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Elbow Trauma for Postgraduate Orthopaedic Exams
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Elbow Trauma for Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
Good evening, everyone. So once again, thank you for joining our webinar today in conjunction with orthopedic Research UK and the folks mental group. We're going to have a talk today on elbow trauma and we're delighted to have Louis van rensburg with us.
He is a consultant, orthopedic surgeon from Addenbrooke's Hospital Cambridge, who has a special interest in them and particularly problems of the shoulder and elbow. So he'll give us a talk about elbow trauma with regards to the triad and beyond. We'll have some short questions, so please write those questions down in the chat box and imagine and the other members of the Uruk team will be able to pick those up, as will we and we'll bring those across to.
Mr Van rensburg will then go through maybe some case discussions with regards to the GMFCS exam, and we will finish off with some vyver practice. So if you wish to take part in the Viva, please let us through the. Chat box again. And we'll make note of the names, I appreciate it's difficult, but it will be a first come, first served basis and then we'll finish at 9.30, hopefully and wish you all the best.
OK, so I'll hand you over to Mr Van rensburg. Right great, thank you. My screen coming through. OK good. OK, so today I'm going to be talking a bit about elbow instability and beyond the triads is the title. So, yeah, we have a 54-year-old male who gets involved in an accident, he falls off his bicycle and sustains this injury.
I don't know if you can put the first pole up, perhaps Ruth. We launch polling continued, so there are options for polling. Are you going to just reduce the elbow? Are you going to? Fix the railhead with a plate. Are you going to fix it with a tripod and screws?
Are you going to do a radial head replacement? Well, you're going to just excise the radial head because it's too common, you try to fix. At the moment, radial head replacement is winning. Men no one wants to fix it yet. OK, I think I'll stop the polling there we are about 3/4 of the way through the people and.
There we go. So seven per cent, seven or seven, we'll just reduce the elbow, 20% will fix the real head with a plate. 18% will fix the radial head with a tripod screws on the UK website. I debated with Roger Bennett whether to use screws or tripods and on that plates or tripods, and on that occasion he won.
Obviously, his teaching didn't last, and I'll remind him of that when I see him next time. 51% are going to fix that are going to replace that radial head and 5% organic size the radial head. Ok? um, just move to the next slide. So this same case based on what you're going to do.
Are you going to take a boyed approach between ulna and antonius? Are you going to do a cock between unconscious and icu? Are you going to do a Kaplan ECB and edc? Are you going to do the etic split or the rossington approach?
OK so we're getting up to about 100 people who've polled or voted this a reasonable numbers. 10% are going to go through Boyd's interval, that's between ulnar and unconscious. 40% are going to do a B the Cocker. 30% are going to do a Kaplan and 12% are going to do an EDC split and only 6% are going to do the writing and the writing is on osteotomy. And I think that probably fits that stayed fairly steady over my time, I seem to see that people in Europe or certainly in the UK tend to prefer Cocker.
I guess they think it's safer downside with cockroaches. You don't get to see a lot. When I go to Europe and possibly see people talking from America, they more talking about the Kaplan. If I had to pick that a approach, I'd do the etic split because I can never find that interval between ECB and EDC. But interesting, funny.
We don't all do the same things. OK going to stop the polling there and just do a little bit of talking. So we're talking about instability today and we're coming down the tree. From simple instability to complex and within complex instability, you've got the severe soft tissue injuries, you've got the terrible triad, which is a dislocation, radial head fracture and convoyed fracture, posterior medial rotator instability or that enter medial coronary and then the proximal ulna fracture dislocations, which include the silicon on fracture dislocations and the montejo variants.
And what I'm going to be talking about mostly today is these terrible triads, the kind of instability that often comes with posterior lateral rotator stability, but not unique to that. Many people have written about it, lots of different texts, but this is probably the first text that sort of highlighted to us of how bad it can be. I'll just clear those annotations. 2002 Ring and Jupiter found 11 cases over seven years.
And this pattern of injury is so troublesome and unpredictable that the surgeon should be prepared intraoperatively for persistent elbow instability in spite of repairing the coronary, the radial head lateral collateral ligament complex. And they went on to say that even if you repair the MCL, it then doesn't add a lot of stability and you might need to transfix the only human joint, or you might need to do an external fixator.
So that's what we thought in 2002. So how we see a 47-year-old lady who has a posterior lateral dislocation, there's a radial head fracture and a tiny little piece of the coroner. Those are initial post-production forms with the concentric reduction, small, little it reasonable side radial head fracture. Day two, she gets re x-rayed and you can see that it's really dislocated.
So what do you do in a dislocates? You put it back in again. She gets manipulated on day 5 and reproduced. And you can see on the back slap image the one on your far right. The drop sign. The increased distance between the humerus and the ulnar. And as you suspected, day 14, she falls out again. Day 16, she gets a radial head replacement, and that's all that's really not notes.
No mention of the crown or no mention of the entire capsule. No mention of the lateral collateral ligament. And after the real hip replacement gets done, she gets put back into a back slap. You guessed it. Unfortunately, now they left it six weeks before they took another X-ray and that's who X-ray six weeks. They changed the cost for slightly better cost the lightweight, soft, soft cost.
And again, you see that the radial head is dislocated. And that's why the terrible triet has got such a bad name and why it's so terrible, because if you don't treat it properly from the start, then you will need to put an external fixator onto it. I'm not sure he's doing the drawings. Now, this is not a drop zone, by the way. This is only a human distraction because you've got stiffness and instability, which is one of the worst situations you can be in.
That's the job to. This is her now at 14 weeks with the Zexal moved, and she's got an arc of movement from 110 to 45. Not a bad looking X-ray at six months, but when you take it out to months, you'll see that there's absolutely no cartilage left in it on only human joint. And that's a shocking outcome. And that's why the terrible tide is terrible.
These are the pictures that ring and Jupiter showed us in their paper of 2002 with trans fixation of the only human joint radial head replacements with lots of head ossification. They only found 11 cases. All of them were initially reduced, and out of those that were initially reduced, seven we dislocated. So those five that we're just going to simply reduce the elbow and leave it at that, not do anything to the radial head.
There's a 70% chance you're going to dislocate. 10 out of them had surgery. Those seven that dislocated and three others, and in fact, of those that had surgery, five dislocated in their post-operative splint. More importantly, those that had a radial head excision all dislocated. So one of the things you can't do in complex instability, one of the things you can't do as an absolute, there's very few times I'll say there's absolute things, but one of the things you can't do in terrible triad is excised.
The radial head. Now, the thing is up for debate. Now and Jupiter said at the end of their paper, in the treatment of this troublesome pattern of injuries, the primary goal should be restoration of elbow stability, and they even went as far as transfixing on human joint or putting an external fixates.
This is where it's important, where you need to buy into this concept of static incongruity and dynamic concrete. This idea that if you mobilize an elbow, if you put a back slap or cost onto an unstable elbow, it does not make that elbow more stable. All that being put into a splint of the seven dislocated of those that were operated on five dislocated in the splint.
And these were the pictures that we've seen earlier of the lady who spent. Four or five times going back to theater to try and get a good elbow. And you see the back slap, the back slap doesn't keep the elbow in all the back slap does is add weight to the elbow, increasing the drop zone. Now I disagree with this article that came out in 2005, and if you see a drop sign that you need to put an external, fixate on it.
If you see a drop sign, you need to worry about that elbow. But more importantly, you need to get that elbow moving. You need to believe in dynamic concrete. Adding a cost to an unstable elbow merely increases the distraction of your own human joint, adding a splint. Now I do sometimes use Hinsdale my braces. It only adds about 2 millimeters if you can see here on distraction.
So I don't use them often, but I do use them sometimes. Sometimes the patient needs them. Sometimes they psych needs them, sometimes I need them. So I don't normally immobilize people. But sometimes I will use a hinged elbow brace if I want to limit the extension a little. You genuinely need to buy into this concept of dynamic concreting. This is a paper by Duckworth.
I love what he writes. This is 2008, and he showed us these x-rays of a 24-year-old post-adoption with laxity, a drop sign on the lateral view, and several weeks later, with exercises and avoidance of varus stress. Various stress puts a lateral collateral ligament stress on your elbow, and they've got a good elbow. When you move an elbow, biceps fires up, reduces your own human joint if you actively supernaturally elbow, you fire up biceps biceps pulls on bas status tuberosity, which reduces your radio capital, a joint if you promote your forearm.
It doesn't really, I don't believe, tighten up the lateral structures, as is often written in textbooks. But what it does is it wraps biceps around the possible tuberosity, increasing the tone in biceps, pulling your radio joint, reducing you on a human joint, stopping that disrupt the structure. This extraction of only human joint allowing the elbow to just dislocate.
Now, how do if an elbow is stable enough to get it moving because sometimes, yes, the elbow is so unstable, you can't get it moving. And a number of signs have been advocated here as the hanging arm sign. And by this paper by Russia and 2011. And that's just basically putting the arm out in full extension, and if that arm is stable and doesn't dislocate like that, that's stable enough to get it moving with the provisos of avoidance of varus stress.
So don't have ducked your shoulder work in straight lines up and down, lie down in the bed and move your arm up and down. That reduces your rate of capital and reduces your only human joint. Another definition that has often been used is an elbow that is stable and congruent to within the last 30 degrees of extension. Because if your elbow is stable and congruent within the last 30 degrees of extension, it is stable enough to get that elbow moving.
It is stable enough to not need an external fixator, not need Crosswhite fixation, not normally need an elbow brace. And so this is how I will egawa and elbow a lot of them flat on their back. Mat on the image, intensifier arch straight and get an X-ray to make sure that your elbow is reduced. Flex the elbow 30 degrees to disengage the electron from the olecranon fossa and then place a varus stress.
You can see a little bit of opening on the lateral side, so lightly disrupted partly the lateral collateral ligament complex, but the common extensor origin is likely intact in this one. This is a big stress test in a normal elbow, and it looks like the elbows drifting a long way away. And what you need to do is protect the forearm, lock the radial head. Onto the Capitol and also into irritate the shoulder so that you lock that elbow and so you'll always find my vulgar stress tests or with the arm protonated.
And that's how, you know, it's a bogus test because the radius will be crossing the honor, then that tells me what's happening to the medial structures and the lateral structures, the collateral ligaments and the muscle origins. Common extents and common extent surgeons. But I actually don't really worry too much what's happening there. What I want to know is that elbow stable and congruent to within 30 degrees of extension, because if it is, it's stable enough to get it moving and elbow instability is treated with movement.
So you start with the elbow reduced, fully flexed, and you gradually extend the elbow and screen it. And that's the picture you want to see an absolutely reduced radio capital, a joint in an absolutely congruent only human joint. If you're really confident you can go on and take an X-ray with your drop on sign. I do worry sometimes, particularly in those that are fixed or spent a lot of time reconstruction.
I don't often go to the drop arm. I normally stop at about 30 degrees. If it's stable till there, that's it. I stop. I wake the patient up. I've done enough. Then the next step is for me to inspire the confidence in that patient to get that elbow moving. So the treatment of all instability, whether it's simple or complex, is movement, what you need to do is make sure or allow that elbow to be stable enough to move and often in the second level of complex instability.
It means repairing the soft tissues. It means fixing or replacing the broken bones. And restoring bone incongruity and then repairing the soft tissues to a degree sufficient enough to allow the elbow to move. And we know it's enough when it's stable and congruent within 30 degrees of extension. A little bit of screening just to show you what I mean. Vulgar stress test, we know that because the radius is crossing the ulnar, and on this occasion he's ruptured his medial collateral ligament and the common flexor origin.
You don't open that medial side like that if you've just done the MCL. This is MQL and CFO. And as you go up the ladder of injury from just ligament to ligament and soft tissue, it's more likely to be complex. It's more likely not to be stable to within 30 degrees of extension and more likely to acquire some form of surgical intervention to stabilize it.
There's the various test, and we see the radial head and neck fracture, we see how the lateral collateral ligament in common extents origin is gone. There's not much holding this elbow in place. We start on the lateral now. Make sure you bring your eye around to do the lateral. Don't twist the arm because if you twist the arm, you're applying an external rotation force on that elbow pierre-louis pierre-mauroy, but you basically twist it elbow out.
So bring your eye around so that you're testing your extension in one plane. And here we see how the elbow goes gradually into extension and we get to about 70 or 80 degrees and it jumps out. And what does that tell me? Tells me that this elbow isn't stable enough to get moving, and so I need to fix it. Whatever needs fixing till it's stable enough to get moving and in the terrible triad, we need to think about the radial head.
We need to think about the convoyed and the dislocation. And in fact, the dislocation is really thinking about the soft tissue components, MCL, LCL, common stents and common flexo-pronator. Now probably start with the most controversial with the coroner would. So he has an article that came out 20, 14 terrible injuries to the elbow. Does the cronut always need to be fixed?
