use this the shortest plate so that it has the least interference with the ulnar nerve. As you can see here in my evolution, I used to use the right hand picture, it was an X-ray from an A fracture that I fixed many years ago and that I use the longer plate with the thicker screws.
And here I've used a shorter plate with smaller screws. Mind the gap both in the front and the back in the olecranon fossa and the cardioid fossa to make sure that the screws do not penetrate there and make sure that your screws are as long as possible into digitale and they all go through the plate and as many fragments as possible to get the strongest construct. And you can see once again, the hair the girth of the screws has is different and not half a millimeter difference.
Times 4 gives you a bit more to play with in the distal fragment. OK, six, so this looks a little bit different to the others that we've shown, it's intra articular. It looks a bit more osteopenia because it's a 70-year-old. If you need a CT scan, then here you go. And if you need more evidence that this is a comminuted osteopenia fracture, then hopefully that's being provided by the CT scan.
So should you go for arthroplasty or an RF in these great and 65 year olds? Well, Michael McKee from originally from Canada and the Canadian Orthopedic trauma society ran a randomized, controlled trial many years ago and small numbers which showed that the total elbow arthroplasty did much better than the rf, which is here in the blue on this graph, whereas the elbow passes in red and they published this in the Journal of shoulder and elbow surgery in 2009.
What if you choose to delay and elbow arthroplasty from trauma? Well, this publication from Prasarita hotel in 2008 shows there wasn't statistically significant difference in outcome, but it was trending at the seven year mark to a greater survivorship if they had early elbow replacement following trauma complications following total elbow arthroplasty. You can see there's a lot of them, so patients with a reoperation in these different series, you can see even in total elbow arthroplasty, you can have one quarter of patients requiring further surgery.
But in comparison to the operatively fixed patients in each of the papers, it's significantly less. So there's great data from the National Joint registry, and you should use this for your exams. There is a section on the elbows with using it for acute trauma, and you can see that there's been a massive rise in using distal humor or heavy arthroplasty. As you can see on this right hand graph, it's become extremely popular.
So the rise of the hemi arthroplasty, you can see this anecdotal results. Has a really good technique from joy, deep sadness and brighten. He's published it in shoulder and elbow on fixing the tube. The condylar fragments to both the shaft and to the implant. And you can see the little tips and tricks he's given there. And he, in that same paper published the results of hemiarthroplasty as opposed to total of arthroplasty.
Once again, they are small k-series only patient 7 to 42 patients at the most. So we need more long term data on that, and I think that will come from the National Joint registry, but complications occur in those hemi Arthur arthroplasty as well. And you can see the nerve is usually the ulnar nerve is the one that gets irritated the most. Pick your winners, look at the mortality rate of those patients that had a total elbow replacement or hemi after for acute trauma 20% at five years.
So and 13% at four years, 10% at three years, just like the proximal humeral fractures. These are usually fragile patients, so you need to have that conversation with the patient and make sure that they are optimized. So in summary, if you're not operative, get them moving early. Otherwise they get a very stiff elbow. Your surgical approach is Carte selective ulnar nerve transposition.
Plating technique doesn't matter which approach arthroplasty me to say, but without further ado. An overall summary of today's three topics it's all about the evidence based shared decision making. There are many decisions that we use are based on tribal instincts, and there are lots of new randomized controlled trials that hopefully you are now familiar with or will go and look up, and that there is lots of data within the National Joint Registry for using arthroplasty.
Fractures of the humerus are not funny, but treating them hopefully will now be fun. Thank you for your time. Thank you very much. There is no much questions about the lower third humerus. OK, I'm actually one question from the middle third. The brace, is it for the whole three months all the time?
I say, yeah, that's really good. So initially, yes, it will be all the time. But the hydrostatic pressure works by adjusting the brace regularly and frequently as the swelling comes down. So in the first couple of weeks, the patient's going to be in a lot of pain. It's going to be pretty swollen. And so they're going to stay in that brace for the 24/7.
They you will teach them about hygiene, about auxiliary hygiene, you will ask. They won't be able to adjust the Velcro straps themselves. They'll need help from their family and friends. And so it will be good to have some sort of resource on patient information how to do that, and that's why you bring them to the clinic as well. So you get your plaster technicians who are vital team members to help them look after that in the longer term.
And as time goes on, then, especially after a couple of months, the patients become much more comfortable and they can take the brace off for longer periods of time and they wean themselves out of it over that last couple of months, basically. Thank you very much. I think this is all the questions being asked. Thank you. Thank you.
Yeah, thank you very much, Neal. That was a really interesting talk. I liked the little musical interludes as well. And yeah, I guess, you know, the three things that I picked up that I thought were the buzzwords for the exam. And I picked three because I was always told less than three things a day was lazy and more than learning three things a day was greedy.
So the three things that I picked up were was the Sammy enterprise and how it works. I got our start in my vyver, and you gave a really good explanation of it. So candidates, you need to take that with you. And remember it. The second one was where to find the radial nerve in those fractures. You know, I was kind of taught wherever you want to put your plate, the radial nerve will be just at the end of the plate.
But yeah, I remember the bit about the patient's hand above the lateral epicondyle that's been asked in the exams as well frequently. And the third thing was, I like the phrase selective transposed for the ulnar nerve. I thought that was just such a nice way of saying because you always get asked, are you going to transpose the ulnar nerve? And the answer is it depends on the situation. But I liked that phrase, and I think that's a nice buzz word for the candidates to take forward.
So thank you very much. I had a, you know, a really entertaining talk, and I'm sure that everybody's learned quite a lot. And as I said before, guys, this will be available on the websites for you to watch it again and go through it. So thank you very much. Have you got anything to add, neal? No just enjoy your training.
Best days of your lives in school. Have fun. Great thank you very much, Neal. Thank you.
Segment:0 .
