Cadmore media player playing video ORIF Proximal Humerus with Strut Allograft
Video Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the video. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Language
1x
Play Speed
Adjust Volume
Transcript
Search
Result Count
of
Click to jump to result
Search
Re-center
Segments
Result Count
of
Click to jump to result
Search
Name:
ORIF Proximal Humerus with Strut Allograft
Description:
ORIF Proximal Humerus with Strut Allograft
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/061edfec-3d72-4abd-87de-43356714c1ea/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H34M08S
Embed URL:
https://stream.cadmore.media/player/061edfec-3d72-4abd-87de-43356714c1ea
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/061edfec-3d72-4abd-87de-43356714c1ea/ORIF Proximal Humerus with strut allograft..mp4?sv=2019-02-02&sr=c&sig=2vE5kcOTlY2SPDQ4%2Bl7t0Ii0VLBmSKhtS4j1QvVktPs%3D&st=2024-12-04T08%3A41%3A07Z&se=2024-12-04T10%3A46%3A07Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. I'm going to demonstrate ORIF of proximal humerus using a lock plate. In some patients where there is loss of medial hinge, I use a strut allograft as is very beneficial to provide support.
BIJAYENDRA SINGH: And I've used this fairly regularly in patients with medial comminution and lack of medial calcar. If for whatever reason allograft is not available, then a fibula can be used as a strut graft. Look at an example for a male 50-year-old who fell from his horse. These are his pre-op radiographs showing a comminution and displacement with valgus position.
BIJAYENDRA SINGH: A CT scan is utilized to assess the fragments. And the sizes and plan for the surgery. These are the actual sections. So in a reasonable sized head, what this doesn't show that the humeral head is not in line with the shaft and it certainly moved the valgus position.
BIJAYENDRA SINGH: That's why it's mismatched on the oblique sections. One can appreciate this a bit better and you can see the alignment isn't great overall. And the 3D reconstruction images, actually shows the best views of where the fragments have gone.
BIJAYENDRA SINGH: And in fact, although on the initial radiographs that looked a bit valgus it seems there is some varus in this. So here we've got a patient who's in a beach chair prepped and draped. I always put a mixture of 20 mils of 1% xylocaine with adrenaline in the plane of incision, draw my landmarks, the acromion and I mark the spot between 5 to 7 centimeters from the edge of the acromion.
BIJAYENDRA SINGH: And this helps to identify the axillary nerve. Obviously, this will vary on the size of the patient. Once I'm happy I make a skin incision along that line about 12 to 15 centimeters long. And you can see the bleeding is less compared to without the adrenaline. At this stage, I raise fairly thick skinned flaps right up to the level of the more zone just towards the fascia.
BIJAYENDRA SINGH: And I would advise to raise these flaps nicely as it allows easy closure of the muscle layer after at the end of the case. Continue doing the dissection till you get the desired length and insert a self retainer. I'll continue to raise the flags till I'm happy.
BIJAYENDRA SINGH: Focus my attention at the top end, and I've always tried to go right up to the AC joint exposure as I need to release the deltoid up to this point. Once I'm happy. Clearly I think that needs more release so that I can see the muscle layer quite easily.
BIJAYENDRA SINGH: Once I'm happy with this, I reposition the self retainer and feeling for the front of the acromion about five six millimeter behind that. Using a diathermy, I make a sharp dissection onto the bone, and that's the edge of the acromion. I go full thickness at one small point so that I know how much deltoid I have to release and I lift the fascia over the acromion, as I do, to remove a small portion of the acromion bone as you will see second.
BIJAYENDRA SINGH: So I've done that and I also release the deltoid fascia. Now this is the opening of the sub-acromial space and you can see the fracture haematoma. As this is a two-day-old injury. Often when it's more than a week, then you may not see this haematoma.
BIJAYENDRA SINGH: Put a small retractor in that deltoid split. Which allows me to identify the edge of the acromion quite quickly. And what you can see is the top of the rotator cuff. And this will be exposed nicely once I've done that. I use a sharp osteotome, leaving about 4 or 5 millimeters of the anterior edge of the acromium, usually with one or two sharp knocks and release this.