In two years, they found 14. No ring and Jupiter in seven years at a level one trauma center took them seven years to find 11. But that's OK. They found 14 in two years. Talking about Reagan Murray, 1 and 2 comminuted fractures, our clinical results challenge the accepted belief that the current award must be fixed in all troubled prior injuries support the notion that the current order and capsule repairs are not required.
And avoidance of this unnecessary surgical fixation in these instances may positively affect functional outcomes. I've highlighted the words that worry me there Reagan Mori top one and 2 when it comes to the corner. We've moved on from Reagan mori, no longer this two dimensional appreciation of the coroner. There's so much more interesting stuff about the coroner than just the two dimensional classification that came out in 1989.
In select cases, well, how do you select the cases and how do the convoyed didn't need fixing until it's dislocated or capsule didn't need repairing until it's dislocated on you? And if you've only had 14? I'm sorry, but this suffers from a power problem here. A necessary surgical fixation in these may. OK, well, it may. Lots of things.
May 2014 and they show you these pictures of a terrible triad with repair of the lateral collateral ligament in common extents origin and a radial hip replacement that did well. We're going to take a little bit of a detour now and talk about the classification. Reagan Maori from 89 O'Driscoll in 2003 and Adam Watt's classification of elbow instability, where he talks about the terrible triad that could be the combined with the C. That's when it's that little bit of coroner Ed often the radial head, and he also have highlights to us the importance of this big facet, this basil one.
Now, sometimes it's not right at the base, so it's not quite basil, so it doesn't fit into a Driscoll. Its classification of the top 3s and is often a little bit of overlap, and sometimes you'll have a big facet which is hiding or masquerading for want of a better word as a tip fracture. Although there isn't really a tip to the canutt because there's lots of tips to the coroner. So none of the classifications are perfect, and I'd certainly move away from Reagan Mori because it's no longer just the size of the convoyed, but nowadays when you're thinking about the corner, that's where that corner is broken.
Now, Jessica alluded to that in 2003, we talked about the tip ventromedial ridge. And the basil fractures. Adam writes in his classification from rimington, talking about these combined fractures, which are the true pure, pure, terrible triads where you just need to do the radial head and lateral collateral ligament. But if you've got that big facet to the basilar, it's a little bit more to that paranoid.
Sometimes you do need to fix that coracoid. Yeah this article came out in 2013 and really shows us beautifully how the coroner is not this two dimensional buffer, which we see it as we see it, as this buffer that stops the radial head from jumping up and running forward that stops the chocolate from jumping up and running forward. It's got the three ridges and in the terrible triad, the classic pattern is that it breaks off this intermediate ridge like you see here on this volume rendered traject.
This little piece here, that's the classic, but sometimes it's a big facet masquerading as a terrible triad, sort of classic one. And then you need to worry about it. And I think that the cronut works more than just a buffer just from stopping the chocolate or convoyed, but because of that little overhang, because of that little hook. It works almost like you see ladies bags, hooks or, you know, a bag hook that's holding on to a table.
You don't need a lot of an overhang to really improve the stability to that construct. Now, one of the reasons people don't like fixing the car annoyed is depending on your approach, depending on how you try and get to that elbow, because often if it's breaking off on the lateral side of the road, you can't get to it from the medial side unless it's an intermediate coronary.
You can't get it from the medial side. So now you often trying to get to that small corner would fragment from the lateral side. And really, if you're going with a Cocker, the only way you can get to it with the car is if you take the radial head out the way they are. And that's why probably 50% of you are excising the radial head not saying that you can get to the it, but it then provides you access to everything.
If you do a Kaplan on EDC split, you can get to it, but often to get to it. It comes at an expense and that expense is that you have to strip the capsule off the proximal humerus. And as far as I'm concerned, when I'm fixing a terrible triad, I want mechanical stability but also want to return the proprioception to this elbow. I want this elbow to know that it's developing a drop sign, that it's falling out of the elbow and that it needs to pull itself up and it needs to pull itself up with biceps with brachial.
You can see the coroner, Lloyd, and this corner here through Boyd's dental. That's the approach I like, but you don't have to do Boyd, but you can see that. But of course, annoyed you can move the radial head. If it's partially fractured to the side, you can get to that anterior capsule. Now, this was an article that alluded to the fact that such a fixation of that foreign aid doesn't restore the kinematics.
And it doesn't restore the kinematics, because it no longer works as a buffer. It doesn't restore the kinematics, because it's probably no longer working as that bag hook. I talked about. We're just a little bit of an overhang. OK but I love reading articles, the text and then looking at the pictures. And when I look at these pictures, I think about this orange structure and that unstructured there is capsule.
And I look at this reflected yellow structure with the blue outline that comes around it. And do you know what that is yet? Yes, that's the anterior insertion of the annular ligament. So now you go cut annular ligament with your Kaplan, with your Cocker, with your SDDC split and you break your annular ligament in two places because often it's ripped off the front part.
Of the electron, because that's the weak point we learned about that in 1958. And so for me, repairing these small paranoids, these I'm going to say it, Reagan worry type one, type two, I'm going to say two fractures, but in fact, no, what I'm going to say is these small pieces of the intermediate ridge because it's that piece of the cone with that breaks and I'm not tripping.
I used to say I'm a pain in the corner, but I'm not. What I'm repairing is that anterior capsule and I'm repairing in confluence. The anterior part of the annular ligament because I want to bring as much stability back to this elbow as I can so that I don't have to transfix my ulnar human joints so that I don't have to put an external fixate on this elbow and take out the patient's radial nerve.
And I don't want to know that I should have fixed it when I'm all finished and I'm closed. And that's what the problem is with those small papers that tell you you don't need to fix the car annoyed or repair the capsule if they suffer from the fact that they've only really come across those lowest small lowercase t conoil. So he has a dichotomy, 2002 we got ring and Jupiter telling us that despite fixing coronal electrical ligament, radial head and media, Michelle doesn't add much that you're in a world of pain.
And here in 2014, and these are not the only authors, there are the authors who are saying the same thing that you don't need to do the paranoid. Watch out if you're reading about Reagan Marie 1 and 2. It's a two dimensional structure now I want to be talking about someone who's talking about a drizzles classification, or possibly even now, the writing and classification of fracture dislocations of the elbow.
And I think what you'll certainly find if you've come across enough terrible trades is that as there is a spectrum in instability from simple to complex, even within the terrible triads, there's three people who belong to a gang and there's three notes played on a piano. They're terrible triads with a capital T and the terrible triads with a small t. Let's have a look at that.
There we see a 74-year-old female with a dislocation. It's jumped back. It hasn't moved any further laterally or medially. The displacement between the humerus and the ulnar are close. And so I can almost predict that the collateral ligaments and the soft tissue injury, the dislocation part to this elbow is actually relatively small. Small, little bit of coronal.
And there's another piece here, but I don't know quite what that is. It turns out that happens to be radial head and he off day, not x-rays, post reduction in a back slap. I don't have a problem immediately putting them into a backslide for a week or so. But I wouldn't leave them much longer than that. And in those production forms, I see no drops on some. My heart rate is coming down and becoming more.
This is a terrible triad with tiny teeth. I'm not going to have to worry about this. If I have a look at the actual scans. They're not great because you can see that the scan was done with the elbow off the side. We'll see a little chunk of bone. I see another little flake of bone and I see the radial head coming into view. I'll go and do the coronal fractures, and they haven't quite got the Gantry in the right thing.
And that's the problem with CT. Again, radiographers don't always to put it into the plane of the humerus or the plane of the forearm. But what you really wanted on is the plane of the coronary, and that's why the volume rendered CDC is really make a big difference. I'll just play that note again because I got distracted while I was talking.
And there's this picture and just the way you've got those Hard sclerotic edges to me, that piece. That piece looks like it's a sorry that. That piece looks to me like it's a radial head fragment. I just had to move the Zoom sort of bits might have missed that day on the sagittal, but it looks like there's a small little flake off the top of the radial head.
So just by definition, yes, the terrible triad, radial head coronary dislocation, but really not really significant, hasn't displaced fire. He has the X-rays in a brace at one week. There's the X-rays at three weeks and there's the X-rays at six weeks and there's the X-rays at three months. A little bit of H0 kicked out in the front, but pretty good. Only will joined a pretty good radio capital, a joint stable, conjoined elbow and a happy patient.
So can non operative treatment work, Yes. Again, ring from 2010, published in the Journal of hand surgery, but it was only a case series of four, and that's pretty good to get a case as of four in the Journal of hand surgery treated well and one was stiff. And they go on to say that in selected cases, you can treat them non operatively with a small radial head. Well, aligned.
Minimally displaced. No mechanical block. So there's no reason to fix that radial head. For whatever good reason, patients might regain good elbow movement. And I just highlight some of the things important thing here are selected cases well, aligned small, minimally displaced might. And so if you're going to treat a terrible triad or complex instability non operatively, I think it is reasonable.
But then you need to keep a close eye on them. You don't then just see them again at six weeks because the elbow will slip out without you knowing she will come back at six weeks with a dislocated elbow. And then you're getting into that realm of chronic instability and stiffness, particularly if it's around three months. And sometimes you'll see that, which is a bit of a sadness.
So yes, you can treat the terrible crime on operatively with those provisos, but then watch them closely bring them back early. So we see a 45-year-old male has an opening due to his elbow. Again, I see a posterior dislocation hasn't really gone a long way lateral. I see a convoyed fragment. I see the radial head fragment there and looks like some of the radial head is probably attached to the shaft.
I had floating meeting controls. Let's run the sagittal first. So you can see the gas in the soft tissues. I see the radial head fracture, there's a piece off the front. But there's a big piece attached to the shaft. And so although these two pieces of radial head that are separated from the shaft, there's one big piece in fact attached to the shaft.
And that's a winner, winner, chicken dinner when there's a big piece of radial head attached to the shaft because then it's quite easy just to bolt those other little small fragments onto it. If the head is totally disassembled from the shaft and not only are they broken into three big pieces in that dimension, but very thin on the lateral, then I'm thinking maybe I can't fix it. But for me, based on those vegetables, you know, that radial head is fixable.
OK 3-d, we see it spinning around. And I'm starting to see things here that worry me. And the things that worry me are the only human distraction that drops on scene in the city, which means post your band of Michelle is gone, which means MQL is gone, almost certainly into a band of MQL. And I'll just spin this one again. And that's not classic intermediate range, this is not classic tip.
This is the beginning of the basil or by facet. And so is this one of those writings and by facets, which is masquerading as a terrible trial on its own? And that pattern of the railhead, this has more of a buffer. This has been more of a shunt than a rotation to break the Cardinal in this pattern and to break the radial head in that pattern.
There's also more soft tissue ligament mischief happening in this elbow. You get produced and comes up, gets seen at a week, and I'm really nervous now, I see the drop sign, but most importantly, I see subluxation of the cell phone, how it's point loading. And so there's no way I can treat this one on operatively because the cochlear will just erode on this. And within a year you'll find it this Albers arthritic.
OK, so this person is having surgery and here are fixed it with a tripod and I fixed it with a tripod and the mini screws just to fix one or two pieces back because most of it was actually intact. And so this tripod is not taking a lot of force. If those pieces were smaller, if I needed more support, if my annoyed was worse, I might have considered plating it. And I've repaired the lateral collateral ligament is complex and the common extents origin.
There's now various force, so that looks good. There's my values for suggesting MQL and common flexo-pronator is involved, but I really don't mind whether it's involved or not. What I want to know is this elbow stable to within 30 degrees of extension. And I get to about 45 when it hinges a little, but I get it fully straight and it pops back in again because I have repaired the capsule.
I have repaired to a band of that annular ligament in which, as it goes in further extension, it then pops back in. And so I decided to treat him non operatively an extra him day for because I'm a little bit nervous about this one. And I see at a barter day for post op again, he's point loading on that tippecanoe, and you can see it. The convoyed is flown away now, didn't fix the cronut because it was a bit too comminuted for me.
But I look at that, and I think I can't leave a 45 year old's elbow Black or otherwise, he will wear it out and he will get arthritis, we see that with the end to medial. I think that if I flex you, if I start moving you, maybe if you tighten that biceps and break your earlier. So I give him a good talking to you and say, get your elbow going, get it moving. And we see there the X-rays subluxation at 11 days and you can't leave that alone.
And you can't leave that alone because the broccoli's point loading on that corner of the ulnar. And that'll wear away so relatively tenuous fixation on my radial head butt that's held where the capital joint is reduced. But I'll see this drop sign. And so a few days later, I finish off repairing MQL and fixing the canoed. Managed to catch it with a screw from back to front.
I could have, but just plated it. I had in my mind that I would take off the tip of his electron on or in fact, excises radial head if I had to and use his radial head as an auto paranoid if I needed it. But I managed to get a relatively stable, congruent elbow. You see, the cone would still remaining reduced. Do you see you're good on the human joint on the ap?
