Codo

Fracturas del olécranon y del húmero distal

Elbow

Procedure

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El sistema de placas para codo de Arthrex ofrece una opción integral de placas para el húmero distal y el olécranon. Para el húmero distal, existen opciones de placas de 90° y 180°, así como longitudes de placa extraarticulares de hasta 294 mm. Las placas para olécranon dorsal y osteotomía de olécranon completan el portafolio de productos. &nbsp;
El portafolio de productos Arthrex para codo es el más completo del mercado. Compuesto por el cerclaje FiberTape®, anclajes de tejidos blandos, aumento de ligamentos InternalBrace™ para reparaciones de ligamento colateral cubital medial y ligamento colateral cubital lateral, productos biológicos, placas y tornillos complementarios, este portafolio está diseñado para afrontar los retos de los casos de traumatismo de codo más complejos.
La técnica quirúrgica InternalBrace tiene como objetivo únicamente aumentar la reparación/reconstrucción primaria al expandir el área de aproximación del tejido durante el período de cicatrización y no está destinada a reemplazar el ligamento nativo. La técnica InternalBrace se debe usar durante los procedimientos de fijación del tejido blando a hueso y no está autorizada para la fijación de hueso a hueso.

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Arthrex Elbow Plating System Distal Humerus and Olecranon Plating

Steven J. Lee, MD (New York, NY), demonstrates the use of the lateral biplanar plate from the Arthrex Elbow Plating System. The plate provides direct lateral fixation on the epicondyle and posterolateral fixation along the shaft, and a removable tab facilitates capitellum fixation. Dr. Lee uses the lateral positioner from the ElbowLOC® arm positioning system.

video

Distal Humerus Fracture Fixation With the Arthrex Distal Humerus Lateral Biplanar Plate

