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Humerus Anterior Bridge Plate Lecture - Tips and Tricks
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Humerus Anterior Bridge Plate Lecture - Tips and Tricks
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Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Doctor Sergio Rowinski, from ShoulderPlanet, here from São Paulo, Brazil. In this video, I'm presenting you, actually, a lecture, that I have presented, on 4th April 2020, in Gujarat Orthopedic Association webinar on biological fixation on humeral fractures.
It was a nice lecture, showing indications of ABP, anterior bridge plating of the humerus. A lot of technical tips, tricks and a lot of ideas and concepts to understand how the patient is evolving clinically and radiographically, when you use this technique. So I hope you like the video, please subscribe, give your thumbs up and let's see this nice lecture.
OK, now will move to the Sergio's lecture. So that again, we'll have a question answer session later on. So do you believe you can start? Yeah, Yeah. Can I start? Yes, yes, sir. Are you seeing my presentation? Yes, we are seeing your presentation on Humeral Anterior Bridge Plating.
OK, so I'm going to start, the thing is, I'm super happy. Honored to be here. I'm very happy. The thing is, I made a presentation with in which I want to show a lot of comments, a lot of principles, and for the audience to understand how this technique works in different ages and in different clinical pictures, in terms of fractures.
So I want to speak from the beginning to the end, for everybody to understand, and then hope that we have a nice discussion. So the thing is, this is the first case with no radial deficits. 21-year-old girl with a distal humerus, in the distal shaft, with a transverse fracture. The thing is, I can do all of the patterns of fractures and this is one thing that I want to show.
So what to do and the thing is, I love interior bridge plating, I do this with focus, passion, but still with scientific methods, and it works tremendously in my hands. So this is the first message, this plate, well, I always use a 12 hole plate, with two screws up and two screws down. So there is a lot of discussion. A lot of people have been discussing with me, "but I am afraid of using two screws,
I want to use three", and, in my opinion, and in my team's opinion, and in Brazilian guys' opinion, this is a fallacy. This is a myth, from the word mythology, because with two up and two down, that's absolutely enough. In this case, the plate could be a little bit lower, but it doesn't matter. As long as I can put two up and two down, that's absolutely enough.
I'm going to show very challenging cases. So the thing is what I want everybody to understand, this is the immediate post-op. So what about the incisions? Well, there is a way to perfectly, I repeat, to wonderfully position the incisions. I'm going to show it. But what about the sizes? As a rule, I don't care about the sizes, but as a rule, the proximal incision, in the last 10 years, have been around centimeters 2 and 1/2, and distal incision about 3 and 1/2.
But for some, I would say, skin reasons that I don't understand, and I don't care about it, these distal incision, it has a shrinkage with time, in a way that it becomes very, very, very, very small but thought out, and I'm going to show it soon. So what I want people to understand is that there is a very important thing in this technique, which is something like what Shiva has said.
Clinical healing precedes radiographycal healing. This is very important. Clinical healing precedes radiographycal healing a lot, and I'm going to show you beautiful examples. So when does the callus start? I would say literature is very clear from 12 to 16, but you can have less or you can have more. And I'm going to show both cases that, in my opinion, it depends on the age, because this is a biological technique in which you need a lot of biological response.
So this girl, you see, with eight weeks, she has already a beautiful callus. But this is not this is not the average, OK, this is happening because she's very young, in my point of view and, with five weeks post-op, she was wonderful. And when you come to eight weeks, you have the starting callus. But this is not the average, Ok? The average, in my practice, is exactly what literature says.
It's 12 to 16 weeks, to have radiographycal healing, because clinical healing comes much first. So this is the post-opm four months, and people must understand that bone remodeling is something that takes months and years. And this is written in Rockwood, in Campbell, and in Jupiter, all of the classical books. So if you pick up this girl and you see another image with eight months, it's going to be, I would say, a much, much more nicer and mature callus.
The thing is that these are young patients, they have to take care of their lives, and they come to me and they say, doctor Sergio, I'm so nice. It's a little bit difficult to come here, and I just I want to live my life. There are so many patients, so please discharge me. And then I just discharged that girl, on that day. So this is a beautiful view, post-op, and how was, I would say, this is a beautiful callus,
so these are the incisions, and I'm going to talk about the incisions, how to proper place them, in a second. But, I told you, there is a shrinkage process in the skin, I cannot explain why, but it doesn't matter to me, because it's good. So see, she ended up having such a small incision, OK? And I'm going to talk about where to put the incisions in a minute. So what about the clinical results?
I'm talking in the video, so let's see and listen to my voice. Six months post-op, anterior bridge plate, surgery 29/December/2016, very small incision. (now I am talking in Portuguese to patient) Extend it,
(now I am talking in Portuguese to patient) She wants to go boxing (now I am talking in Portuguese to patient) Absolutely no pain, no pain. (now I am talking in Portuguese to patient) No, no, no. The rides a bike, she doesn't remember she has a plate.
So the first message You can do it in any pattern, I'm going to show order patterns. So how to, so now I'm going to talk about the technique, and then I'm going to show three other very nice cases, in different patterns and ages. So you have to draw the incisions for them to be in perfect position, and very small.