So I think we might have got away with that one. But watch out, though, those big facet by cord injuries in terms of the radial head. Most people wanted to do a Cocker. Some would do a Kaplan. Yeah, I'm not going to go into the approaches today because I don't have all the time. I just need to keep moving. So this was about 54-year-old.
Do you fix it? Do you replace it? Do you excise it? There's lots of things that go into that in general principles. If there are three pieces, if you see three, there'll be four. And if you see four, there'll be five. You can fix it generally if there's three.
And if you do replace it, make sure that you don't stuff it. Whether you screws or plate really depends on the other injuries and how much support this lateral structure is going to need, and so I tailor it despite what I tried to on the truck debate. I do use tripod screws quite often. I use plates if I need to. But increasingly, I'm using screws. If you replace it, don't overstuffed.
This radial head is overstuffed. It's proud of the lateral facet of the only human joint. This was fixed through a corker, and so they started fixing a three part fracture, the radial head couldn't fix it, then they decided to replace it, and by the time they got in there, they'd repeat at least the lateral ulnar collateral ligament. Because you're coming through the car, you can't see the relationship between your radial head and your lateral facet of conjoined.
Unless you X-ray it and before you know it, you've overstuffed it. Is this actually overstuffed? Yeah, it probably is not a lot, but it probably is. I would want that to be just in line here with your lateral facet. Now you can't take widening of the lateral human joint. I used to look at this and think that widening of the lateral a humid joint was an indication of over stuffing.
But that can be very variable, as shown here by Graham King in 2007. And so the real way to tell if your radial head is the right height, the best way is intraoperatively to see it. You can see it from a chaplain, you can see it from an IED split from the front. You can see it from the back, from the Boyd, but you can't see it from the car unless you really have stripped off all of lateral collateral ligament common extents origin.
Sometimes you'll see these X-rays post op, is this overstuffed that is proud of the lateral facet of the only humanoid, but there are the X-rays intraoperatively. And the reason that happened is because the X-ray beam is there a little bit stiff when they come for their first X-ray and so the elbow is partially flexed and the radiography, instead of taking an AP radiograph of the forearm, takes an AP radiograph of the elbow in Midway between flexion and extension sort of halfway across.
And what you want to do is ask them to take an AP radiograph of the forearm, see an absolutely tangential view of your radial head replacement, and then you can tell whether it's the correct length because this is the exact same patient. Remember that the real head moves proximally and distally on pronation and cuponation, just for completeness, this Hank is in the wrong place.
It should be sitting there. This paper showed us how to take into account the cartilage, and so sometimes your radial head should actually be a millimeter too proud of that corner. But that's probably taking real heat replacement a little bit too far. But it does need to be a little bit proud. Just a smidgen. And remember that the Capitol nestles inside your radial head.
Don't make it too big. Don't overstock. Don't make it too wide. But it also nestled inside the real head, so you real hair is often a little bit wider than your Capitol Hill. As for rich railhead, there's no right or wrong. This paper suggested that the most best regulation is this bipolar cemented by Italian prosthesis. And the reason it's the best radial hip replacement is because once you put that real head replacement in, no one is going to revise that radial head.
You need to come to me saying that you can't walk before I'm going to think about changing that stem. And so people just get into the basement, they get just into Stockholm, whereas these radial heads where they work themselves loose. My threshold to replace that, to revise it or just take it out once everything else is healed is actually very low. Did miss epicondyle did a good study review article?
Looking at all the articles 2016 and said that there's no one that's better than the other, really, that philosophy of the anatomic versus the non anatomic space, I think it's really a 50-50 ball. The proviso being is that the silicone you can't really use silicon. It doesn't work. Keep away from it. The last thing to talk about is the soft tissue injury that the lateral collateral ligament is complex.
The center of access runs through on the medial on the lateral side and the center of the capital. And that's where you want to put your anchor dead center in the capital. In essence, if you think of your lateral collateral ligament is complex, is a y lateral collateral ligament, is conflict proper, then the anti-carbon, which goes over the top and attaches to that little ridge where your intermediate ridges and then onto the supernatant crest.
Remember showed you that picture earlier, that top one, colonel, the little piece of the intermediate ridge. It's not about that little piece of bone because you can't buy mechanically construct that bag hook, but you can buy repairing the entire capsule. And by repairing that part of the annular ligament through transocean's drill holes through your owner, which you can see if you've removed the radial head, which you can see if you've done a boyed approach will bring more stability to the elbow.
Now you won't dislocate if you don't fix it. You'll have laxity. And that's what this article is saying, if you break it in one place, you'll get laxity. If you break it in two places, you'll get instability. If you're doing a Caplin or an EDC spit, you need to make sure that you repair that and your ligament well. For me, the nice thing about Boyd is I can get a really good modified Kessler in my annular ligament with Transocean drill holes through the subcutaneous board of the ulnar and get it absolutely rock solid repair.
Most times the annular ligament is a complete abortion. Of the common extensor origin with the soft tissues. Sometimes it's shredded in the middle. Occasionally you'll see a ripping of the Super crest, but that's like a rarity. And so most times a single anchor into the common extents origin, a matter of your lateral collateral ligament in common extents origin, but do be prepared to create an internal brace.
If they have one of those where you've shredded the MCL in the middle. Normally it's this and you can fix it fairly easily in acute repair. You can just put an anchor into the center of the capital and repair it all as a mash repair. I'll use a decent sized anchor, so 5.5 Twin Peaks with two fiber wire.
You really want to be able to have the confidence to inspire your patient to get it moving. You can't be tenuous at that elbow because if you don't move it, it'll just dislocate again. Those 10 ring showed us. These sort of anchors for me are a little bit too small that loaded with one is not going to hold on to anything if the LCL is shredded mid substance. And be prepared to create an internal brace, an internal braces.
This concept of a high density polyethylene suture between the insertion and the origin of that ligament and the insertion and the origin of the lateral ulnar collateral ligament is sent of capitalism and the Super to crest. Yeah, you can see an internal brace created on the medial side, but you can create the same on the lateral side. Where do you put your anchor or where do you put your holes for your internal brace on that Super native crest?
The answer came from this study looking at single bundle lateral collateral ligament reconstruction, not internal brace. They looked at a distal hole and a proximal hole, and basically they showed that there's no difference. And so they simply put it in the middle. It's very seldom an acute terrible trial that you need. Couldn't need to reconstruct it. You need to reconstruct it if it's been delayed or if it's really dislocated or it's dislocated four or five times and been left for three months.
Most times in acute setting, you can get away with an acute repair or an acute repair plus or minus an internal brace. In general, most of the protocols will be to address that, although there may be laxity of the MCL only to repair the MCL if there's absolute instability, if that elbow is no longer stable to within the last 30 degrees of extension, then you need to go around the medial side.
And the one we repairing most often is the anterior band of the medial collateral ligament. A few articles looking at whether it's in tight in flexion extension from the late nineties, slightly better studies showing us the three dimensional structure of that and two band of the NCL suggesting that it winds around and that they all probably are symmetric. But the bottom line is anatomically, when you repairing a medial collateral ligament and you don't know where to put your anchors is, that's the spot not in the trolley there, but in the anterior inferior medial epicondyle and then running along that crest of the sublime cubicle.
And that time when you going to be repairing the muscle on the medial side is often when the bombs going off. So the CFO pulled off and you just need to feel for those bony prominences and you can put your anchor in repair with whatever sutures you got. What little bit of the medial collateral ligament you can find, but then leave one set to tie to each other as an internal brace.
So let's have a look at this case. MQL complex origin lateral collateral ligament goes into extension unstable. Gets radial head replacement, lateral collateral ligament reconstruction. And you can see the drill holes from front to back here, so I always repair a capsule and annular ligament. That little bit of coronary, I'm not really fixing the cronut, I'm repairing that capsule.
There we see the various force there we see the Vargas force opens up. Starts off, reduced, goes into extension. And starts to hinge out. Now, I'm worried a little here that this may not be stable enough to just absolutely get it moving. And so now I need to go around the medial side and repair the medial side. It was quite a significant injury to medial collateral ligament complex origin, and he had shredded the MCL, so I've created an internal brace between medial collateral ligament insertion on the anterior inferior medial epicondyle and on the sublime cubical and turn.
And to a medial carcinoid. Just showing you again, the significance of that middle engine likely why they required it. And once you've done lateral side and medial side testing the elbow in extension, elbows fully congruent in extension, and what does that tell me. That tells me that this elbow is stable enough to get it moving? That tells me that I don't need to transfix this elbow, don't need to put an ex fix onto this elbow.
And in the last 15 or so years, I've never had to transfix an acute terrible triad. If I followed the principles of repairing the very structures and then reassessing it and not stopping until I've got full extension and stable incongruent within the last three weeks of extension, just another case showing you, again, the internal brace and how that returned stability to the elbow. So in summary.
The terrible tide is a complex injury involving the radial head, the conoil and the dislocation. And even within the terrible triad, which is within the spectrum of elbow instability and complex instability, there remains a spectrum within the terrible triad. You need to think about your radial head. You can fix it, you can replace it, but you can never excise it.
You possibly don't need to repair the convoy, but those are only in those terrible triads that are small teeth. Think about your lateral structures, start off on the lateral side first. Fix that, reassess the elbow and only go round to the medial side if you have to. When it comes to the Kono classification and thinking about your would fracture, if you have the luxury, get yourself a volume rendered traject, look at that conoil.
Is that a true terrible triad carcinoid from the intermediate ridge? Just a small little piece? Or is this perhaps one of those bio facet by basil basil fractures that Adam watts was sort of alerting to us? And those are the ones that maybe you need to buttress it. Maybe you need to reconstruct it, either using tip of electron or radial head fragment if you need.
Watch out for those befits its buffets. They'll catch you sometimes once you've done the lateral side, and for me, I always do the capsule in that fixation of coronel because I can because I'm going to Boyd, then reassess it, and I'm not worried if there's ACL injury. I'm only worried if it's not stable within 30 degrees of extension. So if this elbow looked nice and congruent at this point, I wouldn't go around and fix that medial side, and I only fix the medial side if I need to.
And generally, if you get an acute terrible triad and you deal with everything appropriately right from the start, you don't bury your head in the sand and simply reduce the elbow and hope it'll be OK. The terrible triad often is not so terrible. Any questions? So, yes, there are a few questions.
Thank you for the excellent talk. And that cleared a lot of things in my mind, actually. So which classification do you use for the kernel fracture? I think there is a bit of is it to use the O'Driscoll classification or the classical tip less than 50 or more than 50 percent? I think although when I first started 2005, I looked at Fiona Driscoll's classification. Sir, you've just complicated it too much.
You do. You need to at least go to the level of Sean O'Driscoll, and you can't just look at it on a lateral anymore, particularly because it masking inside. This whole spectrum of instability is the intermediate Connolly and. And if you and you only picked those up if you look at the dimensional structure. I'm just going to move there quickly.
Share screen, sorry. So within the spectrum of instability, you've got complex instability. One of them is the ploy tarp, the terrible triads. But you've got this posterior medial rotator instability, which affects the entire medial paranoid. And if you don't look out for that injury now, if you're generalists, you probably will only come against one or two in your career.
But a year down the line, a relatively innocuous looking injury to the corner, it will end up with quite severe arthritis. And the reason people don't tolerate arthritis of that intermediate facet is because every time I pick up something, every time I reach for a cup of tea, every time I reach for product placement, coca-cola, I know you're not allowed to do product placement, but every time you reach for something, you put a very stress across your elbow and you load it, you offload joint and so you don't tolerate action or you can't tolerate a Starbucks Elmo.
And if you miss that big facet which is running on that, but of course, annoyed, not corner on that bit of yeah, the little bit left in ulnar the corner, but that's left. It wears out start process, which leads to fairly rapid arthritis within the elbow. So I think if classification, if you're treating elbow instability, you need to at least think of a driskell's. I disagree a little with this concept of the tip.
This is more to the middle. I like the idea of the intermediate ridge because I've got to be different somehow. I like Adam Watson's classification, but too complex for me. But Yeah. OK, thank you. So another question, how much joint space opening do you consider significant and do you compare to the other side?
That's a good question. So are you talking about joint space opening on your own humor joint, i.e. yours? Or are you talking about joint space narrowing on the medial side when you're testing missile or lateral sides? And the answer for that is I actually don't have an answer. We are hoping we will come to a height of the colloid, which is significant, which separates it from those little pieces that you don't need to worry about to the bigger pieces that do constitute a back convex facet, I think I take a lot of things in my head as to deciding when this is stable enough and when I've done enough.
But the most important really is that you fix something or do something on the lateral side. It's often easy to start there and then reassess how congruent is that elbow? For that radial head that had an ACL injury, I then look back at that ACL injury and is that a monstrously big ACL injury? Is it just opening on the medial compartment four or five millimeters?