Hi, I'm Steven Lee from Lenox Hill Hospital in New York City. I'm going to talk about arthrex cool new contoured plates for the distal humerus. And this particular plate is the Biplanar lateral plate system. A couple of cool features about these plates is the one, of course, the anatomic contouring of the plate to the bone, but also the addition of special different tabs that are added to the distal aspect of the plate, which allows for more screw fixation abilities, especially for those hard to treat distal humerus comminuted fractures. Each one of these screw holes can take either a 2.7 or 3.5 locking screw, and the crew lock screws are a variable pitch locking screw, so it gives some mild compression and at the same time can also lock into the plate at the same time. A couple more features that I really like about this plate are that the distal end of the plate has scallops to it, which allows us to bend the plate a little bit more easily to help contour it, just in case it doesn't perfectly fit the bone. There are also suture holes to allow for you to put sutures to repair your ligament and or tendon, and you can also add suture underneath the tab as well. Some of the features that I really love about this set are that it's been very well thought out, especially the instrumentation. So there's a bunch of different reduction clamps that you're probably used to using, but also this one reduction clamp called the tooth choker. Especially like this because of the fact that it has sharp ends on the on the tip, sort of like your pointed reduction clamps, and yet is not bowed out so that when you are dealing with fractures and trying to reduce them, the Kocher clamp tooth choker would will hug the bone and it doesn't get caught up in soft tissue or the nerve here or whatever. And so it holds things very, very nicely. There are instrumentation, thoughtful features for which there are each. Most of the instruments are double sided. So I do like to use different sized freezer freezers. So there's a wide area on one side that you can use to help scrape the soft tissue off. It's appropriately sharp and soft and dull enough, and then you can flip it around and use the smaller end or the thinner end for your regular, freer application. Same thing for the other cool tool, which is the curette on one side, and the dental toothpick for reducing your fractures at the same time. And it's wonderfully balanced. You can spin it in your in your hands very easily. Also the screws in the set are all stadium seating screws, which means that they don't need to be measured by your surgical tech. Only if it sits flush on the set, then that only that screw can fit in there. So they don't. You don't have to wait for each screw to be measured, which is a very time saving feature. Often we'll put in a tack first, and I'm going to go ahead and put in my first screw in the oblong hole. This is going to be a 3.5 screw cortical screw. So that's going to be a 22. So this does come with a torque limiter. And of course to if you want to go ahead and tighten by hand as well. So I'm going to put in a 2.7 non-locking screw in distally. Again you can put either locking or non-locking screw in each one of these holes. This is a variable angle locking drill guide. So it does give you a 24 degree arc of variability. I do like reading my screw lengths directly off of the drill guide. But to note, there's two different lines on the drill. There's a single black line that you read for up to 50mm of length of the screw, and anything over that you would read off of the double black line that's on the drill. So. Hopefully you can just start seeing the double black line coming into view. So again we're going to put a non-locking screw in first. Okay. So I'm going to go ahead and put in a 2.7 non-locking screw into one of these tabs. This is a 2.7 non-locking screw going into one of the tab holes. It looks like that's conforming really nice onto the bone as well. This is our screw in locking tower guide. You can use this tower to also bend the tab. If for whatever reason, the tab is not conforming perfectly down onto the bone. So this is a 2.7 locking screw going into the tab hole distally. I'm going to put in a 2.7 distal locking screw using the screw in locking guide. So this is the distal most screw. This is going to be a 2.7mm locking screw. There is a torque limiter on the drill. This is a AP with some of our screws in. You can see the plate sits really nicely on the bone. And very importantly the screws that are put in distally are missing the olecranon fossa and providing extra fixation distally, which is my usual biggest concern with these type of injuries. This is a lateral provisional x ray. I think it looks unbelievable how well it sits on the humerus. It's very well contoured and screw positioning of where they go is optimal. This is the final AP x ray for the biplanar lateral plate. The cool thing to note here is that we have a total of five screws that are distal to the olecranon fossa, just the angle of where those screws go. Just I think are perfect. They miss the olecranon fossa and gives us extra fixation for those really difficult distal humerus comminuted fractures. So very happy with the way that looks on the bone. This is the final lateral x ray for the biplanar lateral plate. Again getting five separate screws distal to the olecranon fossa is absolutely amazing. The plate is very skinny. It's low profile, it's smoothened on the ends and the ability to take both locking and non-locking screws either 2.7 or 3.5 and any of the holes gives us so much flexibility on treating what is often very difficult fractures to treat.

Lee Hunter, MD (Columbia, TN), presents the Arthrex Elbow Fracture Plating System, using a dorsal olecranon fracture plate to reduce the fracture. The elbow is positioned using the ElbowLoc® arm positioner, allowing the surgeon to complete the surgery in supine, as shown in this video, or lateral position. KreuLock™ locking compression screws allow for compression across the fracture and stability in the plate.