So how am I going to draw incisions? So this is a very old picture, just for pedagogical purposes. This is a 10 hole, but, for many years, I only use 12. And what yo must understand, you are looking to this and looking to the C-arm, the image intensifier, all of the time, with traction, and I don't have this image, but imagine you have a reduced fracture, in C-Arm, just like this X-ray,
with a very good reduction. So what do I do? When it's a midshaft, I can put the middle of the plate in the focus. So what do I do? I pick a marking pen, and I mark on the skin, the upper part of the plate, and the interval between the second and the third screw, and the same thing, inferiorly, in the inferior part of the plate,
and the second to the third screw from down to up. And I mark it on the skin. I'm going to show it. And this is going to be the upper and the superior and the lower limit of my incision. So I pas this line, and I pass this line between the second, the third, and this is going to be my incision, OK ? I'm going to do the same thing inferiorly, and this is going to be my incision.
So where do I put them, from medial to lateral? Well, the upper is easy, it's in the delto-pec line, you don't have to worry about the musculocutaneous nerve. A lot of people ask me, this is a fallacy, because you don't see it. I, I say it again, I repeat and I quote, it's not the problem. The problem is the radial nerve. And I'm going to show the solution, too. Where do I put my lateral incision?
It's never in the middle. I don't split the biceps. I put it lateral to the biceps, with the long head of the triceps, because what do I want? So this is where I put my incision, exactly in this place, because I have to see the radial nerve. And I'm going to talk about it a lot. So what about the sequence of the surgery? I do both incisions and I connect them, from inferior, the inferior to superior, superior to inferior,
it doesn't matter. I prefer from the upper to the lower incision, always with traction. Without traction this surgery is worse than coronavirus. I'm very serious about that. You must always have traction, and three people, and I'm going to tell you why. So with which hole do I start? I always start with the upper hole of the interior part and why?
Because I do so many difficult cases, and distal cases, that I have to have a perfect position of this hole. So I learned to do like this, not in any book, in my mind, and it works wonderfully. So this is my first perforation, which can be done through the plate or freehand, without the plate, it doesn't matter. And, after that, I introduce the plate, the traction is all of the time, with semi flexion,
there is one guy that is always doing this, he is there only for traction, and I put a screw in that hole, partially screwed. This is a very key point. And after that, I'm going to check reduction, under C-arm, always with traction, in semi flexion, someone doing this all of the time, constant traction, this is a must, and then I'm going to see the position to drill the upper hole, under C-arm guidance. With traction all of the time. I use
the distal hole from the upper part. So I put that screw, partially screwed, so both screws, now, they are partially screwed, because, with this situation, I can adjust valgus, so I adjust varus and valgus, and then I lock. So why is 3 people? No, we are lost your voice.
Is adjusting the VARUS and VALGUS, and holds with both hands, and the third surgeon locks the two screws, so we need six hands, to do this technique, in my, this is something that is absolutely clear, for us. Two people is a mess, is a tragedy, is catastrophical. You cannot do this. It's catastrophic.
In my opinion, it's impossible. A first one (surgeon) to the traction, with two hands. A second one (surgeon), with two hands, clinical and C-arm guidance, to adjust Valgus and Varus, and a third one (surgeon), with both hands, to lock the upper screw, the inferior screw, and then it's done, and you have to put one more and one more, 2 up and two down. So what about the radial nerve?
The thing is, you will always have a Hohmann, medially, OK, always under traction. And the thing is, do I want to see it? Yes, but sometimes I find it, and sometimes I don't. And it doesn't matter, because, pay attention to the rule a nerve that you don't see is the nerve that doesn't exist. I'm going to say it again. A nerve you don't see is a nerve that doesn't exist.
So, but I need to have space, I need to have space to work, so there is traction, a Hohmann medially, try to avoid a Hohmann laterally, literature is clear, not to damage the radial nerve, but sometimes I do it with a lot of delicacy. But, before that, try to have space, a Hohman medially, a farabeuf, or a langenbeck, taking a lot of care with the radial nerve.
So the biceps and the brachialis are being retracted with the media Hohmann, the traction is there, the lateral part, the long head of the triceps is being retracted, with a Farabeuf or a langenbeck. If you have space, wonderful, and you must use an aspirator, because it bleeds a lot in that part. It doesn't bleed in the upper part, it bleeds a lot in the inferior part.
But, if you don't have space, this is my personal Hohmann, which is nothing but a long artery forceps. OK, this is Dr. Sergio's lateral Hohman. Everybody has this. It's not a small one, it's a bigger one, and in my mind, it damages the radial nerve, much less. So this is one picture, extremely hefty, obese lady,
I'm seeing the radial nerve, in the end, whenever I end the surgery, I try to see the nerve to see that it is OK, and I close the skin. This is another image of the radial nerve, you don't have to fear the nerve, you have to respect it, it is completely different, I learned this in the United States.
A fellowship with Snyder, with Snyder, and people taught me that, it changed my mind, it's a game changer. This is the other, another case, this is another case, a left left shoulder and arm, and, in the end of the surgery, many times the nerve is very close to the inferior part of the plate. It doesn't matter. This is another case,
and so on and so on. So the thing is, how far can we go? How distal can we go? The answer is, we can go extremely distal, when you, I don't like to use the word master, but when you do it in a very major level. So let me show you this case. A very, very fat lady, obese, 23-year-old lady, the vast majority of the younger surgeons, they would do a posterior plating, with a very big incision, it is academically never wrong.
What about managing this conservatively? You can do this, but it's very difficult, it's painful. The plaster, the cast, can damage the skin, I have seen catastrophic scenarios in obese patients, in the axila, OK? I have seen one case of a cellulitis infection, on the dermis, below the skin, it was a tragedy, and, in obese patien ts, it's a mess.