So i.e. just medial collateral ligament, not medial collateral ligament and common flexo-pronator? But like that one I showed you, it was both. Whereas I can actually make a big difference to that if I've got a 2 or three moves of only human distraction and my MCL injury isn't that big. It only opens four or five miles. I'd probably take a run with it and wake you up and just get you moving your elbow.
Thank you. And, well, why did you check the elbow stability from 0 to 30 degrees. If the electron is already engaged? Yes so, you know, the last 30 probably doesn't make a difference, so once the Lieutenant engages, in fact, I've seen elbows that jump in the middle zone. Yes, but but what I want is an elbow.
I've got it reduced. At 90, I wanted to get out to at least 30 because if it gets to 30 and reduced any further, it normally locks into the Lebanon and then stabilizes itself. I think it's pretty sure that I can look that patient in the eye and say to them, look, your elbow is stable enough to get it moving. No, I mean it elbow stable enough to get it moving.
Yes, I know you've dislocated your elbow, but get it moving. Thank you. And do we need to always repair the capsule and travel traject? Well, that's the debate, sir. No luck. There's some of those articles which suggest you don't, but I worry a little about those articles with numbers of 14 that they're not really picking up the really complex, terrible triad, the one that is completely ripped his entire capsule that NATO bound themselves.
So Yes. Yeah, it's still a little bit open to debate. The wind is swinging to not having to repair that capsule. I repair it because I like the proprioception. And anecdotally, one of my Fellows has written a paper, but it hasn't been published yet. I see less of a drop zone when I switch a that anterior capsule. And in fact, for me, going through Boyd's interval. I don't have to fight to get to it.
I don't have to do anything more to get to it. I push the radial head to the side with a laminar spreader or with a ring handle spike or through if the head's not there anymore. Put one or two sutures into the capsule to drill holes from the subcutaneous port of the ulnar retrograde shuttle them. And it's done. It's not a big fight.
If you're coming from a lateral approach, if you're coming from a Cocker, yes, you can't get to it unless you've taken out that radial head. OK, thank you. And if you have to repair it, will you use sutures or anchors? I normally do sutures by looking down into the wound. I'll put sutures through the capsule, normally a fiber wire suture and then drill from subcutaneous border of ulnar down into the coronary.
I'll just show you a picture. Yeah well. So this one will do.
So this is the area that I'm catching here. Really, this cap. And if you take a stab incision over the point of the mikonan and drill with a 2 millimeter drill and exit into the base of where your fracture is or we have fractures on the other side, you can then reverse shuttle those sutures. You weave it in here. It's in this article.
So there you can see the drill holes and the statutes that have been passed. Through the subcutaneous board of ulnar nerve into capsule and then pulled on those sutures, reducing the capsule, reducing that little bit of coronary.
OK, thank you. And, well, the classical question of whether or not to when to fix, replace or excise the radial head, I wish I had an absolute number there. It really depends on a number of things, so it depends on the. So it's not just dependent in the terrible triad on the radial head, because I'm also looking at how much support this lateral column is going to have to afford this elbow.
So if MQL is intact, for example, the conoil fracture is just a tiny little piece of the intermediate ridge. It's not masquerading as a facet, then that radial head is not going to take a lot of load. So my fixation of that radial head can be tenuous because it'll be locked between capitalism and locked between annular ligament. But if my radial head is absolutely if my car annoyed is dust or lots of little pieces, I've got a big medial injury to the medial collateral ligament in the common flexor.
And then I made a lot more support on the lateral side. If you're in your 60s '50s. Well, I might as well. Just I'm 50 now, so OK. But I must still just chop out your radial head and give you a really, really, really rock solid lateral side, which will then support my MCL repair, which will then support my coronoid repair.
So, yeah, when do I fix it, I fix it when I can, because I'm a fixer more than I'm a replacer. And yeah, I'm always prepared if I've fixed it and it just doesn't look right because sometimes it can be difficult to get it anatomic. Sometimes, you know, particularly using a plate, you can't quite get those 15 degrees right. But it's not running true. It doesn't take long to replace the radial head.
Take out the saw sort of in a place radial head if you're in your 20s. 30s, 40s, 30s, maybe I'll work very hard to repair it and keep it for you because you can reconstruct it on the back table and put it back in and incorporated. So it's amazing how this fresh, osteochondral autographed actually incorporates. Yes, thank you.
So if there is a patient with a well reduced elbow and there is an isolated colloid fracture. Do you always do an examination under anesthesia plus minus stabilization afterwards? Or you can just treat him conservatively? A good question. So now what I want to know is where is that Cottonwood fractured? So I have a presentation on that, but it might take me a bit too long to get it up.
So I'll just talk you through it because if it is this intermediate ridge, OK, so it's the beginning of a terrible trial, but there's no radial head fracture, but the elbow. The only human bones is absolutely rock solid, congruent. You look at the elbow and there's no significant swelling medially laterally. When you look at your first images and you find that the elbow hasn't really moved far apart and the post-production forms are absolutely congruent.
No, then I don't think you need to do anything. If I'm worried that it's maybe not that pure classic intermediate range, but actually stretching across to the medial side, then I would get a CT and I want to then see on that CT I, in fact, if you've got 30 seconds, most of the time.
I still see my screen. Yes OK. This is the reason why. So here we see 45-year-old who injured his elbow feels it pop comes in with it reduced. And these are the x-rays that you see and I see here that this worries me. The first picture on the right now, you don't see it on the post-production form.
We just got lucky that we saw it in this plane. But this is involved the Crow node on the medial side. If I look on the lateral, this is a Maya mcevers one, maybe even two, OK, doesn't worry me. The post-production form on a human joint is congruent. But I get a seat. So the Zoom. And I asked him.
And I see how this injury is all the way across on the media side of the coronary. That without a radial head fracture, which is unusual because it's not a terrible triad, so how does that fit? OK, now I'm getting worried about this album, and in the 45 year old, for him, I'm worried enough to do an egawa. I see a perfect cradle here, not a scratch on that radial head.
Woods coming into view now. And I see it starting on the medial side, so that's intermediate ridge. But as I come more immediately, this fracture just gets bigger and bigger. But it's not point loading on the ulnar. So I'm still thinking this is probably OK, maybe I can just get this elbow moving.
But I'm so scared now of the anti-media. I take him to theater. And you can do the egawa without the aid. You can just do the examination under anesthetic. And I do a very stress, and this is the classic to medial paranoid if the next one on from the terrible triad is the intermediate kroner to read about it if you don't know it as an isolated entity or injury to the elbow itself. And I see some rupture of the lateral collateral ligament, but most of the force that has been entered into this intermediate paranoid.
There is my horse, and I see the entry medial epicondyle is good, I put my goggles force on it, but as soon as I bring him into extension, he's a Black. And so you do need to have a three dimensional view of where that kernel is broken. And in the end, that's the code word that needs fixing or otherwise they will wear out their elbow. And that took an end to a plate, whereas the 16-year-old in the next case has a really tiny little piece of his current with their.
But when I asked him. There's a little crack in his radial head that says it started rolling out of the back of the cab, so it looks like a paler pattern that looks like a typical tried pattern, which is never quite completed. I see the little piece of the intermediate ridge, but I come across to my intermediate corner to the medial side, and that's pristine.
This elbow don't need to worry about this person doesn't need to go to theater to have any. OK, thank you. What is the sequence of repair or fixation you recommend? I would recommend start well, examine the elbow first and decide where you're at the majority of your injuries. Start on the lateral side. Fix or replace your radial head. The pay your sutures in the anterior capsule, depending on where you are before you've definitively replaced your radial head, if you're going to do the capsule and the coroner would then do your lateral collateral ligament.
So essentially, I've done everything on the lateral side. I've done radial head. I do cone within capsule because I like capsule and then to a band of that angular ligament and the lateral collateral ligament is complex and then you them. Then I see whether they're stable to within two degrees of extension. And if they are, I stop.
If they're not, that normally means they've got a medial injury. I'll go around the medial side and repair the medial side. And if you've done those properly and well, then it's very seldom that I've yet found that I've ever needed to expect someone or transfix someone. And what's the approach for the medial side, medial side, so I would normally do my elbows supine, but I do a universal posture, skin incision, so I come down the point of on just to the lateral part.
I fold it back and I go through rhomboids interval. It's between Antonius and ulna. Once I've done everything here on the lateral side, if I need to come around the medial side, I just elevate my skin bridge. And then often on these elbows, particularly if they've done c.f.o, it's like a bomb's gone off. But essentially you're going through Hotchkiss, you're splitting with the ponyta muscle mass.
So I'll find the ulnar nerve, which is sitting just about there just to keep an eye on it. And then come in front of the ulnar nerve. And often the common origin has been shredded off the medial epicondyle and you just go straight into the elbow. You put one anchor into the anterior inferior medial epicondyle one enter into the sublime cubicle or the tenotomy convoyed tied.
One set of those together, creating an internal brace on the medial side weave the rest of his sutures into whatever rat's tail you can find of your medial collateral ligament and then weave that into your common flex origin. And that's how I'd repair it. But often the dissection has been done for you on the medial side. If you were a classic Cocker Kaplan from one single lateral incision, then you just have to make a separate medial incision.
Be aware of the medial and theoretical cutaneous nerve because you are coming close in its territory if you haven't lifted your skin flap. And thank you, and what's the post op rehab you recommend post up rehab? No one gets a back slap sometimes if I've had a really big medial injury into a hinged elbow brace, but most people will wake up without the back slap just in the bulky bandage and they get active assisted flexion as much as is comfortable for them.
Active supination because active supination pulls on biceps, pulls on by several tuberosity reduces radial capital, a joint active and passive pronation because pronation actively tightens up your radial biceps tendon as it wraps around possible tuberosity and avoidance of various stress, and basically for the instruction to the physios is to avoid shoulder abduction. So what?
I'm out to the side. I lie them often for the rehab flat on their back and get them to extend against gravity because if they're lying on their back, it reduces the only human joint. It detentions the biceps and the triceps, which wants to fight to keep the elbow in joint, and so people will get more movement by rehabbing supine. I do put my hand onto that elbow to show them and to reduce their minimal joint.
We'll show them how to do it so they can hold it in place and then fight again to push up. Again, the elbow is proprioception poor, and so it needs all the help it can get so you can give themselves a chibi grip or something just to give some skin sensation to reassure the elbow that it's not dislocating so that biceps relaxes or triceps relaxes at the appropriate time. And that's often rehabbing them.
Supine is better. But what they get told to do, no shoulder abduction and those that I'm a little worried about don't really push those last two degrees of extension. Uh, thank you. And I haven't heard about that, but someone asked about a.j.'s or internal joint stabilizer. Yeah so the internal joint stabilizer from lidar, that is basically an internal external fixator, basically.
I think you need that on occasion if you haven't done the other bits properly. And again, Jupiter and ring in their first article, I think really have scared a lot of people, and rightfully so, because if you don't do a terrible tried properly the first time, it becomes a world of pain. If you're doing an acute injury and you know how to repair the collateral ligaments, and if you can't repair them, then create an internal brace in the acute setting, I think there's enough intrinsic healing within those collateral ligaments to heal it.
If you do get to that situation where you can't repair it, you can't do it. That's when the idea helps. I've never had never needed one. I've seen some great results with it. It looks nice, but they put it in and then they don't worry too much about the soft tissue repair. I personally like putting in a few stitches and I use decent sized anchors.
I'm not using any bond, you know, or small to a vehicle. It's a 2 fiber wire that I'm using to reconstruct my collateral ligament. Thank you very much, I think we have to stop questions here. And for to start the Viva. Thank you very much. There's only one that the. The do you always attempt to reduction fixation of the radial head, even if it's totally knocked out?
If it's very if it's very common, you did then know, then I'll just replace it. If it's a big piece and the three big pieces in the youngest person and I'm 59, I'd say I'm still trying to fix you if I can. Um, I still try and fix you up, but what I just need is an elbow that's stable enough, so I'll never set out to do a terrible triad unless I had the ability to do a hair replacement at the same sitting.
So I've got the plate, I've got my long. Extend screws, because if you're trying to do a tripod, you need to have long headless screws, which are normally the standard ones are a little bit too short. My plate, I've got my screws and I've got a real hip replacement. Next to me. Thank you very much. That's the end of the questions.
Thank you. Very nice. Thank you very much. Kris Van rensburg, that was very informative and from the questions that we had. You can see that actually a lot of trepidation and anxious worry about some of these things that can come up in the exam. But hopefully we as answers our candidates be more well prepared now.
I know you went through quite a few case reports in your presentation. We'll probably move on to the Viva the stage you've been doing a lot of talking to. If you need to have a break or be really grateful, and then one of the other mentors can help us with some of the questions. OK OK. So people have really asked we've got a list of people who've asked to have a vive session.
We've got Mohamed asaka, are you here? Yes, I'm here. Thank you, Renee. OK stop recording.
