Okay, so I was asked to talk about radial head fractures, the last talk of the session. I am a consultant for Acumet. This is a 23-year-old guy. He's a better skateboarder than I am, but unfortunately he's not good enough. And he tries a trick and he falls, and he has this valgus trauma. And I'll show it again. I had some sound as well, which is a very dramatic effect, but... Do it again. Yeah, it's in slow motion, Graham, just for you. Can you show it again? No, that's it. The Americans told me Canadians were a little bit slow, but... Anyway, so he has a medial collateral ligament damage there. This is his CT. I won't ask if you need a CT. I think you definitely need one, so I didn't want to go into the discussion about this. He has a dislocated radial head fragments, but his only humeral joint is congruent. So dislocation of fragments there. So the options, would anyone treat this conservatively? I don't think that's a big discussion. Just to know that the old series Broberg and Mori and Josephson, they did sometimes treat these just in a cast, and then they had to deal with the forearm rotation problems on occasion with the secondary radial head excision. But instability wasn't a problem. I presume this person has a block to forearm rotation with that radial head fragment. I would assume if they don't, they're going to have... So I think everyone would operate. Yes. Okay. So what? So I do a lateral incision. We can discuss that as well. I know some of you do a posterior incision. So take out the fragments, and they were all fractured away from the neck, and this was them. Then I tested stability and fluoroscopy, and there was absolutely no restraint to valgus stress. So I could continue until the forearm came off, basically. So these are the options I want to discuss. Would anyone still try an osteosynthesis here? He's 23 years old, so... IOM? Was the interosseous membrane intact? I didn't test that. I'll tell you why in a minute. So no one osteosynthesis. Anyone for a resection? The reason why I didn't test the IOM is I think it's when it's this unstable for valgus, I think the whole discussion about the IOM is mute, and this guy deserves a prosthesis in IOM. Probably a valgus load. I just test it routinely. It's part of my checklist, part of my pilot's checklist. So when you check it, David, do you put a reduction clamp on the neck and do what Dave Rusch taught us? No, I don't put an etho on the neck. I just push-pull. Axial push-pull test. Okay. So I put a prosthesis in, and then evaluated again in fluoroscopy, and as you can see, there's still very clear medial opening. But there is a block. So before there was no block to valgus stress. Now there is a block. And I'll show you again there. So it's really opening, and it's more than two millimeters. I'd say it's more than half a centimeter. So it's safe to say that the MCL is definitely ruptured. And I think this would be a discussion, who to repair the MCL. Okay. So let's take a poll of the, starting with Dr. Bain. Would you fix the MCL? Yes. Yes, for Dr. Bain. Dr. Rusch? Is it stable? Can you flex next to him? It doesn't dislocate. It stays congruent. And there's no sag on the lateral side. So if there's no sag, I don't go to medial. I wouldn't fix it. No. No, Dr. Beppe? No. Dr. Beppe wouldn't fix it. I wouldn't fix it either, unless the patient, I guess, was a throwing athlete or gymnast. But that's rare in my practice. Yeah, plus now he has a radial head replacement, so he's not going to be a gymnast anyway after this. You'd be surprised. Not with his prosthesis. Maybe with yours. Not with that one. Dr. Rusch is trying to talk about this in his discussion, so maybe give him the microphone for a second. Oh, he's even getting up. So I'm just going to tell you why he's on the left side. There's some psychology research. He's not allowed to show slides. That's a violation. That's some psychology. Who's got that horn? Bing! All right. There's some psychology research saying that if the speaker stands on the right side, you're actually talking to the right side of the brain, which is the rational side. And the left side is the emotional side. And that's why he went that way, I'm sure. You've got a couple of slides, don't you? I think the other part of the examination that's important is not just to do the valgus but also the pronation. So it may be that the posterior medial ligaments are also torn, so I do the valgus, the posterior medial. And for me, this was all about actually just getting stability to create a joint that's stable for functional activities. So that's where I was. Now, Bernie Mori had a very interesting graph that came out of his book some years ago. And I think a lot of people will know that basically we took the radial head out in the MCL and talked about the percentages of instability. And maybe it's a little bit crude in concept, but I actually found that actually very useful to help me understand some of these problems. The next issue, Denise's paper's been mentioned, and my understanding was it was associated with laxity on the medial side and degenerative osteoarthritis on the lateral side. So from that point of view, in those elbow dislocations, the long-term outcome of MCL instability is not benign. And then the other issue is a paper that came from Turkey by a guy called Torres, which I was going to show his slides. He did 16 cases, eight in each group. Eight had a repair of the MCL, and eight didn't. The cases that did not have a repair got a lot more heterotopic ossification on the medial side, and those cases often went on, 50% of them, I think, was a number that went on to develop ulnar nerve problems and required often an ulnar nerve release, and some of those patients had pain, et cetera. That's really funny that you say that, because actually, you published on this, and David published on this, and you both used a posterior approach to the elbow, the posterior incision, and posterior skin incision. And in your series, the MCL repair was common. In David's series, the MCL repair wasn't common, and both had similar amount of ulnar neuritis afterwards, about five in 27, and you had three out of 16. And there's another paper from Mark Cohen in 2012, who actually used the same approach as I did, so a lateral incision, lateral approach to the elbow. He did not repair the MCL in any of the 37, and he had zero ulnar neuritis. It's a late thing. It comes around one or two years afterwards. The follow-up was similar for all three papers. So the bottom line is we're not sure, right? Whether we should fix it or not. Correct. There's another difference. It's a randomized trial, because otherwise, we just don't know. Maybe. There's another thing with Denise's paper. I didn't fix it, no. How did the patient do? Yeah, I'll show you. So obviously, the reason to fix it would be instability, right? And this patient, after two weeks, this is the patient after six weeks, and he's developing heterotopic ossification anteriorly, and this is the patient after three months, so he's stiff, he's completely stable, and he has lost some rotation. So I'm actually probably going to have to do an arthrolysis with him. I didn't do it yet, because he's still improving. So he's 70-70, and you're going to do an arthrolysis? No, for flexion extension, if he doesn't improve further. But he's still improving, so I left him. Sorry, I don't understand. Is it 45-120? I'm sorry, it's 45 extension deficit, and he can flex to 120. Because he is a skateboarder. He's going to be back. He's already done that. Yeah, he's already back on his board. Well, people were asking about rehab. So Graham, at three months, with no HO in the back, you think you're going to get better than 45 degree flexion contracture? Yes. Really? Definitely. And you probably do better than 120, but you might not. But I keep trying. Yeah, yeah. And 120 is plenty. So I don't think this guy's going to improve. Don't rush into this. No, as long as he is still improving, I don't think you should. I've got a question for the panel as well. I took out the slides, but who would consider to do immobilization, or an X-fix, or a dynamic brace, or anything to protect him afterwards, if you don't repair the MCL, or even if you do repair the MCL? Put him in supination flexion extension. Immobilization? No, no. Just get him moving in supination. Okay. Full stop. Split him in supination. Well, we should end now, because we're already over time, and the previous one was as well. So I thank my investigators and commentators from around the world, and I thank the audience for your participation in the little Twitter thing up here. Thank you.

skateboarder

radial head fracture

CT scan

surgical intervention

MCL rupture