BIJAYENDRA SINGH: I take about 4 or 5 millimeters of the acromion and do like an acromionectomy. It reduces the chance of the plate impinging onto the acromion. Just releasing some of the bursa here to identify the fracture split. I identify the level of where I'm expecting the axiliary nerve now before I start to feel for it. The best technique I find is to run my finger at the back of the deltoid, which allows to identify a cord like structure
BIJAYENDRA SINGH: and then I'll leave my index finger under the nerve and dissect with a pair of scissors on top of the nerve. Do not aim to skeletonize the nerve completely. Often we leave a fair amount of muscle see that so that it's not completely de vascularized. I then put a vascular sloop or you could use a nylon tape, but it needs to be a smooth structure because the nerve is not very big.
BIJAYENDRA SINGH: I always make a knot so that my vascular loop doesn't slip and I recommend not to put any artery clip or a clamp on it, as it's more likely to get caught in somewhere along the procedure and cause damage to the nerve. Once I'm happy with that, I'm just trying to identify the fracture pattern.
BIJAYENDRA SINGH: Let's just see where the splits are and then identify to put my initial sutures in. So I can see the greater tuberosity fragment right to now. Try and isolate it a bit more.
BIJAYENDRA SINGH: Now I think I'm happy with the fragment. Sometimes you do have to really do a rotator interval release between the greater and the lesser tuberosity fragment, as you can see there. Identify the top of the humeral head there, that's the head. Fragment and under the retractor is the greater tuberosity fracture, that's the plane.
BIJAYENDRA SINGH: And first, we will aim to put some sutures around that fragment. That's the GT frag there you can see. And then using the ethibond suture or any non-absorbable suture. I generally put at least three sutures in the cuff.
BIJAYENDRA SINGH: Two in the each, one each in the supra, and the infraspinator and as well as in the front and the subscapularis even for the simple fractures is provides retraction traction as well as additional fixation at the end.
BIJAYENDRA SINGH: So that's one of my sutures in the greater tuberosity. A second suture. A second suture going as well into the top of the Supraspinatus tendon. And I generally try and put a Mason Allen type of stitch which gives a better control and better hold in the rotator cuff tendon.
BIJAYENDRA SINGH: It's vital that the suture is placed in the tendon junction bone interface. Now I use a bristow or an osteotome to try and elevate that fragment which has gone into valgus. Trying to maneuver in its position sometimes I use the thumb to manipulate that fragment back into place.
BIJAYENDRA SINGH: I can see the head has gone posteriorly as well so I'm trying to move my elevator from front to back to lift that. Almost like the ice cream cone on top of the humorous head that's the {cuts out]...
BIJAYENDRA SINGH: Realize that I need more suture anchors er sutures in the cuff so I'm going to put some more on the anterior aspect of the rotator cuff to get a better hold of the fragment.
BIJAYENDRA SINGH: Once I'm happy I'm pushing that humeral head fragment back into its position and pulling the tuberosity on top. Then checking on the image intensifier to see what my position looks like. I can see that there is a varus. there is a media lack of medial continuity. But I can also see that I can reduce it well and the upper end of the fracture looks like an upper end of humerus.
BIJAYENDRA SINGH: Now I'm going to prepare the bone graft? A strut bone graft. I've got a half split femur and try not to use the most thickest part. I mark out about 8 to 10 centimeters length. Usually half an oval shape, which is slightly thicker on one side. It's narrower on the other side.
BIJAYENDRA SINGH: Once I've drawn that, then I will use k-wires to make some drill holes along the line where I want to make the cut. This avoids crack in the bone as this is, although it provides stability, it's quite brittle bone.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Once I've done that, I use a saw. Usually try with a slightly thinner saw So there is less vibration and less likely to split or splinter the graft.
