Cadmore media player playing video Gunshots around the Elbow - Tips and Tricks for Such Unusual Fracture Scenarios
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:
Gunshots around the Elbow - Tips and Tricks for Such Unusual Fracture Scenarios
Description:
Gunshots around the Elbow - Tips and Tricks for Such Unusual Fracture Scenarios
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/cee76d63-21a0-407a-8eba-a750c4643bf0/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H41M34S
Embed URL:
https://stream.cadmore.media/player/cee76d63-21a0-407a-8eba-a750c4643bf0
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/cee76d63-21a0-407a-8eba-a750c4643bf0/GUNSHOTS AROUND THE ELBOW - TIPS AND TRICKS FOR SUCH UNUSUAL.mp4?sv=2019-02-02&sr=c&sig=tKUc5%2FzxlpabOQdbNUM8rjb4KBlEmp6duAtVy%2BjCec8%3D&st=2024-11-23T10%3A36%3A37Z&se=2024-11-23T12%3A41%3A37Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, here from Sao Paulo, Brazil, from shoulder planet. In this video, I'm showing you very interesting lecture about gunshots around the elbow, so I'm showing you different cases, very interesting cases with very, I would say, strategic ideas to deal with these challenging scenarios, which is gunshots around the elbow.
So I hope you like the video. Please subscribe to the channel, your comment and of course, give us your thumbs up and let us see the video. So hello, my good friends. This is me, Dr. Sergio Rowinski, from shoulder planet, there from Brazil. Sao Paolo, Brazil. And this is a very interesting lecture about a very unusual topic with which I have quite good experience, which is how to manage gunshot fractures around the elbow.
So here I'm going to show you, guys, some cases, actually six different cases, with different clinical and radiographical scenarios, showing your tips and tricks in order to deal with these unusual lesions. And after that, I will come to some interesting conclusions. So let's see the first of our cases. So this is the case number one. So in this case, I'm talking about a 22-year-old boy, who, in September 2011, had a gunshot in the right elbow.
He came with a lot of pain to our emergency department. Really, really, really a lot of pain, and it was quite difficult to do well done X-rays. We could see that there was a fracture, in the lateral condyle, and, in the proximal ulna area. So he was taken to surgery, in order for us to wash the orifices as it is, of course, an open fracture.
He was put in a cast, and then, that was his left view. So in this lateral view, we can see, here, in a well-done lat view, a highly comminuted fracture of the olecranon and, actually, of the proximal ulna. Here we are seeing an AP view, just after surgery, in which we can see that there was a fracture of the medial condyle, and, much probably, with articular involvement.
It's very important to say that in these cases, a CTi s a very important exam, and a CT was done just after that day. This is a case from almost 10, 11 years ago, and, at that time, I didn't have the idea, in my mind, that it's very important to put, in such cases, in the beginning, when they come to our emergency departments, andexternal fixator for damage control, as I'm going to show you guys in the next cases.
But nevertheless, this case was put in a cast, and then a CT was done, in the next day. So this is an axial view, in which we can see that there was indeed a fracture of the medial condyle, with displacement, with articular displacement. Here we are very close to the trochlea. And this is another view, a coronal view of the CT, in which we can easily see the path of the gunshot, from the inlet point, where it entered to, the exit point, which was around the olecranon .
So this is the path of the bullet, that we are seeing, on the left side, painted in Red, and this is a 3D CT view, the anterior view. So it's very important it doesn't matter if we are talking about gunshots or other kind of fractures, whenever we have involvement of the articular surface is very important to do a CT
And, in these cases, a CT was quite really welcome. And if we take a look in the very anterior part of the CT, in the anterior view, it's not difficult for us to see that, indeed, that was an articulate defect in the trochlea, that would definitely need surgical fixation. So this is the posterior view in which we can see a displaced fracture of the medial condyle, together with a comminuted fracture of not only the olecranon, but the whole proximal ulna.
So this is the patient two days after surgery. Here we are seeing the sutures in the inlet orifice and, here, we are seeing the sutures on the outlet orifice. Incredibly, the patient, this patient has absolutely no neurovascular injury, and he was operated so on that day for definitive osteosynthesis. So we did a posterior approach, and I would say that, somehow, it was quite easy to do the olecranon osteotomy because of the gunshot.
But nevertheless, we would have to take a lot of care not to damage that comminuted olecranon. So we isolated the ulnar nerve, as we are seeing on the left part of the image. And here we are seeing a beautiful photo of the fixation of the medial condyle, and we did what we could call the best possible reduction, and I say that because we have a lot of communication in these cases, even in young patients like this one.
So this is the immediate post of X-rays, in which we can see that we achieved a lovely reduction of the medial condyle. We put two washers in the medial condyle, and a plate on the proximal ulna. I would say that the plate could be a little bit more closer to the olecranon, and it was not in this case, but nevertheless the construction was really, really well done.
When we take a look at these x ray, I mean, one week post-op, we can see that we achieved what I call the an almost perfect reduction. And it was not perfect because there is a lot of communication in these cases, adding difficulty to thos osteosynthesis. Nevertheless, this is the patient, nine months post-op, in which we can see a wonderful healing of the whole fractures.
The patient was quite nice, and and I only could see that patient at that moment. This is a clinical picture. Nine months post-op, is very, very important to say that I have, that I, doctor Sergio that I have a lot of difficulty in the follow up of these cases, because, unfortunately, these young boys, they have a lot of problems with police and justice.
So this boy was in jail. He was very young, so it's quite difficult to ask the policeman to come to bring them for medical follow up. So we are seeing, here, the cloths of prison, he's using cuffs in his hands. So it's quite difficult for me as a doctor to control the follow up. But nevertheless, he appeared nine months after surgery with a very, very good final clinical result, obviously without any physical therapy.
So this is the second case, I want to show you. And then this is a case about an another young boy. In 22 November 2011, he received two shotguns when he was running away from police. So one shot was in the middle of the femur, as we are seeing here. And he had a very, very comminuted fracture of basically the middle shaft of the left femur with a lot of comminution, as we are seeing here, and a very, very bad fracture of by a shotgun in the left proximal ulna.
