T2™

Proximal Humeral Nailing System

Operative Technique
Introduction

Contributing Surgeons:

Rupert Beickert, M.D.

Senior Trauma Surgeon, Murnau Trauma Center
Murnau,
Germany

Rosemary Buckle, M.D.

Orthopaedic Associates, LLP, Christus St. Joseph Hospital, Clinical Instructor,
University of Texas, Medical School
Houston, Texas,
USA

Prof. Dr. med. Volker Bühren

Chief of Surgical Services, Medical Director of Murnau Trauma Center
Murnau,
Germany

Joseph D. DiCicco III., D.O.

Director Orthopaedic Trauma Service, Good Samaritan Hospital, Dayton, Ohio
Associate Clinical Professor of Orthopaedic Surgery,
Ohio University and Writght State University,
USA

Carl Ekholm, M.D., Ph.D.

Associate Professor, Senior Trauma Surgeon Orthopaedic Trauma,
Department of Orthopaedic Surgery
Sahlgrenska University Hospital and Gothenburg University
Gothenburg,
Sweden

Anders Jönsson, M.D., Ph.D.

Senior Trauma Surgeon Orthopaedic Trauma,
Department of Orthopeadic Surgery
Sahlgrenska University Hospital and Gothenburg University
Gothenburg,
Sweden

Robert J. Nowinski, D.O.

Assistant Clinical Professor of Orthopaedic Surgery,
Ohio University College of Osteopathic Medicine
Private Practice, Orthopaedic Specialists & Sports Medicine, Inc.
Newark, Ohio,
USA
This publication sets forth detailed
Anthony T. Sorkin, M.D. recommended procedures for
Rockford Orthopaedic Associates, LLP, Clinical Instructor, using Stryker Trauma devices and
Department of Surgery University of Illinois, instruments.
College of Medicine Director,
Orthopaedic Traumatology Reckford Memorial Hospital It offers guidance that you should
Rockford, Illinois, heed, but, as with any such technical
USA guide, each surgeon must consider
the particular needs of each patient
and make appropriate adjustments
when and as required.

A workshop training is required prior

to first surgery.

2
Contents

1. Introduction 4

1.1. Implant Features 4

1.2. Instrument Features 6

2. Indications 7

3. Pre-operative Planning 7

4. Locking Option Examples 8

5. Operative Technique 9

5.1. Patient Positioning 9

5.2. Incision 9

5.3. Entry Point 9

5.4. Nail Selection 12

5.5. Nail Insertion 14

5.6. Proximal Guided Locking 16

5.7. Proximal A/P Locking 20

5.8. Distal Locking 21

5.8.1. Distal Guided Locking (Short PHN) 21

5.8.2. Distal Freehand Locking (Long PHN) 22

5.9. End Cap Insertion 23

5.10. Nail Removal 23

Ordering Information-Implants 24

Ordering Information-Instruments 25

3
Introduction

1. Introduction 1.1. Implant Features

Proximal humeral fractures can To complement the T2™ Nailing However, they can also stabilize the
be difficult to treat, particularly System, Stryker Trauma has created a nail, allowing compression of the
multifragmented fractures in "new generation" humeral implant: surrounding bone against the nail.
osteopenic bone. A large number the T2™ Proximal Humeral Nail for • The Distal Locking Hole configu-
of treatment modalities have been the treatment of complex proximal ration allows for either Static
developed over the years. humeral fractures, and those with or Dynamic Locking Modes.
diaphyseal extension. In the Dynamic Locking mode,
Treatments range from conservative the pull of muscles spanning the
measures such as swathe, to per- Although based on the well-known fracture may be used for secondary
cutanous procedures using pins, T2™ platform, the T2™ Proximal dynamization.
wires and screws onwards to open Humeral Nail design incorporates a • The bend of the nail allows
procedures with plate fixation and number of unique features: insertion at the standard insertion
even joint replacement. point, i.e. lateral entry just inside
• Small diameter intramedullary the Greater Tuberosity, or central
Problems lie in the difficulty of implant that requires only a 10mm insertion, i.e. through the articular
obtaining fixation of one or several entrance hole and minimal canal surface at the top of the humeral
fragments and achieving rotator cuff preparation. head. Central insertion improves
stability to allow early motion. • Left and right versions, designed fixation through interference
Reduction and fixation must be to reduce possible interference with between the subchondral bone at
performed without disturbing the axillary nerve. the entry point and the proximal
the blood supply to the fracture • End Caps, of three different end of the nail.
fragments. heights in 2mm increments, allow • The 6° lateral bend allows insertion
Finally, the implants used should fine adjustment to the length of the of the nail along an almost straight
be low profile so as not interfere nail and optimize the purchase of path. The risk of losing reduction
with surrounding soft tissue or the the nail in the entrance hole. of fragments during insertion is
acromion. Additionally, the risk • Four Proximal Locking Holes thereby minimized.
of implant migration should be strategically placed to enable The nail may be used for percu-
minimized. locking of separate fragments of tanous reduction and insertion,
the Lesser Tuberosity, the Greater or open insertion through a
Tuberosity and the Humeral Head. deltopectoral approach when
• The Proximal Locking Holes in indicated.
the nail are threaded. Thus, the • The long nails (220mm−300mm)
holding strength of the Locking are cannulated and allow reaming
Screws will not depend on purchase of the medullary canal over the
in the often poor cancellous bone. 2.5×800mm Ball Tip Guide Wire
The Locking Screws can also pro- (1806-0083S). The solid nail design
vide firm anchoring for suture of the short nail (150mm) should
augmentation of the Tuberosity not require additional reaming for
fragment. nail insertion.
• The Proximal Locking Holes in the
nail have a nylon bushing. This All implants of the T2™ Proximal
will further improve the holding Humeral System are made from
strength of the screws and helps Type II Anodized Titanium Alloy
avoid screw back out. It also stops (Ti6Al4V) to maximize mechanical
screw toggle, thereby minimizing strength and biocompatibility.
mechanical destruction of osteo-
penic bone. See the detailed chart on the next
• Washers may be used in page for design specification and size
conjunction with the screws for offering.
fixing fragmented tuberosities.