Good evening, everyone, and welcome to our teaching session on nothing funny about the humerus fractures, which is a combined session with OK. My name is Nikki Evans and I'll be co-hosting with Imogen and Hannah from OR UK and Joe, one of our mentors.
So this is the timetable for this evening. The presentation will be split into three parts, so the proximal part of the humerus, the shaft of the humerus and the distal part of the humerus. And we'll have space for two or three questions in between each segment. So if you write your questions in the chat box as soon as you want to, then Joe will keep an eye and ask those particular questions at the end of each segment will probably fit in about two or three questions for each segment.
OK, so we'll then move on to some polling and I think Mr. can do some polling throughout the lecture as well, which we'd like you all to participate in. Of course it's anonymous. Then we'll move on to this discussion and top tips for the Fox. We will be recording this lecture and the questions, so if you missed any part of it, don't panic.
It is recorded and it will be available on the Fox mentor YouTube channel and our UK websites in due course. If you would like to participate in one of the survivors, we ask that you get in touch with Hannah as soon as you decide that you want to so that we can schedule it will do as many as we have time for. We realized that this is quite intimidating putting yourself forward, but it's the best way to learn.
And you can rest assured that both Joe and I have been through this multiple times in your shoes. At this stage, I'd also say there's quite a few viable practice courses between ourselves and our UK, which you can find on the websites. As always, we recommend our study guide cancel orthopedic notes. This has been written by our mentors and our UK have is excellent books, which I used for my own exam.
Following the presentation this evening, imaging will be taught you regarding feedback and we really appreciate your input to help us improve these sessions. CPD certification is also available from our UK. If you contact with you. OK, so this evening, we're privileged to welcome Mr. Neil Kang, the consultant orthopedic surgeon at Cambridge University Hospitals NHS Foundation Trust.
Mr Kang combines his full time clinical work with educational activities and is a convener and faculty on multiple regional and national courses. He is keen on the clinical application of basic science and Orthopedics. As you all know, one of our mentors, one hinari, is also director of education for the East of England higher surgical training, rotation and trauma clinics, as well as associate lecturer for the School of clinical medicine in Cambridge and a member of the shoulder board.
I'm sure we're all going to learn a lot from this evening. So without further ado, I will pass you over to Mr. Neil King. Thank you. Thank you very much, KneeKG. I'm going to share my screen. Right so three parts to the talk today. First part, let's go for it, proximal humeral fractures, and hopefully you'll see that there are themes in common with all of today's talks.
Firstly, decisions and incisions. Secondly, pattern recognition. And thirdly, a few technical tips that will hopefully help you manage these better. Starting off with our proximal humeral fractures, what kind of decisions and decisions do we have to make? Well, here we have a class example of what presents at the beginning of COVID in lockdown 1 March 2020.
What would you do with this or what would you recommend for this patient? Well, because of COVID and the pandemic, much of our decision making was challenged and we had to use non operative methods and in fact, it did go on to heal. But as you can see, it didn't heal very well, and unsurprisingly, she didn't have a great result. So decision number one is always going to be.
Are you going to operate or not operate? And this is going to be multifactorial depending on the amount of displacement, the number of fragments and also the fitness for surgery of the patients. But ultimately, it will be a shared decision between you and the patient. So another example of pre-covid management, you can see here a three part fracture with the greater tuberosity and the neck.
And this one went on to do healed, just as you would expect and much better movement and less pain than the first example. So this play did give an idea of how well we're going to do. But if you are going to go for non operative, then I would recommend that you are aggressive with your physiotherapy and that you make sure that they do get good physiotherapy. There are some videos on the Cambridge University Hospital's website for and at different stages, as demonstrated here by my physiotherapist Laura.
And if you get the patients engage with those on, then the outcome usually is better. And that's what we probably found from the paper, which will come across later. So here's another example smashed up for Part proximal humeral fracture. In a '51 year old hair, this is a slightly older patient, 80 years old, completely displaced. And then a young person, 48, and you can see that the head is unsub coracoid, so quite a variety of scenarios that you could be presented with in the exam and in real life, which is more important, isn't it?
Because if you face these in real life and know how to deal with them in real life, then the exam will be a breeze. First, the paper that I want you to think about is this one from the Edinburgh group and Clement Gentile in the bone and Joint Journal in 2014. And basically the 10% mortality at one year. This is a sentinel fracture. Basically, it's another one of those fragility fractures that social the, you know, the patient is just at the tip of the iceberg and you have to treat these with care and understand their whole medical problems before jumping in and operating.
Next question will come up in the exams, probably classifications in the exams itself. Classification systems aren't required, but if you are going to classify it, what classification can we use for the proximal humerus? Everyone knows about nia's classification, the two three four part fractures and whether they are associated with the fracture dislocation or not.
Now, the mayor's paper talked about the degree of displacement, and it should be a centimeter and greater than 45 degrees of angulation if it is to be classified as a displaced part. And you got this awesome team from Imperial College and St Mary's hospital, Professor Roger Emory and Ralph Hertel, a famous shoulder surgeon from Switzerland, got together and they published a paper looking at the different classification systems and observe the variability between people reading the classification.
And guess what? They found that it was crap between everyone out, between all the classification systems. So even if you've got the fancy Hertel binary LEGO model, it doesn't really correlate to a good classification system. And so I would just stick to the simple nears two three four part fracture dislocation system. Next question what is the blood supply and which is the predominant blood supply to the humeral head?
We are all familiar with, we're all familiar with the anterior humoral so complex artery, and the archaeal artery climbs up the lateral edge of the bicep to groove with the longer the biceps. But that is not the predominant artery. Brooks Chris Brooks from when he was working at guy's and Tommy's, published this in 1993, and he found that the posterior branch posterior humerus complex was the predominant branch congenital thought, a similar or a similar thing that because Avorn is rare and the PHC is minimally disrupted in most fractures.