It's very difficult to control the varus, the valgus, and you have a lot of issues with elbow stiffness. So, as long as I can put two up and two down, I'm happy, it's enough. I have space, one here, for one, I have space for two, and there is absolutely space, and no place for any mistake. So this is, in my opinion, something for people with a lot of experience. Another trick, I know it's difficult to go to the radiology department,
I did this with my hands, to have a perfect lateral view, in order to see, "Can I put one? Yes... Can I put two? Yes ... So I can do a Bridge plate. No space for any mistakes". I mean, he lost. Yes Hello.
Your voice has gone. Sir, can I stop your video about it? I was afraid about impingement of the coronoid on the plate. Excuse me. Yeah, I stopped with you only to get good bandwidth. You can speak. Can I speak? Yeah, you can speak. OK, so the thing is, so the thing is, I was thinking about impingement of the biceps and the coronoid, and it doesn't happen.
So there is no problem of putting the plate so low. I'm going to show you the final clinical result. As long as I can put two up and two down, I'm happy. A wonderful reduction, one week post-op. So how do I conduct these cases? Pay attention, everybody we want immediate motion, but I don't want to stress my construction.
Whenever we are in surgery, we see that, with flexion, the deformity forces are much less, so, having that in mind, this is a personal idea, I keep these patients, to avoid elbow stiffness, in a cuff-and-collar, it costs 10 rupees, super easy to get, extremely cheap, a cuff-and-collar, only allowing flexion, from 90° to 130°, 140°, all of the day, many times a day, to avoid elbow stiffness.
It works fantastically in my hands. What about seven weeks? You have no callus, but the clinical picture is very nice, I'm going to show it in the next case, because people must understand, clinical healing precedes radiographical healing, you must never forget, the clinical healing comes much faster than radiographical healing. So see this, 11 weeks, a beautiful callus is forming posteriorly,
but you have nothing in the AP, see the image on the left side, between the segmental fracture, medially, and the metathesis, you have nothing. The patient is doing fine. Sergio, do we have a problem? No, no. You just have to wait, because when you see the patient, with 16 weeks, see the image on the right side, it's lovely, and this bone is going to remodel for one year, two years.
It's written on Rockwood, Campbell, Jupiter and many other books, and many others, because remodeling is a process that goes on. If you see this with 16, there's callus formation posteriorly, and I like to see these patients for a lot of time to document the, I would say, the radiographical healing, but clinically it's done, I'm going to show you, guys. So you see, 20 weeks, see on the right side, lovely, mature callus is forming.
And, if you see this in more two months, it's going to be better. More five months, is going to be better, but these patients, this lady, she said to me that day, I am perfect, I'm going to show you now, I have a small baby, my husband, he works a lot, it's difficult to come here, please discharge me. She's very nice.
So I did it, and a lovely image on the lat view, and this is going to remodel, from still a lot of time. So see the size of the arm, see the very small incisions, in my opinion, perfectly positioned. OK, OK. And I dare to say, I repeat, I dare to say, that posterior incision, not only a big, gigantic damage to soft tissue, never academically wrong, but incision would be, in my opinion, and I'm quite sure, at least as long as the length of the connection between the upper and the inferior, or much bigger, much longer.
So I consider this, to be very honest, a revolution, fat patient, obese, minimally invasive, very small incision. People say it's percutaneous, it's not percutaneous, it's minimally invasive and, in my opinion, maximally resolutive. So let's see the video, five months, when she said, please discharge me, just listen to my voice now.
This is the distal incision, the distal scar. This is the proximal scar. Very, very small, very close to the fossa. (talking to patient in Portuguese) (talking to patient in Portuguese) Very good external rotation. (talking to patient in Portuguese)
Perfect internal rotation, see the shoulder elevation, she's smiling. This is what we want in the end of the day, a happy patient. But can we go more far? The answer is yes, as long as you have a lot of experience with that. I have two cases like this one, I'm going to show you, this one and another one, so far,
and everybody will say, Sergio, you are absolutely crazy to do this, in such this case. But the thing is, when you do this in a major level, and you understand that this distal part of the humerus is completely different from the upper part, the humeral head have a soft bone, is what we call, in the shoulder universe, the eggshell, but this bone is extremely hard. So, you don't have any space for a mistake, and this was a very strong man, going to the gym five times in the week, so I did it.
I know it sounds a little bit scary, but I trust this so much, there is a lot of bleeding, this is metaphysical area. It heals fast, I keep this guy, this guy, two weeks with a cuff and collar, Just doing this, to avoid elbow stiffeness, as you are going to see the final result.
This is the immediate post-op, Very, very, very difficult to position the screws, but I knew I would do it. And this is three weeks, absolutely nothing in terms of callus. This is super important, clinical healing precedes radiographical healing, clinical healing precedes radiographical healing. Basically nothing,
radiographically, clinical healing precedes. So let's see the boy, seven weeks, attention everybody. Seven weeks post-op, see his biceps. (talking to patient in Portuguese) (talking to patient in Portuguese)
No pain, absolutely NO PAIN, (talking to patient in Portuguese) Seven weeks. He is doing physical therapy. (talking to patient in Portuguese) Nothing with the radial nerve, OK ? And then you come to me and you say, Sergio, but what about bone healing?
The answer is, you just have to wait. Three months after that, lovely Callus, because radiographical healing comes much, much after the clinical healing. OK, so this is the final callus, I discharged this guy that day, December 15, 2016. But how is this guy clinically at that moment? Let's see. (talking to patient in Portuguese)
Five months post-op, strong man bridge plate. (talking to patient in Portuguese) (talking to patient in Portuguese) He's doing now Pushups. (talking to patient in Portuguese) No pain, absolutely no pain.