BIJAYENDRA SINGH: You have this graft now which I can remove. Then I insert it into the medullary canal. So that's about two centimeters is jutting out of the fracture site. Rotate it so that I can give like a snug fit or a press fit and then Ish will check radiograph to see the reduction of location of the bone graft and how much it's occupying the medullary canal.
BIJAYENDRA SINGH: Need to readjust as required to provide the best fit. The key thing here is to jam the graft in so that it provides an internal pillar kind of structure for the humeral head and you can see I've pulled the tuberosity on top which has reduced and can form like an upper end of the humerus on which we can work afterwards.
BIJAYENDRA SINGH: Final readjustments are made to the graft and then I'm going to close the sutures from the front and the back and tie them off so that I form, so that it forms like an upper end of the humerus and the humeral plate will then be used more or less like a neutralization mode if you are doing a long bone fracture.
BIJAYENDRA SINGH: So the tuberosites have been reduced on top of the humerus head, from the position on the right to the one on the left.
BIJAYENDRA SINGH: I'm putting one more suture in the anterior cuff to give that extra hold. I've already got one of the posterior aspects. I feel that these sutures are quite vital in providing additional stability for these fractures. So I'm now going to put my fifth and final suture on the top of the humerus through the rotator cuff.
BIJAYENDRA SINGH: I have decided to use a three hole standard PHILOS plate plate which I'm going to use to put a chimney instead of the block which is another option, which provides me a good hold on to the plate without worrying about losing it. Before I put any screws. I pass those sutures through the top and on the side of the suture holes on the plate.
BIJAYENDRA SINGH: Suture holes on the plate which provides more stability to the fixation.
BIJAYENDRA SINGH: Once I've put the plate, I check on the X-ray to adjust the height and then I will start to put the screws. The first is a cortical screw in the oblong hole which allows you to adjust the height of the plate before you finalize a fixation. It's usually between 24 and a 30 millimeter screw, depending on the size of the patient.
BIJAYENDRA SINGH: So the cortical screw is going in. And when one I stop a couple of millimeters short and then check the radiographs. If required, at this stage, I will adjust the height of the plate. In this case it was slightly higher.
BIJAYENDRA SINGH: And I brought the plate down once I've got that fixation. I sometimes pull on the sutures on the cuff to see if I need to tie them before or towards the end of the procedure. So here I can see if I don't fix the tuberosities first, it's likely that it will escape and may not be held within the place.
BIJAYENDRA SINGH: So I've tied this. Then I start to put the locking screws. First this, for this part, I always use the image intensifier. Sometimes the feeling is not as great because of the bone corrosive nature of the bone.
BIJAYENDRA SINGH: Start with putting the screws, locking screws. So from now on, all the screws that go in are locking. My standard fixation will have one cortical screw in the distal fragment two locking in the distal and varying between 6 to 8 locking in the humeral head. I prefer to use them as higher power as it saves time and also to trajectories slightly to be moved.
BIJAYENDRA SINGH: Key is to use it on high torque, low speed. Now the calcar goes up to three if you can get in and these are quite vital to provide more stability to that medial buttress.
BIJAYENDRA SINGH: Certainly feel even if you don't need the strutt allograft, these two or three screws in the calcar are very important to provide stability to your fixation.
BIJAYENDRA SINGH: Some of them are locking screws going into the proximal fragment in the calcar. The important thing to remember, certainly with the PHILOS is that if your screws are flush with the plate, then they are locked in the proper place. Sometimes you may get the talk limiting noise, but may not be in the right place. The final two distal locking screws going in.
BIJAYENDRA SINGH: Finish the fixation.
BIJAYENDRA SINGH: For this final check you can see the image on the right and the left can see from where until valgus. It's gone into a nice, reduced position. At this stage, I spend a couple of minutes to screen and make sure that there is no screw penetration or tuberosity escape. It's quite important to go near the screen to look at this.
BIJAYENDRA SINGH: And if you're farther away than some of the small displacements may be missed. I do not worry about the perfect positioning of the plate as long as I get a good reduction but generally, this goes hand in hand. Just tying out the final cut sutures onto the plate to finish the fixation.