So this is what I like to call a bone explosion. So it's very difficult to do well done X-rays when these patients come to our emergency, because they are in a lot of pain, and it's very, very difficult for them to collaborate in order for us to obtain proper images, because they have multiple injuries, and, obviously, a lot of pain. So this patient was operated in the same day. Of course, he was submitted to washing of both open fractures, and an external fixator was put in the affected arm and in the affected the femur, too.
It's very important for us to say that the role of putting an ex fix in these cases around the elbow is very, very big because we have a lot of advantages when putting these external fixators in the upper limb, on these complex fractures around the elbow. So first of all, we give a lot of stability to the bony anatomy, and, in this sense, we protect the soft tissues,
once we put these external fixators, th and that brings us a lot of, I would say, facility in order to make the definitive osteosynthesis a few days later. And still, with this ex fix, we have time, I would say, to do the pre-op examinations. The pre-op exams, a well done CT, and we have time to discuss, with the most experienced surgeons, in order for us to define what would be the best kind osteosynthesis to do.
So it's very important to put external fixators in these cases, even if these lesions are, I would say, isolated, but it was not in this case, as we had a simultaneous femur. So here we can see an extreme fragmentation of the proximal ulna, after our residents put the external fixator . Really, very important, severe comminution of the proximal ulna, here, and this is the ex fix that was applied on the femur, of course.
So now we are seeing a 3D CT medial view, in which we can see a lot of comminution with some bullet fragments around this bone. OK, in the medial view, and, here, the Lat view It's interesting for us to say that depending on the kind of gunshot, we have more or less bullet pieces around the fracture area, so much probably, I live in Brazil and I, I quite know that policemen here, they use two different guns.
I mean pistols. One is the 38, as we are seeing here, in this image, and the other one is the 0.40, and they are different machine guns. And, as we know, the 38 usually leaves a lot of bullet pieces around the fracture site, differently from the .40, that I'm going to show you, in some minutes, in another case. So for sure, all of these bullets came for a 38 pistol.
Here we are seeing a postero medial view in which we can see, again, a very, very ugly fracture of the proximal ulna, and a lot of small pieces of the bullet. So this patient was operated by two different teams, so our inferior limb team applied this beautiful bridge plate, on the affected femur, a very well done surgery, and obviously that was not done by me, as I, doctor Sergio am dedicated
and exclusive shoulder and elbow surgeon, who does a lot of shoulder and elbow trauma. And so after a few days, we did this surgery in 1st December 2011, that would be something around 9 days after the gunshot injury. So this is a very pedagogical image in which we can see how useful is the ex fix in terms of maintaining a good quality of the surrounding soft tissues around the elbow.
And this is a key point for us to do a safe incision for definitive osteosynthesis. So in this case, this is what we did with we did a bridge plate with locked reconstruction plate. And this is the final clinical result in the very end of the surgery. This is the lat view, just after surgery, in which we can see a very nice construction.
And in my opinion, it was very, I would say, clever to use a locked plate since the quality of the bone in the proximal ulna is, I would say, not the best, even being a very young patient, because we are talking, of course, about metaphyseal bone. And in this sense, it was quite wise, and, I would say, almost mandatory, in my point of view, to use locked screws in this region of the proximal ulna.
So this is the immediate view, in the AP view, after this, the surgery, in my opinion, are very well done surgery, and we did a bridge plate, of course. And this patient, he disappeared. He also went to jail, is very, very difficult to manage the follow up because these are things that are beyond my control. Of course, this is a problem of lawyers and police, but nevertheless he came back just after six months.
Here we are seeing a wonderful healing of the femur and in the end, in what concerns the elbow, this is the six months post op. Lat X-ray and AP view. In that day, I was, I would say, happy with the AP view, but not happy with the Lat view. I would like to have a better view, but when these patients come, it's quite stressful. They come in, they usually come in cuffs with a lot of policemen, and the policemen
they don't want to stay a lot of time in the hospital, and they just want to bring the patient back to the prison. So it's very difficult to repeat X-rays. In this. I would say OPD scenario, so I couldn't repeat the X-rays at that day, because of pressure of policemen, but nevertheless I could realize that we achieved good union of the fracture. So this is the boy, unfortunately, a very young boy making, I would say, wrong decisions and robbing people in the streets.
But again, this is absolutely beyond my control. And so you see, he's using cuffs. And it was difficult to position him because of the cuffs. But nevertheless, it's quite easy for us to see that he has had a very good final clinical range of motion in the elbow, obviously without any physical therapy. And this is the six months post-op view of the bridge construction around the proximal ulna.
So this is case number 3, another interesting case. This is another shot that happened in a very, very young boy in July 2010. So here we are seeing, what we call the entry point or the inlet point. So the bullet entered, I would say, almost in a point blank scenario, from anterior, n the distal part of the arm, and the exit point was here,just very close to the olecranon.
And amazingly, also, in this case, absolutely no neurovascular injuries. So what we are seeing here is that he developed a lateral condyle fracture, which seemed to have a lot of comminution in the articular part. And this is the lat view that was quite innocent. So it's not difficult for us to understand that, in these cases, a CT is an absolutely mandatory exam for us to better comprehend the fracture.
So this is a sagittal view of the CT, in which we can see a lot of comminution, but not exactly in the radiocapitellar joint, but in a position, I would say, more posterior. And so from an anatomical point of view, that was an extra articular comminution. Even if we see the same case in the AP VIEW, we can see a lot of comminution, and it seemed to be really extra articular, when we consider, also, the ulno-humeral joint.
And this is, again, a 3D CT posterior view in which we can see the same comminution in a displaced lateral condyle fracture, and this is the anterior view. So in these cases, whenever possible. it is interesting to try to do a percutaneous fixation. So in this case, we tried a percutaneous fixation that was quite successful. But if it was not, intraoperatively, then we would have to open that for obvious reasons.
So we could, in that case, do a very nice fixation with two cannulated screws, a beautiful fixation, with washers, this is one week post op AP view, and one week post op lat view. That was the only chance I had to see that boy after surgery. So here we can see the boy, already with the clothes of prison. Unfortunately, he had problems with justice and police.