It is the predominant blood supply to the humeral head. If you need more evidence, there's a kind of studies using MRI and sico. Nearly 2/3 of the head was applied by the posterior humerus and artery. Next question that might come up in the Fox's how can you predict whether the humeral head will survive and/or will it go on to even? And so hurtle that surgeon and Swiss surgeon that I mentioned earlier with the classification system and the binary LEGO model?
Well, he did an intraoperatively study. So all those fractures that he was fixing, he drilled and then put on a Doppler ultrasound to check the blood flow and found that those patients that had a medial calcar segment less than 8 millimeters. So that's the head fragment. And if the cow calf fragment where I'm pointing my cursor is less than 8 millimeters or there was more than 2 millimeters of medial hinge disruption.
Then there was a higher rate of ischemia. However, his junior followed up those same patients and published the results of their fixation, and they found that although the ischemic heads were all the other, the heads were ischemic intraoperatively only 80 percent, 80% of them survived, so they deemed that fixation is worth considering, even if they've got the hurtles ischemic predictors.
So decision two, should we fix or should we replace? Can I ask Coldplay to help us with this? And if you are going to go for a fixation replacement, then which approach and that's decision 3 on the tree and to help you because common question for the exam is that what is the Delta to approach or maybe even the Delta in split?
These videos are both available for you to view after this course on Cambridge orthopedics YouTube channel, courtesy of my mate Lee. So if we're going to fix, should we fix? Well, proffer was is the largest randomized controlled trial in the world about fixation versus non operative treatment with aggressive physiotherapy.
Remember that aggressive physiotherapy because lots of patients get referred to physiotherapy and they don't do anything? And what was the outcome of proffer? Well, it basically demonstrated that there was no difference in the outcome, which the primary outcome was the Oxford Shoulder score at 112 months. So 24 months.
Once again. If you want a Fuller appraisal of the paper, one of the alumni from the East of England or the rotation arm and mosaddegh has designed a little video and it's on our website, which you can see at the bottom there. Eoa or. So in the paper, you can see that the vast majority were fixed, but there was a small percentage that went on to have hemiarthroplasty during the operation.
So it was a bit of a heterogeneous study and that's why it's called a pragmatic trial. And they found that the study of operative versus non operative treatment patients at all time points, including in this paper at 5 years, were pretty much the same. So this graph shows it all really. Look at the Oxford Shoulder score. Look at the different time points.
OK, non operative had a non statistically significant difference at six months by, but by one year, it was pretty much the same. And you can tell all your patients that if you fracture your proximal humerus that you'll continue to improve up to about four years after the injury, whether you have surgery or not. And then is there other evidence besides the proffer trial? Yes, definitely.
There's loads of trials in our own subspecialty journal Jesus in 2011 and general orthopedic trauma and showed no difference between whether it was an RF and non-op or hemi and non-op. so Basement Jaxx are asking, where's your header? What are you going to do with this case? That what approach are you going to take?
So you've already heard about the Delta petrol and the deltoid. Think about it, which one will give you better access to this and also. What other things do you have to contemplate? Well, if you look at that fracture, it's stuck under that coracoid. So my preference would be in a delta petrol approach from the front, obviously, and then you can perform a coracoid osteotomy because otherwise it's going to be nigh impossible to get that humeral head disengage from the anterior glenoid.
Then temporarily stabilize the humeral head to the glenoid. Use your bicep2 groove to line up the plate. Put in several screws and use sutures through the rotator cuff to grab hold of the tuberosity fragments and make sure that the plate is below the level of the greater tuberosity below the height of the Great tuberosity so that it doesn't impinge first. Screws should normally be the locking screw at the straight, a non locking screws to the shaft and then locking screws through the head, especially at the bottom for the raft and the calcar screws.
Make sure none of the screws penetrate the articular surface. And here's a quick summary of what we've just said. Decision for shall we go for a reverse or a hemi? Well, that's pretty much tribal, as Frankie Goes to Hollywood would tell us. And what happens if you do a hemi arthroplasty? Well, like the British weather, it is pretty unpredictable.
And despite using a vipers orgy of sutures, as you can see demonstrated here in this technique, there is still only a 75% tuberosity healing rate. Here's another example of a proximal human fracture that went on to a hemi arthroplasty, and you can see the tuberosity well reduced to the implant. But now, six months down the line, where's it gone? It's vanished, so people decided that reverse shoulders might be the way forward for trauma, given that you don't need to rely on the tuberosity.
And before the NJR reports were available, there were some equivocal evidence about using a reverse shoulder. And you can see from this recent NJR report that of 4,000 cases used for trauma. 2000 were for reverse shoulder compared to 1,100 with a human or hemi. So it's definitely in Vogue.
What are the revision rates for replacements following trauma? And we can see the blue line, which is trauma is rising and diverging away from the elective rates of revision. So that's a concerning feature. And here you can see the mortality figures. So pick your winners, is my suggestion to you. The purple line here is actually the acute trauma, and that shows that mortality rises significantly more than those that have shoulder replacements for elective care.
So do you take care in choosing your patients? So what are we going to do next? Well, you've heard about proffer there is proffer to ongoing. So if you're coming up to the exam, you would want to quote that we are looking at around the UK in another multicenter, randomized controlled trial at the use of hemiarthroplasty versus reverse hemiarthroplasty and also a cohort of nonsurgical patients in those patients aged 65 and over.
And for those of you who need to get an audit completed, don't miss out on famous C19, which is looking at retrospectively those patients that were treated with proximal humeral fractures back in the first lockdown. And that's another trial that's come out from York and am Rangan. And you can see the contact details there if you want to get involved.
So enough talking from me, I want to know what you think and learn from you. So I'm going to put up a poll and what I'd like you to do is tell me what you would do for these cases. Just trying to find the poll so. Would you a. No, not treat this, for part, displaced fracture.
