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Prophylactic IM Nailing of Humeral Shaft Impending Fracture

Planning

B

Preoperative Plan

1

Template instrumentation

  • template implant size

2

Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical Instrumentation

  • Intramedullary humeral nail system

2

Room setup and Equipment

  • standard OR table

3

Patient Positioning

  • beach chair position
  • place a small roll between the medial borders of the scapula
  • turn the head to the contralateral side

Technique

D

Approach

1

Palpate and outline the anatomy of the humerus, clavicle and the humeral head

  • identify and mark out the midline

2

Make the skin incision

  • make a small longitudinal incision over the anterolateral corner of the acromion centered over the greater tuberosity
  • extend the incision distally 3 cm

3

Perform skin incision

  • use 10 blade for skin incision

4

Divide the deltoid

  • split the deltoid fibers in line with the longitudinal incision
  • do not extend the incision more than 4 cm because of the axillary nerve
  • use knife down to fascia lata

5

Reflect the supraspinatus

  • longitudinally incise the the supraspinatus in line with the skin incision for 1 to 2 cm just posterior to the bicipital tuberosity
  • place suture tags
E

Canal Entry

1

Make the entry hole

  • make the entry hole just medial to the to of the greater tuberosity, just lateral to the articular margin and 0.5 cm posterior to the bicipital groove
  • make sure the entry hole is centered on AP and Lateral radiographs

2

Place the Kwire

  • insert the kwire into the medullary canal to the level of the lesser tuberosity

3

Open the medullary canal

  • use an awl or pass a cannulated drill bit over the kwire
  • extend the shoulder to improve clearance of the acromion
  • once the canal is opened, remove the kwire and place a ball tip guidewire

4

Advance the guidewire

  • advance the guidewire until it is 1 to 2 cm proximal to the olecranon fossa
F

Determine Nail Length

1

Guide rod method

  • with the distal end of the rod 1 to 2 cm proximal to the olecranon fossa, overlap a second guide rod extending proximally from the humeral entry portal
  • subtract the length in mm of the overlapped guide rod from the total length of the identical guidewire to determine the nail length

2

Nail length gauge

  • place the radioopaque gauge anterior to the humerus
  • move the the C-arm to the proximal end of the humerus
  • read the length from the stamped measurements on the gauge
G

Reaming and Nail Insertion

1

Ream the humeral shaft

  • slowly ream the entire humerus over the ball tipped guidewire in 0.5 mm increments
  • choose a nail that is 1 mm smaller than the last reamer used

2

Insert the nail

  • attach the nail to an adaptor
  • place the nail holding screw through the adaptor
  • place the radiolucent targeting device onto the nail adaptor

3

Verify the nail assembly

  • insert a drill bit through the assembled tissue protector placed in the required holes of the targeting device

4

Advance the nail

  • manually advance the nail with sustained pressure
  • insert the nail to at least the first circumferential groove on the nail adaptor but no deeper than the second groove
  • countersink the nail 5 mm below the articular surface
H

Distal Locking Screws

1

Place the interlocking screws in a specific order

  • place anterior, then posterior, then lateral then medial directed interlocking screws

2

Place the anterior-posterior screws

  • advance the C arm over the distal humerus until the oval slot is seen in a perfect circle
  • use a scalpel over the skin to precisely determine the location of the incision
  • keep incision lateral to the biceps tendon
  • after skin incision use a blunt hemostat to spread under the brachialis muscle
  • insert a short drill bit through a soft tissue protector
  • center the drill bit in the locking hole hole
  • attach the drill and penetrate the near cortex
  • detach the drill bit then use a mallet to advance the drill bit to the far cortex
  • reattach the drill and penetrate the far cortex
  • place a depth gauge and measure the length of the interlocking screws
  • place the interlocking screws
  • use C arm to confirm placement and length

3

Place the lateral-medial screws

  • advance the C arm over the distal humerus until the oval slot is seen in a perfect circle
  • use a scalpel over the skin to precisely determine the location of the incision
  • after skin incision use a blunt hemostat to spread to the bone
  • insert a short drill bit through a soft tissue protector
  • center the drill bit in the locking hole hole
  • attach the drill and penetrate the near cortex
  • detach the drill bit then use a mallet to advance the drill bit to the far cortex
  • reattach the drill and penetrate the far cortex
  • place a depth gauge and measure the length of the interlocking screws
  • place the interlocking screws
  • use C arm to confirm placement and length
I

Wound Closure

1

Repair the supraspinatus and deltoid

  • use nonabsobable suture to perform a side to side repair

2

Close the deep fascia

  • use 0 vicryl for deep fascia

3

Perform superficial closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 nylon for skin

4

Dressings

  • place soft dressings
  • place in sling or shoulder immobilizer

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • history
  • pain and function
  • past medical/surgical/social/family history
  • review of systems
  • physical exam
  • heart
  • lungs
  • extremity exam
  • range of motion
  • strength
  • sensation
  • skin changes
  • tenderness

2

Screen medical studies to identify and contraindications for surgery

3

Orders basic imaging studies

  • radiographs
  • AP/lateral of the lesion
  • Joint above and below the lesion

4

Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention

5

Perform operative consent

  • describe complications of surgery including
  • Infection
  • Wound complications
  • Neurovascular compromise
  • Tumor progression
  • DVT/PE
  • Pneumonia
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • remove dressings POD 2

2

Appropriately orders and interprets basic imaging studies

  • post-op xrays of the humerus in post-op

3

Appropriate medical management and medical consultation

4

Inpatient physical therapy

  • start pendulum and elbow ROM exercises

5

Discharges patient appropriately

  • pain meds
  • outpatient pt
  • schedule follow up appointment in 2 weeks
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • history:
  • past history of cancer or radiation,
  • prior treatments
  • pre-existing pain
  • smoking or chemical exposure
  • constitutional symptoms
  • fever
  • physical exam
  • notes lymph node involvement, lumps/nodules

2

Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic

3

Prescribes and manages nonoperative treatment

  • understand when to have the patient back to clinic for follow-up
  • understand when to order new radiographic imaging studies

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • check radiographs
  • start formal physical therapy
  • diagnose and management of early complications
  • infection
  • DVT/PE
  • wound breakdown
  • neurovascular compromise
  • hardware failure
  • postop: 4-6 week postoperative visit
  • check radiographs
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies/lab studies

  • 3D radiographic studies to include CT
  • MRI
  • lab studies
  • SPEP/UPEP
  • PSA
  • other tumor markers

2

Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty

3

Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)

4

Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling
O

Complex Patient Care

1

Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy

2

Develops unique, complex post-operative management plans

 

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