This is the bullet entry point, just as we said preoperatively. And this is the bullet exit point, and her what we are seeing is the two percutaneous incisions for the two cannulated screws. Unfortunately, I couldn't follow this case. This patient never came back. As I have said, it's quite difficult to follow these cases because they have a lot of problems with Justice police, and it's difficult for policemen to bring them.
So I never saw him, but I'm quite sure that he a had quite good outcome. It's interesting to say that whenever they have very bad outcomes, especially infections, they come back automatically, by police, from prison. But as long as they do good, unfortunately, it's quite difficult to have a good follow up of these cases. This is case number four, and in this case, the patient received multiple gun shots.
So here we can see something around three bullets in the thorax. The thorax was operated, and they put a drain in the right part of the thorax, as we can see in the inferior and left part of the screen. And also, this patient received a gun, which probably by a 38 pistol, in the supracondylean area. A very young boy that also was put in an external fixator. This is something very important.
As I have said, for us to have a good control of soft tissues, we take them out of emergency, and then we can plan, with calm and tranquility, the best possible solution discussing with a CT, of course, and with very specialized shoulder and elbow surgeons, as my team, of course. So this is again another view of the ex fix, and this is a 3D CTin which we can see a lot of comminution around the fracture area.
So for sure, that was a gunshot from a 38 pistol. So this is the patient a few days after the trauma. Here we can see again how important it is to put an external fixator in order for us to have a good condition of this surrounding soft tissues around the fracture site. And we can see, here, some, some bandages on the thorax, because,bI would say,two or three days before that surgery, the thorax drain was, so, removed.
So this is what we have done, and here there is an important message because we did a very typical osteo synthesis with orthogonal plates, but what we did here was a bridge construction over a formal open approach. So this is something that I, Doctor Sergio, have learned, after 15 years doing these kind of cases. Sometimes the comminution is so high that the only possible solution is to do a Bridge construction even with a formal open approach,
and the max you can do is some suturing of the comminuted area with some sutures, as we did in this case with Vicryl sutures. So this is one week post up, quite well done osteosynthesis, one screw in the proximal area had a backup, but nevertheless I was not worried about that. And this patient also he disappeared. He told me on that day, he told me, I remember Doc, I'm having problems and I'm going to disappear for some time, but you bet I'm coming in some months.
And so he kept his promise. And after eight months he appeared. So here we can see that the fracture had a complete healing in spite of the fact that we had a fracture around the plate. I mean a fracture around the medial plate. But nevertheless, the patient had a wonderful clinical result. And this is the movie that I have done eight months post-op absolutely no physical therapy.
We can see some wounds in the thorax, of the gunshots. Full range of motion. This is the scar of the posterior approach and a very, very good final clinical result in a young boy, absolutely without physical therapy. So now I'm coming to case five, so this case is almost very interesting. This is a very young boy that received a gunshot in the proximal third of the radius and the ulna.
But in this case, I'm talking about a different kind of pistol, because I see no remaining pieces of the bullet on the affected area. So a highly comminuted fracture on the proximal third radius and the ulna. And hear a lat view. So in this case, we are definitely talking about a four 0.40 pistol, this is how we call them here in Brazil.
So this is a bullet that has, amongst other characteristics, not to let a lot of pieces of metal around the fracture site. So an ex fix was applied, and in that case, here we are seeing, again, a nex fix, and the message, here, is the same it's very important to put a ext fix, in these cases, for damage control to keep the joint much more stable, to protect the soft tissues,
for us to have time, to do a well-done CT and to discuss with very specialized surgeons how to do and how to, I would say, do the best possible osteosynthesis. So here we are seeing, again, the fracture and a lot of comminution in the fracture site. And what we did in this case was something different. We did a volar approach instead of a postero lateral approach, which is called the Thompson approach.
So this is the volar approach that we done, which is the continuity of the Henry'sm approach, which is a very beautiful approach for us to deal with the radius. We have to take a lot of care with the pin, the posterior interosseous nerve. Here we can see beautifully the plate passing below the supinator, but a lot of care must be done with the radial nerve. I mean, the posterior interosseous nerve on that part. And we still did a bridge construction in the ulna.
So what we can see here is that in spite of putting, an inter fragmentary screw, on the radius fracture, We did Open Bridge constructions on the ulna and on the radious, and this is something that we have been doing for many years, and it works a lot. So there is a message in this case, as in the other case, in the other cases, which is doing bridge constructions over or with formal approaches is something very useful, in these cases, because we have a lot of comminution.
So this is the AP view, to something around one week post up, and this is the lat view. Three weeks post-op, and this is the patient only three weeks post-op. So we see a big volar approach, anteriorly, and a big posterior approach, around the ulna. It was impossible to deal with these cases, and to do a Bridge construction, here, only with two small incisions, because the instability of the fracture is very high because of the comminution.
So teh message here is the same. You can do Bridge constructions over formal approaches in this gunshot cases, and this is something that has been quite useful to me in the last 14 years. So this is a clinical video of the patient, five weeks post-op, a lovely range of motion, absolutely no physical therapy, some edema on, I would say, the postero lateral side of the forearm.
The wounds were healing, no problems with the radial nerve, as we are seeing here, and a quite reasonable flexion and extension of the elbow, as we are seeing here, only five weeks post-op. So in a normal scenario, I would follow that patient for a lot of time, but that was the last time I saw that patient. As I have said, these patients, they have a lot of problems with justice, with drug addiction, with the police, and it's very difficult to do a good follow up.
And this is the sixth case, the last one much probably the most beautiful one, and his case show will show us how important it is for us to have clinical judgment in our daily practice. So this case happened in July 2009. A point Blank gunshots in the middle of the arm, a very comminuted fracture, much probably by a 38 pistol, with a lot of comminution in the humerus. We did an anterior bridge plate.
All my Indian friends known that I do a lot of these plates, and I, Doctor Sergio, have a lot of contribution, in the Indian scenario, introducing the anterior bridge plate of the humerus since 2009. We know that, but I was beginning to do this technique at that time. So all my Indian friends know that I use a 12 hole plate, in spite of a 10 hole plate, as in this case.