Segment:0 .
Good evening, everyone. So once again, thank you for joining our webinar today in conjunction with orthopedic Research UK and the folks mental group. We're going to have a talk today on elbow trauma and we're delighted to have Louis van rensburg with us.
He is a consultant, orthopedic surgeon from Addenbrooke's Hospital Cambridge, who has a special interest in them and particularly problems of the shoulder and elbow. So he'll give us a talk about elbow trauma with regards to the triad and beyond. We'll have some short questions, so please write those questions down in the chat box and imagine and the other members of the Uruk team will be able to pick those up, as will we and we'll bring those across to.
Mr Van rensburg will then go through maybe some case discussions with regards to the GMFCS exam, and we will finish off with some vyver practice. So if you wish to take part in the Viva, please let us through the. Chat box again. And we'll make note of the names, I appreciate it's difficult, but it will be a first come, first served basis and then we'll finish at 9.30, hopefully and wish you all the best.
OK, so I'll hand you over to Mr Van rensburg. Right great, thank you. My screen coming through. OK good. OK, so today I'm going to be talking a bit about elbow instability and beyond the triads is the title. So, yeah, we have a 54-year-old male who gets involved in an accident, he falls off his bicycle and sustains this injury.
I don't know if you can put the first pole up, perhaps Ruth. We launch polling continued, so there are options for polling. Are you going to just reduce the elbow? Are you going to? Fix the railhead with a plate. Are you going to fix it with a tripod and screws?
Are you going to do a radial head replacement? Well, you're going to just excise the radial head because it's too common, you try to fix. At the moment, radial head replacement is winning. Men no one wants to fix it yet. OK, I think I'll stop the polling there we are about 3/4 of the way through the people and.
There we go. So seven per cent, seven or seven, we'll just reduce the elbow, 20% will fix the real head with a plate. 18% will fix the radial head with a tripod screws on the UK website. I debated with Roger Bennett whether to use screws or tripods and on that plates or tripods, and on that occasion he won.
Obviously, his teaching didn't last, and I'll remind him of that when I see him next time. 51% are going to fix that are going to replace that radial head and 5% organic size the radial head. Ok? um, just move to the next slide. So this same case based on what you're going to do.
Are you going to take a boyed approach between ulna and antonius? Are you going to do a cock between unconscious and icu? Are you going to do a Kaplan ECB and edc? Are you going to do the etic split or the rossington approach?
OK so we're getting up to about 100 people who've polled or voted this a reasonable numbers. 10% are going to go through Boyd's interval, that's between ulnar and unconscious. 40% are going to do a B the Cocker. 30% are going to do a Kaplan and 12% are going to do an EDC split and only 6% are going to do the writing and the writing is on osteotomy. And I think that probably fits that stayed fairly steady over my time, I seem to see that people in Europe or certainly in the UK tend to prefer Cocker.
I guess they think it's safer downside with cockroaches. You don't get to see a lot. When I go to Europe and possibly see people talking from America, they more talking about the Kaplan. If I had to pick that a approach, I'd do the etic split because I can never find that interval between ECB and EDC. But interesting, funny.
We don't all do the same things. OK going to stop the polling there and just do a little bit of talking. So we're talking about instability today and we're coming down the tree. From simple instability to complex and within complex instability, you've got the severe soft tissue injuries, you've got the terrible triad, which is a dislocation, radial head fracture and convoyed fracture, posterior medial rotator instability or that enter medial coronary and then the proximal ulna fracture dislocations, which include the silicon on fracture dislocations and the montejo variants.
And what I'm going to be talking about mostly today is these terrible triads, the kind of instability that often comes with posterior lateral rotator stability, but not unique to that. Many people have written about it, lots of different texts, but this is probably the first text that sort of highlighted to us of how bad it can be. I'll just clear those annotations. 2002 Ring and Jupiter found 11 cases over seven years.
And this pattern of injury is so troublesome and unpredictable that the surgeon should be prepared intraoperatively for persistent elbow instability in spite of repairing the coronary, the radial head lateral collateral ligament complex. And they went on to say that even if you repair the MCL, it then doesn't add a lot of stability and you might need to transfix the only human joint, or you might need to do an external fixator.
So that's what we thought in 2002. So how we see a 47-year-old lady who has a posterior lateral dislocation, there's a radial head fracture and a tiny little piece of the coroner. Those are initial post-production forms with the concentric reduction, small, little it reasonable side radial head fracture. Day two, she gets re x-rayed and you can see that it's really dislocated.
So what do you do in a dislocates? You put it back in again. She gets manipulated on day 5 and reproduced. And you can see on the back slap image the one on your far right. The drop sign. The increased distance between the humerus and the ulnar. And as you suspected, day 14, she falls out again. Day 16, she gets a radial head replacement, and that's all that's really not notes.
No mention of the crown or no mention of the entire capsule. No mention of the lateral collateral ligament. And after the real hip replacement gets done, she gets put back into a back slap. You guessed it. Unfortunately, now they left it six weeks before they took another X-ray and that's who X-ray six weeks. They changed the cost for slightly better cost the lightweight, soft, soft cost.
And again, you see that the radial head is dislocated. And that's why the terrible triet has got such a bad name and why it's so terrible, because if you don't treat it properly from the start, then you will need to put an external fixator onto it. I'm not sure he's doing the drawings. Now, this is not a drop zone, by the way. This is only a human distraction because you've got stiffness and instability, which is one of the worst situations you can be in.
That's the job to. This is her now at 14 weeks with the Zexal moved, and she's got an arc of movement from 110 to 45. Not a bad looking X-ray at six months, but when you take it out to months, you'll see that there's absolutely no cartilage left in it on only human joint. And that's a shocking outcome. And that's why the terrible tide is terrible.
These are the pictures that ring and Jupiter showed us in their paper of 2002 with trans fixation of the only human joint radial head replacements with lots of head ossification. They only found 11 cases. All of them were initially reduced, and out of those that were initially reduced, seven we dislocated. So those five that we're just going to simply reduce the elbow and leave it at that, not do anything to the radial head.
There's a 70% chance you're going to dislocate. 10 out of them had surgery. Those seven that dislocated and three others, and in fact, of those that had surgery, five dislocated in their post-operative splint. More importantly, those that had a radial head excision all dislocated. So one of the things you can't do in complex instability, one of the things you can't do as an absolute, there's very few times I'll say there's absolute things, but one of the things you can't do in terrible triad is excised.
The radial head. Now, the thing is up for debate. Now and Jupiter said at the end of their paper, in the treatment of this troublesome pattern of injuries, the primary goal should be restoration of elbow stability, and they even went as far as transfixing on human joint or putting an external fixates.
This is where it's important, where you need to buy into this concept of static incongruity and dynamic concrete. This idea that if you mobilize an elbow, if you put a back slap or cost onto an unstable elbow, it does not make that elbow more stable. All that being put into a splint of the seven dislocated of those that were operated on five dislocated in the splint.
And these were the pictures that we've seen earlier of the lady who spent. Four or five times going back to theater to try and get a good elbow. And you see the back slap, the back slap doesn't keep the elbow in all the back slap does is add weight to the elbow, increasing the drop zone. Now I disagree with this article that came out in 2005, and if you see a drop sign that you need to put an external, fixate on it.
If you see a drop sign, you need to worry about that elbow. But more importantly, you need to get that elbow moving. You need to believe in dynamic concrete. Adding a cost to an unstable elbow merely increases the distraction of your own human joint, adding a splint. Now I do sometimes use Hinsdale my braces. It only adds about 2 millimeters if you can see here on distraction.
So I don't use them often, but I do use them sometimes. Sometimes the patient needs them. Sometimes they psych needs them, sometimes I need them. So I don't normally immobilize people. But sometimes I will use a hinged elbow brace if I want to limit the extension a little. You genuinely need to buy into this concept of dynamic concreting. This is a paper by Duckworth.
I love what he writes. This is 2008, and he showed us these x-rays of a 24-year-old post-adoption with laxity, a drop sign on the lateral view, and several weeks later, with exercises and avoidance of varus stress. Various stress puts a lateral collateral ligament stress on your elbow, and they've got a good elbow. When you move an elbow, biceps fires up, reduces your own human joint if you actively supernaturally elbow, you fire up biceps biceps pulls on bas status tuberosity, which reduces your radio capital, a joint if you promote your forearm.
It doesn't really, I don't believe, tighten up the lateral structures, as is often written in textbooks. But what it does is it wraps biceps around the possible tuberosity, increasing the tone in biceps, pulling your radio joint, reducing you on a human joint, stopping that disrupt the structure. This extraction of only human joint allowing the elbow to just dislocate.
Now, how do if an elbow is stable enough to get it moving because sometimes, yes, the elbow is so unstable, you can't get it moving. And a number of signs have been advocated here as the hanging arm sign. And by this paper by Russia and 2011. And that's just basically putting the arm out in full extension, and if that arm is stable and doesn't dislocate like that, that's stable enough to get it moving with the provisos of avoidance of varus stress.
So don't have ducked your shoulder work in straight lines up and down, lie down in the bed and move your arm up and down. That reduces your rate of capital and reduces your only human joint. Another definition that has often been used is an elbow that is stable and congruent to within the last 30 degrees of extension. Because if your elbow is stable and congruent within the last 30 degrees of extension, it is stable enough to get that elbow moving.
It is stable enough to not need an external fixator, not need Crosswhite fixation, not normally need an elbow brace. And so this is how I will egawa and elbow a lot of them flat on their back. Mat on the image, intensifier arch straight and get an X-ray to make sure that your elbow is reduced. Flex the elbow 30 degrees to disengage the electron from the olecranon fossa and then place a varus stress.
You can see a little bit of opening on the lateral side, so lightly disrupted partly the lateral collateral ligament complex, but the common extensor origin is likely intact in this one. This is a big stress test in a normal elbow, and it looks like the elbows drifting a long way away. And what you need to do is protect the forearm, lock the radial head. Onto the Capitol and also into irritate the shoulder so that you lock that elbow and so you'll always find my vulgar stress tests or with the arm protonated.
And that's how, you know, it's a bogus test because the radius will be crossing the honor, then that tells me what's happening to the medial structures and the lateral structures, the collateral ligaments and the muscle origins. Common extents and common extent surgeons. But I actually don't really worry too much what's happening there. What I want to know is that elbow stable and congruent to within 30 degrees of extension, because if it is, it's stable enough to get it moving and elbow instability is treated with movement.
So you start with the elbow reduced, fully flexed, and you gradually extend the elbow and screen it. And that's the picture you want to see an absolutely reduced radio capital, a joint in an absolutely congruent only human joint. If you're really confident you can go on and take an X-ray with your drop on sign. I do worry sometimes, particularly in those that are fixed or spent a lot of time reconstruction.
I don't often go to the drop arm. I normally stop at about 30 degrees. If it's stable till there, that's it. I stop. I wake the patient up. I've done enough. Then the next step is for me to inspire the confidence in that patient to get that elbow moving. So the treatment of all instability, whether it's simple or complex, is movement, what you need to do is make sure or allow that elbow to be stable enough to move and often in the second level of complex instability.
It means repairing the soft tissues. It means fixing or replacing the broken bones. And restoring bone incongruity and then repairing the soft tissues to a degree sufficient enough to allow the elbow to move. And we know it's enough when it's stable and congruent within 30 degrees of extension. A little bit of screening just to show you what I mean. Vulgar stress test, we know that because the radius is crossing the ulnar, and on this occasion he's ruptured his medial collateral ligament and the common flexor origin.
You don't open that medial side like that if you've just done the MCL. This is MQL and CFO. And as you go up the ladder of injury from just ligament to ligament and soft tissue, it's more likely to be complex. It's more likely not to be stable to within 30 degrees of extension and more likely to acquire some form of surgical intervention to stabilize it.
There's the various test, and we see the radial head and neck fracture, we see how the lateral collateral ligament in common extents origin is gone. There's not much holding this elbow in place. We start on the lateral now. Make sure you bring your eye around to do the lateral. Don't twist the arm because if you twist the arm, you're applying an external rotation force on that elbow pierre-louis pierre-mauroy, but you basically twist it elbow out.
So bring your eye around so that you're testing your extension in one plane. And here we see how the elbow goes gradually into extension and we get to about 70 or 80 degrees and it jumps out. And what does that tell me? Tells me that this elbow isn't stable enough to get moving, and so I need to fix it. Whatever needs fixing till it's stable enough to get moving and in the terrible triad, we need to think about the radial head.
We need to think about the convoyed and the dislocation. And in fact, the dislocation is really thinking about the soft tissue components, MCL, LCL, common stents and common flexo-pronator. Now probably start with the most controversial with the coroner would. So he has an article that came out 20, 14 terrible injuries to the elbow. Does the cronut always need to be fixed?