Olecranon Fracture Fixation Using the Arthrex Elbow Plating System

My name is Lee Hunter. I'm an upper extremity orthopedic surgeon with Tennessee Orthopedic Alliance. So we've chosen to repair this elbow fracture using this elbow lock arm positioning system. And it's perfect for a lot of things elbow related, but particularly olecranon fractures because, say, for example, now we have this patient's arm at 90 degrees, and there's some inherent tension on this proximal fragment from the triceps. How you reduce that tension as you extend the elbow. And what that does, it just makes maintaining the reduction a lot easier. Today we're using the six hole proximal ulnar olecranon plate system also offers a shorter straight two hole plate. Arthritis also offers extended versions of these proximal ulna plates, all of which really nicely mirror the bow of the proximal ulna. Now, we've got our provisional fixation. My assistant's not really doing anything because elbow lock's doing all the work. We generally start with this oblong, most proximal compression hole. It is placed by cortically. You're well anterior to the coronoid process. We've got these nice ratcheting screwdrivers with an ergonomic handle which is really nice. Generally the oblong screw first and then one of these proximal screws just kind of dealer's choice on those just to make sure you got both fragments stabilized. So this is what I like to call a point and shoot guide. It could also be called a calibrated drill guide. And it's really done a fine job with this. As you drill and you advance, the single etching actually refers to the shorter screw lengths that are in this image on the top. And as you keep drilling and you advance the drill bit, you'll notice a double line comes in and that actually references these longer screw lengths. So as you put in these proximal screws, you just keep in mind where your joint is. Now we can see it through this window that we've made. Be cognizant of that with these proximal screws. What I'm trying to do with this is I'm trying to aim obliquely, staying in the proximal ulna, but engaging this good coronoid bone up here because a lot of times the bone just distal to that is not quite as good a bone as in the coronoid process. This is what all these proximal screws are trying to aim and get up in. I would like to point out, as you're exposing, these proximal ulna fractures, leave as much soft tissue attached to the bone as you can. I've left this sleeve of soft tissue here purposefully because my ulnar nerve is protected from that. Always be aware that sometimes there's metaphyseal comminution here. So there is. I would encourage you to strip this more, to expose more where you can actually see the interdigitation of the fracture fragments. And after we after we lock the plate, after we put this screw in, we'll have the plate secured to the distal fragment. And we'll image and make sure that we're happy with our reduction and our proximal most screw. And I would suggest that before you get too committed to this kind of temporary fixation that we have, that you bring in fluoro and make sure you're happy with your reduction and your placement of these initial screws, particularly this proximal screw, and how we image with the elbow lock system in this situation is you loosen the humeral collet, you just slip out the humeral brace, and the surgeon abducts the arm off the table, and you bring in fluoro from the side. If you notice this lateral view that we have the elbow, you'll see a few things. The plate fits really nicely on the back of the ulna, particularly proximally. There it does over the olecranon that proximal most screw, how it survives right under the joint surface and engages that really hard metaphyseal bone at the base of the coronoid. That's really what you're after. And that's my temporary fixation. Right below that, there's another screw that's going to mirror that course as well. And you can see really nice position of the distal screws. So now we're happy with our reduction. We know our plates right. We don't have to change anything. We can just place the rest of the screws. We've removed our provisional fixation. Now we're moving on to securing the plate to the proximal ulna. This proximal most screw is oriented relatively longitudinally. So this apical screw is actually going to be quite a bit shorter. You'll bump up against the articular cortex of the olecranon, but just don't perforate it. This is another one of those oblique screws that's designed to advance up into the metathesis of the coronoid. And keep in mind, as you begin to do this, you're after two cortices. If you feel four, you're in and out of the proximal ulna and into the distal humerus, which can easily happen. So maintain some awareness of where your joint is and the inclination of your drilling. So for the purposes of this presentation, we won't fill all the holes. But you get the concept a really nice reduction. We've got really good purchase for solid screws proximally and for distally. So we'll again for imaging we'll slip off this humeral support. And the surgeon or their assistant will just abduct the arm off the table. Bring in fluoro from the side. So now this is our final reduction. This looks really nice. You know the fracture is reduced. All the screws have a really nice length. Those two oblique proximal screws that just go kind of almost juxta cortical engage that coronoid fragment proximally. That's really what you're after. And I particularly like that longer first proximal screw just immediately distal to the fracture. How that really engages the bulk of it. So I'm really happy with how our X-rays look. I inserted this proximal most screw using a variable angle guide. But alternatively you can use this fixed angle guide threaded in. And it gives you the longitudinal orientation that some people refer to as a home run screw. So here are our final images. Again. Really nice fit of the plate to the bone. The screws are all placed really nicely. You can see the home run ish type screw there proximally, just a butting up against the distal cortex which is really what you want.

Erik Kubiak, MD (Las Vegas, NV), presents the Arthrex extra-articular distal humerus plate for distal ⅓ shaft fracture fixation. The Arthrex Elbow Plating System provides a comprehensive solution for distal humerus and olecranon fracture fixation, using next-generation KreuLock™ locking compression screws. Dr. Kubiak has positioned the patient using the ElbowLOC® arm positioning system.