(talking to patient in Portuguese) (talking to patient in Portuguese) (talking to patient in Portuguese) Just want to highlight that it took me a lot of time to prepare this lecture, and I wanted to cover the face of the patient, this is an international presentation, but I am in Brazil, and according to Federal Council of Medicine, I can show, in Brazil, of course, Brazilian Federal Council of Medicine,
I can show the face of the patient, as long as I am doing pedagogical presentations, so I am under the laws of my country, from the maximum Medical Council, I just want to highlight that. But there is another thing, and this is my last case, and I'm coming to conclusions. A lot of people have been discussing with me, Deepak sutra, which is here, has discussed this with me countless times.
How far can we go in terms of old people, older or elders? The thing is, one thing that I have been doing is I have been trying to do this in older patients, My record so far is a seventy, 70 guy, but this is a 68-year-old lady. So this is my last case. This is something, a short, oblique, a midfshaft, a wonderful indication, Shiva will do it, with a nail, of course, and many other guys,
butt we did an ABP, of course, and this is another thing that I want to show Sergio, how much contact do you need to have in this basically transverse cases? I don't have the answer, mathematically speaking, but as long as I have minimal contact, this is enough. I have been seeing this for almost 15 years. So this is the radial nerve, and this is two weeks post-op, and this is seven weeks, in which you have nothing,
and in my practice, older patients, it takes much more time for you to have radiographical healing, but clinical healing comes much, much faster. So this is almost a 70, 70-year-old lady, I see basically no callus here. And I started to see callus 15 weeks, which is not against the literature, because radiographical callus comes, in average, from 12 to 16.
But if you see the image on the right, I see nothing. But how is this lady clinically speaking? I'm going to say it again, I've been saying this for 12 years in India, clinical healing precedes radiographical healing. Let's see the lady, there is no sound here. So a wonderful external rotation, still, I'm going to show you, difficulty for internal rotation,
This has nothing to do with, you see, here, a little pain, this has nothing to do with the fracture, only the shoulder. Very good forward elevation. Let's see the size of the scars, as I have said, there is a phenomena in which you have a shrinkage of the skin.
So it's very short. OK, very small. This is again in deltopec line. There is no problem with the musculocutaneous nerve, This is a myth, from the word mythology, it's not there, and she's very happy, absolutely no issues with radial nerve. This is what we want, happy patients in the end of the day.
But when will callus come? See, on the AP, not much, but if you followed this patients, the Callus started to appear after six months, but if you keep on following her, a lovely callus, eight months, on the lar view. And then, what about nine months? Now we have callus and callus and callus and callus, and if you keep on following these patients, the Callus will get better, because, this is Rockwood, Campbell, Jupiter, remodeling takes months and years to happen.
So this is the last view, I discharged her on that day. Proximal incision, distal incision, and how was the lady, 68-year-old lady, complete shoulder elevation, (talking to patient in Portuguese) external rotation, and still, I'm going to show, some pain in the shoulder for internal rotation.
The other one is fine, still some difficulty. This is because of the shoulder, not of the fracture. (talking to patient in Portuguese) This is the final scar, at that moment, very small, very small. This is the proximal scar. What about the elbow? It's absolutely OK.
The radial nerve is OK. This is what I want in the end of the day, happy patient. Snyder says If the patient is happy, I'm happy. If the patient is happy, I'm happy. So I have four take home messages, and then I'm going to finish. I can do ABP in any, and I repeat, any pattern of humeral fractures, and I'm talking about diaphyseal fractures, in any pattern, proximal metaphyso-diaphyseal fractures and distal metaphyso-diaphyseal fractures.
I'm not talking about proximal humerus fractures. I'm not I'm not talking about supracondyleans, but, as long as I can put two up and two down, for me that's enough, for my team, that's absolutely enough. What do I use? Take home message number 2, 12 holes, long narrow big fragments 4.5 mm plate. 02 (screws) is enough, this is a, I would say, established thing, here, in my hospital, my team.
And what about locking screws? There is no paper, and, if there is, I'm not aware of, comparing locked with non locked, but we have a consensus here, that locked would make the the construction quite stiff, in a way that that would impede a good healing. Maybe we are wrong, but this is a sensation, and I'm so happy with this technique, and I'm keeping it, and, another thing, from an economic point of view, I work in a good public hospital, but we have financial issues, as any public hospital in this planet.
So the locking screws, they are much more expensive, so the medical decision fits the economical decision, and everything becomes fine in this point of view. So what about the musculocutaneous nerve? Many guys have been asking me, last 3, last 10 years, or more. ,Don't worry, I can promise you, it's not there. You have to worry about the radial nerve.
Last take home message. What about the radial nerve? Respect, don't fear. I learned this in France. Game changer in my mind. Any nerve? Respect, I respect it a lot, I don't fear it. Very delicate movements.
When I'm doing the distal incision and the distal fixation, I have the sensation I am operating in slow motion, because I am extremely delicate. This is an extremely delicate surgery to be done in three people, six hands, and use long, curved artery forceps as a Hohmann, to avoid damage to the radial nerve. So I'm very happy to be here.
It's an honor to be here. This is my email, and I invite all of the audience who have interest in shoulder arthroscopy, physiopathology, clinics and trauma to follow me in my YouTube channel. Thank you very much. And that's it. I'm finished.
So, my friends, I hope you liked, this nice lecture about ABP humeral anterior bridge plate, and I hope you liked it. Please subscribe, show it to your friends, leave your comment, give us your thumbs up. See you in the next video. And as Dr. Sergio loves to say, never stop flying.