In two years, they found 14. No ring and Jupiter in seven years at a level one trauma center took them seven years to find 11. But that's OK. They found 14 in two years. Talking about Reagan Murray, 1 and 2 comminuted fractures, our clinical results challenge the accepted belief that the current award must be fixed in all troubled prior injuries support the notion that the current order and capsule repairs are not required.
And avoidance of this unnecessary surgical fixation in these instances may positively affect functional outcomes. I've highlighted the words that worry me there Reagan Mori top one and 2 when it comes to the corner. We've moved on from Reagan mori, no longer this two dimensional appreciation of the coroner. There's so much more interesting stuff about the coroner than just the two dimensional classification that came out in 1989.
In select cases, well, how do you select the cases and how do the convoyed didn't need fixing until it's dislocated or capsule didn't need repairing until it's dislocated on you? And if you've only had 14? I'm sorry, but this suffers from a power problem here. A necessary surgical fixation in these may. OK, well, it may. Lots of things.
May 2014 and they show you these pictures of a terrible triad with repair of the lateral collateral ligament in common extents origin and a radial hip replacement that did well. We're going to take a little bit of a detour now and talk about the classification. Reagan Maori from 89 O'Driscoll in 2003 and Adam Watt's classification of elbow instability, where he talks about the terrible triad that could be the combined with the C. That's when it's that little bit of coroner Ed often the radial head, and he also have highlights to us the importance of this big facet, this basil one.
Now, sometimes it's not right at the base, so it's not quite basil, so it doesn't fit into a Driscoll. Its classification of the top 3s and is often a little bit of overlap, and sometimes you'll have a big facet which is hiding or masquerading for want of a better word as a tip fracture. Although there isn't really a tip to the canutt because there's lots of tips to the coroner. So none of the classifications are perfect, and I'd certainly move away from Reagan Mori because it's no longer just the size of the convoyed, but nowadays when you're thinking about the corner, that's where that corner is broken.
Now, Jessica alluded to that in 2003, we talked about the tip ventromedial ridge. And the basil fractures. Adam writes in his classification from rimington, talking about these combined fractures, which are the true pure, pure, terrible triads where you just need to do the radial head and lateral collateral ligament. But if you've got that big facet to the basilar, it's a little bit more to that paranoid.
Sometimes you do need to fix that coracoid. Yeah this article came out in 2013 and really shows us beautifully how the coroner is not this two dimensional buffer, which we see it as we see it, as this buffer that stops the radial head from jumping up and running forward that stops the chocolate from jumping up and running forward. It's got the three ridges and in the terrible triad, the classic pattern is that it breaks off this intermediate ridge like you see here on this volume rendered traject.
This little piece here, that's the classic, but sometimes it's a big facet masquerading as a terrible triad, sort of classic one. And then you need to worry about it. And I think that the cronut works more than just a buffer just from stopping the chocolate or convoyed, but because of that little overhang, because of that little hook. It works almost like you see ladies bags, hooks or, you know, a bag hook that's holding on to a table.
You don't need a lot of an overhang to really improve the stability to that construct. Now, one of the reasons people don't like fixing the car annoyed is depending on your approach, depending on how you try and get to that elbow, because often if it's breaking off on the lateral side of the road, you can't get to it from the medial side unless it's an intermediate coronary.
You can't get it from the medial side. So now you often trying to get to that small corner would fragment from the lateral side. And really, if you're going with a Cocker, the only way you can get to it with the car is if you take the radial head out the way they are. And that's why probably 50% of you are excising the radial head not saying that you can get to the it, but it then provides you access to everything.
If you do a Kaplan on EDC split, you can get to it, but often to get to it. It comes at an expense and that expense is that you have to strip the capsule off the proximal humerus. And as far as I'm concerned, when I'm fixing a terrible triad, I want mechanical stability but also want to return the proprioception to this elbow. I want this elbow to know that it's developing a drop sign, that it's falling out of the elbow and that it needs to pull itself up and it needs to pull itself up with biceps with brachial.
You can see the coroner, Lloyd, and this corner here through Boyd's dental. That's the approach I like, but you don't have to do Boyd, but you can see that. But of course, annoyed you can move the radial head. If it's partially fractured to the side, you can get to that anterior capsule. Now, this was an article that alluded to the fact that such a fixation of that foreign aid doesn't restore the kinematics.
And it doesn't restore the kinematics, because it no longer works as a buffer. It doesn't restore the kinematics, because it's probably no longer working as that bag hook. I talked about. We're just a little bit of an overhang. OK but I love reading articles, the text and then looking at the pictures. And when I look at these pictures, I think about this orange structure and that unstructured there is capsule.
And I look at this reflected yellow structure with the blue outline that comes around it. And do you know what that is yet? Yes, that's the anterior insertion of the annular ligament. So now you go cut annular ligament with your Kaplan, with your Cocker, with your SDDC split and you break your annular ligament in two places because often it's ripped off the front part.
Of the electron, because that's the weak point we learned about that in 1958. And so for me, repairing these small paranoids, these I'm going to say it, Reagan worry type one, type two, I'm going to say two fractures, but in fact, no, what I'm going to say is these small pieces of the intermediate ridge because it's that piece of the cone with that breaks and I'm not tripping.
I used to say I'm a pain in the corner, but I'm not. What I'm repairing is that anterior capsule and I'm repairing in confluence. The anterior part of the annular ligament because I want to bring as much stability back to this elbow as I can so that I don't have to transfix my ulnar human joints so that I don't have to put an external fixate on this elbow and take out the patient's radial nerve.
And I don't want to know that I should have fixed it when I'm all finished and I'm closed. And that's what the problem is with those small papers that tell you you don't need to fix the car annoyed or repair the capsule if they suffer from the fact that they've only really come across those lowest small lowercase t conoil. So he has a dichotomy, 2002 we got ring and Jupiter telling us that despite fixing coronal electrical ligament, radial head and media, Michelle doesn't add much that you're in a world of pain.
And here in 2014, and these are not the only authors, there are the authors who are saying the same thing that you don't need to do the paranoid. Watch out if you're reading about Reagan Marie 1 and 2. It's a two dimensional structure now I want to be talking about someone who's talking about a drizzles classification, or possibly even now, the writing and classification of fracture dislocations of the elbow.
And I think what you'll certainly find if you've come across enough terrible trades is that as there is a spectrum in instability from simple to complex, even within the terrible triads, there's three people who belong to a gang and there's three notes played on a piano. They're terrible triads with a capital T and the terrible triads with a small t. Let's have a look at that.
There we see a 74-year-old female with a dislocation. It's jumped back. It hasn't moved any further laterally or medially. The displacement between the humerus and the ulnar are close. And so I can almost predict that the collateral ligaments and the soft tissue injury, the dislocation part to this elbow is actually relatively small. Small, little bit of coronal.
And there's another piece here, but I don't know quite what that is. It turns out that happens to be radial head and he off day, not x-rays, post reduction in a back slap. I don't have a problem immediately putting them into a backslide for a week or so. But I wouldn't leave them much longer than that. And in those production forms, I see no drops on some. My heart rate is coming down and becoming more.
This is a terrible triad with tiny teeth. I'm not going to have to worry about this. If I have a look at the actual scans. They're not great because you can see that the scan was done with the elbow off the side. We'll see a little chunk of bone. I see another little flake of bone and I see the radial head coming into view. I'll go and do the coronal fractures, and they haven't quite got the Gantry in the right thing.
And that's the problem with CT. Again, radiographers don't always to put it into the plane of the humerus or the plane of the forearm. But what you really wanted on is the plane of the coronary, and that's why the volume rendered CDC is really make a big difference. I'll just play that note again because I got distracted while I was talking.
And there's this picture and just the way you've got those Hard sclerotic edges to me, that piece. That piece looks like it's a sorry that. That piece looks to me like it's a radial head fragment. I just had to move the Zoom sort of bits might have missed that day on the sagittal, but it looks like there's a small little flake off the top of the radial head.
So just by definition, yes, the terrible triad, radial head coronary dislocation, but really not really significant, hasn't displaced fire. He has the X-rays in a brace at one week. There's the X-rays at three weeks and there's the X-rays at six weeks and there's the X-rays at three months. A little bit of H0 kicked out in the front, but pretty good. Only will joined a pretty good radio capital, a joint stable, conjoined elbow and a happy patient.
So can non operative treatment work, Yes. Again, ring from 2010, published in the Journal of hand surgery, but it was only a case series of four, and that's pretty good to get a case as of four in the Journal of hand surgery treated well and one was stiff. And they go on to say that in selected cases, you can treat them non operatively with a small radial head. Well, aligned.
Minimally displaced. No mechanical block. So there's no reason to fix that radial head. For whatever good reason, patients might regain good elbow movement. And I just highlight some of the things important thing here are selected cases well, aligned small, minimally displaced might. And so if you're going to treat a terrible triad or complex instability non operatively, I think it is reasonable.
But then you need to keep a close eye on them. You don't then just see them again at six weeks because the elbow will slip out without you knowing she will come back at six weeks with a dislocated elbow. And then you're getting into that realm of chronic instability and stiffness, particularly if it's around three months. And sometimes you'll see that, which is a bit of a sadness.
So yes, you can treat the terrible crime on operatively with those provisos, but then watch them closely bring them back early. So we see a 45-year-old male has an opening due to his elbow. Again, I see a posterior dislocation hasn't really gone a long way lateral. I see a convoyed fragment. I see the radial head fragment there and looks like some of the radial head is probably attached to the shaft.
I had floating meeting controls. Let's run the sagittal first. So you can see the gas in the soft tissues. I see the radial head fracture, there's a piece off the front. But there's a big piece attached to the shaft. And so although these two pieces of radial head that are separated from the shaft, there's one big piece in fact attached to the shaft.
And that's a winner, winner, chicken dinner when there's a big piece of radial head attached to the shaft because then it's quite easy just to bolt those other little small fragments onto it. If the head is totally disassembled from the shaft and not only are they broken into three big pieces in that dimension, but very thin on the lateral, then I'm thinking maybe I can't fix it. But for me, based on those vegetables, you know, that radial head is fixable.
OK 3-d, we see it spinning around. And I'm starting to see things here that worry me. And the things that worry me are the only human distraction that drops on scene in the city, which means post your band of Michelle is gone, which means MQL is gone, almost certainly into a band of MQL. And I'll just spin this one again. And that's not classic intermediate range, this is not classic tip.
This is the beginning of the basil or by facet. And so is this one of those writings and by facets, which is masquerading as a terrible trial on its own? And that pattern of the railhead, this has more of a buffer. This has been more of a shunt than a rotation to break the Cardinal in this pattern and to break the radial head in that pattern.
There's also more soft tissue ligament mischief happening in this elbow. You get produced and comes up, gets seen at a week, and I'm really nervous now, I see the drop sign, but most importantly, I see subluxation of the cell phone, how it's point loading. And so there's no way I can treat this one on operatively because the cochlear will just erode on this. And within a year you'll find it this Albers arthritic.
OK, so this person is having surgery and here are fixed it with a tripod and I fixed it with a tripod and the mini screws just to fix one or two pieces back because most of it was actually intact. And so this tripod is not taking a lot of force. If those pieces were smaller, if I needed more support, if my annoyed was worse, I might have considered plating it. And I've repaired the lateral collateral ligament is complex and the common extents origin.
There's now various force, so that looks good. There's my values for suggesting MQL and common flexo-pronator is involved, but I really don't mind whether it's involved or not. What I want to know is this elbow stable to within 30 degrees of extension. And I get to about 45 when it hinges a little, but I get it fully straight and it pops back in again because I have repaired the capsule.
I have repaired to a band of that annular ligament in which, as it goes in further extension, it then pops back in. And so I decided to treat him non operatively an extra him day for because I'm a little bit nervous about this one. And I see at a barter day for post op again, he's point loading on that tippecanoe, and you can see it. The convoyed is flown away now, didn't fix the cronut because it was a bit too comminuted for me.
But I look at that, and I think I can't leave a 45 year old's elbow Black or otherwise, he will wear it out and he will get arthritis, we see that with the end to medial. I think that if I flex you, if I start moving you, maybe if you tighten that biceps and break your earlier. So I give him a good talking to you and say, get your elbow going, get it moving. And we see there the X-rays subluxation at 11 days and you can't leave that alone.
And you can't leave that alone because the broccoli's point loading on that corner of the ulnar. And that'll wear away so relatively tenuous fixation on my radial head butt that's held where the capital joint is reduced. But I'll see this drop sign. And so a few days later, I finish off repairing MQL and fixing the canoed. Managed to catch it with a screw from back to front.
I could have, but just plated it. I had in my mind that I would take off the tip of his electron on or in fact, excises radial head if I had to and use his radial head as an auto paranoid if I needed it. But I managed to get a relatively stable, congruent elbow. You see, the cone would still remaining reduced. Do you see you're good on the human joint on the ap?