BIJAYENDRA SINGH: Once this is over, I go back to the area where the metaphyseal gap. And if required, I'll put any more bone graft surgeries certainly these small piece of the achromium plus here, because I've got the whole allograph, sometimes I have used that as well to provide them some lateral support as well under the plate. And if required, I'll use a mix of dBm putty and some bone chips.
BIJAYENDRA SINGH: Do a thorough a check of the implant and the reduction looking at the AP view internal and external rotation views. As always, teach that this is the best chance to check for any articular penetration. Also, do a dynamic screen to check the position.
BIJAYENDRA SINGH: When coming to the repair I do an transosseous repair of the deltoid using a non absorbable suture like a number five ethibond. In the younger patient sometimes you may have to use a k-wire or a 2 millimeter drill bit - to make that entry through the to make that entry through the acromion do a robust mattress or a figure of eight type of suture to repair this.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: For that I use a number two to absorb vicryl type stich. Start at the apex of the deltoid split. Do a mattress repair to begin with and then I go in the he vertical direction rather than criss cross, which reduces the crushing of the muscle tissue. And I've not noted any inversion of the skin margins in this patient once I've taken the first couple of bites,
BIJAYENDRA SINGH: You will see that I changed the direction of the - how I passed the suture, there you go so that's gone vertical now. It gently apposes the margin of the muscles. Just supply it loosely, not over tightening to avoid any muscle necrosis.
BIJAYENDRA SINGH: Then I use a 2-0 undyed absorbable suture. To close the fat there I continuous stitch.
BIJAYENDRA SINGH: I always use some sub cuticular monocryl stich to close my skin and this gives a better scar, less chances of any inflammation. I start about a centimeter and a half to 2 centimeters beyond the skin incision. And I tie the sutures as I found some skin reaction if you bury the knot under the skin. Small bites across the skin and gives a very nice repair.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Now these are radiographs done at six weeks post-op. Looking good alignment. That good number of screws, the strutt graft's in place. That picture also shows screws to within the humeral head to do a re-alignment the reviews to best confirm or check penetration. So as you can see, humeral strutt graft has a vital role in some of these complex fractures.
BIJAYENDRA SINGH: Thank you very much. Hopefully I provided some vital tips and tricks to undertake a fixation of the proximal humerus fracture using a deltoid split approach. And this has now become my standard technique and approach for fixation of most of these fractures. Thank you.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. I'm going to demonstrate ORIF of proximal humerus using a lock plate. In some patients where there is loss of medial hinge, I use a strut allograft as is very beneficial to provide support.
BIJAYENDRA SINGH: And I've used this fairly regularly in patients with medial comminution and lack of medial calcar. If for whatever reason allograft is not available, then a fibula can be used as a strut graft. Look at an example for a male 50-year-old who fell from his horse. These are his pre-op radiographs showing a comminution and displacement with valgus position.
BIJAYENDRA SINGH: A CT scan is utilized to assess the fragments. And the sizes and plan for the surgery. These are the actual sections. So in a reasonable sized head, what this doesn't show that the humeral head is not in line with the shaft and it certainly moved the valgus position.
BIJAYENDRA SINGH: That's why it's mismatched on the oblique sections. One can appreciate this a bit better and you can see the alignment isn't great overall. And the 3D reconstruction images, actually shows the best views of where the fragments have gone.
BIJAYENDRA SINGH: And in fact, although on the initial radiographs that looked a bit valgus it seems there is some varus in this. So here we've got a patient who's in a beach chair prepped and draped. I always put a mixture of 20 mils of 1% xylocaine with adrenaline in the plane of incision, draw my landmarks, the acromion and I mark the spot between 5 to 7 centimeters from the edge of the acromion.