Distal Humerus Shaft Fracture Fixation Using the Extra-Articular Plate From the Arthrex Elbow Plating System

So Eric Kubiak from Las Vegas, Nevada. Today we're going to demonstrate application of the extra articular humerus plate through a posterior approach to humerus. We'll go through some anatomy, show you the salient structure at risk, which is the radial nerve, and then go through plate length options. My preference is to do these operations without the tourniquet, for the reason being that the tourniquet tends to shorten the surgical field and puts the radial nerve, which is the structure, at risk, potentially tethered and stuck under the plate. So of the plates this is the shortest. This is the longest. Operating holes increase by two holes as we escalate the plate sizes. You can see for this specimen this person the longest plate would be too long. These plates are differentiated from the conventional periarticular distal humerus plates in that they're much thicker. They're A35 plate in stiffness. Whereas the conventional periarticular plates are thinner and less stiff. These are really meant to treat those hybrid fractures, which are a combination of a shaft meta diaphyseal injury, the distal humerus. I tend to use these plates more than I use the periarticular plates. I tend to fix most of these with a longer, stouter lateral plate and then the appropriate medial plate. The design concept here is that the shaft plate and the periarticular plate have very similar distal screw pattern. To address the periarticular fracture. This distal screw cluster can either use the three five screws or two seven screws. I tend to treat most of these fractures with a stout lateral plate and appropriate periarticular medial plate as necessary. The only difference in the distal screw pattern between the periarticular plate and the extra articular distal humerus plate is the addition of this cross tab, which would allow screw across the trochlea. Important features of a direct posterior approach to the humerus would be positioning. So most of the patients we're doing lateral over an arm holder. Other people do them prone over a similar arm holder with the elbow to be extended or flexed. The incision is centered over the center of the triceps for an extra articular injury or an extra articular humeral shaft fracture. I often don't need to develop the medial side of this approach. If you do not develop the medial side, I would say you have to be very careful of the ulnar nerve or trapping the ulnar nerve, which is just on the other side of the humerus. So retractor is placed under the triceps, can catch the ulnar nerve and inadvertently injure it when the patient triceps is immobilized out of the way. The easiest way to do this is in skin incision down on the fascia over the triceps. Open the triceps fascia, and then elevate the triceps off this overlying fascia. That'll allow you to find the cutaneous branch of the radial nerve, which then will take you to the radial nerve. When you're actually doing the live dissection, the vessels that travel with the radial nerve can be quite bloody. And so we use a bipolar cautery because you're cauterizing right around the nerve. And it's easier than using the pickups in the cautery. Electrocautery. The other thing I would say is, when you're doing this approach and you're mobilizing the radial nerve, make sure you get underneath of it and make sure you can get underneath of it proximally and distally. Most of the time when I'm doing this procedure, I'm demonstrating it. We go up all the way to the deltoid and, and come to the confluence of the two heads of the triceps and the deltoid. That kind of marks the top of this incision for me. Once I'm here, then I can track back. If you're having trouble finding the radial nerve, go to a place that's safe distally. Work proximally. Go to a safe place proximally. Work distally and find the nerve between the two approaches. That's a really easy way to get at it without getting in too much trouble. When you need to do that, most of the time it's because this is a fracture that's gone on to nonunion, and you're picking the nerve out of the nonunion ball. So in that circumstance, just come somewhere where you're safe proximately somewhere you're safe distally, and work until you find the radial nerve in between the two. One of the important points of humerus fractures is the humerus. Has some curve to it in the anterior posterior plane, or in the coronal plane, it has a radius of curvature. These plates also have a radius of curvature in that coronal plane. This particular patient has an extra kind of kink in the distal third of the humerus, where if this was broken, we'd probably just take the kink away and reduce it. Take this. But in this circumstance, we had to put a little bit of a bend in the plate to facilitate her anatomy. Again, the plate's going to come up under the radial nerve. Be fitted to the distal humerus and the shaft of the humerus. Be really careful of the radial