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We
detail below the three installation's
methods of short Telegraph nail
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The
are three methods for fitting the
Télégraph nail, depending on
fracture complexity :
-
percutaneous method
- the
standard technique
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Ball-and-socket principle
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The
percutaneous method
This
technique is recommended in two-fragment
fracture cases, or fractures with three
little dislocated fragments or some
fractures with four impacted fragments.
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It
is increasingly used and accounts for over
half our cases. One requirement of this
technique is prior reduction, either by
external manoeuvring or percutaneous,
using a spatula or punch. When the
reduction is achieved and controlled on
the amplifier, the entry point is marked.
A short pre-acromion incision a little
over one centimetre is used to introduce
the square point and the proximal reamer
and lastly, the nail with its nail holder.
The amplifier controls the nail position
ad height. There only remains to put both
proximal front screws in place, always
using a percutaneous technique and a
convenient soft section retractor supplied
in the ancillary equipment. Distal locking
is an option..
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These
three Telegraph nail-fitting techniques
are used to treat all proximal humerus
fractures.
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The
standard technique
This
technique is recommended for fracture with
3 and 4 dislocated fragments. .
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Two points are
vital : the installation and the
antero-external approach.
The
patient is in a half-sitting position, the
shoulder stump protrudes from the external
edge of the table, the arm is in a 25
° retro-pulsion in relationship to
the thorax, and is held by the forearm,
which rests on an arm-rest.
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INSTALLATION
: The patient is in a half-sitting
position at 45 ° in relationship to
the horizontal, the arm is in a 25 °
- 30 ° retro-pulsion position. The
forearm rests on an armrest. The
brilliance amplifier is ahead, and the
shoulder stump fully protrudes from the
table.
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The
antero-external approach includes and
incision and the creation of the
trapezo-deltoidian digastric.
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INCISION
:
It is 8 cm long, overlapping the AAEA, one
third proximal,
two thirds distal
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The
incision measures 8 to 10 cm. It is
centred by the antero-external angle of
the acromion, 1/3 proximal, 2/3 distal. It
is directed in the direction of the
deltoid fibres and measures 8 to 10 cm.
The trapezo-deltoïdian digastric is
created by dissecting between medium
deltoid and front deltoid. The digastric
is reclined towards the front, taking the
acromio-coracoidian ligament to the front
edge of the acromion. The approach is
direct on the various fragments,
especially on tuberosities. It is the
approach way of the rotator caps.
Fragment
reduction is carried out using a spatula,
a Lambotte hook, or external manoeuvring,
using he arm or forearm.
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TRAPEZO-DELTOIDIAN
DIGASTRIC :
The deltoid is divided in the direction of
its fibres between the medium third and
the front third. The acromion periosteum
is cut up to a few trapezoid fibres
towards the top. The front periosteum
detachment takes the acromio-coracoidian
ligament.
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The
nail entry hole is identified with the
brilliance amplifier. It has to be located
at the top of the humerus head, therefore
in the articular area. The entry hole is
done using one or two square points and a
proximal boring.
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The entry hole has to be located at the
top of the reduced humerus head in the
articular area.
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The nail is then lowered with its nail
holder. The smallest diameter is used,
except in the event of a wide diaphysis
canal. The descent height is controlled by
the amplifier. The nail should be
positioned at least half a centimetre
lower than the upper bony section of the
humerus head (amplifier control).
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Nail introduction
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The
proximal locking is done as usual with the
nail holder viewfinder. Both front screws
are used to stabilise the large tuberosity
and the humerus head. The double aiming
prevents going the wrong way.
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Front proximal locking (Double
aiming)
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Sagittal
screws are not fitted a lot in our
practice. It is fitted using an ancillary
system extension.
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Sagittal proximal locking (view from
above)
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Distal
locking is not mandatory. It is done with
one or two front screws on the deltoidian
V, fitted using the nail-holder
viewfinder. At this level, because of bone
resistance, tapping is necessary.
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A
last check is done using the brilliance
amplifier to make sure that no equipment
protrudes (too long screws).
Closing
is very simply done as usual. Owing to the
trapezo-deltoïdian digastric, there
are no muscle-bone stitches and early
mobilisation is possible.
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The
most frequent assembly : the TELEGRAPH
nail with two front proximal screws
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The
crucifixion technique
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Ball-and-socket
principle
This
technique is used for highly dislocated,
complex, 4 or 3 fragment fractures, where
a shoulder prosthesis is usually required.
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The
fitting and surgical approach are the same
as the standard technique. The difference
lies in the fact that the fragments are
not reduced. The nail is fitted with its
nail-holder. It is distally locked by two
screws or one, using the nail-holder. The
proper height is found by adjusting the
most distal proximal hole above the
internal metaphysis cortical of the distal
fragment. Indeed, this cortical is always
free of 4 or 3 fragment fracture and
represents the exact junction between the
internal articular area of the head and
the metaphysis area.
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The
nail is introduced in the diaphysis and
distally locked at 10 cm
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The
nail-holder viewfinder is then removed.
The next steps consists in reducing the
humerus head fragment, also using a hook
or spatula or even Museux pliers. The head
is put in place directly on the free
proximal section of the nail. It may be
necessary to remove some spongy matter, to
allow the head to grip the end of the
nail. The head is then screw directly in
the nail using one or two screws, which
will merge into the bone.
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The
viewfinder is removed. Reduction and
stabilisation of the humerus head by one
or two self-stable screws.
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The
last step consists in reducing any
tuberosity, which will have been
previously marked on threads. Tuberosities
are osteo-stitched to the head, to one
another, to the nail and to the proximal
section of the diaphysis, as is
recommended with traumatic shoulder
prosthesis.
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Tuberosity osteo-stitches
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Another
option consists in putting in place
tuberosity osteo-synthesis screws, but
this technique is not used much in our
practice, as it requires putting the nail
holder back in place by crossing the
humerus head.
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These
three techniques for positioning the
Telegraph nail make it possible to treat
all proximal humeral fractures.
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Technical
surgery