And just move it, would you be? Fix with a plate C fix with a nail D replace with a hemi E replace with a reverse. So I'm going to end that poll now because we've got lots of polls and decisions coming up, and it's great to see so much activity. Just give you two more seconds. Good OK, so I'll share the results and the vast majority view 3/4 would like to replace this with the reverse.
OK and. A smaller majority would fix it with a plane, which is perfectly reasonable, but make sure you discuss the results with the air, discussed all options in a shared fashion with the patient. And hopefully that's what you will take away from this talk at all. All options are viable, but you need to share that discussion with the patient.
Next example. So 48-year-old fit and healthy patient who has sustained this four part fracture. And what are you going to do? So are you going to a fix it with a plate? That's right. A non operatively treat it and move it, be fix it with a plate C fix it with a nail D replace with a hemi E replace with a reverse.
So some rapid answers coming in, and I'm going to stop the poll there, and I'm going to share it. And once again, a 3/4 majority for fixing this with the plate and be replaced with a hemi, that's not a bad shell. And I'll show you why. So if you needed a CT scan to show you where the fragments were, then there it is.
So you can see that there's been lots of screws to fix that. And a coracoid osteotomy, you can see the fixation there and then what happened? Well, 18 months down the line, it all died away, so ischemic predictor. Definitely and maybe that hemi was a better shell straight off. Ironically, that patient actually, once they had metz-werke removed because he's not a manual labor.
He was pretty pragmatic and doesn't want and hasn't wanted any surgery since. Next up, so this fracture going to show you the next slide as well. Because I think it will be helpful for you. And then let's get your thoughts on whether what you would like to do with this one. So would you a non operatively treat it and move it, be fix it with a plate c, fix it with a nail D replace with a hemi E replaced with reverse.
Cool OK. It's rather mixed bag this time. I'm going to share the results with you and. Just under 2/3 would fix it with a plate. And then, as I say, a bit of a mixture between non operatively treat it and replace with a hemi. But all options were used, really?
This one, I just want to highlight on the. The reason I showed you the CT is you can see that it's actually dislocated out the back. And so this required an open reduction and in my hands, a fixation. But you could have nailed it. You could have just reduced it open and see if there was much displacement, if there wasn't much displacement, then you could treat it without any metal work as well.
So all options are open. Another one. So let's see if proffer has had any bearing on your stance on the management of fractures. Here we go. So in this? Essentially, three part Vegas impacted fracture. Would you not optimally treat it and move it? Fix it with a plate, fix it with a nail, replace with a hemi or replace it with a reverse.
So it's. Looking good, it's going to end the poll there, give you share the results with you. So you all know what each other's is doing. And you can see a lot more of you would treat this non operatively. And I think that's a perfectly sensible suggestion. A few of you would fix this with the plate, which in a 65-year-old female is perhaps what Prosser was trying to say is the results are no better than non-operated treating it, and a few of you would also treat it with a hemiarthroplasty and couple with a reverse.
So let's see. What did I do? This was a few years ago before proffer, and you can see this is one I replaced with a hemiarthroplasty and the tuberosity did heal, so got a bit lucky there. So in summary, there's going to be an increasing burden of these humeral head fracture, proximal human fractures and 10% will be likely to die within a year.
Shared decision making is key, and non operative treatment is best for most. And if you are going to use non-addictive treatment, be aggressive and use the physiotherapy as the proper regimen. I'm going to stop there and ask if there's any questions. Hello yeah, thank you, Neal, for the proximal humeral token. Yeah, there is a couple of questions, so I think someone was a little bit, you know?
Is there any Black and white in either to fix versus to replace? It's this is that's the beauty of upper limb surgery. Yes, it's all about sharing all the, you know, all the evidence that you have your experience. It's as you will come across in the next couple of lectures. In cases, it's terrible what you've been brought up with, whether you use a nail or a plate, whether you use delta petrol approach, whether you use deltoid split approach, all these things.
There is no binary evidence that Black and white evidence that you should do whatever you whichever way. Sorry. OK. So you don't have, you know, like decision. What helps you in deciding whether either? Yeah so since there's something called the Hawthorne effect where when you've been observed, you change your practice, and that's certainly something that was observed during the profit trial.
And as a trainee myself, I was very keen to operate on everything and fix everything. But I didn't have the blessing of being able to look after those patients in the longer term. And now, as a consultant of nearly nine years, it's have that luxury that you can follow up your patients. And so everything is to talk to at length about the different options, and it's just what the patient wants, really.
You know, after discussion with yourself, you know, you have the experience, you have the knowledge, but what you don't have is what that patient wants. And that's so the take-home message is just take your time and make sure you discuss everything in detail with the patients. And that's the best way to get the outcome. Best outcome?
Thank you. And how to measure the medial Kessler or the hinge on the X-ray. So it was less than 8 millimeters. So if, Uh, is it from the articular surface, the medial articular surface? So actually, here you are. There is. Can you see on my screen now?
Yes, I'm sure you can see that there is a nice bit of calcar and actually that probably does measure about. Six to eight millimeters, so this would be quite borderline, but remember that they themselves published the results later down the line and showed that those ischemic predictors don't mean anything. Yes Yes. Yeah good.
Thank you very much. That concludes the questions for the proximal humerus. OK right? Less without further ado, get onto the shaft and. I mean, by the way, if anybody wants to send CBDS, I'm happy to fill those out as well. Not only do you get excellent training for your mock exams, but we can give you case based discussions as well to validate if you want to hear more sharp fractures.
So same pattern. It's all about the decisions and incisions and pattern recognition, with a few technical tips thrown in. So here was a throwaway comment by bola all the fractures of the long bones human skull fractures are the most benign. Well, let's have a look. Why are they benign? Well, because we can tolerate great disturbances of the alignment of the fractures.