BIJAYENDRA SINGH: And this helps to identify the axillary nerve. Obviously, this will vary on the size of the patient. Once I'm happy I make a skin incision along that line about 12 to 15 centimeters long. And you can see the bleeding is less compared to without the adrenaline. At this stage, I raise fairly thick skinned flaps right up to the level of the more zone just towards the fascia.
BIJAYENDRA SINGH: And I would advise to raise these flaps nicely as it allows easy closure of the muscle layer after at the end of the case. Continue doing the dissection till you get the desired length and insert a self retainer. I'll continue to raise the flags till I'm happy.
BIJAYENDRA SINGH: Focus my attention at the top end, and I've always tried to go right up to the AC joint exposure as I need to release the deltoid up to this point. Once I'm happy. Clearly I think that needs more release so that I can see the muscle layer quite easily.
BIJAYENDRA SINGH: Once I'm happy with this, I reposition the self retainer and feeling for the front of the acromion about five six millimeter behind that. Using a diathermy, I make a sharp dissection onto the bone, and that's the edge of the acromion. I go full thickness at one small point so that I know how much deltoid I have to release and I lift the fascia over the acromion, as I do, to remove a small portion of the acromion bone as you will see second.
BIJAYENDRA SINGH: So I've done that and I also release the deltoid fascia. Now this is the opening of the sub-acromial space and you can see the fracture haematoma. As this is a two-day-old injury. Often when it's more than a week, then you may not see this haematoma.
BIJAYENDRA SINGH: Put a small retractor in that deltoid split. Which allows me to identify the edge of the acromion quite quickly. And what you can see is the top of the rotator cuff. And this will be exposed nicely once I've done that. I use a sharp osteotome, leaving about 4 or 5 millimeters of the anterior edge of the acromium, usually with one or two sharp knocks and release this.
BIJAYENDRA SINGH: I take about 4 or 5 millimeters of the acromion and do like an acromionectomy. It reduces the chance of the plate impinging onto the acromion. Just releasing some of the bursa here to identify the fracture split. I identify the level of where I'm expecting the axiliary nerve now before I start to feel for it. The best technique I find is to run my finger at the back of the deltoid, which allows to identify a cord like structure
BIJAYENDRA SINGH: and then I'll leave my index finger under the nerve and dissect with a pair of scissors on top of the nerve. Do not aim to skeletonize the nerve completely. Often we leave a fair amount of muscle see that so that it's not completely de vascularized. I then put a vascular sloop or you could use a nylon tape, but it needs to be a smooth structure because the nerve is not very big.
BIJAYENDRA SINGH: I always make a knot so that my vascular loop doesn't slip and I recommend not to put any artery clip or a clamp on it, as it's more likely to get caught in somewhere along the procedure and cause damage to the nerve. Once I'm happy with that, I'm just trying to identify the fracture pattern.
BIJAYENDRA SINGH: Let's just see where the splits are and then identify to put my initial sutures in. So I can see the greater tuberosity fragment right to now. Try and isolate it a bit more.
BIJAYENDRA SINGH: Now I think I'm happy with the fragment. Sometimes you do have to really do a rotator interval release between the greater and the lesser tuberosity fragment, as you can see there. Identify the top of the humeral head there, that's the head. Fragment and under the retractor is the greater tuberosity fracture, that's the plane.
BIJAYENDRA SINGH: And first, we will aim to put some sutures around that fragment. That's the GT frag there you can see. And then using the ethibond suture or any non-absorbable suture. I generally put at least three sutures in the cuff.
BIJAYENDRA SINGH: Two in the each, one each in the supra, and the infraspinator and as well as in the front and the subscapularis even for the simple fractures is provides retraction traction as well as additional fixation at the end.
BIJAYENDRA SINGH: So that's one of my sutures in the greater tuberosity. A second suture. A second suture going as well into the top of the Supraspinatus tendon. And I generally try and put a Mason Allen type of stitch which gives a better control and better hold in the rotator cuff tendon.
BIJAYENDRA SINGH: It's vital that the suture is placed in the tendon junction bone interface. Now I use a bristow or an osteotome to try and elevate that fragment which has gone into valgus. Trying to maneuver in its position sometimes I use the thumb to manipulate that fragment back into place.