nerve. Try not to wind it up in the drill bits, screws, etc. and then in the dictation we always dictate where the nerve passed over the plate. So in this circumstance we would say the nerve passed over the first proximal hole. Again true three five screws. So 2.5mm drill bit. By cortical. This should always in most human beings is going to be 26 to 28. So this is measuring 26. Titanium is really nice. Now the one thing I would say is in this circumstance where the pulling the apex into position tended to lift the one end of the plate or the other off. I would fix to the metastasis first, because that's going to be my dominant thing that I'm worried about. Fix the metastasis first and then draw the bone to the plate. Calibrated drill guide has two marks on the drill bit. The first mark is for the short side so up to 50mm. So as you can imagine we're at 15 and there's 15mm of drill bit extended exposed. If you come up to the second line drilling across the trochlea, the double mark starts at 55, 60, 65, 70. Drilling towards the coronoid. If you're really in the coronoid can be up to 30. Most of the time down here it's going to be 16 something like that. So we're at 26 here. So 2627. My preference is pin the plate. Conventional compression screws. And then if if locking screws or fixed angle screws are indicated A, i.e. secondary to bone quality. Then I would go to the fixed angle screws or locking screws. After I'd already put the cortical screws in place, you can see how the plate pulls really nice down the bone appropriate to the bone. Once that plate's appropriate to the bone. The other cortical screw. And you've got this like really, really perfect plate contour plate sitting against the humerus. Appropriate. So this would be the intermediate step of this procedure. You have the plate pinned to the bone fracture reduced plate pinned to the bone. And then the cortical screws pulling the bone plate construct so that it's appropriately fit. Now when you look from the lateral sort of at the lateral aspect of the humerus, you can see this really nice plate contour fitting the humerus appropriately address, you know, appropriate to the bow of the humerus and a really nice distal fit to the distal humerus, which is going to be important because there's not a lot of soft tissue on the and the distal aspect the lateral humerus. If you feel it, and people will feel that plate pretty easily. So the number one reason to take these plates out is that distal lateral prominence. And again that's why you got to be a little careful about the radial nerve because you'll be pulling these things out. So so we're here we're going to demonstrate the three five distal lock. So 2.5mm drill 2.5mm calibrated cannula. Same concept with the single mark marks the depth. When I place this screw, I don't try to go by cortical because I know it's going right for the coronoid and the radial head. So here we're. About 22 3.5mm locking screw. With the. Limiting torque limiting attachment which if you're going to place locking screws with power. I would always recommend using the torque limiter, and then you can come back and address them by hand at the end to make yourself feel better, but I would always use a torque limiter with power. You know, when we first pull the plate down, often we're using we're measuring a screw from a plate that's not on the bone. For me, I'm going to pull it down and don't change these screws, which are obviously long on the lateral. The distal screws obviously long. I would place the distal locking screw first before changing this screw and shortening it. If you don't do that then the plate can pull off the bone. You can lose the reduction. The goal in my life is to obtain the reduction, then maintain that reduction until the patient's healed. And nowhere along those lines sort of lose the reduction. So I don't want to lose reduction once I've sort of gotten the fixation started. So this screw will be shortened after the definitive locking screws are placed. Final plate bone construct demonstrating a typical pattern of fixation with multiple screws placed into the Capitellum them these screws for me. Fixed angle variable angle screws are helpful because I like divergent or convergent screws to to really maximize fixation in this distal metaphyseal bone. The distal fragment will also have a minimum of a cortical screw and a fixed angle screw to really lock in that lateral column. Again, we'll go through the typical spiral fracture of the distal humerus. The proximal shaft fragment needs a minimum of three points of fixation. That's going to be, in most intents and purposes, a cortical screw to help hold the plate bone construct where it needs, and then backed up by locking screws or fixed angle screws. At a minimum, I would say of two, but I like three is kind of the number that I'm going to shoot for. And again, the radial nerve crossing over the top of the plate and making sure that all the additional wires are put in, all that stuff's removed.