They also know that I only put two screws up and two screws down, but nevertheless, it was quite a reasonable construction. And six months after, without any physical therapy, this patient was quite nice, with a very good final, or six months post op radiographic and clinical result. Here we can see that the fracture was healing quite good, was healed, indeed, after six months. And this is the patient after six months.
Absolutely no physical therapy, good flexion, good extension of the elbow, a very good extension of the left elbow and a very good flexion of the affected arm. He was very happy and it's important for me to say that, at that day, the patient disappeared, and he would only come back to me after 1 and 1/2 year in June 2011. So in June 2011, he came back to me,1 and 1/2 year after the first, the last medical appointment, and two years after surgery, and he had a very atypical clinical picture.
He had a lot of numbness from the distal, from the lateral part of the distal arm. In this point in which I made this mark, the letter X, coming from the posterolateral part of the forearm, until the hand, what means a lot of numbness in the trajectory of the radial nerve, in the territory of the radial nerve. The Tinnel sign was positive, when I did digital percussion of that point marked by the letter x, and that numbness was indeed bothering the patient too much.
He had no pain, that the numbness was really driving the patient crazy, and my interpretation, my clinical interpretation, was not difficult. So there was a bullet, a piece of bullet, here, that much probably would be bothering the radial nerve. So it's important for us to understand this in the ideal scenario, the ideal \ conduct would be to ask for an electroneuromyography, What means, a nerve conduction study, and especially with a very experienced electroneuromyophaphist.But nevertheless it's difficult to do this, in my public hospital.
This case is from 2009, and still nowadays, 11 years after, I have difficulty in asking this exam, for a nerve conduction study, because it's very difficult to all to obtain. We have a big waiting list. My public hospital takes care of 1.3 million people, I repeat 1.3 million people, here in the periphery of the city of São Paulo, and I couldn't wait for that electroneuromyography, because the patient was very symptomatic and I would be afraid of nerve damage over time.
So what was my clinical solution? Well, if we consider that the clinical picture was extremely clear, the patient was very symptomatic and, as we all know, clinics is always sovereign, I discussed the case with the hand surgeon, with our hand surgeon, and we decided to explore the radial nerve, to see what was happening, to do a neurolysis, and try to remove the bullet fragment. And so that was done, and the patient had a little bit of, I would say, a little pain,
not exactly pain, but something was bothering him around the plate, so, once we operated that, I took the opportunity to remove the plate. I would not remove that plate in a normal scenario, the patient would not come to me just about the very, I would say, the very low complaints around the plate. But once I was there, I took the opportunity to also remove the plate.
So immediately after we removed the plate, we marked the position of the bullet with a marking pen, as we are seeing here. We established the position of the bullet fragment with the C-ARM, in true ap view and in lat view, and that would be our incision, as per our hand surgeon. So from postero lateral, from posterior superior to antero inferior, as per the decision of our hand surgeon.
So this is a beautiful picture of the radial nerve fully dissected. And what we are seeing here, in this beautiful image is what is called a neuroma in continuity, is a kind of neuroma that can affect some nerves and much probably that was related to a thermal lesion, to problems with temperature, as this was a point blank gunshot. So what we did here was exactly, exactly this and ample neurosysis, which usually is enough for these patients to get better.
So we made a broad neurolysis of the neuroma in continuity, and that was the final picture, in the end of the surgery. I wanted to avoid a lot of bleeding, and a lot of hematoma to damage or to bother the radial nerve, because we already had, I would say, enough problems with the radial nerve, so I put a drain, and, very interestingly, that was the patient eight hours, I repeat, eight hours, in that night, before I left surgery, the hospital, quite late in the night, with a full movement and a full function of the affected radial nerve.
I was quite sure that the patient would have a dropped hand, and a full palsy of the radial nerve, for about three months, but for reasons that I, Doctor Sergio, cannot explain, He was with a perfect function of the radial nerve, as we can see in this video. So the radial nerve, in the same day, was working perfectly and no palsies after that big surgery around that radial nerve.
So this is the X-rays, taken 1 and 1/2 months after the surgery, with a quite good reduction of the humerus, a little bit antecurvatum, as we see in the lat view, but absolutely acceptable, as we all know. And this is the clinical view one month post-op, of the patient with the scars that were healing quite good. And this is the scar of the radial nerve surgery.
Full range of motion of the elbow. And the numbness was quite better. He was quite happy, very fast recovery of all of this, that numbness. And this is the patient one month post up. In which we can see that his wrist was extending, the radial nerve was OK from a motor point of view, a little bit of difficulty in flexion, but he would gain that over time for sure, and he was very, very happy at that moment.
So a beautiful and fast outcome over these very unusual and quite odd case. So having said that, I'm going, I'm showing you now my final conclusions, so I have theses take-home messages for you, guys. So, the first one is this some gunshot wounds they can reproduce quite known patterns of fractures that we are used to treat around the elbow. So I'm talking about fractures of the lateral condyle, the medial condyle, the olecranon, the proximal ulna, and the Supracondylean area.
And as long as we comprehend the fracture, we can treat them accordingly, as we do in a regular basis. And the second message, it's important for us to understand that whenever these patients, they come to emergency, it's very useful to put, as I have shown in many cases, and external fixation for damage control, because once we do that, we will strongly protect the soft tissues around the elbow, around the affected area,
and that will give us time to do a CT to discuss the case with very specialized surgical surgeons, OK, until we do the definitive management and the ultimate and definitive, osteosynthesis. And this is my number three take home message, which is Whenever we have a big comminution, as we have seen, in many cases ,here, we must always consider doing bridge constructions even with formal big open approaches.
This is something very important about these cases. This is a very good tool for such cases because when we have the comminuted area, sometimes it's impossible to do any fixation in some kinds of small and simple cerclage, as I have said, as I have shown in one case with Vicryl sutures. And I would say other simple sutures. So keep in mind, my friends, you can do Bridge constructions with even, I would say, big formal approaches,
there is no problem about it, and this is something very useful for these kind of cases with highly comminuted fractures caused by gunshots. So having said that, this is the end. Thank you, my good friends. This is my email. You can send me an email wherever, whenever you wish. Please help me to spread my channel.