4
Technical Details

Long Nail Short Nail

Nails (left & right) 0

Distal Diameter 8mm*

10° 9.5
Sizes 150mm (Short Nail)
220−300mm (Long Nail) 17

23

Note: 29.5
9°
Screw length is measured
from top of head to tip.

62
Fully Threaded Bend, 6°
Locking Screw**
Length 25−60mm
Diameter 5mm
80

95

101

Fully Threaded
Locking Screw***
Length 20−60mm
Diameter 4mm

Washers
Round:
Diameter 17mm

Square:
Size 10×18mm

36

28.5

21
13.5
Proximal Humerus
End Cap
7.5

standard**** +2mm +4mm 0

* Nail driving end has a diameter of 10mm.

** For Proximal Locking Only
*** For Distal Locking Only
**** standard End Cap is flush with the nail
5
Features

1.2. Instrument Features

The majority of the instruments come from the existing T2™ platform.
A new Targeting Device* has been designed, unique for the T2™
Proximal Humeral Nail.

The instrumentation is characterized

as follows: Nail Holding Screw

• A unique carbonfiber, radiolu-

cent Targeting Device (Fig. 1) Nut, Proximal Humerus
that allows exact placement of
all Proximal Screws, and Distal
Locking Screws of the short nail.
• A K-Wire inserted through the
Targeting Device and aligned
with the forearm indicates the
correct rotational alignment
of the Targeting Device and
Nail. Alignment is based on the
assumption that anatomical
retroversion of the humeral head
Nail Adapter,
is 30°. Proximal Humerus
• A second K-Wire inserted
through the Targeting Device
indicates the exact top end of the
nail to aid achieving the correct
insertion depth.
• A Friction Locking Mechanism
firmly holds the Drill Sleeves in
their required position. The Drill
Sleeves, when locked into the
targeting device, will also help to
stabilize the nail and may tempo-
rarily stabilize fragments during
fixation.
• Calibrated Drill bits give correct
measurements of screw length. Targeting Arm,
• Proximal screw holes are manu- Proximal Humerus

ally drilled. This improves the

surgeons “feel” of the bone.
• Two sets of Tissue Protection
Sleeves and Drill Sleeves provide
the opportunity to temporarily
fix the nail with one set, while
the other set can be used for pla-
cing the first screw.

Fig. 1

6
Indications
2-part 3-part 4-part

Anatomical
2. Indications Neck

The T2™ Proximal Humeral Nail is Surgical

indicated for: Neck

− Two-part fractures of
the proximal humerus Greater
− Three-part fractures of Tuberosity
the proximal humerus
− Four-part fractures of
the proximal humerus
Lesser
− Proximal Humeral Fractures Tuberosity
with diaphyseal extension
(Long PHN only).

Anterior
Fracture
Dislocation
Note:
The most important step before
surgery remains a proper analysis of
the fracture type.

Posterior
NEER Classification

3. Pre-operative Planning

X-Ray Templates are available for

pre-operative planning (Fig. 2 & 3).
• X-Ray Template, Short PHN
(1806-2008)
• X-Ray Template, Long PHN
(1806-2007)

Thorough evaluation of pre-operative Fig. 2

radiographs of the affected Upper
Arm and Shoulder is critical. Careful
radiographic examination of the
Humeral head region may prevent
intra-operative complications.

The proper nail length when inserting

long nails should extend from
subchondral bone proximally, to 1cm
above the olecranon fossa distally.

Fig. 3
7
Indications

4. Locking Option Examples:

T2™ Proximal Humeral Nail

Short Nail

Long Nail

8
Operative Technique

5. Operative Technique
5.1. Patient Positioning and Fracture Reduction

The patient is placed semi-reclined

in the “beach chair position” or
supine on a radiolucent table. Patient
positioning should be checked to
ensure that imaging and access to
the entry site are possible without
excessive manipulation of the affected
extremity (Fig. 4).

Note:
Closed reduction by ”Joystick-tech-
nique” with K-wires to manipulate
fragments can be used.

