Summary The T2 Alpha® Humerus Nailing System is an intramedullary fixation system designed for stable treatment of humeral shaft and proximal humerus fractures Utilizes a single core tray across all Gamma4 and T2 Alpha indications to enhance platform consistency and ease of use Allows minimally invasive insertion with multiple locking options to enhance rotational and axial stability The system is engineered to support accurate alignment, controlled compression, and reliable fracture healing Related Implants Short nail diameter: Ø8mm length: 150mm Long nail diameter: Ø7mm–Ø10mm in 1mm increments length: 180-315mm in 15mm increments Design Stryker Orthopedic Modeling and Analytics (SOMA) designed straight nail design allows for alignment of the epiphyseal fragment with the diaphysis and gives structural support to the humeral head fragment proximal screw trajectories are designed to aim for dense bone to reduce the potential of displacement of the humeral head diameters defined through the SOMA database cover a wide range of intramedullary canal diameters in the analyzed population Active intraoperative compression up to 6mm of controlled compression for long nails designed to allow for a more controlled reduction of the fragments when compared to the traditional backslapping/backstroke method Guided targeters targeters available for every hole except the distal lateral to medial Unique instrumentation nail height stop: facilitates precise nail depth placement, while reducing the risk of nail protrusion through the proximal humerus Advanced locking screws designed to provide increased axial fracture stability in any 4mm round locking hole when the surgeon chooses Hybrid locking configuration designed for fixation of varying fracture patterns Anatomy Osteology greater tuberosity landmark humeral shaft diaphysis distal humerus flare Muscles anterolateral split supraspinatus entry interval proximal landmark anterior humerus Ligaments coracoacromial ligament coracohumeral ligament superior glenohumeral ligament middle glenohumeral ligament Nerves axillary nerve radial nerve musculocutaneous nerve median nerve ulnar nerve Blood supply anterior circumflex humeral artery posterior circumflex humeral artery profunda brachii artery periosteal branches of the brachial artery Approach Incision an anterolateral incision splits the deltoid, exposing the bursa and supraspinatus tendon percutaneous approach using an incision on the upper arm, the deltoid muscle is bluntly split to expose the rotator cuff superior transdeltoid approach the anterior deltoid is detached from the anterior acromion to expose the rotator cuff Entry point central entry point located at the very top of the humeral head, in the articular surface, in line with humeral axis Technique Reaming guide wire insert the ball tip guide wire 2.5 x 800mm advance the Ball Tip Guide Wire through the fracture site and to the desired insertion depth reaming (long nail only) commence reaming in 0.5mm increments until the desired diameter has been achieved to help maintain the position of the guide wire during reamer extraction, press the funnel tip end of the guide wire pusher at the end of the wire while extracting the reamer from the medullary canal the diameter of the selected humeral nail should be 1–1.5mm smaller than that of the last reamer used a guide wire exchange is required to enable the guided insertion of the humeral nail Nail selection length determine appropriate nail length by measuring the remaining length of the guide wire confirm the position of the tip of the guide wire prior to measurement ensure that the tip of the Guide Wire Ruler is fully seated on the bone prior to determining measurement if the measurement is between markings, use of the shorter nail is recommended Nail insertion the selected nail is assembled onto the Nail Adapter with the Nail Holding Screw pre-tighten the screw to the nail by hand then use the Ball Tip Screwdriver to tighten the assembly remove all targeting devices from the Nail Adapter prior to inserting the nail insert the nail by hand over the Smooth Tip Guide Wire and into the entry site of the proximal humerus advance the nail past the fracture site insert the nail so that it is countersunk below the articular surface do not leave the nail proud as this could damage the joint surface remove the guide wire once the nail is appropriately positioned two circumferential grooves are located on the insertion post of the Nail Adapter at 2mm and 8mm from the driving end of the nail depth of insertion may be visualized with the aid of fluoroscopy when apposition/compression is desired, the recommended depth of insertion is at least 6mm to avoid protrusion of the nail Targeting device assembly attach the Targeting Device (left/right specific) to the Nail Adapter, ensuring the knob on the Targeting Device is in the unlocked position and sliding the targeting device down the interface of the Nail Adapter until it