• approach
    • mark out anterior, lateral, and posterior borders of acromion 
    • incision and dissection along anterolateral border of acromion down to rotator cuff interval
  • Guidewire insertion
    • guidepin start point is between greater tuberosity and sulcus in center of humeral head
      • aim for 50% bare area, mallet into place, and check on fluoro
      • divide rotator interval then drive guidewire down canal on power
      • check AP/Lat fluoro to make sure in center of canal
    • use lateral entry awl or reamer (~8mm) with soft tissue protector and ream until it hits the stop plate
  • fracture decrease
    • reduce fracture by using traction, varus/vagus, and rotational force applied manually
    • once fracture reduced, manually push long balltip guidewire past fracture site using T-handle (with slight bend at tip)
      • mallet to distal aspect of humerus (olecranon fossa), check on fluoro AP/Lat
    • use radiolucent ruler to measure appropriate nail length on AP fluoro of shoulder
      • need to recheck fracture site to ensure no gapping in order to get accurate length
      • use ruler on contralateral side to measure intact humerus if segmental comminution exists
  • Reaming
    • start with size 6-7mm reamer, then ream up 0.5-1.0mm with each reamer
      • push through entry hole before reaming to avoid reaming out anterior cortex
      • check chatter from reamer feedback and diaphyseal fit on fluoro AP
      • ream 1.5-2.0mm above size of final nail
      • “ream and run”: ream up to fracture site with smaller reamers then push through fracture site and restart reamer full speed to avoid eccentric reaming
      • don’t stop reamer in canal with larger reamer sizes (avoids reamer head from getting stuck)
  • Nail Insertion
    • build nail on backtable and make sure targeting guide lines up with holes in nail, check sleeves for each interlock hole
      • tighten top locking screw with pumpkin screwdriver to lock together
    • insert nail over guidewire, follow 6° lateral bend of nail, mallet in with strikeplate
    • targeting jig should be 30° anterior to bed for proper alignment
    • hold nail by handle, not the targeting guide, mallet or manually advance to fracture site, check on fluoro AP/Lat
    • manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines possible with use of the mallet
    • insert nail completely and seat fully, check seating in humeral head
      • need to bury nail ~7-10mm to decrease incidence of shoulder pain
      • remove long balltip guidewire
  • Humeral Head Interlocking Screws
    • check on AP fluoro to see where humeral head interlock screws will be located
      • can insert 3-4 (5mm) proximal interlock screws
      • multiplanar screws for right vs. left sides
    • mark skin with triple sleeve through jig, use 15blade through skin and deep fascia
      • place inner sleeves (x2) into guide, push guides down to bone
      • drill through 1st cortex, tap second, measure, then drill through 2nd cortex
      • insert screw and check length and placement on fluoro to ensure no articular penetration on multiple fluoro views
    • can add endcap into top of nail to lock in most proximal interlock screw and prevent bony ingrowth into top of nail
    • use pumpkin screwdriver to remove locking screw from nail and remove handle and targeting guide
  • distal Interlocking Screws
    • recheck fracture site and reduction prior to insertion of distal interlock screws
    • if gapping at fracture use hand to strike elbow and compress across fracture site
    • place arm on mayo stand or stack of towels and move to distal nail at elbow
    • take AP fluoro for perfect circles technique for interlocking screws
      • c-arm stays still and rotate arm to get perfect circles (anterolateral direction for screws)
    • once distal interlock holes appear as perfect circles, use hemostat handle to localize holes, mag x2 in with fluoro
    • 10blade through skin, hemostat spread down to bone
    • need to visualize bone in order to prevent injury to surrounding nerves
      • radial nerve can be damaged with lateral to medial interlock screws, musculocutaneous nerve with anterior to posterior screws
    • place drill through hole, then make drill perpendicular to C-arm beam and drill through first cortex and nail
    • stop at 2nd cortex, measure (add 5mm to length to add 2nd cortex thickness), and then drill 2nd cortex
    • while still in perfect circles lat fluoro, complete 2nd distal interlock screw and measure
      • c-arm to AP position to get out of the way, insert both interlock screws
  • Confirm Nail Position and Extremity Check
    • take final AP/Lat of distal and proximal aspects of nail and fracture
    • check limb length, rotation, and alignment

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