If closed reduction was not successful,

open reduction should be performed. Fig. 4

5.2. Incision

A small incision is made in line with

the fibers of the deltoid muscle antero-
lateral to the acromion. The deltoid
is split to expose the subdeltoid bursa
(Fig. 5). The supraspinatus tendon is
then incised in line with its fibers.

5.3. Entry Point

To indicate the exact entry point

before incising the supraspinatus
tendon, a K-Wire (1806-0050S) can
be placed through the tendon into the Fig. 5
bone at the expected entry point
(Fig. 6): Confirmation should be made
with the image intensifier, in both lat-
eral and A/P views.

The T2 Proximal Humeral Nail is

designed to be inserted either through
a lateral (A) or a central (B) entry B
point (Fig. 6).
A
The lateral entry point (A) is located
just inside the Greater Tuberosity (as
seen on the A/P view) and aligned
with the humeral axis (as seen on the
lateral view). Verify with the image
intensifier.

The central entry point (B) is located

at the very top of the humeral head, in Fig. 6
the articular surface, in line with the
humeral axis (in both A/P and lateral
views).
9
Operative Technique

5.3. Entry Point (continued)

Note:
If the greater tuberosity is fractured
or compromised, the central entry
point is recommended to achieve
stability between the humeral head
fragment and the proximal end of
the nail.

The entry point is made with the

cannulated 10mm Awl, Straight
(1806-0045) or by using the Small
K-Wire (1806-0050) with the Guide
Wire Handle (1806-0095)
(Fig. 7a, b, c). Image intensification
is required to identify the correct
entry point. The proximal metaphysis
should be reamed with the Rigid
Reamer, 10mm (1806-2010) through
the Rigid Reamer Sleeve, 10mm
(1806-0410).
Fig. 7a

Alternatively, the optional Crown

Drill (1806-2020) may be used
over the K-Wire for entry portal
preparation. If the Rigid Reamer or
Crown Drill cannot be used because
of the fracture pattern or poor bone
quality, use the 10mm Awl, Straight
to prepare the proximal metaphysis.

Note:
During opening of the entry portal
with the Awl, dense cortex may
block the tip of the Awl. An Awl Plug
(1806-0032) can be inserted through
the Awl to avoid penetration of bone
debris into the cannulation of the
Awl shaft. Fig. 7b

Further reaming is not necessary

with the Short PHN. The nail may be
inserted directly.

Fig. 7c

10
Operative Technique

Reamed Technique
(Long PHN):

For insertion of the Long PHN,

reaming of the medullary canal may
be necessary.

For reamed techniques, the

2.5×800mm Ball Tip Guide Wire
(1806-0083S) is inserted across the
fracture site. The optional Reduction
Rod (1806-0363), or the Universal
Fig. 8
Rod, Short with the optional
Reduction Spoon (1806-0125), may
be used as a fracture reduction tool to
facilitate guide wire insertion across
the fracture site (Fig. 8).

Reaming is commenced in 0.5mm

increments. Final reaming should be
1mm−1.5mm larger than the diameter
of the nail to be used (Fig. 9).

When reaming is completed, the

Teflon Tube (1806-0073S) should be
used to exchange the Ball Tip Guide
Wire (1806-0083S) with the Smooth
Tip Guide Wire (1806-0093S) for nail
insertion (Fig. 10).

An unreamed technique can be

considered in cases, where the
medullary canal has the appropriate Fig. 9
diameter. In these cases, the nail can
be introduced over the 2.2×800mm
Smooth Tip Guide Wire (1806-
0093S).

Note:
X-Ray Templates should be used
pre-operatively to determine the canal
size radiographically.

Fig. 10

11
Operative Technique

5.4. Nail Selection

The T2™ PHN is available in left and

right, short and long.
Ø10mm

Diameter
Both the Short and the Long version
have a proximal diameter of 10mm
and a shaft diameter of 8mm (Fig. 11).

Length
The Short PHN is available in 150mm
length only. The Long PHN are
available in five different lengths
(220−300mm).

The proper nail length when inserting

long nails should extend from
subchondral bone proximally, to 1cm
above the olecranon fossa distally.

Ø10mm

Ø8mm

Ø8mm

Short Nail Long Nail

Fig. 11

12
Operative Technique

The Guide Wire Ruler (1806-0020)

may be used by placing it on the Guide
Wire and reading the correct nail
length at the end of the Guide Wire on
the Guide Wire Ruler (Fig. 12 & 13).

Confirm the position of the tip of the

Guide Wire prior to measurement.

End of Guide Wire Ruler

equals Measurement Reference

Fig. 12

Fig. 13

13
Operative Technique

5.5. Nail Insertion

The selected nail is attached to the

Nail Adapter (1806-2025) until its
three connection teeth engage into the
corresponding slots of the Nail
(Fig. 14).

The Nail Holding Screw (1806-0163)

is placed through the Nail Adapter,
and tightened securely with the 2mm
Insertion Wrench (1806-0135) or 5mm

Wrench 8/10mm (1806-0130) to avoid

loosening during Nail insertion.
Fig. 14
Engravings on the Nail Adapter will
indicate lateral and medial direction
(Fig. 15).