We don't need to walk on our arms, and our shoulder and elbows have a large range of motion that can compensate for those fractures that may be more United. My mate, Graham Tilley, strong in Edinburgh, once again, published this paper in 98 about the epidemiology of the human fractures, and you can see that pattern again. There's a low energy state that high energy in young adult males and low energy fragility fractures in females, we choose a theme of humor or sharp humor practically.
So let's get you engaged straight away. Paul Warren here's a fracture that's been referred to you whilst you're in A&E. What are you going to do? Are you going to a put this patient into a collar and cuff for gravity, B put it into a sling for support? C put it into an above elbow hanging cast. D put it into a class brace, including the shoulder and elbow, or E put it into a humerus brace straight away.
So we've got a few. Lots of answers coming in. And slowing down now, so I'm going to end the poll, share the results with you. And you can see 50% would put this straight into a human race. A few would put it into a cast brace, including the shoulder and elbow, and others would put it into a collar and cuff for gravity.
So what would I do this one? I definitely would put into a humoral brace in. And what am I going to tell them? Well, I'm going to tell them that it's going to take about three to four months for that fracture to heal. Not that typical six weeks, the arbitrary unit of time in orthopedics. And I'm going to tell them that they may have a stiff shoulder and may have a stiff elbow as well because of the time spent within when the humoral brace.
We can put them in that brace straightaway. As I say, just going back to that mid shaft humoral fracture, three parts minimally displaced. What would you tell them about the healing? That's right. So going to relaunch, let's go back. We launch a poll.
This type of fracture heals in 90 greater than 95% B, this type of fracture heals in six weeks. See, this type of fracture heals in four months. D we need to see you every week in clinic for six weeks. E! physiotherapy will not help you. So get it in the poll there.
And you can see 60% going for c, and that's the one correct answer that I would give here that this type of fracture heals within about four months. That's what I would tell my patients or the others are not what I would tell my patients. And you can see here that first example I gave you even at three months later, it's still not quite healed. It's got some bridging callus there.
And then by 6 months, though, it's healed suddenly. Although it's a bit undulated, it's not causing them any problems. So the bracing regimen, you can brace them immediately. You should then see them in shoulder fracture clinic to or whichever fracture clinic to teach them and their friends or next of kin about brace hygiene demonstrate the exercises for hand, wrist, elbow and shoulder and see them again, if they've decided on non operative treatment.
Following a discussion with you and a shared decision, then they should be prepared to be in this for about three months. And it's probably not worthwhile bringing them back every week for an X-ray. And then you can see here it may take up to six months for them to have an X-ray that shows that it has completely healed. So next question from the farces examiner how does the brace work?
Well, Thanks to queen, it's remember that it was under pressure. Is hydrostatic pressure compressing the muscles around the fractured bones, helping to align them? When is a brace contraindicated? If there's massive soft tissue loss, if it's an unreliable patient and if there's a big fracture gap because there's an increased risk nonunion here, we have an example of when we might use it under pressure.
Sarmiento published his results of 900 patients used that had to brace used, but only 565 actually had follow up radiograph, so quite a high dropout rate and the mean to union, you can see that was about three months, but quite a range up to 22 weeks. And he also used it in open fracture, so gunshot wounds as well. And he reckoned there were no infections and quite a high union rate of 94% What about modern day studies looking at that?
Because that was the one man band of sarmiento? Well, my friends into the strong and Lee Van rensburg at Cambridge published this paper in 2015, and they found that anatomy matters that if you're trying to heal a proximal, you're more proximal third humeral shaft fracture that 3/4 will heal in a brace. 90% will heal an abrasive. It's the middle third, and if it's the distal third.
85% will heal. So these are quite useful figures for you to discuss with your patients. So toll to is the hair of the radiographs a very healthy non-smoker? And what would you do for this? Just bring it up in the poll. Would you put them into a collar and cuff for gravity?
Would you put it into a sling for support? Would you put them into an above elbow hanging cast? A cast brace, including shoulder and elbow or into a humeral brace. Just give you 5 more seconds. Quite a few still flying in. OK, let's share the results and mixed back, so.
Mixture, probably between putting it in an above elbow hanging cast and humeral brace. So a third of you human race slightly less than last time. And let's see what we did. US being Cambridge, we put a brace. And you can see even braces can have complications. This guy had a problem with the reaction to the brace.
For some reason, lots of people have problems with hygiene in the armpit and auxiliary issues. But this guy was particularly allergic and he didn't comply very well with the brace. And you can see there's quite a fracture gap that appeared now and then. Three months later, you can see that he's been abducting his shoulder because it's now angular. So are you going to change your plan now?
What are you going to say to the patient? You can imagine that I had the full Frank discussion, went through the options with him and decided in a shared fashion to go with an operation. But which approach would you take if you were going to operate on this patient? So option a, would you use a posterior approach? Option b, would you use a lateral c, a D extended deltopectoral E and trilateral?
And I'm assuming that we're plating and not nailing. So give you another couple of seconds, and it looks like most of you. Finish answering, and you can see that. 41% of you would go for a posterior approach. That's cool. That's a very generalized universal approach to this fracture.
And I personally go for an anterior approach, and there's no right or wrong for whichever you use, because what we will find is that this friend, the radial nerve, will be wherever, whichever approach that we choose. And you just have to be comfortable finding that approach that you can be safe with the radial nerve. If you are using the anterior or Antrel lateral approach, a little tip on how to find that radial nerve is was given by an elbow surgeon called Stanley from Sheffield.
And if you put the patient's Hand's breadth above the lateral epicondyle, then the nerve is usually there, coming out between breaking loose and breaking radiators. So here we have another example a slightly more complicated and a more proximal third fracture. So what would you do for this patient? Are you going to put them into a collar and cuff for gravity into a sling for support above elbow hanging cast?