BIJAYENDRA SINGH: I can see the head has gone posteriorly as well so I'm trying to move my elevator from front to back to lift that. Almost like the ice cream cone on top of the humorous head that's the {cuts out]...
BIJAYENDRA SINGH: Realize that I need more suture anchors er sutures in the cuff so I'm going to put some more on the anterior aspect of the rotator cuff to get a better hold of the fragment.
BIJAYENDRA SINGH: Once I'm happy I'm pushing that humeral head fragment back into its position and pulling the tuberosity on top. Then checking on the image intensifier to see what my position looks like. I can see that there is a varus. there is a media lack of medial continuity. But I can also see that I can reduce it well and the upper end of the fracture looks like an upper end of humerus.
BIJAYENDRA SINGH: Now I'm going to prepare the bone graft? A strut bone graft. I've got a half split femur and try not to use the most thickest part. I mark out about 8 to 10 centimeters length. Usually half an oval shape, which is slightly thicker on one side. It's narrower on the other side.
BIJAYENDRA SINGH: Once I've drawn that, then I will use k-wires to make some drill holes along the line where I want to make the cut. This avoids crack in the bone as this is, although it provides stability, it's quite brittle bone.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Once I've done that, I use a saw. Usually try with a slightly thinner saw So there is less vibration and less likely to split or splinter the graft.
BIJAYENDRA SINGH: You have this graft now which I can remove. Then I insert it into the medullary canal. So that's about two centimeters is jutting out of the fracture site. Rotate it so that I can give like a snug fit or a press fit and then Ish will check radiograph to see the reduction of location of the bone graft and how much it's occupying the medullary canal.
BIJAYENDRA SINGH: Need to readjust as required to provide the best fit. The key thing here is to jam the graft in so that it provides an internal pillar kind of structure for the humeral head and you can see I've pulled the tuberosity on top which has reduced and can form like an upper end of the humerus on which we can work afterwards.
BIJAYENDRA SINGH: Final readjustments are made to the graft and then I'm going to close the sutures from the front and the back and tie them off so that I form, so that it forms like an upper end of the humerus and the humeral plate will then be used more or less like a neutralization mode if you are doing a long bone fracture.
BIJAYENDRA SINGH: So the tuberosites have been reduced on top of the humerus head, from the position on the right to the one on the left.
BIJAYENDRA SINGH: I'm putting one more suture in the anterior cuff to give that extra hold. I've already got one of the posterior aspects. I feel that these sutures are quite vital in providing additional stability for these fractures. So I'm now going to put my fifth and final suture on the top of the humerus through the rotator cuff.
BIJAYENDRA SINGH: I have decided to use a three hole standard PHILOS plate plate which I'm going to use to put a chimney instead of the block which is another option, which provides me a good hold on to the plate without worrying about losing it. Before I put any screws. I pass those sutures through the top and on the side of the suture holes on the plate.
BIJAYENDRA SINGH: Suture holes on the plate which provides more stability to the fixation.
BIJAYENDRA SINGH: Once I've put the plate, I check on the X-ray to adjust the height and then I will start to put the screws. The first is a cortical screw in the oblong hole which allows you to adjust the height of the plate before you finalize a fixation. It's usually between 24 and a 30 millimeter screw, depending on the size of the patient.
BIJAYENDRA SINGH: So the cortical screw is going in. And when one I stop a couple of millimeters short and then check the radiographs. If required, at this stage, I will adjust the height of the plate. In this case it was slightly higher.
BIJAYENDRA SINGH: And I brought the plate down once I've got that fixation. I sometimes pull on the sutures on the cuff to see if I need to tie them before or towards the end of the procedure. So here I can see if I don't fix the tuberosities first, it's likely that it will escape and may not be held within the place.
BIJAYENDRA SINGH: So I've tied this. Then I start to put the locking screws. First this, for this part, I always use the image intensifier. Sometimes the feeling is not as great because of the bone corrosive nature of the bone.