Fig. 15

Fig. 16

Note: Note:
Two circumferential grooves are The Strike Plate (1806-0150)
located on the insertion post at 2mm (Fig. 16) or the Short Universal Rod
and 5mm from the driving end of (1806-0113) may be used to improve
the nail (Fig. 14). Depth of insertion handling during insertion. These
may be visualized with the aid of are screwed into the Nail Holding
fluoroscopy. Screw and have to be removed if the
Targeting Arm (1806-2035) is to be
mounted after introduction of the
nail.

14
Operative Technique

Alternatively, the Targeting Arm is

assembled onto the Nail Adapter with
the Nut (1806-2030) (Fig. 17a). Hand
tighten the Nut so that it does not
loosen during nail insertion.

Note:
Before inserting the nail, verify
that the assembly is locked in the
appropriate position: the smaller
peg of the Nail Adapter engaged into
the smaller slot of the Targeting small large
Arm indicated by the ”LATERAL
Locking” sign (Fig. 17a) and the
larger peg into the larger slot on the
Fig. 17a Fig. 17b
opposite side (Fig. 17b).

Note:
Prior to nail insertion please check Tip Guide Wire. The Short PHN is Note:
correct alignment by inserting a drill solid and can be inserted directly. Do not hit the Targeting Device
bit through the assembled Tissue Advance it through the entry point and/or the Nail Holding Screw.
Protection - and Drill Sleeve placed (Fig. 19).
in the required holes of the targeting The nail should be advanced with Note:
device (Fig. 18). manual pressure. Aggressiveness The nail should be inserted at least
can result in additional fractures or up to the first circumferential
The nail is ready for insertion. The fragment displacements. If the nail groove on the Nail Adapter but not
Long PHN is cannulated and can be does not advance easily, use the image deeper than the second groove.
inserted over the 2.2×800mm Smooth intensifier to identify the problem.

Fig. 18 Fig. 19

15
Operative Technique

5.6. Proximal Guided Locking

Fig. 20 Fig. 21

Prior to guided locking via the Target

Device, the Nail Holding Screw and
the Nut must be firmly tightened K-Wire
to ensure that the nail is in correct (A/P Direction)
alignment with the Targeting Device
(Fig. 20).

Remove the Strike Plate if used.

Withdraw the guide wire if used
(Long PHN).

Two sets of Tissue Protection Sleeves,

Drill Sleeves and Trocars can be used
at the same time. The tight fit of the
friction lock mechanism provides the
opportunity to temporarily stabilize
the nail and the fragment with one
set, while using the second to perform
locking.

Note:
A K-Wire placed through the Target-
ing Device and aligned with the
forearm indicates anatomical 30°
retroversion of the humeral head
(Fig. 21).

Note: Tar
g et in
Prior to proximal locking of the Long gA
rm
Pl a
PHN, ensure correct alignment of ne
the distal holes as these are locked
by freehand technique. The K-Wire
placed through the targeting device
is in the same plane as the AP locking
Obl
holes at the nail tip whereas the plane iqu
eh
ol es
of the targeting arm is the same for
the distal Oblique holes (Fig. 22).

Fig. 22

A/P holes
16
Operative Technique

Except for the A/P Proximal Locking

Screw, all of the Proximal and Distal
Locking procedure (Short PHN only)
can be performed without changing
position of the Targeting Arm.

Note:
For the use of an A/P Locking Screw
see Chapter 5.7.

Note:
Ensure correct rotational alignment
of the nail prior to proximal locking,
to avoid penetration of the biceps
tendon with the proximal anterior
screw.

The Short Tissue Protection Sleeve

(1806-0180) together with the Short
Drill Sleeve (1806-0210) and the Short
Trocar (1806-0310) are inserted into
the Targeting Arm by pressing the
Safety Clip (Fig. 23a & b).

The friction locking mechanism is Fig. 23a

designed to keep the sleeve in place. It
will also stop the sleeve from sliding
during screw measurement. To release
the Tissue Protection Sleeve, the Safety
Clip must be pressed again. Locked
Released

Fig. 23b

17
Operative Technique

5.6. Proximal Guided Locking (continued)

The Trocar is removed, while the

Tissue Protection Sleeve and the
Drill Sleeve remain in position. The
T-Handle (702427) is assembled with
the 3.5×230mm Drill (1806-3540S).
Drilling is preferably done manually
to improve feel of resistance in soft
3,5mm
bone. The Drill is forwarded through
the Drill Sleeve and pushed onto the
cortex (Fig. 24).

Advance the Drill until it is in con-

tact with the subchondral bone. The
appropriate screw length may be read
directly off of the Drill at the end of
the Drill Sleeve (Fig. 24).

50mm

Fig. 24

Note:
Do not drill through the far cortex as
this will penetrate the joint.
The position of the Drill tip placed
in the subchondral bone is equal to
where the end of the screw will be.

Note:
The Locking Screw length determi-
nation is very important and must be 5mm
carried out carefully.