Shoulder planet is my personal project in international education in shoulder and elbow medicine and surgery, so please help me spread in my channel. And that's it, my friends. Thank you very much. So, my friends, I hope you liked, It is beautiful lecture, and video, about gunshots around the elbow, so please, don't forget. subscribe to the channel.
Leave your comment, give us your thumbs up and see you in the next video, as Doctor Sergio always says, and we'll keep on saying. Never stop flying. See, you're my good friends.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, here from Sao Paulo, Brazil, from shoulder planet. In this video, I'm showing you very interesting lecture about gunshots around the elbow, so I'm showing you different cases, very interesting cases with very, I would say, strategic ideas to deal with these challenging scenarios, which is gunshots around the elbow.
So I hope you like the video. Please subscribe to the channel, your comment and of course, give us your thumbs up and let us see the video. So hello, my good friends. This is me, Dr. Sergio Rowinski, from shoulder planet, there from Brazil. Sao Paolo, Brazil. And this is a very interesting lecture about a very unusual topic with which I have quite good experience, which is how to manage gunshot fractures around the elbow.
So here I'm going to show you, guys, some cases, actually six different cases, with different clinical and radiographical scenarios, showing your tips and tricks in order to deal with these unusual lesions. And after that, I will come to some interesting conclusions. So let's see the first of our cases. So this is the case number one. So in this case, I'm talking about a 22-year-old boy, who, in September 2011, had a gunshot in the right elbow.
He came with a lot of pain to our emergency department. Really, really, really a lot of pain, and it was quite difficult to do well done X-rays. We could see that there was a fracture, in the lateral condyle, and, in the proximal ulna area. So he was taken to surgery, in order for us to wash the orifices as it is, of course, an open fracture.
He was put in a cast, and then, that was his left view. So in this lateral view, we can see, here, in a well-done lat view, a highly comminuted fracture of the olecranon and, actually, of the proximal ulna. Here we are seeing an AP view, just after surgery, in which we can see that there was a fracture of the medial condyle, and, much probably, with articular involvement.
It's very important to say that in these cases, a CTi s a very important exam, and a CT was done just after that day. This is a case from almost 10, 11 years ago, and, at that time, I didn't have the idea, in my mind, that it's very important to put, in such cases, in the beginning, when they come to our emergency departments, andexternal fixator for damage control, as I'm going to show you guys in the next cases.
But nevertheless, this case was put in a cast, and then a CT was done, in the next day. So this is an axial view, in which we can see that there was indeed a fracture of the medial condyle, with displacement, with articular displacement. Here we are very close to the trochlea. And this is another view, a coronal view of the CT, in which we can easily see the path of the gunshot, from the inlet point, where it entered to, the exit point, which was around the olecranon .
So this is the path of the bullet, that we are seeing, on the left side, painted in Red, and this is a 3D CT view, the anterior view. So it's very important it doesn't matter if we are talking about gunshots or other kind of fractures, whenever we have involvement of the articular surface is very important to do a CT
And, in these cases, a CT was quite really welcome. And if we take a look in the very anterior part of the CT, in the anterior view, it's not difficult for us to see that, indeed, that was an articulate defect in the trochlea, that would definitely need surgical fixation. So this is the posterior view in which we can see a displaced fracture of the medial condyle, together with a comminuted fracture of not only the olecranon, but the whole proximal ulna.
So this is the patient two days after surgery. Here we are seeing the sutures in the inlet orifice and, here, we are seeing the sutures on the outlet orifice. Incredibly, the patient, this patient has absolutely no neurovascular injury, and he was operated so on that day for definitive osteosynthesis. So we did a posterior approach, and I would say that, somehow, it was quite easy to do the olecranon osteotomy because of the gunshot.
But nevertheless, we would have to take a lot of care not to damage that comminuted olecranon. So we isolated the ulnar nerve, as we are seeing on the left part of the image. And here we are seeing a beautiful photo of the fixation of the medial condyle, and we did what we could call the best possible reduction, and I say that because we have a lot of communication in these cases, even in young patients like this one.
So this is the immediate post of X-rays, in which we can see that we achieved a lovely reduction of the medial condyle. We put two washers in the medial condyle, and a plate on the proximal ulna. I would say that the plate could be a little bit more closer to the olecranon, and it was not in this case, but nevertheless the construction was really, really well done.
When we take a look at these x ray, I mean, one week post-op, we can see that we achieved what I call the an almost perfect reduction. And it was not perfect because there is a lot of communication in these cases, adding difficulty to thos osteosynthesis. Nevertheless, this is the patient, nine months post-op, in which we can see a wonderful healing of the whole fractures.
The patient was quite nice, and and I only could see that patient at that moment. This is a clinical picture. Nine months post-op, is very, very important to say that I have, that I, doctor Sergio that I have a lot of difficulty in the follow up of these cases, because, unfortunately, these young boys, they have a lot of problems with police and justice.
So this boy was in jail. He was very young, so it's quite difficult to ask the policeman to come to bring them for medical follow up. So we are seeing, here, the cloths of prison, he's using cuffs in his hands. So it's quite difficult for me as a doctor to control the follow up. But nevertheless, he appeared nine months after surgery with a very, very good final clinical result, obviously without any physical therapy.
So this is the second case, I want to show you. And then this is a case about an another young boy. In 22 November 2011, he received two shotguns when he was running away from police. So one shot was in the middle of the femur, as we are seeing here. And he had a very, very comminuted fracture of basically the middle shaft of the left femur with a lot of comminution, as we are seeing here, and a very, very bad fracture of by a shotgun in the left proximal ulna.
So this is what I like to call a bone explosion. So it's very difficult to do well done X-rays when these patients come to our emergency, because they are in a lot of pain, and it's very, very difficult for them to collaborate in order for us to obtain proper images, because they have multiple injuries, and, obviously, a lot of pain. So this patient was operated in the same day. Of course, he was submitted to washing of both open fractures, and an external fixator was put in the affected arm and in the affected the femur, too.
