0x6.001.247_AB 10.10.11 10:57 Seite Cvr1 MultiLoc Proximal Humeral Nail. Proximal humeral nail with multiple locking options for simple and complex fractures. Technique Guide

0x6.001.247_AB 10.10.11 10:57 Seite Cvr2 Image intensier control Warning This description alone does not provide sufficient background for direct use of the instrument set. Instruction by a surgeon experienced in handling these instruments is highly recommended. Reprocessing, Care and Maintenance of Synthes Instruments For general guidelines, function control and dismantling of multi-part instruments, please refer to: www.synthes.com/reprocessing

0x6.001.247_AB 10.10.11 10:57 Seite 1 Table of Contents 2 4 Indications 5 Screw Configuration 6 Clinical Cases Surgical Technique MultiLoc Proximal Humeral Nail AO Principles Introduction 8 12 Patient Positioning and Approach 13 Opening of the Humerus 16 Nail Insertion 20 Nail Positioning 22 Proximal Locking MultiLoc Screws 3.5 mm Locking Screws 26 32 Distal Locking and Ascending Screw 37 End Cap Insertion 41 Implant Removal (Optional) 44 Implants 47 Instruments 53 Angular Stable Locking System (ASLS) (Optional) Product Information Preoperative Planning 60 Bibliography 62 MultiLoc Proximal Humeral...

0x6.001.247_AB 10.10.11 10:57 Seite 2 MultiLoc Proximal Humeral Nail. Multiply your options. Flexible system with multiple locking options for simple and complex fractures ᕤ MultiLoc screws ᕤ ᕡ Blunt screw tip to minimize the risk of secondary screw perforation ᕣ ᕢ 4 suture holes per screw for reliable attachment of the rotator cuff muscles ᕣ Countersunk screw head to reduce implant prominence ᕤ Optional secondary 3.5 mm locking screws (screw-in-screw) for improved stability, especially in poor bone quality, i.e. osteoporosis.* ᕥ The 3.5 mm locking screws provide support for the posteromedial...

0x6.001.247_AB 10.10.11 10:57 Seite 3 MultiLoc Proximal Humeral Nail ᕡ – Straight nail design for central insertion point: – Improved anchorage in strong subchondral bone2 – Potentially avoiding insertion through fracture site in typical 3-part fractures2,3 – Preservation of hypovascular supraspinatus footprint – Proximal locking holes with polyethylene inlay for angular stability and to reduce instances of screw back-out – Ascending screw option providing support for the calcar – Multiplanar distal locking options for less implant toggling – Right and left cannulated nails, diameters 8.0 and...

0x6.001.247_AB 10.10.11 10:57 Seite 4 AO Principles In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation.1, 2 Those principles as applied to the MultiLoc Proximal Humeral Nail are: Anatomic reduction Prior to nail insertion, reduction is achieved e.g. by manual traction, joystick manipulation, or traction sutures. Reduction is held temporarily by Kirschner wires while the medullary canal is opened and the nail is inserted. The nail is then locked proximally and distally in order to maintain the reduction. Stable fixation In the humeral head,...

0x6.001.247_AB 10.10.11 10:57 Seite 5 Indications The MultiLoc Proximal Humeral Nail is indicated for fractures of the proximal humerus, including: – 2-part surgical neck fractures – 3-part fractures – 4-part fractures MultiLoc Proximal Humeral Nail Technique Guide Synthes 5

0x6.001.247_AB 10.10.11 10:57 Seite 6 Screw Configuration Proximal locking: Levels A to D The three lateral screws (greater tuberosity, levels A, B, and D) must be used in any fracture situation as they ensure the basic stability of the construct. Screw type: – MultiLoc screw л 4.5 mm (gold) A The anterior screw (minor tuberosity, level C) increases the stability of the construct. It may be used in fractures with a minor tuberosity fragment if the fragment is large enough to accommodate the screw head. Do not insert a 3.5 mm locking screw in this location. C B D E Screw type: – MultiLoc screw...

0x6.001.247_AB 10.10.11 10:57 Seite 7 Ascending screw: Level E The ascending screw supports the medial calcar region which can be helpful in medially comminuted fractures. Screw types: – Locking screw л 4.0 mm (blue) – ASLS screw л 4.0 mm (brown; optional) Distal locking: Levels F and G The two distal locking screws are located in different planes to reduce implant toggling in the humeral canal. Screw types: – Locking screw л 4.0 mm (blue) – ASLS screw л 4.0 mm (brown; optional) MultiLoc Proximal Humeral Nail Technique Guide Synthes 7

0x6.001.247_AB 10.10.11 10:57 Seite 8 Clinical Cases Case 1: 2-part surgical neck fracture 78 year old woman. Simple fall. Treatment with: – MultiLoc PHN л 8.0 mm – 3 MultiLoc screws – Standard distal locking Preoperative, AP view Preoperative, scapular Y-view Postoperative, AP view 8 Synthes Postoperative lateral view MultiLoc Proximal Humeral Nail Technique Guide

0x6.001.247_AB 10.10.11 10:57 Seite 9 Case 2: 3-part fracture 53 year old woman. Simple fall, after 6 weeks of conservative treatment with severe pain and impossible active rehabilitation. Treatment with: – MultiLoc PHN л 9.5 mm – 3 MultiLoc screws – 1 3.5 mm locking screw (screw-in-screw) – Ascending screw with ASLS – Distal locking with ASLS Preoperative, AP view Postoperative, AP view Preoperative, scapular Y-view Postoperative, lateral view MultiLoc Proximal Humeral Nail Technique Guide Synthes 9

0x6.001.247_AB 10.10.11 10:57 Seite 10 Clinical Cases Case 3: Osteoporotic 4-part fracture 80 year old woman. Simple fall. Treatment with: – MultiLoc PHN л 8.0 mm – 3 MultiLoc screws – 1 3.5 mm locking screw (screw-in-screw) – Suture fixation of minor tuberosity fragment – Standard distal locking Preoperative, AP view Preoperative, scapular Y-view Postoperative, lateral view 10 Synthes MultiLoc Proximal Humeral Nail Technique Guide Preoperative, 3-D CT reconstruction

0x6.001.247_AB 10.10.11 10:57 Seite 11 MultiLoc Proximal Humeral Nail Technique Guide Synthes 11