In cases with dense bone, the cortex

of the proximal locking holes may be
opened with the 5.0×180mm Drill
(1806-5010S).

Note:
Drill the lateral cortex only. In cases
where the nail is inserted close to the
lateral cortex, manual drilling will
help to avoid nail contact.

Fig. 25

18
Operative Technique

When the Drill Sleeve is removed,

the correct 5.0mm Fully Threaded
Locking Screw is inserted through
the Tissue Protection Sleeve using the
Screwdriver Shaft Short (1806-0224)
with the Teardrop Handle (702429)
(Fig. 26).

Note:
In order to optimize screw insertion
in the threaded screw hole, push
the Locking Screw without turning
through the first cortex until it is
in contact with the nail. Then start
turning the Locking Screw with gentle
axial pressure to engage the internal
thread of the nail. In cases with
dense bone where the screw cannot be
pushed forward, the lateral cortex may
be opened with the 5.0×180mm Drill
to ease screw insertion as described
above. Fig. 26

Note:
To avoid loss of reduction or position
of the nail when the Drill is removed,
you may leave the first Drill in the
bone. Then, using the second set of
Sleeves, drill the second hole and
insert this screw while the nail is Fig. 27
stabilized by the first Drill.

The Locking Screw is near its proper

seating position when the groove
around the shaft of the Screwdriver
is approaching the end of the Tissue
Protection Sleeve (Fig. 27).

Note:
Fluoroscopic visualisation during
Locking Screw insertion is absolutely
necessary to place the tip of the
Locking Screw in the subchondral
bone, to stabilize the head fragment
and avoid penetration of the Locking
Screw into the articular surface.

Note:
In four-part fractures, the role of
the first Proximal Screw is to obtain
fixation of the Head Fragment and
not of the Greater Tuberosity.

Repeat the locking procedure for all

lateral Proximal Locking Screws
(Fig. 28). Fig. 28
19
Operative Technique

5.6. Proximal Guided Locking (continued)

A Washer, either Rectangular or

Round, is available for patients with
osteoporotic bones. They can be used
in conjunction with a screw for fixing
fragmented tuberosities. However, they
can also be used to stabilize the nail,
allowing compression of the surround-
ing bone against the nail.

Note:
Do not use a Washer with the most
Proximal Locking Screw as it may
cause Acromial impingement.

5.7. Proximal A/P Locking

Note:
The A/P Screw is designed to fix the
Lesser Tuberosity. If an A/P Screw is
inserted, it is recommended to per-
form the A/P Screw locking after all
other required screws are inserted.

To place the A/P Locking Screw,

the Targeting Arm must be rotated.
The Nut must be released with four
complete turns. Pull-up the Targeting Fig. 29
Arm and turn it anteriorly around the
Nail Adapter (Fig. 29). Push down the
Targeting Arm and lock the system in
the appropriate position indicated on
the Targeting Arm (Fig. 30a).

For the left nail, the larger peg of the (For the right nail, the smaller peg Hand tighten the Nut to ensure it does
Nail Adapter engages into the larger must be engaged into the smaller slot, not loosen during locking procedure.
slot indicated by the ”AP locking left” indicated by the ”AP Locking right”
sign (Fig. 30a) and the smaller peg into sign and the larger peg into the oppo- Routine locking procedure is
the opposite smaller slot (Fig. 30b). site larger slot.) performed as described in Chapter 5.6.

Fig. 30a Fig. 30b

20
Operative Technique

5.8 Distal Locking

5.8.1. Distal Guided Locking (Short PHN only)

The Targeting Device is designed to

provide two Distal Locking Options;
Static Mode or Dynamic Mode.

For Static Locking Mode, two Distal

Locking Screws should be used (round
and oblong hole).

The Short Tissue Protection Sleeve

together with the Short Drill Sleeve
and the Short Trocar are inserted into
the Targeting Arm in the static hole.

A small skin incision is made and the

assembly is pushed through until it is
in contact with the lateral cortex.

The Trocar is removed, while the

Tissue Protection Sleeve and the Drill
Sleeve remain in position.

After drilling both cortices with the

calibrated 3.5×230mm Drill (1806-
3540S), the screw length may be read
Fig. 31
directly off of the calibrated Drill at
the end of the Drill Sleeve.

Alternatively, after removal of the Drill

Sleeve, the Screw Gauge, Short (1806-
0330) can be used for screw length
measurement.

A 4mm Locking Screw is inserted with

the assembled Short Screwdriver Shaft
and the Teardrop Handle.

For the second distal Locking Screw,

routine Screw insertion is employed
using the dynamic hole on the
Targeting Arm.

Note:
The dynamic hole on the Targeting
Arm will allow placement of the
Locking Screw in a Dynamic Locking
Mode (at the bottom of the oblong
hole) (Fig. 31).

Depending on the fracture type,

secondary dynamization can be
achieved by extracting the static distal
Locking Screw (round hole) (Fig. 32).
Fig. 32

21
Operative Technique

5.8.2. Distal Freehand Locking (Long PHN only)

Note:
Never use the the distal holes (Static/
Dynamic) of the Targeting Device.
There are no corresponding holes in
the Long PHN.