It's very important for us to say that the role of putting an ex fix in these cases around the elbow is very, very big because we have a lot of advantages when putting these external fixators in the upper limb, on these complex fractures around the elbow. So first of all, we give a lot of stability to the bony anatomy, and, in this sense, we protect the soft tissues,
once we put these external fixators, th and that brings us a lot of, I would say, facility in order to make the definitive osteosynthesis a few days later. And still, with this ex fix, we have time, I would say, to do the pre-op examinations. The pre-op exams, a well done CT, and we have time to discuss, with the most experienced surgeons, in order for us to define what would be the best kind osteosynthesis to do.
So it's very important to put external fixators in these cases, even if these lesions are, I would say, isolated, but it was not in this case, as we had a simultaneous femur. So here we can see an extreme fragmentation of the proximal ulna, after our residents put the external fixator . Really, very important, severe comminution of the proximal ulna, here, and this is the ex fix that was applied on the femur, of course.
So now we are seeing a 3D CT medial view, in which we can see a lot of comminution with some bullet fragments around this bone. OK, in the medial view, and, here, the Lat view It's interesting for us to say that depending on the kind of gunshot, we have more or less bullet pieces around the fracture area, so much probably, I live in Brazil and I, I quite know that policemen here, they use two different guns.
I mean pistols. One is the 38, as we are seeing here, in this image, and the other one is the 0.40, and they are different machine guns. And, as we know, the 38 usually leaves a lot of bullet pieces around the fracture site, differently from the .40, that I'm going to show you, in some minutes, in another case. So for sure, all of these bullets came for a 38 pistol.
Here we are seeing a postero medial view in which we can see, again, a very, very ugly fracture of the proximal ulna, and a lot of small pieces of the bullet. So this patient was operated by two different teams, so our inferior limb team applied this beautiful bridge plate, on the affected femur, a very well done surgery, and obviously that was not done by me, as I, doctor Sergio am dedicated
and exclusive shoulder and elbow surgeon, who does a lot of shoulder and elbow trauma. And so after a few days, we did this surgery in 1st December 2011, that would be something around 9 days after the gunshot injury. So this is a very pedagogical image in which we can see how useful is the ex fix in terms of maintaining a good quality of the surrounding soft tissues around the elbow.
And this is a key point for us to do a safe incision for definitive osteosynthesis. So in this case, this is what we did with we did a bridge plate with locked reconstruction plate. And this is the final clinical result in the very end of the surgery. This is the lat view, just after surgery, in which we can see a very nice construction.
And in my opinion, it was very, I would say, clever to use a locked plate since the quality of the bone in the proximal ulna is, I would say, not the best, even being a very young patient, because we are talking, of course, about metaphyseal bone. And in this sense, it was quite wise, and, I would say, almost mandatory, in my point of view, to use locked screws in this region of the proximal ulna.
So this is the immediate view, in the AP view, after this, the surgery, in my opinion, are very well done surgery, and we did a bridge plate, of course. And this patient, he disappeared. He also went to jail, is very, very difficult to manage the follow up because these are things that are beyond my control. Of course, this is a problem of lawyers and police, but nevertheless he came back just after six months.
Here we are seeing a wonderful healing of the femur and in the end, in what concerns the elbow, this is the six months post op. Lat X-ray and AP view. In that day, I was, I would say, happy with the AP view, but not happy with the Lat view. I would like to have a better view, but when these patients come, it's quite stressful. They come in, they usually come in cuffs with a lot of policemen, and the policemen
they don't want to stay a lot of time in the hospital, and they just want to bring the patient back to the prison. So it's very difficult to repeat X-rays. In this. I would say OPD scenario, so I couldn't repeat the X-rays at that day, because of pressure of policemen, but nevertheless I could realize that we achieved good union of the fracture. So this is the boy, unfortunately, a very young boy making, I would say, wrong decisions and robbing people in the streets.
But again, this is absolutely beyond my control. And so you see, he's using cuffs. And it was difficult to position him because of the cuffs. But nevertheless, it's quite easy for us to see that he has had a very good final clinical range of motion in the elbow, obviously without any physical therapy. And this is the six months post-op view of the bridge construction around the proximal ulna.
So this is case number 3, another interesting case. This is another shot that happened in a very, very young boy in July 2010. So here we are seeing, what we call the entry point or the inlet point. So the bullet entered, I would say, almost in a point blank scenario, from anterior, n the distal part of the arm, and the exit point was here,just very close to the olecranon.
And amazingly, also, in this case, absolutely no neurovascular injuries. So what we are seeing here is that he developed a lateral condyle fracture, which seemed to have a lot of comminution in the articular part. And this is the lat view that was quite innocent. So it's not difficult for us to understand that, in these cases, a CT is an absolutely mandatory exam for us to better comprehend the fracture.
So this is a sagittal view of the CT, in which we can see a lot of comminution, but not exactly in the radiocapitellar joint, but in a position, I would say, more posterior. And so from an anatomical point of view, that was an extra articular comminution. Even if we see the same case in the AP VIEW, we can see a lot of comminution, and it seemed to be really extra articular, when we consider, also, the ulno-humeral joint.
And this is, again, a 3D CT posterior view in which we can see the same comminution in a displaced lateral condyle fracture, and this is the anterior view. So in these cases, whenever possible. it is interesting to try to do a percutaneous fixation. So in this case, we tried a percutaneous fixation that was quite successful. But if it was not, intraoperatively, then we would have to open that for obvious reasons.
So we could, in that case, do a very nice fixation with two cannulated screws, a beautiful fixation, with washers, this is one week post op AP view, and one week post op lat view. That was the only chance I had to see that boy after surgery. So here we can see the boy, already with the clothes of prison. Unfortunately, he had problems with justice and police.
This is the bullet entry point, just as we said preoperatively. And this is the bullet exit point, and her what we are seeing is the two percutaneous incisions for the two cannulated screws. Unfortunately, I couldn't follow this case. This patient never came back. As I have said, it's quite difficult to follow these cases because they have a lot of problems with Justice police, and it's difficult for policemen to bring them.
So I never saw him, but I'm quite sure that he a had quite good outcome. It's interesting to say that whenever they have very bad outcomes, especially infections, they come back automatically, by police, from prison. But as long as they do good, unfortunately, it's quite difficult to have a good follow up of these cases. This is case number four, and in this case, the patient received multiple gun shots.