hits the stop turn knob to lock insert the Tissue Protection Sleeve together with the Drill Sleeve into the holes of the targeting devices and insert the Locking Drill Ø3.5 x 360mm to confirm that the devices have been assembled properly repeat the procedure with the Anterior Targeting Device Implant positioning ensure the humeral head is anatomically reduced to the shaft, rotate the nail to allow screw insertion into the Greater and Lesser Tuberosities then position the Nail Adapter on the ML plane and insert a K-wire through the adapter the wire represents the AP plane align the wire with the forearm to achieve approximately 30° humeral-head retroversion the most proximal screw is positioned within the triangle formed by the posterior border of the bicipital groove and the cranial border of the Greater Tuberosity, which is where the Tissue Protection Sleeve should be sitting once all planned screws are inserted into the humeral head, any torsion between the head and the shaft can be adjusted before securing the distal fragment using the targeting device Guided proximal locking all of the proximal screws can be targeted through the Targeting Device (as well as the distal screws for the 150mm short nail), except for the Static Lesser Tuberosity Screw insert the Tissue Protection Sleeve, Locking Drill Sleeve and trocar assembly into the desired locking hole in the Targeting Device (or Anterior Targeting Device if placing the static lesser tuberosity screw) mark the position on the skin and create an incision ensure nail orientation and height is suitable prior to the creation of the incision insert the sleeve assembly until it touches the bone ensure a sharp drill bit is used to minimize resistance during drilling a dull bit may require increased force, which can compromise accuracyor damage bone remove the trocar and insert the Locking Drill drill through the first cortex and advance the drill without rotating through the nail until it is in contact with the subchondral bone the appropriate screw length can be measured with the sleeve assembly insert a second drill bit through the sleeve assembly into an additional proximal hole and keep it in position during insertion of the first screw this should help stabilize the targeting arm and maintain alignment the gray friction lock mechanism is designed to maintain the position of the Tissue Protection Sleeve to remove the sleeve assembly from the targeting device, press the gray mechanism while pulling the sleeves and trocar remove the Locking Drill and Locking Drill Sleeve and insert the selected Locking Screw through the Tissue Protection Sleeve using the Screwdriver Bit and QuickLock Delta Handle when the marking on the screwdriver nears the head of the Tissue Protection Sleeve, the screw is close to its final position use imaging to confirm placement of the screw the paddle tip of the Tissue Protection Sleeve allows the user to visually verify that the screw head is seated on the bone under X-ray without retracting the sleeve from the bone alternatively, the sleeve can be pulled away from the bone to verify that the screw is fully seated repeat the procedure for all proximal screws Guided distal locking (short nail) the targeting device is designed to provide three Distal Locking Options for static mode place screws in both round holes (add a screw in the oblong hole for additional support, if needed) for dynamic mode place a screw in the oblong hole to place screws distally, use the same technique for placement of proximal locking, but ensure bi-cortical fixation make sure the Tissue Protection Sleeve/Drill Sleeve Assembly is seated on bone prior to selecting final screw length Guided distal locking (long nail) use of the Distal Targeting Device is recommended when performing distal locking of the AP and oblique screws the distal LM screw is not targeted and requires freehand distal locking pre-operative assembly is recommended prior to nail insertion to perform guided distal locking, it is essential to place the X-ray beam of a C-arm approximately 30° oblique to the axis of the drill sleeve assembly once the C-arm has been adjusted so that nail and sleeve are shown in parallel, the deviated image will show the sleeve either medial or lateral to the nail if the sleeve and the nail are shown parallel and collinear no further adjustment of the sleeve is needed if the sleeve and nail tip are not seen on the same axis, sleeve adjustment is required by turning the knob of the Distal Targeting Device begin with the most proximal of the distal screw set to help maintain targeting accuracy and reduce the potential for nail deformation when placing the first screw distally, always begin with a standard bicortical Locking Screw to help prevent skiving once the correct nail and sleeve adjustment has been obtained, make a small skin incision at the sleeve entry point ensure that the incision is aligned with the sleeve to avoid excess force advance the