Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation check ipsilateral distal humerus and elbow for concurrent injuries (floating elbow) document neurovascular exam (radial nerve) Positioning radiolucent table with or without ipsilateral arm board, rotate bed 90° patient supine with shoulder at edge of table c-arm in from foot of bed with monitor parallel to bed Approach anterolateral approach to shoulder incision 3-4cm along anterolateral aspect of acromion, split fascia and then rotator cuff interval Guidewire Insertion start point is between greater tuberosity and sulcus in center of humeral head (50% bare area) Fracture Reduction reduce fracture using traction, varus/vagus, and rotational force applied manually Reaming use entry awl or reamer (~8mm) curved laterally then guidewire to end of humerus start with size 6-7mm reamer, ream 1.5-2.0mm above size of final nail Nail Insertion insert nail over guidewire following lateral bend, targeting guide 30° anterior to table, mallet in using strikeplate, bury nail 7-10mm Interlocking Screws 3-4 proximal locking screws into humeral head through targeting jig get perfect circles of distal interlock screws, drill and insert Postoperative weight-bearing as tolerated, physical therapy, range of motion exercises to elbow/wrist/hand, pendulems for shoulder Planning & Preparation Extremity Exam before case need to check ipsilateral distal humerus for fracture extension and elbow (floating elbow) check compartments, limb length, rotation, and alignment need AP/Lat xrays of entire shoulder, humerus, and elbow location of fracture site will indicate amount of deforming forces: proximal fragment abducted, distal segment in varus document distal neurovascular status (radial nerve) Indications nonoperative management in coaptation splint and functional brace for fractures with <20° anterior angulation, <30° varus/valgus angulation, <3cm shortening absolute indications include open fracture with soft tissue injury, vascular injury, brachial plexus injury relative indications for nailing include pathologic fractures, segmental fractures, severe osteoporosis, skin compromise, polytrauma Equipment & Positioning Equipment humeral intramedullary nailing system c-arm fluoroscopy radiolucent table Position patient supine with ipsilateral shoulder at edge of bed with or without arm board if no armboard use assistant to manipulate and hold arm tape down and secure head, chest, and abdomen rotate bed 90° so that ipsilateral arm is away from Anesthesia prep and drape entire arm into axilla and over medial clavicle to ensure adequate working area OR Setup and C-arm radiolucent table c-arm in from foot of bed with monitor screen parallel to bed take initial fluoro AP/Lat of shoulder and humerus to ensure proper positioning during remainder of case can internal/external rotate arm to get Lat view Approaches Anterolateral Shoulder incision 3-4cm along anterolateral border of acromion tenotomy to develop soft tissue plane then cautery through subcutaneous tissue sharp dissection through fascia, bursa, and rotator interval Surgical Technique 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 Reduction 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 Closure Irrigation & Hemostasis strongly flush out nail insertion site and interlocking screw sites with saline bulb irrigation cauterize peripheral bleeding vessels Rotator Interval and Fascia Closure close rotator cuff and fascia with 0-vicryl or 2-0 Ethibond sutures subcutaneous and skin closure with 2-0 vicryl and staples Dressing soft incision dressings over shoulder and proximal/distal interlock incisions Postoperative Care Immediate Post-op weight-bearing as tolerated, physical therapy sling for comfort immediate range of motion exercises to elbow/wrist/hand to reduce swelling pendulems for shoulder range of motion recheck neurovascular exam (radial nerve) 2 Weeks wound check staples/sutures removed continue physical therapy and range of motion exercises Complications Document Complications screw penetration into articular surface shoulder pain varus malunion nonunion avascular necrosis malrotation nerve injury (radial nerve with lateral to medial interlock screws, musculocutaneous nerve with anterior to posterior screws) infection