So here we can see something around three bullets in the thorax. The thorax was operated, and they put a drain in the right part of the thorax, as we can see in the inferior and left part of the screen. And also, this patient received a gun, which probably by a 38 pistol, in the supracondylean area. A very young boy that also was put in an external fixator. This is something very important.
As I have said, for us to have a good control of soft tissues, we take them out of emergency, and then we can plan, with calm and tranquility, the best possible solution discussing with a CT, of course, and with very specialized shoulder and elbow surgeons, as my team, of course. So this is again another view of the ex fix, and this is a 3D CTin which we can see a lot of comminution around the fracture area.
So for sure, that was a gunshot from a 38 pistol. So this is the patient a few days after the trauma. Here we can see again how important it is to put an external fixator in order for us to have a good condition of this surrounding soft tissues around the fracture site. And we can see, here, some, some bandages on the thorax, because,bI would say,two or three days before that surgery, the thorax drain was, so, removed.
So this is what we have done, and here there is an important message because we did a very typical osteo synthesis with orthogonal plates, but what we did here was a bridge construction over a formal open approach. So this is something that I, Doctor Sergio, have learned, after 15 years doing these kind of cases. Sometimes the comminution is so high that the only possible solution is to do a Bridge construction even with a formal open approach,
and the max you can do is some suturing of the comminuted area with some sutures, as we did in this case with Vicryl sutures. So this is one week post up, quite well done osteosynthesis, one screw in the proximal area had a backup, but nevertheless I was not worried about that. And this patient also he disappeared. He told me on that day, he told me, I remember Doc, I'm having problems and I'm going to disappear for some time, but you bet I'm coming in some months.
And so he kept his promise. And after eight months he appeared. So here we can see that the fracture had a complete healing in spite of the fact that we had a fracture around the plate. I mean a fracture around the medial plate. But nevertheless, the patient had a wonderful clinical result. And this is the movie that I have done eight months post-op absolutely no physical therapy.
We can see some wounds in the thorax, of the gunshots. Full range of motion. This is the scar of the posterior approach and a very, very good final clinical result in a young boy, absolutely without physical therapy. So now I'm coming to case five, so this case is almost very interesting. This is a very young boy that received a gunshot in the proximal third of the radius and the ulna.
But in this case, I'm talking about a different kind of pistol, because I see no remaining pieces of the bullet on the affected area. So a highly comminuted fracture on the proximal third radius and the ulna. And hear a lat view. So in this case, we are definitely talking about a four 0.40 pistol, this is how we call them here in Brazil.
So this is a bullet that has, amongst other characteristics, not to let a lot of pieces of metal around the fracture site. So an ex fix was applied, and in that case, here we are seeing, again, a nex fix, and the message, here, is the same it's very important to put a ext fix, in these cases, for damage control to keep the joint much more stable, to protect the soft tissues,
for us to have time, to do a well-done CT and to discuss with very specialized surgeons how to do and how to, I would say, do the best possible osteosynthesis. So here we are seeing, again, the fracture and a lot of comminution in the fracture site. And what we did in this case was something different. We did a volar approach instead of a postero lateral approach, which is called the Thompson approach.
So this is the volar approach that we done, which is the continuity of the Henry'sm approach, which is a very beautiful approach for us to deal with the radius. We have to take a lot of care with the pin, the posterior interosseous nerve. Here we can see beautifully the plate passing below the supinator, but a lot of care must be done with the radial nerve. I mean, the posterior interosseous nerve on that part. And we still did a bridge construction in the ulna.
So what we can see here is that in spite of putting, an inter fragmentary screw, on the radius fracture, We did Open Bridge constructions on the ulna and on the radious, and this is something that we have been doing for many years, and it works a lot. So there is a message in this case, as in the other case, in the other cases, which is doing bridge constructions over or with formal approaches is something very useful, in these cases, because we have a lot of comminution.
So this is the AP view, to something around one week post up, and this is the lat view. Three weeks post-op, and this is the patient only three weeks post-op. So we see a big volar approach, anteriorly, and a big posterior approach, around the ulna. It was impossible to deal with these cases, and to do a Bridge construction, here, only with two small incisions, because the instability of the fracture is very high because of the comminution.
So teh message here is the same. You can do Bridge constructions over formal approaches in this gunshot cases, and this is something that has been quite useful to me in the last 14 years. So this is a clinical video of the patient, five weeks post-op, a lovely range of motion, absolutely no physical therapy, some edema on, I would say, the postero lateral side of the forearm.
The wounds were healing, no problems with the radial nerve, as we are seeing here, and a quite reasonable flexion and extension of the elbow, as we are seeing here, only five weeks post-op. So in a normal scenario, I would follow that patient for a lot of time, but that was the last time I saw that patient. As I have said, these patients, they have a lot of problems with justice, with drug addiction, with the police, and it's very difficult to do a good follow up.
And this is the sixth case, the last one much probably the most beautiful one, and his case show will show us how important it is for us to have clinical judgment in our daily practice. So this case happened in July 2009. A point Blank gunshots in the middle of the arm, a very comminuted fracture, much probably by a 38 pistol, with a lot of comminution in the humerus. We did an anterior bridge plate.
All my Indian friends known that I do a lot of these plates, and I, Doctor Sergio, have a lot of contribution, in the Indian scenario, introducing the anterior bridge plate of the humerus since 2009. We know that, but I was beginning to do this technique at that time. So all my Indian friends know that I use a 12 hole plate, in spite of a 10 hole plate, as in this case.
They also know that I only put two screws up and two screws down, but nevertheless, it was quite a reasonable construction. And six months after, without any physical therapy, this patient was quite nice, with a very good final, or six months post op radiographic and clinical result. Here we can see that the fracture was healing quite good, was healed, indeed, after six months. And this is the patient after six months.