BIJAYENDRA SINGH: Start with putting the screws, locking screws. So from now on, all the screws that go in are locking. My standard fixation will have one cortical screw in the distal fragment two locking in the distal and varying between 6 to 8 locking in the humeral head. I prefer to use them as higher power as it saves time and also to trajectories slightly to be moved.
BIJAYENDRA SINGH: Key is to use it on high torque, low speed. Now the calcar goes up to three if you can get in and these are quite vital to provide more stability to that medial buttress.
BIJAYENDRA SINGH: Certainly feel even if you don't need the strutt allograft, these two or three screws in the calcar are very important to provide stability to your fixation.
BIJAYENDRA SINGH: Some of them are locking screws going into the proximal fragment in the calcar. The important thing to remember, certainly with the PHILOS is that if your screws are flush with the plate, then they are locked in the proper place. Sometimes you may get the talk limiting noise, but may not be in the right place. The final two distal locking screws going in.
BIJAYENDRA SINGH: Finish the fixation.
BIJAYENDRA SINGH: For this final check you can see the image on the right and the left can see from where until valgus. It's gone into a nice, reduced position. At this stage, I spend a couple of minutes to screen and make sure that there is no screw penetration or tuberosity escape. It's quite important to go near the screen to look at this.
BIJAYENDRA SINGH: And if you're farther away than some of the small displacements may be missed. I do not worry about the perfect positioning of the plate as long as I get a good reduction but generally, this goes hand in hand. Just tying out the final cut sutures onto the plate to finish the fixation.
BIJAYENDRA SINGH: Once this is over, I go back to the area where the metaphyseal gap. And if required, I'll put any more bone graft surgeries certainly these small piece of the achromium plus here, because I've got the whole allograph, sometimes I have used that as well to provide them some lateral support as well under the plate. And if required, I'll use a mix of dBm putty and some bone chips.
BIJAYENDRA SINGH: Do a thorough a check of the implant and the reduction looking at the AP view internal and external rotation views. As always, teach that this is the best chance to check for any articular penetration. Also, do a dynamic screen to check the position.
BIJAYENDRA SINGH: When coming to the repair I do an transosseous repair of the deltoid using a non absorbable suture like a number five ethibond. In the younger patient sometimes you may have to use a k-wire or a 2 millimeter drill bit - to make that entry through the to make that entry through the acromion do a robust mattress or a figure of eight type of suture to repair this.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: For that I use a number two to absorb vicryl type stich. Start at the apex of the deltoid split. Do a mattress repair to begin with and then I go in the he vertical direction rather than criss cross, which reduces the crushing of the muscle tissue. And I've not noted any inversion of the skin margins in this patient once I've taken the first couple of bites,
BIJAYENDRA SINGH: You will see that I changed the direction of the - how I passed the suture, there you go so that's gone vertical now. It gently apposes the margin of the muscles. Just supply it loosely, not over tightening to avoid any muscle necrosis.
BIJAYENDRA SINGH: Then I use a 2-0 undyed absorbable suture. To close the fat there I continuous stitch.
BIJAYENDRA SINGH: I always use some sub cuticular monocryl stich to close my skin and this gives a better scar, less chances of any inflammation. I start about a centimeter and a half to 2 centimeters beyond the skin incision. And I tie the sutures as I found some skin reaction if you bury the knot under the skin. Small bites across the skin and gives a very nice repair.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Now these are radiographs done at six weeks post-op. Looking good alignment. That good number of screws, the strutt graft's in place. That picture also shows screws to within the humeral head to do a re-alignment the reviews to best confirm or check penetration. So as you can see, humeral strutt graft has a vital role in some of these complex fractures.
BIJAYENDRA SINGH: Thank you very much. Hopefully I provided some vital tips and tricks to undertake a fixation of the proximal humerus fracture using a deltoid split approach. And this has now become my standard technique and approach for fixation of most of these fractures. Thank you.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode