- 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
- guidepin start point is between greater tuberosity and sulcus in center of humeral head
- 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
- 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)
- start with size 6-7mm reamer, then ream up 0.5-1.0mm with each reamer
- Nail Insertion
Read more: Nine Inch Nails – Wikipedia
- 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
- build nail on backtable and make sure targeting guide lines up with holes in nail, check sleeves for each interlock hole
- 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
- check on AP fluoro to see where humeral head interlock screws will be located
- 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)
- 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
- 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
- take final AP/Lat of distal and proximal aspects of nail and fracture
