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Supine with Cardiac board extension for arm

Draw sheet rolled, placed between scapulae
Make sure anesthesia tapes the ET tube to the opposite side, have them move all of their chest
leads away from prep area
Bring patient to the edge of the table, rotate 90 deg
Drape with 1015 coming from top-down, from hairline to nipple to midline
Prep the entire hand in
Down sheet over body, sticky blues, splints, stocking to elbow and large coban.
Ioban around edges of splits, with thicker over armpit
C-arm to come in from head of patient
Mark landmarks ant/post clavicle, AC joint, Acromion, soft V of Nevasier, coracoid process
Draw incision from sup edge of coracoid, extending 10-15cm distally toward lateral condyle of
elbow, when held in neutral position feel for DP groove, center incision over this.
Make incision SUPERFICIAL just through the dermis, then use tonsil to begin dissecting with
assistant using bovie.
Use self-retainers from above and below in early stages to put tension on soft tissue. Bovie
down to look for fat stripe/cephalic v.
Once you identify the interval and the vein, can take it either medial or lateral lateral is
generally preferred because it has many perforators to the deltoid
Use debakeys to grab any perforators to coagulate
Pick a side, and develop the plane with the tonsil
Once developed, use your finger to define the sub-deltoid space you want to get all the way
around the humeral head to the CA ligament and inferior to the deltoid insertion.
Place the deltoid retractor make sure the patient is RELAXED
May release part of the proximal deltoid insertion if needed, as well as superior aspect of the
Pec Major leave 5-10mm of insertion cuff to repair at end of case
Can make incision in clavipectoral fascia, just lateral to conjoined tendon, place Covell retractor
under this and under deltoid dont want to pull too hard on conjoined tendon (Msk nerve)
Identify bursa on top of rotator cuff and remove with rongeur/bove remove superior aspect to
the rolled border of the CA ligaement obviously DO NOT go deep to get the cuff, better to
leave some bursa
Use #5 Ticron sutures to grab most posterior aspect of rotator cuff (Infra) take as big of bites
as possible from leading edge to medial aspect, then take bite to insertion edge again, forming a
U (3mm apart), then cut needle and use hemostat
Place 4 sutures through cuff to enable you to mobilize the cuff/GT fx
Identify the long head biceps tendon (LHBT) insertion dont grab this or CA ligament with your
cuff sutures
Clean fracture sites and mobilize, irrigate (use pituitary, dental pick, K-rongeur)
Reduce using small Weber clamps
Hold in place using 2-0 K-wires (fluoro reduction)

Fit plate to fracture, should be approx. 5mm inf to RC and lateral to LHBT
Hold plate in place using .016 k-wire be careful b/c you can fit .02 k-wire through plate hole,
but will get stuck!
Hold plate on with K-wire and get fluoro to look at A/P, Lat position of plate, reduction
Start with non-locking shaft screw in mid-plate (2.5mm gold drill) approx. 30mm
Then put in locking guide to put in calcar/kickstand screw first
When drilling, make sure you are co-linear and use bouncing technique goal is to go through
cancenllous head to the subchondral bone and then STOP. DO NOT GO THROUGH
SUBCHONDRAL BONE better to be short, really difficult to measure and easy to penetrate.
Make sure to take more fluoro then you probably need to check screw length (airball)
Eaiser to put in screws with IR and then check AP/Grashey view for screw length, but need to
fluoro to check b/c round head.
Fill all locking holes in head
Place 2-3 non-locking holes in shaft, may need to place 1-2 locking
Once happy with screw lengths, irrigate and get final AP/Lat shots
Use free needle to pass Ticron sutures through superior holes to tie down the RC
Use #2 Ethibond to repair Pec Major if you released earlier (Dont grab LHBT)
Close D-P interval with 0-Vicryl to close over cephalic vein
2-0 Victryl to subdermal layer
Staples v. 3-0 monocril
Use ultrasling for post-op immobilization
Post-op XR Make sure you fluoro for screw length!