See you, my friends.
Segment:0 .
Hello, my friends, how are you? This is me, Doctor Sergio Rowinski, from ShoulderPlanet, here from São Paulo, Brazil. In this video, I'm presenting you, actually, a lecture, that I have presented, on 4th April 2020, in Gujarat Orthopedic Association webinar on biological fixation on humeral fractures.
It was a nice lecture, showing indications of ABP, anterior bridge plating of the humerus. A lot of technical tips, tricks and a lot of ideas and concepts to understand how the patient is evolving clinically and radiographically, when you use this technique. So I hope you like the video, please subscribe, give your thumbs up and let's see this nice lecture.
OK, now will move to the Sergio's lecture. So that again, we'll have a question answer session later on. So do you believe you can start? Yeah, Yeah. Can I start? Yes, yes, sir. Are you seeing my presentation? Yes, we are seeing your presentation on Humeral Anterior Bridge Plating.
OK, so I'm going to start, the thing is, I'm super happy. Honored to be here. I'm very happy. The thing is, I made a presentation with in which I want to show a lot of comments, a lot of principles, and for the audience to understand how this technique works in different ages and in different clinical pictures, in terms of fractures.
So I want to speak from the beginning to the end, for everybody to understand, and then hope that we have a nice discussion. So the thing is, this is the first case with no radial deficits. 21-year-old girl with a distal humerus, in the distal shaft, with a transverse fracture. The thing is, I can do all of the patterns of fractures and this is one thing that I want to show.
So what to do and the thing is, I love interior bridge plating, I do this with focus, passion, but still with scientific methods, and it works tremendously in my hands. So this is the first message, this plate, well, I always use a 12 hole plate, with two screws up and two screws down. So there is a lot of discussion. A lot of people have been discussing with me, "but I am afraid of using two screws,
I want to use three", and, in my opinion, and in my team's opinion, and in Brazilian guys' opinion, this is a fallacy. This is a myth, from the word mythology, because with two up and two down, that's absolutely enough. In this case, the plate could be a little bit lower, but it doesn't matter. As long as I can put two up and two down, that's absolutely enough.
I'm going to show very challenging cases. So the thing is what I want everybody to understand, this is the immediate post-op. So what about the incisions? Well, there is a way to perfectly, I repeat, to wonderfully position the incisions. I'm going to show it. But what about the sizes? As a rule, I don't care about the sizes, but as a rule, the proximal incision, in the last 10 years, have been around centimeters 2 and 1/2, and distal incision about 3 and 1/2.
But for some, I would say, skin reasons that I don't understand, and I don't care about it, these distal incision, it has a shrinkage with time, in a way that it becomes very, very, very, very small but thought out, and I'm going to show it soon. So what I want people to understand is that there is a very important thing in this technique, which is something like what Shiva has said.
Clinical healing precedes radiographycal healing. This is very important. Clinical healing precedes radiographycal healing a lot, and I'm going to show you beautiful examples. So when does the callus start? I would say literature is very clear from 12 to 16, but you can have less or you can have more. And I'm going to show both cases that, in my opinion, it depends on the age, because this is a biological technique in which you need a lot of biological response.
So this girl, you see, with eight weeks, she has already a beautiful callus. But this is not this is not the average, OK, this is happening because she's very young, in my point of view and, with five weeks post-op, she was wonderful. And when you come to eight weeks, you have the starting callus. But this is not the average, Ok? The average, in my practice, is exactly what literature says.
It's 12 to 16 weeks, to have radiographycal healing, because clinical healing comes much first. So this is the post-opm four months, and people must understand that bone remodeling is something that takes months and years. And this is written in Rockwood, in Campbell, and in Jupiter, all of the classical books. So if you pick up this girl and you see another image with eight months, it's going to be, I would say, a much, much more nicer and mature callus.
The thing is that these are young patients, they have to take care of their lives, and they come to me and they say, doctor Sergio, I'm so nice. It's a little bit difficult to come here, and I just I want to live my life. There are so many patients, so please discharge me. And then I just discharged that girl, on that day. So this is a beautiful view, post-op, and how was, I would say, this is a beautiful callus,
so these are the incisions, and I'm going to talk about the incisions, how to proper place them, in a second. But, I told you, there is a shrinkage process in the skin, I cannot explain why, but it doesn't matter to me, because it's good. So see, she ended up having such a small incision, OK? And I'm going to talk about where to put the incisions in a minute. So what about the clinical results?
I'm talking in the video, so let's see and listen to my voice. Six months post-op, anterior bridge plate, surgery 29/December/2016, very small incision. (now I am talking in Portuguese to patient) Extend it,
(now I am talking in Portuguese to patient) She wants to go boxing (now I am talking in Portuguese to patient) Absolutely no pain, no pain. (now I am talking in Portuguese to patient) No, no, no. The rides a bike, she doesn't remember she has a plate.
So the first message You can do it in any pattern, I'm going to show order patterns. So how to, so now I'm going to talk about the technique, and then I'm going to show three other very nice cases, in different patterns and ages. So you have to draw the incisions for them to be in perfect position, and very small.