So I think we might have got away with that one. But watch out, though, those big facet by cord injuries in terms of the radial head. Most people wanted to do a Cocker. Some would do a Kaplan. Yeah, I'm not going to go into the approaches today because I don't have all the time. I just need to keep moving. So this was about 54-year-old.
Do you fix it? Do you replace it? Do you excise it? There's lots of things that go into that in general principles. If there are three pieces, if you see three, there'll be four. And if you see four, there'll be five. You can fix it generally if there's three.
And if you do replace it, make sure that you don't stuff it. Whether you screws or plate really depends on the other injuries and how much support this lateral structure is going to need, and so I tailor it despite what I tried to on the truck debate. I do use tripod screws quite often. I use plates if I need to. But increasingly, I'm using screws. If you replace it, don't overstuffed.
This radial head is overstuffed. It's proud of the lateral facet of the only human joint. This was fixed through a corker, and so they started fixing a three part fracture, the radial head couldn't fix it, then they decided to replace it, and by the time they got in there, they'd repeat at least the lateral ulnar collateral ligament. Because you're coming through the car, you can't see the relationship between your radial head and your lateral facet of conjoined.
Unless you X-ray it and before you know it, you've overstuffed it. Is this actually overstuffed? Yeah, it probably is not a lot, but it probably is. I would want that to be just in line here with your lateral facet. Now you can't take widening of the lateral human joint. I used to look at this and think that widening of the lateral a humid joint was an indication of over stuffing.
But that can be very variable, as shown here by Graham King in 2007. And so the real way to tell if your radial head is the right height, the best way is intraoperatively to see it. You can see it from a chaplain, you can see it from an IED split from the front. You can see it from the back, from the Boyd, but you can't see it from the car unless you really have stripped off all of lateral collateral ligament common extents origin.
Sometimes you'll see these X-rays post op, is this overstuffed that is proud of the lateral facet of the only humanoid, but there are the X-rays intraoperatively. And the reason that happened is because the X-ray beam is there a little bit stiff when they come for their first X-ray and so the elbow is partially flexed and the radiography, instead of taking an AP radiograph of the forearm, takes an AP radiograph of the elbow in Midway between flexion and extension sort of halfway across.
And what you want to do is ask them to take an AP radiograph of the forearm, see an absolutely tangential view of your radial head replacement, and then you can tell whether it's the correct length because this is the exact same patient. Remember that the real head moves proximally and distally on pronation and cuponation, just for completeness, this Hank is in the wrong place.
It should be sitting there. This paper showed us how to take into account the cartilage, and so sometimes your radial head should actually be a millimeter too proud of that corner. But that's probably taking real heat replacement a little bit too far. But it does need to be a little bit proud. Just a smidgen. And remember that the Capitol nestles inside your radial head.
Don't make it too big. Don't overstock. Don't make it too wide. But it also nestled inside the real head, so you real hair is often a little bit wider than your Capitol Hill. As for rich railhead, there's no right or wrong. This paper suggested that the most best regulation is this bipolar cemented by Italian prosthesis. And the reason it's the best radial hip replacement is because once you put that real head replacement in, no one is going to revise that radial head.
You need to come to me saying that you can't walk before I'm going to think about changing that stem. And so people just get into the basement, they get just into Stockholm, whereas these radial heads where they work themselves loose. My threshold to replace that, to revise it or just take it out once everything else is healed is actually very low. Did miss epicondyle did a good study review article?
Looking at all the articles 2016 and said that there's no one that's better than the other, really, that philosophy of the anatomic versus the non anatomic space, I think it's really a 50-50 ball. The proviso being is that the silicone you can't really use silicon. It doesn't work. Keep away from it. The last thing to talk about is the soft tissue injury that the lateral collateral ligament is complex.
The center of access runs through on the medial on the lateral side and the center of the capital. And that's where you want to put your anchor dead center in the capital. In essence, if you think of your lateral collateral ligament is complex, is a y lateral collateral ligament, is conflict proper, then the anti-carbon, which goes over the top and attaches to that little ridge where your intermediate ridges and then onto the supernatant crest.
Remember showed you that picture earlier, that top one, colonel, the little piece of the intermediate ridge. It's not about that little piece of bone because you can't buy mechanically construct that bag hook, but you can buy repairing the entire capsule. And by repairing that part of the annular ligament through transocean's drill holes through your owner, which you can see if you've removed the radial head, which you can see if you've done a boyed approach will bring more stability to the elbow.
Now you won't dislocate if you don't fix it. You'll have laxity. And that's what this article is saying, if you break it in one place, you'll get laxity. If you break it in two places, you'll get instability. If you're doing a Caplin or an EDC spit, you need to make sure that you repair that and your ligament well. For me, the nice thing about Boyd is I can get a really good modified Kessler in my annular ligament with Transocean drill holes through the subcutaneous board of the ulnar and get it absolutely rock solid repair.
Most times the annular ligament is a complete abortion. Of the common extensor origin with the soft tissues. Sometimes it's shredded in the middle. Occasionally you'll see a ripping of the Super crest, but that's like a rarity. And so most times a single anchor into the common extents origin, a matter of your lateral collateral ligament in common extents origin, but do be prepared to create an internal brace.
If they have one of those where you've shredded the MCL in the middle. Normally it's this and you can fix it fairly easily in acute repair. You can just put an anchor into the center of the capital and repair it all as a mash repair. I'll use a decent sized anchor, so 5.5 Twin Peaks with two fiber wire.
You really want to be able to have the confidence to inspire your patient to get it moving. You can't be tenuous at that elbow because if you don't move it, it'll just dislocate again. Those 10 ring showed us. These sort of anchors for me are a little bit too small that loaded with one is not going to hold on to anything if the LCL is shredded mid substance. And be prepared to create an internal brace, an internal braces.
This concept of a high density polyethylene suture between the insertion and the origin of that ligament and the insertion and the origin of the lateral ulnar collateral ligament is sent of capitalism and the Super to crest. Yeah, you can see an internal brace created on the medial side, but you can create the same on the lateral side. Where do you put your anchor or where do you put your holes for your internal brace on that Super native crest?
The answer came from this study looking at single bundle lateral collateral ligament reconstruction, not internal brace. They looked at a distal hole and a proximal hole, and basically they showed that there's no difference. And so they simply put it in the middle. It's very seldom an acute terrible trial that you need. Couldn't need to reconstruct it. You need to reconstruct it if it's been delayed or if it's really dislocated or it's dislocated four or five times and been left for three months.
Most times in acute setting, you can get away with an acute repair or an acute repair plus or minus an internal brace. In general, most of the protocols will be to address that, although there may be laxity of the MCL only to repair the MCL if there's absolute instability, if that elbow is no longer stable to within the last 30 degrees of extension, then you need to go around the medial side.
And the one we repairing most often is the anterior band of the medial collateral ligament. A few articles looking at whether it's in tight in flexion extension from the late nineties, slightly better studies showing us the three dimensional structure of that and two band of the NCL suggesting that it winds around and that they all probably are symmetric. But the bottom line is anatomically, when you repairing a medial collateral ligament and you don't know where to put your anchors is, that's the spot not in the trolley there, but in the anterior inferior medial epicondyle and then running along that crest of the sublime cubicle.
And that time when you going to be repairing the muscle on the medial side is often when the bombs going off. So the CFO pulled off and you just need to feel for those bony prominences and you can put your anchor in repair with whatever sutures you got. What little bit of the medial collateral ligament you can find, but then leave one set to tie to each other as an internal brace.
So let's have a look at this case. MQL complex origin lateral collateral ligament goes into extension unstable. Gets radial head replacement, lateral collateral ligament reconstruction. And you can see the drill holes from front to back here, so I always repair a capsule and annular ligament. That little bit of coronary, I'm not really fixing the cronut, I'm repairing that capsule.
There we see the various force there we see the Vargas force opens up. Starts off, reduced, goes into extension. And starts to hinge out. Now, I'm worried a little here that this may not be stable enough to just absolutely get it moving. And so now I need to go around the medial side and repair the medial side. It was quite a significant injury to medial collateral ligament complex origin, and he had shredded the MCL, so I've created an internal brace between medial collateral ligament insertion on the anterior inferior medial epicondyle and on the sublime cubical and turn.
And to a medial carcinoid. Just showing you again, the significance of that middle engine likely why they required it. And once you've done lateral side and medial side testing the elbow in extension, elbows fully congruent in extension, and what does that tell me. That tells me that this elbow is stable enough to get it moving? That tells me that I don't need to transfix this elbow, don't need to put an ex fix onto this elbow.
And in the last 15 or so years, I've never had to transfix an acute terrible triad. If I followed the principles of repairing the very structures and then reassessing it and not stopping until I've got full extension and stable incongruent within the last three weeks of extension, just another case showing you, again, the internal brace and how that returned stability to the elbow. So in summary.
The terrible tide is a complex injury involving the radial head, the conoil and the dislocation. And even within the terrible triad, which is within the spectrum of elbow instability and complex instability, there remains a spectrum within the terrible triad. You need to think about your radial head. You can fix it, you can replace it, but you can never excise it.
You possibly don't need to repair the convoy, but those are only in those terrible triads that are small teeth. Think about your lateral structures, start off on the lateral side first. Fix that, reassess the elbow and only go round to the medial side if you have to. When it comes to the Kono classification and thinking about your would fracture, if you have the luxury, get yourself a volume rendered traject, look at that conoil.
Is that a true terrible triad carcinoid from the intermediate ridge? Just a small little piece? Or is this perhaps one of those bio facet by basil basil fractures that Adam watts was sort of alerting to us? And those are the ones that maybe you need to buttress it. Maybe you need to reconstruct it, either using tip of electron or radial head fragment if you need.
Watch out for those befits its buffets. They'll catch you sometimes once you've done the lateral side, and for me, I always do the capsule in that fixation of coronel because I can because I'm going to Boyd, then reassess it, and I'm not worried if there's ACL injury. I'm only worried if it's not stable within 30 degrees of extension. So if this elbow looked nice and congruent at this point, I wouldn't go around and fix that medial side, and I only fix the medial side if I need to.
And generally, if you get an acute terrible triad and you deal with everything appropriately right from the start, you don't bury your head in the sand and simply reduce the elbow and hope it'll be OK. The terrible triad often is not so terrible. Any questions? So, yes, there are a few questions.
Thank you for the excellent talk. And that cleared a lot of things in my mind, actually. So which classification do you use for the kernel fracture? I think there is a bit of is it to use the O'Driscoll classification or the classical tip less than 50 or more than 50 percent? I think although when I first started 2005, I looked at Fiona Driscoll's classification. Sir, you've just complicated it too much.
You do. You need to at least go to the level of Sean O'Driscoll, and you can't just look at it on a lateral anymore, particularly because it masking inside. This whole spectrum of instability is the intermediate Connolly and. And if you and you only picked those up if you look at the dimensional structure. I'm just going to move there quickly.
Share screen, sorry. So within the spectrum of instability, you've got complex instability. One of them is the ploy tarp, the terrible triads. But you've got this posterior medial rotator instability, which affects the entire medial paranoid. And if you don't look out for that injury now, if you're generalists, you probably will only come against one or two in your career.
But a year down the line, a relatively innocuous looking injury to the corner, it will end up with quite severe arthritis. And the reason people don't tolerate arthritis of that intermediate facet is because every time I pick up something, every time I reach for a cup of tea, every time I reach for product placement, coca-cola, I know you're not allowed to do product placement, but every time you reach for something, you put a very stress across your elbow and you load it, you offload joint and so you don't tolerate action or you can't tolerate a Starbucks Elmo.
And if you miss that big facet which is running on that, but of course, annoyed, not corner on that bit of yeah, the little bit left in ulnar the corner, but that's left. It wears out start process, which leads to fairly rapid arthritis within the elbow. So I think if classification, if you're treating elbow instability, you need to at least think of a driskell's. I disagree a little with this concept of the tip.
This is more to the middle. I like the idea of the intermediate ridge because I've got to be different somehow. I like Adam Watson's classification, but too complex for me. But Yeah. OK, thank you. So another question, how much joint space opening do you consider significant and do you compare to the other side?
That's a good question. So are you talking about joint space opening on your own humor joint, i.e. yours? Or are you talking about joint space narrowing on the medial side when you're testing missile or lateral sides? And the answer for that is I actually don't have an answer. We are hoping we will come to a height of the colloid, which is significant, which separates it from those little pieces that you don't need to worry about to the bigger pieces that do constitute a back convex facet, I think I take a lot of things in my head as to deciding when this is stable enough and when I've done enough.
But the most important really is that you fix something or do something on the lateral side. It's often easy to start there and then reassess how congruent is that elbow? For that radial head that had an ACL injury, I then look back at that ACL injury and is that a monstrously big ACL injury? Is it just opening on the medial compartment four or five millimeters?