Absolutely no physical therapy, good flexion, good extension of the elbow, a very good extension of the left elbow and a very good flexion of the affected arm. He was very happy and it's important for me to say that, at that day, the patient disappeared, and he would only come back to me after 1 and 1/2 year in June 2011. So in June 2011, he came back to me,1 and 1/2 year after the first, the last medical appointment, and two years after surgery, and he had a very atypical clinical picture.
He had a lot of numbness from the distal, from the lateral part of the distal arm. In this point in which I made this mark, the letter X, coming from the posterolateral part of the forearm, until the hand, what means a lot of numbness in the trajectory of the radial nerve, in the territory of the radial nerve. The Tinnel sign was positive, when I did digital percussion of that point marked by the letter x, and that numbness was indeed bothering the patient too much.
He had no pain, that the numbness was really driving the patient crazy, and my interpretation, my clinical interpretation, was not difficult. So there was a bullet, a piece of bullet, here, that much probably would be bothering the radial nerve. So it's important for us to understand this in the ideal scenario, the ideal \ conduct would be to ask for an electroneuromyography, What means, a nerve conduction study, and especially with a very experienced electroneuromyophaphist.But nevertheless it's difficult to do this, in my public hospital.
This case is from 2009, and still nowadays, 11 years after, I have difficulty in asking this exam, for a nerve conduction study, because it's very difficult to all to obtain. We have a big waiting list. My public hospital takes care of 1.3 million people, I repeat 1.3 million people, here in the periphery of the city of São Paulo, and I couldn't wait for that electroneuromyography, because the patient was very symptomatic and I would be afraid of nerve damage over time.
So what was my clinical solution? Well, if we consider that the clinical picture was extremely clear, the patient was very symptomatic and, as we all know, clinics is always sovereign, I discussed the case with the hand surgeon, with our hand surgeon, and we decided to explore the radial nerve, to see what was happening, to do a neurolysis, and try to remove the bullet fragment. And so that was done, and the patient had a little bit of, I would say, a little pain,
not exactly pain, but something was bothering him around the plate, so, once we operated that, I took the opportunity to remove the plate. I would not remove that plate in a normal scenario, the patient would not come to me just about the very, I would say, the very low complaints around the plate. But once I was there, I took the opportunity to also remove the plate.
So immediately after we removed the plate, we marked the position of the bullet with a marking pen, as we are seeing here. We established the position of the bullet fragment with the C-ARM, in true ap view and in lat view, and that would be our incision, as per our hand surgeon. So from postero lateral, from posterior superior to antero inferior, as per the decision of our hand surgeon.
So this is a beautiful picture of the radial nerve fully dissected. And what we are seeing here, in this beautiful image is what is called a neuroma in continuity, is a kind of neuroma that can affect some nerves and much probably that was related to a thermal lesion, to problems with temperature, as this was a point blank gunshot. So what we did here was exactly, exactly this and ample neurosysis, which usually is enough for these patients to get better.
So we made a broad neurolysis of the neuroma in continuity, and that was the final picture, in the end of the surgery. I wanted to avoid a lot of bleeding, and a lot of hematoma to damage or to bother the radial nerve, because we already had, I would say, enough problems with the radial nerve, so I put a drain, and, very interestingly, that was the patient eight hours, I repeat, eight hours, in that night, before I left surgery, the hospital, quite late in the night, with a full movement and a full function of the affected radial nerve.
I was quite sure that the patient would have a dropped hand, and a full palsy of the radial nerve, for about three months, but for reasons that I, Doctor Sergio, cannot explain, He was with a perfect function of the radial nerve, as we can see in this video. So the radial nerve, in the same day, was working perfectly and no palsies after that big surgery around that radial nerve.
So this is the X-rays, taken 1 and 1/2 months after the surgery, with a quite good reduction of the humerus, a little bit antecurvatum, as we see in the lat view, but absolutely acceptable, as we all know. And this is the clinical view one month post-op, of the patient with the scars that were healing quite good. And this is the scar of the radial nerve surgery.
Full range of motion of the elbow. And the numbness was quite better. He was quite happy, very fast recovery of all of this, that numbness. And this is the patient one month post up. In which we can see that his wrist was extending, the radial nerve was OK from a motor point of view, a little bit of difficulty in flexion, but he would gain that over time for sure, and he was very, very happy at that moment.
So a beautiful and fast outcome over these very unusual and quite odd case. So having said that, I'm going, I'm showing you now my final conclusions, so I have theses take-home messages for you, guys. So, the first one is this some gunshot wounds they can reproduce quite known patterns of fractures that we are used to treat around the elbow. So I'm talking about fractures of the lateral condyle, the medial condyle, the olecranon, the proximal ulna, and the Supracondylean area.
And as long as we comprehend the fracture, we can treat them accordingly, as we do in a regular basis. And the second message, it's important for us to understand that whenever these patients, they come to emergency, it's very useful to put, as I have shown in many cases, and external fixation for damage control, because once we do that, we will strongly protect the soft tissues around the elbow, around the affected area,
and that will give us time to do a CT to discuss the case with very specialized surgical surgeons, OK, until we do the definitive management and the ultimate and definitive, osteosynthesis. And this is my number three take home message, which is Whenever we have a big comminution, as we have seen, in many cases ,here, we must always consider doing bridge constructions even with formal big open approaches.
This is something very important about these cases. This is a very good tool for such cases because when we have the comminuted area, sometimes it's impossible to do any fixation in some kinds of small and simple cerclage, as I have said, as I have shown in one case with Vicryl sutures. And I would say other simple sutures. So keep in mind, my friends, you can do Bridge constructions with even, I would say, big formal approaches,
there is no problem about it, and this is something very useful for these kind of cases with highly comminuted fractures caused by gunshots. So having said that, this is the end. Thank you, my good friends. This is my email. You can send me an email wherever, whenever you wish. Please help me to spread my channel.
Shoulder planet is my personal project in international education in shoulder and elbow medicine and surgery, so please help me spread in my channel. And that's it, my friends. Thank you very much. So, my friends, I hope you liked, It is beautiful lecture, and video, about gunshots around the elbow, so please, don't forget. subscribe to the channel.
Leave your comment, give us your thumbs up and see you in the next video, as Doctor Sergio always says, and we'll keep on saying. Never stop flying. See, you're my good friends.
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