So how am I going to draw incisions? So this is a very old picture, just for pedagogical purposes. This is a 10 hole, but, for many years, I only use 12. And what yo must understand, you are looking to this and looking to the C-arm, the image intensifier, all of the time, with traction, and I don't have this image, but imagine you have a reduced fracture, in C-Arm, just like this X-ray,
with a very good reduction. So what do I do? When it's a midshaft, I can put the middle of the plate in the focus. So what do I do? I pick a marking pen, and I mark on the skin, the upper part of the plate, and the interval between the second and the third screw, and the same thing, inferiorly, in the inferior part of the plate,
and the second to the third screw from down to up. And I mark it on the skin. I'm going to show it. And this is going to be the upper and the superior and the lower limit of my incision. So I pas this line, and I pass this line between the second, the third, and this is going to be my incision, OK ? I'm going to do the same thing inferiorly, and this is going to be my incision.
So where do I put them, from medial to lateral? Well, the upper is easy, it's in the delto-pec line, you don't have to worry about the musculocutaneous nerve. A lot of people ask me, this is a fallacy, because you don't see it. I, I say it again, I repeat and I quote, it's not the problem. The problem is the radial nerve. And I'm going to show the solution, too. Where do I put my lateral incision?
It's never in the middle. I don't split the biceps. I put it lateral to the biceps, with the long head of the triceps, because what do I want? So this is where I put my incision, exactly in this place, because I have to see the radial nerve. And I'm going to talk about it a lot. So what about the sequence of the surgery? I do both incisions and I connect them, from inferior, the inferior to superior, superior to inferior,
it doesn't matter. I prefer from the upper to the lower incision, always with traction. Without traction this surgery is worse than coronavirus. I'm very serious about that. You must always have traction, and three people, and I'm going to tell you why. So with which hole do I start? I always start with the upper hole of the interior part and why?
Because I do so many difficult cases, and distal cases, that I have to have a perfect position of this hole. So I learned to do like this, not in any book, in my mind, and it works wonderfully. So this is my first perforation, which can be done through the plate or freehand, without the plate, it doesn't matter. And, after that, I introduce the plate, the traction is all of the time, with semi flexion,
there is one guy that is always doing this, he is there only for traction, and I put a screw in that hole, partially screwed. This is a very key point. And after that, I'm going to check reduction, under C-arm, always with traction, in semi flexion, someone doing this all of the time, constant traction, this is a must, and then I'm going to see the position to drill the upper hole, under C-arm guidance. With traction all of the time. I use
the distal hole from the upper part. So I put that screw, partially screwed, so both screws, now, they are partially screwed, because, with this situation, I can adjust valgus, so I adjust varus and valgus, and then I lock. So why is 3 people? No, we are lost your voice.
Is adjusting the VARUS and VALGUS, and holds with both hands, and the third surgeon locks the two screws, so we need six hands, to do this technique, in my, this is something that is absolutely clear, for us. Two people is a mess, is a tragedy, is catastrophical. You cannot do this. It's catastrophic.
In my opinion, it's impossible. A first one (surgeon) to the traction, with two hands. A second one (surgeon), with two hands, clinical and C-arm guidance, to adjust Valgus and Varus, and a third one (surgeon), with both hands, to lock the upper screw, the inferior screw, and then it's done, and you have to put one more and one more, 2 up and two down. So what about the radial nerve?
The thing is, you will always have a Hohmann, medially, OK, always under traction. And the thing is, do I want to see it? Yes, but sometimes I find it, and sometimes I don't. And it doesn't matter, because, pay attention to the rule a nerve that you don't see is the nerve that doesn't exist. I'm going to say it again. A nerve you don't see is a nerve that doesn't exist.
So, but I need to have space, I need to have space to work, so there is traction, a Hohmann medially, try to avoid a Hohmann laterally, literature is clear, not to damage the radial nerve, but sometimes I do it with a lot of delicacy. But, before that, try to have space, a Hohman medially, a farabeuf, or a langenbeck, taking a lot of care with the radial nerve.
So the biceps and the brachialis are being retracted with the media Hohmann, the traction is there, the lateral part, the long head of the triceps is being retracted, with a Farabeuf or a langenbeck. If you have space, wonderful, and you must use an aspirator, because it bleeds a lot in that part. It doesn't bleed in the upper part, it bleeds a lot in the inferior part.
But, if you don't have space, this is my personal Hohmann, which is nothing but a long artery forceps. OK, this is Dr. Sergio's lateral Hohman. Everybody has this. It's not a small one, it's a bigger one, and in my mind, it damages the radial nerve, much less. So this is one picture, extremely hefty, obese lady,
I'm seeing the radial nerve, in the end, whenever I end the surgery, I try to see the nerve to see that it is OK, and I close the skin. This is another image of the radial nerve, you don't have to fear the nerve, you have to respect it, it is completely different, I learned this in the United States.
A fellowship with Snyder, with Snyder, and people taught me that, it changed my mind, it's a game changer. This is the other, another case, this is another case, a left left shoulder and arm, and, in the end of the surgery, many times the nerve is very close to the inferior part of the plate. It doesn't matter. This is another case,
and so on and so on. So the thing is, how far can we go? How distal can we go? The answer is, we can go extremely distal, when you, I don't like to use the word master, but when you do it in a very major level. So let me show you this case. A very, very fat lady, obese, 23-year-old lady, the vast majority of the younger surgeons, they would do a posterior plating, with a very big incision, it is academically never wrong.
What about managing this conservatively? You can do this, but it's very difficult, it's painful. The plaster, the cast, can damage the skin, I have seen catastrophic scenarios in obese patients, in the axila, OK? I have seen one case of a cellulitis infection, on the dermis, below the skin, it was a tragedy, and, in obese patien ts, it's a mess.