The freehand technique is used to

insert Locking Screws into both the
A/P and Oblique holes in the nail. Fig. 33
Rotational alignment must be checked
prior to distal locking.

Multiple locking techniques and radio-

lucent drill devices are available for
freehand locking. The critical step
with any freehand locking technique,
proximal or distal, is to visualize a
perfectly round locking hole with the
C-Arm.

Note:
In order to avoid damage to the Fig. 34
neurovascular structure, a limited
open approach should be considered.

Note:
Leaving the targeting device attached
can facilitate the freehand locking
procedure. The K-Wire placed
through the targeting device is in the
same plane as the AP locking holes
at the nail tip whereas the plane of
the targeting arm is the same for the
distal Oblique holes (Fig. 22, p. 16).
Fig. 35a
The Ø3.5 × 130mm Drill (1806-3550S)
is held at an oblique angle to the center
of the locking hole (Fig. 33, 34). Upon 35mm

X-Ray verification, the Drill is placed

perpendicular to the nail and drilled
through the anterior cortex. Confirm
these views in both the A/P and M/L
planes by X-Ray.

After drilling both cortices, the screw

length may be read directly off of the
Screw Scale, Short (1806-0360) at the Fig. 35b

orange color coded ring on the center-

tipped Drill (Fig. 35a & b). As with
proximal locking, 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 Shaft and the Teardrop
Handle. Fig. 36
22
Operative Technique

Note:
The A/P oblong hole (Long PHN)
in the nail tip will allow placement
of the Locking Screw in a Dynamic
Locking Mode (at the bottom of the
oblong hole).

If possible, the Long PHN should

be locked distally with two
Fully Threaded Locking Screws.
Additional locking of the Oblique
hole(s) is possible if the image
intensifier can be adjusted (Fig. 36).
Fig. 37

Note:
Use image intensification to confirm
screw position through the nail as
well as screw length.

standard +2mm +4mm

Fig. 38

5.9. End Cap Insertion 5.10. Nail Removal

After removal of the Targeting Device, Nail removal is an elective procedure.

an End Cap may be inserted. End Caps The End Cap, if used, and the most
are available in three sizes. proximal Locking Screw are removed
with the Screwdriver Shaft, Short and
The End Cap is inserted with the the Teardrop Handle.
Screwdriver Shaft, Short assembled on
the Teardrop Handle (Fig. 37). Fully Note:
seat the End Cap to minimize the risk Attaching the Universal Rod, Short
of loosening. to the nail before removal of all other
Locking Screws, will prevent nail
The End Cap may be used to: migration.
− Lock and stabilize the Proximal
Locking Screw. The Short Universal Rod is inserted
− Adjust the height of the nail for into the driving end of the nail. All
optimal purchase of the nail at the Locking Screws are removed with
entry point. the Short Screwdriver Shaft and the
Teardrop Handle (Fig. 38).
Note:
To avoid impingement, carefully The nail may then be removed with
select the length of the End Cap. the Slotted Hammer (Fig. 39).

Close the wound using standard

technique.

Fig. 39
23
Ordering Information - Implants

T2 Proximal Humerus Nail 4mm Fully Threaded Locking Screws*

REF Description REF Diameter Length

mm mm
1832-1025S T2™ Proximal Humeral Nail,
left (8×150mm) 1896-4020S 4.0 20
1832-1015S T2™ Proximal Humeral Nail, 1896-4022S 4.0 22
right (8×150mm) 1896-4024S 4.0 24
1896-4025S 4.0 25
1832-3822S T2 Proximal Humerus Nail long, 1896-4026S 4.0 26
right (8×220mm) 1896-4028S 4.0 28
1832-3824S T2 Proximal Humerus Nail long, 1896-4030S 4.0 30
right (8×240mm) 1896-4032S 4.0 32
1832-3826S T2 Proximal Humerus Nail long, 1896-4034S 4.0 34
right (8×260mm) 1896-4035S 4.0 35
1832-3828S T2 Proximal Humerus Nail long, 1896-4036S 4.0 36
right (8×280mm) 1896-4038S 4.0 38
1832-3830S T2 Proximal Humerus Nail long, 1896-4040S 4.0 40
right (8×300mm) 1896-4045S 4.0 45
short
1896-4050S 4.0 50
version 1832-2822S T2 Proximal Humerus Nail long, 1896-4055S 4.0 55
left (8×220mm) 1896-4060S 4.0 60
1832-2824S T2 Proximal Humerus Nail long,
left (8×240mm)
1832-2826S T2 Proximal Humerus Nail long,
left (8×260mm)
1832-2828S T2 Proximal Humerus Nail long,
left (8×280mm)
1832-2830S T2 Proximal Humerus Nail long,
long left (8×300mm)
version