Cast, brace or humor or brace? OK, I'm going to end the poll that far more of you would put them into a human race straight off, and I think that's fair enough. And then. What are you going to have a discussion with these in the clinic? Well, you remember at that paper from Cambridge, which showed that 75% of fractures healed if they were in the proximal third within the human race.
And then the patient decides, OK, I'm not going to take that. I want to have an operation. So which approach are you going to take for that proximal third fracture? Are you going to stick with the posterior and a.? Are you going to go lateral with b? You're going to go with CD an extended delta petrol E an anterolateral.
We've got a consensus here. I'm going to end the poll on that consensus, nearly 70% would do option d, which is an extended delta petrol. I think that's a very sensible. All of these. Approaches, you need to be aware of the radial nerve, and that's the extended delta petrol approach that I used. Note that there are lots of separate lag screws to help share the strain of the fracture.
Otherwise, you may get on go on to a nonunion the next. Another common question for the folks what do we do with a humeral shaft fracture with a risk drop or a radial nerve palsy? And here we have options a which is. Recommend a brace for six weeks, so this happened at the time of the fracture. Brace for six weeks and see if the nerve recovers. B offer immediate operation, quickly nailing C. C in the clinic in three weeks and check tonsils and imgs D offer immediate operation plating be put into a humoral brace.
This one's causing it a bit more consternation, I can see that on the poll and. OK, we go. I'm going to end the poll. Going to share the results with you, and you can see that some of you. Nearly a third would watch and wait, basically, which is perfectly acceptable, and nearly half of you would offer an immediate operation with plating.
So what should we do? Well, first and foremost is that shared decision making. Whatever you do, you need to talk it through with the patient and find out what they want to do as well. It's not just it's not just about what you feel the evidence shows and showing you nudists have published on this in the bone and Joint Journal. And there is a variability of the rates of rate or nerve injuries, according to different publications.
This was a case that we had before was a primary example of radial nerve injury, secondary ones occur later, either during operative treatment or on application of the brace or plaster, and management is like everything else in upper limb, controversial. Do you notice in their systematic review showed that spontaneous recovery occurred in 90% and even secondary policies have a high rate of spontaneous recovery?
Imgs aren't useful until about three weeks down the line, so if it's before three weeks, don't get an EMG. If there is no recovery, tendon transfer can be utilized and are very reliable. So in 2005, they published their paper. They found that the indications for surgery in most of the papers, including in their review, were for open fractures. The secondary policy's high energy trauma or patient choices, we keep saying, and they've even come up with this decision algorithm for whether there is an indication for an RF following a radial nerve palsy.
And I would say that it's pretty. Uh, difficult to follow this, but essentially if it's a high energy injury, if it's an open injury, if it's something that's likely to have occurred after surgery, then that's when I would operate. And or if the patient is extremely keen to have an operation, then I would. I'm going to skip over this one, we've done quite a few polls.
If you do want to see a video of the anterior approach, then once again on it's available on the Cambridge orthopedics YouTube channel and hopefully the easiest ABC method will help you remember it. And that was the last example. You can see a long plate there with lots of lag screws. So treatment options, non operative that is operative. Lots of different non operative treatments, lots of different operative treatments, indications for surgery, really only open fractures, possibly polytrauma is still a relative indication.
A floating elbow and then anything that may involve extensive nerve injury. And then metastases, that's something that I won't cover in today's book because it's too much to cover and plating versus non operative treatment. There's another trial that's been set up randomized controlled trial.
It's called the hush trial humeral shaft fracture trial, which has only just started recruiting. So the results won't be available for your exams, but you can talk about it in the exam because what it means is that if there's a randomized controlled trial, no one knows the answer. Has the distal third fracture, you can do equally well in a splint or if you are going to operate, then I would recommend using this J shape plate and you can see the forceps they're pointing at the radial nerve document where that crosses.
And this is a posterior approach for that there is a video or will be a video one or both. Cambridge orthopedics. And you can see it take a long time. Once again, eight months later, for that to heal. So whether we use nails or plates, as Frankie says, it's tribal. In summary, it's all about the shared decision making, if you are going to brace, then know about the hygiene and how long it's going to take the fracture to heal.
And I'm going to stop there. Any questions on human skull fractures? Yes, just a couple. So does it take longer to unite the human factor compared to lower limb fractures? Well, good, good. I don't think it does, actually. So once it's this fragility issue, and I have lots of patients who are in Cambridge.
We are blessed with some of the greatest longevity in the country, especially South cambridgeshire, and we, you know, they choose to go for non treatment and they can be in a plaster for several months and longer than a humeral fracture. But what you've discovered, probably as a consultant as well, it's never six weeks, and it's all about setting those expectations.
If we in A&E are telling the patients that, Oh yeah, six weeks it'll all be healed, you'll be moving your arm fine. We're on to a difficult situation, aren't we really? And it's always going to be difficult to please those patients. But if we get them right at the beginning and say, yeah, it's going to take three four months, but your outcome will be as good as if you had an operation, then it does.
It does actually really make a difference. And is there any worries from fixing human fracture after three months other than maybe the second the regular? Anything else? Yeah, Yeah. So is that radial nerve, isn't it? And you know, the calluses there usually is quite a bit of callus and fibrous tissue around that. And in fact, because of covid, lots of patients were choosing to not have an operation, and we've been having to do delayed open reduction internal fixations.
And it does take a lot longer and in terms of finding that site. But actually, the outcomes are just as good because if the beauty of a human skull fracture compared to a delayed union and/or nonunion if compared to lower limb is that you can shorten it, can't you? You can. You don't need to take graft. You can just shorten it and get fresh bleeding bone.
So that's one of the nice, nice things. When are you deciding hanging costs for the patients? A don't rather OK. A brace? We all brace in Cambridge. So unfortunately, yeah, we'll stop questions for the middle third now and go for the distal third. Yeah, the distal third is the quickest you'll be glad to know, but you'll have a full appreciation of the humerus by the end of this, I hope.