It's very difficult to control the varus, the valgus, and you have a lot of issues with elbow stiffness. So, as long as I can put two up and two down, I'm happy, it's enough. I have space, one here, for one, I have space for two, and there is absolutely space, and no place for any mistake. So this is, in my opinion, something for people with a lot of experience. Another trick, I know it's difficult to go to the radiology department,
I did this with my hands, to have a perfect lateral view, in order to see, "Can I put one? Yes... Can I put two? Yes ... So I can do a Bridge plate. No space for any mistakes". I mean, he lost. Yes Hello.
Your voice has gone. Sir, can I stop your video about it? I was afraid about impingement of the coronoid on the plate. Excuse me. Yeah, I stopped with you only to get good bandwidth. You can speak. Can I speak? Yeah, you can speak. OK, so the thing is, so the thing is, I was thinking about impingement of the biceps and the coronoid, and it doesn't happen.
So there is no problem of putting the plate so low. I'm going to show you the final clinical result. As long as I can put two up and two down, I'm happy. A wonderful reduction, one week post-op. So how do I conduct these cases? Pay attention, everybody we want immediate motion, but I don't want to stress my construction.
Whenever we are in surgery, we see that, with flexion, the deformity forces are much less, so, having that in mind, this is a personal idea, I keep these patients, to avoid elbow stiffness, in a cuff-and-collar, it costs 10 rupees, super easy to get, extremely cheap, a cuff-and-collar, only allowing flexion, from 90° to 130°, 140°, all of the day, many times a day, to avoid elbow stiffness.
It works fantastically in my hands. What about seven weeks? You have no callus, but the clinical picture is very nice, I'm going to show it in the next case, because people must understand, clinical healing precedes radiographical healing, you must never forget, the clinical healing comes much faster than radiographical healing. So see this, 11 weeks, a beautiful callus is forming posteriorly,
but you have nothing in the AP, see the image on the left side, between the segmental fracture, medially, and the metathesis, you have nothing. The patient is doing fine. Sergio, do we have a problem? No, no. You just have to wait, because when you see the patient, with 16 weeks, see the image on the right side, it's lovely, and this bone is going to remodel for one year, two years.
It's written on Rockwood, Campbell, Jupiter and many other books, and many others, because remodeling is a process that goes on. If you see this with 16, there's callus formation posteriorly, and I like to see these patients for a lot of time to document the, I would say, the radiographical healing, but clinically it's done, I'm going to show you, guys. So you see, 20 weeks, see on the right side, lovely, mature callus is forming.
And, if you see this in more two months, it's going to be better. More five months, is going to be better, but these patients, this lady, she said to me that day, I am perfect, I'm going to show you now, I have a small baby, my husband, he works a lot, it's difficult to come here, please discharge me. She's very nice.
So I did it, and a lovely image on the lat view, and this is going to remodel, from still a lot of time. So see the size of the arm, see the very small incisions, in my opinion, perfectly positioned. OK, OK. And I dare to say, I repeat, I dare to say, that posterior incision, not only a big, gigantic damage to soft tissue, never academically wrong, but incision would be, in my opinion, and I'm quite sure, at least as long as the length of the connection between the upper and the inferior, or much bigger, much longer.
So I consider this, to be very honest, a revolution, fat patient, obese, minimally invasive, very small incision. People say it's percutaneous, it's not percutaneous, it's minimally invasive and, in my opinion, maximally resolutive. So let's see the video, five months, when she said, please discharge me, just listen to my voice now.
This is the distal incision, the distal scar. This is the proximal scar. Very, very small, very close to the fossa. (talking to patient in Portuguese) (talking to patient in Portuguese) Very good external rotation. (talking to patient in Portuguese)
Perfect internal rotation, see the shoulder elevation, she's smiling. This is what we want in the end of the day, a happy patient. But can we go more far? The answer is yes, as long as you have a lot of experience with that. I have two cases like this one, I'm going to show you, this one and another one, so far,
and everybody will say, Sergio, you are absolutely crazy to do this, in such this case. But the thing is, when you do this in a major level, and you understand that this distal part of the humerus is completely different from the upper part, the humeral head have a soft bone, is what we call, in the shoulder universe, the eggshell, but this bone is extremely hard. So, you don't have any space for a mistake, and this was a very strong man, going to the gym five times in the week, so I did it.
I know it sounds a little bit scary, but I trust this so much, there is a lot of bleeding, this is metaphysical area. It heals fast, I keep this guy, this guy, two weeks with a cuff and collar, Just doing this, to avoid elbow stiffeness, as you are going to see the final result.
This is the immediate post-op, Very, very, very difficult to position the screws, but I knew I would do it. And this is three weeks, absolutely nothing in terms of callus. This is super important, clinical healing precedes radiographical healing, clinical healing precedes radiographical healing. Basically nothing,
radiographically, clinical healing precedes. So let's see the boy, seven weeks, attention everybody. Seven weeks post-op, see his biceps. (talking to patient in Portuguese) (talking to patient in Portuguese)
No pain, absolutely NO PAIN, (talking to patient in Portuguese) Seven weeks. He is doing physical therapy. (talking to patient in Portuguese) Nothing with the radial nerve, OK ? And then you come to me and you say, Sergio, but what about bone healing?
The answer is, you just have to wait. Three months after that, lovely Callus, because radiographical healing comes much, much after the clinical healing. OK, so this is the final callus, I discharged this guy that day, December 15, 2016. But how is this guy clinically at that moment? Let's see. (talking to patient in Portuguese)
Five months post-op, strong man bridge plate. (talking to patient in Portuguese) (talking to patient in Portuguese) He's doing now Pushups. (talking to patient in Portuguese) No pain, absolutely no pain.