Tissue Protection Sleeve, Locking Drill Sleeve, and Locking Trocar, assembly through the incision until the sleeve tip is close to the cortex Distal freehand locking (long nail) the freehand drill is held at an oblique angle to the center of the locking hole upon X-Ray verification, the drill is placed perpendicular to the nail and drilled through the near cortex confirm these views in both the A/P and M/L planes with X-Ray after drilling both cortices, the screw length may be read directly off of the Screw Scale alternatively, the Depth Gauge can be used to determine the screw length the position of the end of the drill is equal to the end of the screw as they relate to the far cortex routine Locking Screw insertion is employed with the assembled Short Screwdriver Bit and the Delta Handle the self-retaining screwdriver assembly may be used to facilitate freehand locking Compression internal apposition / compression mode (long nail only) in transverse, axially stable fracture patterns, active mechanical apposition / compression may be desired when compressing the fracture, the implant must be inserted at an appropriate distance from the entry point to accommodate for the 6mm of active compression after inserting two distal Locking Screws, insert a Locking Screw proximally in the oblong hole to apply compression, attach the Compression Screw to the Compression Screwdriver and Quick-lock Delta Handle assembly insert the Compression Screwdriver through the Nail Holding Screw and apply apposition / compression once apposition / compression has been applied, the compression screwdriver can be removed insertion of the second proximal shaft locking screw is recommended external apposition / compression mode (long nail only) as an alternative to internal compression, the External Compression Device can be used to apply apposition / compression when compressing the nail, the implant must be inserted at an appropriate distance from the entry point to accommodate for the 6mm of active compression after insertion of two distal Locking Screws, insert a Locking Screw proximally in the oblong hole to apply compression, attach the External Compression Device to the Quick-Lock Delta Handle and insert the External Compression Device through the Nail Holding Screw to engage the internal threads of the nail rotate to apply compression once apposition / compression has been applied, insert the second shaft locking screw once the second screw has been inserted, the External Compression Device can be detached Advanced locking screws drill both cortices and determine screw length in a guided or freehand manner as described in sections 'Guided distal locking', 'Proximal locking', or 'Distal freehand locking' once screw length has been determined, open the near cortex using the Counterbore Drill, Manual in combination with the Quick-Lock Delta Handle to ensure that the cortex and the passage to the nail is sufficiently widened turn the drill in a gentle clockwise motion with moderate axial pressure until the pathway to the nail has been opened once drilling has been completed, insert the Advanced Locking Screw with gentle axial force using the appropriate screwdriver through the near cortex without turning the screw, ensuring the axis of the screw is aligned with the corresponding locking hole. proximal screws insert the screw by rotating clockwise until the screw is fully seated for distal and shaft screw push the screw until the leading tip is fully engaged with the nail hole to confirm correct starting point and axial alignment of the screw, gently rotate the screw counterclockwise while applying gentle axial force a click sound or snapping of the thread indicates that the screw is in the correct position once position has been confirmed, insert the screw by rotating clockwise until the screw is fully seated End cap insertion after removal of the Nail Adapter and Nail Holding Screw, an End Cap may be inserted to avoid impingement, carefully select the length of the End Cap the End Cap is inserted with the Screwdriver, Self-Holding, Short, 3.5mm fully seat the End Cap to minimize the risk of loosening the End Cap may be used to adjust the height of the nail for optimal purchase of the nail at the entry point close the wound using standard technique Technical Specifications Driving end diameter driving end diameter of the 7–9mm is Ø10mm; nail size 10mm has a constant diameter Drills 3.5mm – orange 4.5mm – orange (counterbore drill) PEEK insert designed to reduce potential for screw backout with locking screw or advanced locking screw in proximal holes Washers designed to increase surface area while reducing screw head prominence designed to improve bone fragment compression through increased surface area includes suture holes End caps available in three sizes 0mm 2mm 4mm Screws Locking Screw Ø4mm, 20–60mm length in 2.5mm increments Advanced Locking Screw Ø4mm, 20–60mm length in 2.5mm increments Compression Screw Humerus