So i.e. just medial collateral ligament, not medial collateral ligament and common flexo-pronator? But like that one I showed you, it was both. Whereas I can actually make a big difference to that if I've got a 2 or three moves of only human distraction and my MCL injury isn't that big. It only opens four or five miles. I'd probably take a run with it and wake you up and just get you moving your elbow.
Thank you. And, well, why did you check the elbow stability from 0 to 30 degrees. If the electron is already engaged? Yes so, you know, the last 30 probably doesn't make a difference, so once the Lieutenant engages, in fact, I've seen elbows that jump in the middle zone. Yes, but but what I want is an elbow.
I've got it reduced. At 90, I wanted to get out to at least 30 because if it gets to 30 and reduced any further, it normally locks into the Lebanon and then stabilizes itself. I think it's pretty sure that I can look that patient in the eye and say to them, look, your elbow is stable enough to get it moving. No, I mean it elbow stable enough to get it moving.
Yes, I know you've dislocated your elbow, but get it moving. Thank you. And do we need to always repair the capsule and travel traject? Well, that's the debate, sir. No luck. There's some of those articles which suggest you don't, but I worry a little about those articles with numbers of 14 that they're not really picking up the really complex, terrible triad, the one that is completely ripped his entire capsule that NATO bound themselves.
So Yes. Yeah, it's still a little bit open to debate. The wind is swinging to not having to repair that capsule. I repair it because I like the proprioception. And anecdotally, one of my Fellows has written a paper, but it hasn't been published yet. I see less of a drop zone when I switch a that anterior capsule. And in fact, for me, going through Boyd's interval. I don't have to fight to get to it.
I don't have to do anything more to get to it. I push the radial head to the side with a laminar spreader or with a ring handle spike or through if the head's not there anymore. Put one or two sutures into the capsule to drill holes from the subcutaneous port of the ulnar retrograde shuttle them. And it's done. It's not a big fight.
If you're coming from a lateral approach, if you're coming from a Cocker, yes, you can't get to it unless you've taken out that radial head. OK, thank you. And if you have to repair it, will you use sutures or anchors? I normally do sutures by looking down into the wound. I'll put sutures through the capsule, normally a fiber wire suture and then drill from subcutaneous border of ulnar down into the coronary.
I'll just show you a picture. Yeah well. So this one will do.
So this is the area that I'm catching here. Really, this cap. And if you take a stab incision over the point of the mikonan and drill with a 2 millimeter drill and exit into the base of where your fracture is or we have fractures on the other side, you can then reverse shuttle those sutures. You weave it in here. It's in this article.
So there you can see the drill holes and the statutes that have been passed. Through the subcutaneous board of ulnar nerve into capsule and then pulled on those sutures, reducing the capsule, reducing that little bit of coronary.
OK, thank you. And, well, the classical question of whether or not to when to fix, replace or excise the radial head, I wish I had an absolute number there. It really depends on a number of things, so it depends on the. So it's not just dependent in the terrible triad on the radial head, because I'm also looking at how much support this lateral column is going to have to afford this elbow.
So if MQL is intact, for example, the conoil fracture is just a tiny little piece of the intermediate ridge. It's not masquerading as a facet, then that radial head is not going to take a lot of load. So my fixation of that radial head can be tenuous because it'll be locked between capitalism and locked between annular ligament. But if my radial head is absolutely if my car annoyed is dust or lots of little pieces, I've got a big medial injury to the medial collateral ligament in the common flexor.
And then I made a lot more support on the lateral side. If you're in your 60s '50s. Well, I might as well. Just I'm 50 now, so OK. But I must still just chop out your radial head and give you a really, really, really rock solid lateral side, which will then support my MCL repair, which will then support my coronoid repair.
So, yeah, when do I fix it, I fix it when I can, because I'm a fixer more than I'm a replacer. And yeah, I'm always prepared if I've fixed it and it just doesn't look right because sometimes it can be difficult to get it anatomic. Sometimes, you know, particularly using a plate, you can't quite get those 15 degrees right. But it's not running true. It doesn't take long to replace the radial head.
Take out the saw sort of in a place radial head if you're in your 20s. 30s, 40s, 30s, maybe I'll work very hard to repair it and keep it for you because you can reconstruct it on the back table and put it back in and incorporated. So it's amazing how this fresh, osteochondral autographed actually incorporates. Yes, thank you.
So if there is a patient with a well reduced elbow and there is an isolated colloid fracture. Do you always do an examination under anesthesia plus minus stabilization afterwards? Or you can just treat him conservatively? A good question. So now what I want to know is where is that Cottonwood fractured? So I have a presentation on that, but it might take me a bit too long to get it up.
So I'll just talk you through it because if it is this intermediate ridge, OK, so it's the beginning of a terrible trial, but there's no radial head fracture, but the elbow. The only human bones is absolutely rock solid, congruent. You look at the elbow and there's no significant swelling medially laterally. When you look at your first images and you find that the elbow hasn't really moved far apart and the post-production forms are absolutely congruent.
No, then I don't think you need to do anything. If I'm worried that it's maybe not that pure classic intermediate range, but actually stretching across to the medial side, then I would get a CT and I want to then see on that CT I, in fact, if you've got 30 seconds, most of the time.
I still see my screen. Yes OK. This is the reason why. So here we see 45-year-old who injured his elbow feels it pop comes in with it reduced. And these are the x-rays that you see and I see here that this worries me. The first picture on the right now, you don't see it on the post-production form.
We just got lucky that we saw it in this plane. But this is involved the Crow node on the medial side. If I look on the lateral, this is a Maya mcevers one, maybe even two, OK, doesn't worry me. The post-production form on a human joint is congruent. But I get a seat. So the Zoom. And I asked him.
And I see how this injury is all the way across on the media side of the coronary. That without a radial head fracture, which is unusual because it's not a terrible triad, so how does that fit? OK, now I'm getting worried about this album, and in the 45 year old, for him, I'm worried enough to do an egawa. I see a perfect cradle here, not a scratch on that radial head.
Woods coming into view now. And I see it starting on the medial side, so that's intermediate ridge. But as I come more immediately, this fracture just gets bigger and bigger. But it's not point loading on the ulnar. So I'm still thinking this is probably OK, maybe I can just get this elbow moving.
But I'm so scared now of the anti-media. I take him to theater. And you can do the egawa without the aid. You can just do the examination under anesthetic. And I do a very stress, and this is the classic to medial paranoid if the next one on from the terrible triad is the intermediate kroner to read about it if you don't know it as an isolated entity or injury to the elbow itself. And I see some rupture of the lateral collateral ligament, but most of the force that has been entered into this intermediate paranoid.
There is my horse, and I see the entry medial epicondyle is good, I put my goggles force on it, but as soon as I bring him into extension, he's a Black. And so you do need to have a three dimensional view of where that kernel is broken. And in the end, that's the code word that needs fixing or otherwise they will wear out their elbow. And that took an end to a plate, whereas the 16-year-old in the next case has a really tiny little piece of his current with their.
But when I asked him. There's a little crack in his radial head that says it started rolling out of the back of the cab, so it looks like a paler pattern that looks like a typical tried pattern, which is never quite completed. I see the little piece of the intermediate ridge, but I come across to my intermediate corner to the medial side, and that's pristine.
This elbow don't need to worry about this person doesn't need to go to theater to have any. OK, thank you. What is the sequence of repair or fixation you recommend? I would recommend start well, examine the elbow first and decide where you're at the majority of your injuries. Start on the lateral side. Fix or replace your radial head. The pay your sutures in the anterior capsule, depending on where you are before you've definitively replaced your radial head, if you're going to do the capsule and the coroner would then do your lateral collateral ligament.
So essentially, I've done everything on the lateral side. I've done radial head. I do cone within capsule because I like capsule and then to a band of that angular ligament and the lateral collateral ligament is complex and then you them. Then I see whether they're stable to within two degrees of extension. And if they are, I stop.
If they're not, that normally means they've got a medial injury. I'll go around the medial side and repair the medial side. And if you've done those properly and well, then it's very seldom that I've yet found that I've ever needed to expect someone or transfix someone. And what's the approach for the medial side, medial side, so I would normally do my elbows supine, but I do a universal posture, skin incision, so I come down the point of on just to the lateral part.
I fold it back and I go through rhomboids interval. It's between Antonius and ulna. Once I've done everything here on the lateral side, if I need to come around the medial side, I just elevate my skin bridge. And then often on these elbows, particularly if they've done c.f.o, it's like a bomb's gone off. But essentially you're going through Hotchkiss, you're splitting with the ponyta muscle mass.
So I'll find the ulnar nerve, which is sitting just about there just to keep an eye on it. And then come in front of the ulnar nerve. And often the common origin has been shredded off the medial epicondyle and you just go straight into the elbow. You put one anchor into the anterior inferior medial epicondyle one enter into the sublime cubicle or the tenotomy convoyed tied.
One set of those together, creating an internal brace on the medial side weave the rest of his sutures into whatever rat's tail you can find of your medial collateral ligament and then weave that into your common flex origin. And that's how I'd repair it. But often the dissection has been done for you on the medial side. If you were a classic Cocker Kaplan from one single lateral incision, then you just have to make a separate medial incision.
Be aware of the medial and theoretical cutaneous nerve because you are coming close in its territory if you haven't lifted your skin flap. And thank you, and what's the post op rehab you recommend post up rehab? No one gets a back slap sometimes if I've had a really big medial injury into a hinged elbow brace, but most people will wake up without the back slap just in the bulky bandage and they get active assisted flexion as much as is comfortable for them.
Active supination because active supination pulls on biceps, pulls on by several tuberosity reduces radial capital, a joint active and passive pronation because pronation actively tightens up your radial biceps tendon as it wraps around possible tuberosity and avoidance of various stress, and basically for the instruction to the physios is to avoid shoulder abduction. So what?
I'm out to the side. I lie them often for the rehab flat on their back and get them to extend against gravity because if they're lying on their back, it reduces the only human joint. It detentions the biceps and the triceps, which wants to fight to keep the elbow in joint, and so people will get more movement by rehabbing supine. I do put my hand onto that elbow to show them and to reduce their minimal joint.
We'll show them how to do it so they can hold it in place and then fight again to push up. Again, the elbow is proprioception poor, and so it needs all the help it can get so you can give themselves a chibi grip or something just to give some skin sensation to reassure the elbow that it's not dislocating so that biceps relaxes or triceps relaxes at the appropriate time. And that's often rehabbing them.
Supine is better. But what they get told to do, no shoulder abduction and those that I'm a little worried about don't really push those last two degrees of extension. Uh, thank you. And I haven't heard about that, but someone asked about a.j.'s or internal joint stabilizer. Yeah so the internal joint stabilizer from lidar, that is basically an internal external fixator, basically.
I think you need that on occasion if you haven't done the other bits properly. And again, Jupiter and ring in their first article, I think really have scared a lot of people, and rightfully so, because if you don't do a terrible tried properly the first time, it becomes a world of pain. If you're doing an acute injury and you know how to repair the collateral ligaments, and if you can't repair them, then create an internal brace in the acute setting, I think there's enough intrinsic healing within those collateral ligaments to heal it.
If you do get to that situation where you can't repair it, you can't do it. That's when the idea helps. I've never had never needed one. I've seen some great results with it. It looks nice, but they put it in and then they don't worry too much about the soft tissue repair. I personally like putting in a few stitches and I use decent sized anchors.
I'm not using any bond, you know, or small to a vehicle. It's a 2 fiber wire that I'm using to reconstruct my collateral ligament. Thank you very much, I think we have to stop questions here. And for to start the Viva. Thank you very much. There's only one that the. The do you always attempt to reduction fixation of the radial head, even if it's totally knocked out?
If it's very if it's very common, you did then know, then I'll just replace it. If it's a big piece and the three big pieces in the youngest person and I'm 59, I'd say I'm still trying to fix you if I can. Um, I still try and fix you up, but what I just need is an elbow that's stable enough, so I'll never set out to do a terrible triad unless I had the ability to do a hair replacement at the same sitting.
So I've got the plate, I've got my long. Extend screws, because if you're trying to do a tripod, you need to have long headless screws, which are normally the standard ones are a little bit too short. My plate, I've got my screws and I've got a real hip replacement. Next to me. Thank you very much. That's the end of the questions.
Thank you. Very nice. Thank you very much. Kris Van rensburg, that was very informative and from the questions that we had. You can see that actually a lot of trepidation and anxious worry about some of these things that can come up in the exam. But hopefully we as answers our candidates be more well prepared now.
I know you went through quite a few case reports in your presentation. We'll probably move on to the Viva the stage you've been doing a lot of talking to. If you need to have a break or be really grateful, and then one of the other mentors can help us with some of the questions. OK OK. So people have really asked we've got a list of people who've asked to have a vive session.
We've got Mohamed asaka, are you here? Yes, I'm here. Thank you, Renee. OK stop recording.
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