(talking to patient in Portuguese) (talking to patient in Portuguese) (talking to patient in Portuguese) Just want to highlight that it took me a lot of time to prepare this lecture, and I wanted to cover the face of the patient, this is an international presentation, but I am in Brazil, and according to Federal Council of Medicine, I can show, in Brazil, of course, Brazilian Federal Council of Medicine,
I can show the face of the patient, as long as I am doing pedagogical presentations, so I am under the laws of my country, from the maximum Medical Council, I just want to highlight that. But there is another thing, and this is my last case, and I'm coming to conclusions. A lot of people have been discussing with me, Deepak sutra, which is here, has discussed this with me countless times.
How far can we go in terms of old people, older or elders? The thing is, one thing that I have been doing is I have been trying to do this in older patients, My record so far is a seventy, 70 guy, but this is a 68-year-old lady. So this is my last case. This is something, a short, oblique, a midfshaft, a wonderful indication, Shiva will do it, with a nail, of course, and many other guys,
butt we did an ABP, of course, and this is another thing that I want to show Sergio, how much contact do you need to have in this basically transverse cases? I don't have the answer, mathematically speaking, but as long as I have minimal contact, this is enough. I have been seeing this for almost 15 years. So this is the radial nerve, and this is two weeks post-op, and this is seven weeks, in which you have nothing,
and in my practice, older patients, it takes much more time for you to have radiographical healing, but clinical healing comes much, much faster. So this is almost a 70, 70-year-old lady, I see basically no callus here. And I started to see callus 15 weeks, which is not against the literature, because radiographical callus comes, in average, from 12 to 16.
But if you see the image on the right, I see nothing. But how is this lady clinically speaking? I'm going to say it again, I've been saying this for 12 years in India, clinical healing precedes radiographical healing. Let's see the lady, there is no sound here. So a wonderful external rotation, still, I'm going to show you, difficulty for internal rotation,
This has nothing to do with, you see, here, a little pain, this has nothing to do with the fracture, only the shoulder. Very good forward elevation. Let's see the size of the scars, as I have said, there is a phenomena in which you have a shrinkage of the skin.
So it's very short. OK, very small. This is again in deltopec line. There is no problem with the musculocutaneous nerve, This is a myth, from the word mythology, it's not there, and she's very happy, absolutely no issues with radial nerve. This is what we want, happy patients in the end of the day.
But when will callus come? See, on the AP, not much, but if you followed this patients, the Callus started to appear after six months, but if you keep on following her, a lovely callus, eight months, on the lar view. And then, what about nine months? Now we have callus and callus and callus and callus, and if you keep on following these patients, the Callus will get better, because, this is Rockwood, Campbell, Jupiter, remodeling takes months and years to happen.
So this is the last view, I discharged her on that day. Proximal incision, distal incision, and how was the lady, 68-year-old lady, complete shoulder elevation, (talking to patient in Portuguese) external rotation, and still, I'm going to show, some pain in the shoulder for internal rotation.
The other one is fine, still some difficulty. This is because of the shoulder, not of the fracture. (talking to patient in Portuguese) This is the final scar, at that moment, very small, very small. This is the proximal scar. What about the elbow? It's absolutely OK.
The radial nerve is OK. This is what I want in the end of the day, happy patient. Snyder says If the patient is happy, I'm happy. If the patient is happy, I'm happy. So I have four take home messages, and then I'm going to finish. I can do ABP in any, and I repeat, any pattern of humeral fractures, and I'm talking about diaphyseal fractures, in any pattern, proximal metaphyso-diaphyseal fractures and distal metaphyso-diaphyseal fractures.
I'm not talking about proximal humerus fractures. I'm not I'm not talking about supracondyleans, but, as long as I can put two up and two down, for me that's enough, for my team, that's absolutely enough. What do I use? Take home message number 2, 12 holes, long narrow big fragments 4.5 mm plate. 02 (screws) is enough, this is a, I would say, established thing, here, in my hospital, my team.
And what about locking screws? There is no paper, and, if there is, I'm not aware of, comparing locked with non locked, but we have a consensus here, that locked would make the the construction quite stiff, in a way that that would impede a good healing. Maybe we are wrong, but this is a sensation, and I'm so happy with this technique, and I'm keeping it, and, another thing, from an economic point of view, I work in a good public hospital, but we have financial issues, as any public hospital in this planet.
So the locking screws, they are much more expensive, so the medical decision fits the economical decision, and everything becomes fine in this point of view. So what about the musculocutaneous nerve? Many guys have been asking me, last 3, last 10 years, or more. ,Don't worry, I can promise you, it's not there. You have to worry about the radial nerve.
Last take home message. What about the radial nerve? Respect, don't fear. I learned this in France. Game changer in my mind. Any nerve? Respect, I respect it a lot, I don't fear it. Very delicate movements.
When I'm doing the distal incision and the distal fixation, I have the sensation I am operating in slow motion, because I am extremely delicate. This is an extremely delicate surgery to be done in three people, six hands, and use long, curved artery forceps as a Hohmann, to avoid damage to the radial nerve. So I'm very happy to be here.
It's an honor to be here. This is my email, and I invite all of the audience who have interest in shoulder arthroscopy, physiopathology, clinics and trauma to follow me in my YouTube channel. Thank you very much. And that's it. I'm finished.
So, my friends, I hope you liked, this nice lecture about ABP humeral anterior bridge plate, and I hope you liked it. Please subscribe, show it to your friends, leave your comment, give us your thumbs up. See you in the next video. And as Dr. Sergio loves to say, never stop flying.
See you, my friends.
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