End Caps 5mm Fully Threaded Locking Screws*

REF Diameter Length REF Diameter Length
mm mm mm mm
1832-0003S ø6 standard 1896-5025S 5.0 25.0
standard 1832-0002S ø10 +2 1896-5027S 5.0 27.5
1832-0004S ø10 +4 1896-5030S 5.0 30.0
1896-5032S 5.0 32.5
1896-5035S 5.0 35.0
+2mm
1896-5037S 5.0 37.5
1896-5040S 5.0 40.0
1896-5042S 5.0 42.5
1896-5045S 5.0 45.0
+4mm 1896-5047S 5.0 47.5
1896-5050S 5.0 50.0
1896-5052S 5.0 52.5
1896-5055S 5.0 55.0
1896-5057S 5.0 57.5
1896-5060S 5.0 60.0
Washer

REF Description Diameter×

Length
mm
1830-0008S Washer, round ø17.0
round 1830-0009S Washer, square 10×18

square

Note:
Implants in sterile packaging

* Outside of the U.S., Locking Screws may be

ordered non-sterile without the “S” at the end of
the corresponding Reference Number.

24
Ordering Information - Instruments

REF Description REF Description

Standard Instruments Optional Instruments

702427 T-Handle, AO Coupling 1806-0032 Awl Plug

702429 Teardrop Handle, AO Coupling 1806-0125 Reduction Spoon

1806-0020 Guide Wire Ruler 1806-0363 Reduction Rod, ø7mm

1806-0045 Awl, Straight 1806-2020 Crown Drill

1806-0050S K-Wire, ø3×285mm (2×)

1806-0073S Teflon Tube

1806-0083S Guide Wire, Ball Tip, ø2.5×800mm

1806-0093S Guide Wire, Smooth Tip, ø2.2×800mm

1806-0095 Guide Wire Handle

1806-0096 Guide Wire Handle Chuck

1806-0113 Universal Rod, Short

1806-0130 Wrench, 8mm/10mm

1806-0135 Insertion Wrench, 10mm

1806-0150 Strike Plate

1806-0163 Nail Holding Screw, Humerus

1806-0180 Tissue Protection Sleeve, Short (2×)

1806-0210 Drill Sleeve, Short (2×)

1806-0224 Screwdriver Shaft AO, Short

1806-0237 Screwdriver Short

1806-0310 Trocar, Short (2×)

1806-0330 Screw Gauge, Short

1806-0360 Screw Scale, Short

1806-0390 Depth Gauge, Standard Style

for freehand locking (20−60mm)

1806-0410 Rigid Reamer Sleeve, 10mm

1806-0411 Rigid Reamer Trocar, 10mm

1806-2010 Rigid Reamer, 10mm

1806-2000 Targeting Device,

Proximal Humerus, complete

1806-2025 Nail Adapter, Proximal Humerus

1806-2030 Nut, Proximal Humerus

1806-2035 Targeting Arm, Proximal Humerus

1806-3540S Drill ø3.5×230mm, AO (2×) Note:

Federal law (U.S.A) restricts this device
1806-3550S Drill ø3.5×130mm, AO (2×)
to sale by or on the order of a licensed
1806-5010S Drill ø5×180mm, AO (2×) physician.
1806-2007 X-Ray Template (Long PHN)
Note:
1806-2008 X-Ray Template (Short PHN) Outside of the U.S., instruments may be
ordered non-sterile without the “S” at
1806-9300 T2 PHN Dedicated Instrument Tray
the end of the corresponding Reference
1806-9310 T2 PHN Add-On Instrument Tray Number.

25
Ordering Information - Instruments

Bixcut™ Complete range of modular and

fixed-head reamers to match sur-
geon preference and optimize
O. R. efficiency, presented in fully
sterilizable cases.

Large clearance rate resulting from reduced number

of reamer blades coupled with reduced length of
reamer head to give effective relief of pressure and
efficient removal of material.

Cutting flute geometry optimized to lower pressure

generation.

Forward- and side-cutting face combination produces

efficient material removal and rapid clearance.

Double-wound shaft transmits torque effectively and

with high reliability. Low-friction surface finish aids
rapid debris clearance.

Smaller, 6 and 8mm shaft diameters significantly

reduce IM pressure.

Typical Standard Bixcut™

Reamer Ø14mm Reamer Ø14mm
Recent studies1 have demonstrated
that the pressures developed within
the medullary cavity through the
introduction of unreamed IMnails
can be far greater than those devel-
oped during reaming − but this
depends very much upon the design
Clearance area : Clearance area : of the reamer.
32% of cross section 59% of cross section
After a three year development study2
involving several universities, the
factors that determine the pressures
and temperatures developed during
reaming were clearly established.
These factors were applied to the de-
velopment of advanced reamers that
demonstrate significantly better per-
formance than the best of previous
designs.