So with the help of my friend Bono, who has experienced this injury himself, he's going to help us make the right decisions and decisions to have a beautiful day. You've got it, it's all about those decisions, it's all about the pattern recognition and a few technical tips. Oh, look, where is this from? It's from Robinson in Edinburgh, the epidemiology.
And guess what? There is a high energy male preponderance and bimodal distribution with the female fragility fractures of distal himor fractures. They come in whole sizes and shapes. Here's an example that's X-ray. The next example is intra articular, and then it's getting a little bit more displaced. And then boom, you've got a bomb gone off in that one, haven't you?
So exam time classifications, no one really expects you to have a classification. But in clinical cases, what would I use? I wouldn't use the eoe classification. I find it too hard. Instead, I would recommend Jesse Jupiter's classification system in terms of describing it as a T or a y or a lambda into a Lateral medial aspects.
Bono, once again, inspiring us orthopedic surgeons, you'd think he was an orthopedic surgeon with this quote about hammering the world into shape and. This is what you need to think about. Is it a superconductor or intra articular if it's interacting? It doesn't matter, you can still treat it non operatively and/or should you be replacing it or lifting it? And if it's superconductor, you still got that tricky decision of non operative versus RF.
So decision two, if you are going to treat it, not optimally. Are you going to move it like this lady on the left? Or are you going to keep it fixed in that decision? If you do right? The non operative outcomes in a very small paper, a small case series described by batten showed that compared to total elbow arthroplasty were actually very similar in terms of low pain levels at rest and activity, and the Oxford elbow score was statistically superior.
However, there wasn't. The minimal clinical difference was superior, but there wasn't a statistically significant margin of error, no complications. So although there are complications in the non operative treatment group, they are mainly bony and nonunion. Whereas with the internal fixation and arthroplasty, they are a wide variety of nerve injuries, wound deficits and mechanical failure of the implants.
So I'm going to put up a decision about a no. A better comminuted fracture in a young person, and I think there is no it's a no brainer that you would counsel this patient to have an operation. What what approach are you going to use for it? That's the next decision. So you're in theater, are you going to use a Tricep split and power electron on? Are you going to do the electron osteotomy?
Are you going to use power approach? Well, if this was your patient and they had decided with shared decision making to go to the theatre, what would you approach? Would you take on this extra articular test or human fracture? Would you go a not opportunity and move it be try to see an electron osteotomy D a Tricep split with the parallel electron or e?
Another approach? Well, it's pretty 50-50, actually quite a wide distribution, actually. I'm going to end the poll there. Share that with you. And 40% would go with paratransit spittle. A few of you at nearly a third would go with electron osteotomy and then a few would go with a Tricep split and power electron.
Let's go into what I did, and I used a parrot tricep tool, so like the vast majority of you. And let's move on to the next case. All right. What approach are you going to use for this one? So it's slightly more complicated because it's intra articular. And are you going to use or are you going to treat it non operatively and just get it moving?
Are you going to use this power tricep tool like you did in the last case? You're going to use an electron on osteotomy or you're going to use a Tricep split with a parallel approach? Or have you got another trick up your sleeve? I end the poll there because there's quite a unanimous 3/4 of you would do an electron osteotomy and then a complete split between paratriathlon and a parallel approach.
So let's see what did I do in this one? Well, it's a parallel chronology and see from these intraoperatively photographs how what a view you can get. And so this is through the boyed interval and extending it back through into the disk into the lateral third middle third junction of the triceps. And if you want to see a video on this, you can see that approach on Cambridge orthopedics YouTube channel again.
And you can see this is the result that we got from that. Now, once again, a little bit more complicated, but pretty similar. So I'm just going to jump to what I did. And like a lot of you, an electron osteotomy. But can you see on this right hand picture the mischief that can occur from using a plate? There's an abortion almost fracture of the electron there that can occur.
So I always supplement it with a suture fixation through the tendon. This one, I'm confident most of you will go with an electron osteotomy to visualize the joint, and it looks like that there hasn't been an osteotomy. That's because this gentleman went on to have serious stiffness of the elbow, as you can imagine, and has had an arthritis and removal of the electron plate.
But as you can see, I didn't remove the remainder of the metal work because there's still this nonunion on the lateral condyle and. So he's still ongoing under my care. But this one was used, we used an electronic osteotomy again, but this time using a suture technique that was described by Adam watts for simple olecranon fractures.
Decision for. What are you going to do with the nerves? So you're definitely going to decompress the nerve, but transposition is selective. So if you're asked about that, what you're going to do with this fracture. And how you going to deal with it operatively in the exam or even life, you're going to say I'm a selective trans.
And that's because I'm going to check if there's subluxation after I've decompressed it and if there's any contact with the metalwork. The radial nerve should also be seen to be not under the plate. The lateral plate more proximally. I remember that tip about where the radial nerve is. And it's the patient's Hand's breadth above the lateral epicondyle decision, 5 Watt plating technique.
Are you going to use. So you've decided on, you're going to do an rf, you've decided that you've going to use your approach. You decided that you're going to selectively transpose the nerve. Then you've got to make a decision on which plating technique. And there's two different plating techniques. Whether you use a parallel plating, that's the Black line or you use the 90 90 degree plating, which is the dotted line.
You can see from this paper in 2013 that there is no difference in the outcomes. Same with the complications. And so in summary, for grief of an artist or human fracture, use the ABC description for the exam a for attaching the articular fragments again. B for bridging the articular block to the shaft with epicondyle and plates.
Whether it's parallel or orthogonal and see for compressing the condyles through the plates. Remember that case? I showed you where there was a nonunion of the epicondyle. Tips and tricks use a threaded wire if you can. They act for the reduction of the articular surface, they can be left temporarily or take the left permanently cut in situ if you want and it's on, I use a particular set.