1
Jan Paul M. Frolke, et al. ;
Bixcut™ Intramedullary Pressure in Reamed Femoral
Nailing with Two Different Reamer Designs.,
Eur. J. of Trauma, 2001 #5

2
Mehdi Mousavi, et al.;
Pressure Changes During Reaming with Different
Parameters and Reamer Designs,
Clinical Orthopaedics and Related Research
Number 373, pp. 295−303, 2000

26
Ordering Information - Instruments

Bixcut™ Modular Head Bixcut™ Fixed Head − AO fitting

REF Description Diameter REF Diameter Length

mm mm mm

0226-3090 Bixcut Head 9.0 0225-5060 6.0* 400

0226-3095 Bixcut Head 9.5 0225-5065 6.5* 400
0226-3100 Bixcut Head 10.0 0225-5070 7.0* 400
0226-3105 Bixcut Head 10.5 0225-6075 7.5 480
0226-3110 Bixcut Head 11.0 0225-6080 8.0 480
0226-3115 Bixcut Head 11.5 0225-6085 8.5 480
0226-3120 Bixcut Head 12.0 0225-6090 9.0 480
0226-3125 Bixcut Head 12.5 0225-6095 9.5 480
0226-3130 Bixcut Head 13.0 0225-6100 10.0 480
0226-3135 Bixcut Head 13.5 0225-6105 10.5 480
0226-3140 Bixcut Head 14.0 0225-6110 11.0 480
0226-3145 Bixcut Head 14.5 0225-8115 11.5 480
0226-3150 Bixcut Head 15.0 0225-8120 12.0 480
0226-3155 Bixcut Head 15.5 0225-8125 12.5 480
0226-3160 Bixcut Head 16.0 0225-8130 13.0 480
0226-3165 Bixcut Head 16.5 0225-8135 13.5 480
0226-3170 Bixcut Head 17.0 0225-8140 14.0 480
0226-3175 Bixcut Head 17.5 0225-8145 14.5 480
0226-3180 Bixcut Head 18.0 0225-8150 15.0 480
0226-4185 Bixcut Head 18.5 0225-8155 15.5 480
0226-4190 Bixcut Head 19.0 0225-8160 16.0 480
0226-4195 Bixcut Head 19.5 0225-8165 16.5 480
0226-4200 Bixcut Head 20.0 0225-8170 17.0 480
0226-4205 Bixcut Head 20.5 0225-8175 17.5 480
0226-4210 Bixcut Head 21.0 0225-8180 18.0 480
0226-4215 Bixcut Head 21.5
0226-4220 Bixcut Head 22.0
0226-4225 Bixcut Head 22.5
0226-4230 Bixcut Head 23.0
0226-4235 Bixcut Head 23.5 Bixcut™ Fixed Head − Modified Trinkle fitting +
0226-4240 Bixcut Head 24.0
0226-4245 Bixcut Head 24.5 REF Diameter Length
0226-4250 Bixcut Head 25.0 mm mm
0226-4255 Bixcut Head 25.5
0226-4260 Bixcut Head 26.0 0227-5060 6.0* 400
0226-4265 Bixcut Head 26.5 0227-5065 6.5* 400
0226-4270 Bixcut Head 27.0 0227-5070 7.0* 400
0226-4275 Bixcut Head 27.5 0227-6075 7.5 480
0226-4280 Bixcut Head 28.0 0227-6080 8.0 480
0227-6085 8.5 480
0227-6090 9.0 480
0227-6095 9.5 480
Bixcut™ Shaft − AO fitting 0227-6100 10.0 480
0227-6105 10.5 480
REF Description Length 0227-6110 11.0 480
mm 0227-8115 11.5 480
0227-8120 12.0 480
0226-3000 Shaft, AO 450 0227-8125 12.5 480
0226-8240 Shaft, AO 240 0227-8130 13.0 480
0227-8135 13.5 480
0227-8140 14.0 480
0227-8145 14.5 480
Bixcut™ Shaft − Modified Trinkle fitting (sterile) 0227-8150 15.0 480
0227-8155 15.5 480
REF Description Length 0227-8160 16.0 480
mm 0227-8165 16.5 480
0227-8170 17.0 480
0227-3000(S) Shaft, Mod. Trinkle 450 0227-8175 17.5 480
0227-8240(S) Shaft, Mod. Trinkle + 240 0227-8180 18.0 480

Bixcut™ Trays +
Use with Stryker Power Equipment
REF Description * Use with 2.2mm×800mm Smooth Tip and
2.5mm×800mm Ball Tip Guide wires only.

0225-6000 Tray, Modular Head

(up to size 22.0mm) Note:
0225-6001 Tray, Modular Head Federal law (U.S.A) restricts this
(up to size 28.0mm)
0225-8000 Tray, Fixed Head device to sale by or on the order
(up to size 18.0mm) of a licensed physician.

27
 Stryker Trauma GmbH
Prof.-Küntscher-Strasse 1-5
D-24232 Schönkirchen
Germany

www.trauma.stryker.com

The information presented in this brochure is intended to demonstrate a Stryker product. Always refer to the package
insert, product label and/or user instructions before using any Stryker product. Products may not be available in all
markets. Product availability is subject to the regulatory or medical practices that govern individual markets. Please
contact your Stryker representative if you have questions about the availability of Stryker products in your area.

Products referenced with ™ designation are trademarks of Stryker.

Products referenced with ® designation are registered trademarks of Stryker.

Literature Number : B1000009

LOT D5004

Copyright © 2004 Stryker

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