You don't need to use that set. But if you are going to use this equipment plating system, by the way, I get no royalties from them, then I would recommend in the majority of cases to use this the shortest plate so that it has the least interference with the ulnar nerve. As you can see here in my evolution, I used to use the right hand picture, it was an X-ray from an A fracture that I fixed many years ago and that I use the longer plate with the thicker screws.
And here I've used a shorter plate with smaller screws. Mind the gap both in the front and the back in the olecranon fossa and the cardioid fossa to make sure that the screws do not penetrate there and make sure that your screws are as long as possible into digitale and they all go through the plate and as many fragments as possible to get the strongest construct. And you can see once again, the hair the girth of the screws has is different and not half a millimeter difference.
Times 4 gives you a bit more to play with in the distal fragment. OK, six, so this looks a little bit different to the others that we've shown, it's intra articular. It looks a bit more osteopenia because it's a 70-year-old. If you need a CT scan, then here you go. And if you need more evidence that this is a comminuted osteopenia fracture, then hopefully that's being provided by the CT scan.
So should you go for arthroplasty or an RF in these great and 65 year olds? Well, Michael McKee from originally from Canada and the Canadian Orthopedic trauma society ran a randomized, controlled trial many years ago and small numbers which showed that the total elbow arthroplasty did much better than the rf, which is here in the blue on this graph, whereas the elbow passes in red and they published this in the Journal of shoulder and elbow surgery in 2009.
What if you choose to delay and elbow arthroplasty from trauma? Well, this publication from Prasarita hotel in 2008 shows there wasn't statistically significant difference in outcome, but it was trending at the seven year mark to a greater survivorship if they had early elbow replacement following trauma complications following total elbow arthroplasty. You can see there's a lot of them, so patients with a reoperation in these different series, you can see even in total elbow arthroplasty, you can have one quarter of patients requiring further surgery.
But in comparison to the operatively fixed patients in each of the papers, it's significantly less. So there's great data from the National Joint registry, and you should use this for your exams. There is a section on the elbows with using it for acute trauma, and you can see that there's been a massive rise in using distal humor or heavy arthroplasty. As you can see on this right hand graph, it's become extremely popular.
So the rise of the hemi arthroplasty, you can see this anecdotal results. Has a really good technique from joy, deep sadness and brighten. He's published it in shoulder and elbow on fixing the tube. The condylar fragments to both the shaft and to the implant. And you can see the little tips and tricks he's given there. And he, in that same paper published the results of hemiarthroplasty as opposed to total of arthroplasty.
Once again, they are small k-series only patient 7 to 42 patients at the most. So we need more long term data on that, and I think that will come from the National Joint registry, but complications occur in those hemi Arthur arthroplasty as well. And you can see the nerve is usually the ulnar nerve is the one that gets irritated the most. Pick your winners, look at the mortality rate of those patients that had a total elbow replacement or hemi after for acute trauma 20% at five years.
So and 13% at four years, 10% at three years, just like the proximal humeral fractures. These are usually fragile patients, so you need to have that conversation with the patient and make sure that they are optimized. So in summary, if you're not operative, get them moving early. Otherwise they get a very stiff elbow. Your surgical approach is Carte selective ulnar nerve transposition.
Plating technique doesn't matter which approach arthroplasty me to say, but without further ado. An overall summary of today's three topics it's all about the evidence based shared decision making. There are many decisions that we use are based on tribal instincts, and there are lots of new randomized controlled trials that hopefully you are now familiar with or will go and look up, and that there is lots of data within the National Joint Registry for using arthroplasty.
Fractures of the humerus are not funny, but treating them hopefully will now be fun. Thank you for your time. Thank you very much. There is no much questions about the lower third humerus. OK, I'm actually one question from the middle third. The brace, is it for the whole three months all the time?
I say, yeah, that's really good. So initially, yes, it will be all the time. But the hydrostatic pressure works by adjusting the brace regularly and frequently as the swelling comes down. So in the first couple of weeks, the patient's going to be in a lot of pain. It's going to be pretty swollen. And so they're going to stay in that brace for the 24/7.
They you will teach them about hygiene, about auxiliary hygiene, you will ask. They won't be able to adjust the Velcro straps themselves. They'll need help from their family and friends. And so it will be good to have some sort of resource on patient information how to do that, and that's why you bring them to the clinic as well. So you get your plaster technicians who are vital team members to help them look after that in the longer term.
And as time goes on, then, especially after a couple of months, the patients become much more comfortable and they can take the brace off for longer periods of time and they wean themselves out of it over that last couple of months, basically. Thank you very much. I think this is all the questions being asked. Thank you. Thank you.
Yeah, thank you very much, Neal. That was a really interesting talk. I liked the little musical interludes as well. And yeah, I guess, you know, the three things that I picked up that I thought were the buzzwords for the exam. And I picked three because I was always told less than three things a day was lazy and more than learning three things a day was greedy.
So the three things that I picked up were was the Sammy enterprise and how it works. I got our start in my vyver, and you gave a really good explanation of it. So candidates, you need to take that with you. And remember it. The second one was where to find the radial nerve in those fractures. You know, I was kind of taught wherever you want to put your plate, the radial nerve will be just at the end of the plate.
But yeah, I remember the bit about the patient's hand above the lateral epicondyle that's been asked in the exams as well frequently. And the third thing was, I like the phrase selective transposed for the ulnar nerve. I thought that was just such a nice way of saying because you always get asked, are you going to transpose the ulnar nerve? And the answer is it depends on the situation. But I liked that phrase, and I think that's a nice buzz word for the candidates to take forward.
So thank you very much. I had a, you know, a really entertaining talk, and I'm sure that everybody's learned quite a lot. And as I said before, guys, this will be available on the websites for you to watch it again and go through it. So thank you very much. Have you got anything to add, neal? No just enjoy your training.
Best days of your lives in school. Have fun. Great thank you very much, Neal. Thank you.
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