Kevin W. Farmer, MD (Gainesville, FL), demonstrates the lateral distal humerus plate from the Arthrex Elbow Plating System for parallel plating of distal humerus fractures. During the demonstration, Dr. Farmer uses the lateral positioner from the ElbowLOC® arm positioning system. KreuLock™ locking compression screws allow for compression across the fracture and stability in the plate.

Distal Humerus Fracture Fixation With the Arthrex Lateral Distal Humerus Plate

This is Kevin Farmer from the University of Florida. I'm demonstrating the direct lateral plate from the distal humeral plating system. This allows you to get parallel plating of distal humeral fractures. I want to point out some key features. One is the low profile nature of this plate. Number two are the multiple screw holes that fit what are called the screw lock screws. These are locking compression screws, and all screw holes can take either a two 7 or 3 five. I'd also like to point out that suture eyelets in the distal aspect of the plate. Those are nice for ease of access. For suture passage, let's say you take down the lateral collateral ligament for exposure of a shear type fracture. This allows you to have easy access to repair that back down to the plate. At the end of the case, we have exposed the ulnar nerve and moved that out of the way. We've done a typical olecranon osteotomy and then we've used an elevator here. This is the long and back elevator. It's on the sets. Elevate the triceps up out of the way to give us access. And we have provisionally placed the lateral distal humeral plate here where these BB tacks for appropriate placement confirmed on x ray prior to starting to put our screws in place. So we're in the lateral position using the elbow lock arm positioner. This gives you a nice firm fixation for the lateral position, but can also be used in the supine position. So we're using a point and shoot guide here to get our first shaft screw. Putting a 3.5 cortical screw in here. This is a calibrated drill bit which will allow you to get your depth off of that. And obviously you can use a depth gauge as well. I've got 24. For a crew lock fixation. You have the option of using the locking towers as you see here, or you can use a point and shoot guide. I do want to point out that the drill bits are calibrated so that up to 50mm in length of the screw, you use the single line as your measurement, and as you pass 50, you get a double line here to measure a larger screw length. And again, that can be used both on the locking tower and the point and shoot guide. We have our locking tower for the crew lock 2.7 screw in the most distal hole. Again, the nice thing about that is you get both the compression and the locking component so you can compress the plate down and then lock into it. And so we'll take our measurements here and power to start our crew lock. And then we'll switch to hand. Again I want you to watch as you place this in. It's a locking screw, but you get compression initially of the plate down and then it locks in place, which is a nice feature of the system. We're going to put our second distal crew lock screw here. This is a nice long 55 screw. Again I want you to watch as you place that in. You get the initial compression followed by the locking. Now we're placing our 3.5 locking screw in the shaft, using the locking tower with a calibrated drill bit 22. Here we have AP and lateral imaging of the plate and screws. You can see well placed screws. You can certainly see the most distal screws really getting down close to the distal articular surface. And you see on the lateral again trying to achieve O'Driscoll principles of screws as long as possible. Getting that fixation right near the articular surface.

Steven J. Lee, MD (New York, NY), demonstrates the medial plate from the Arthrex Elbow Plating System for distal humerus fracture fixation. Dr. Lee uses the lateral positioner from the ElbowLOC® arm positioning system.&nbsp;

Distal Humerus Fracture Fixation With the Arthrex Distal Humerus Medial Plate

Hi, I'm Doctor Steven Lee from Lenox Hill Hospital in New York City. Today I'm very excited to try out and show the arthritic elbow pre contoured plates. Depending on what kind of fracture pattern you have and what your personal preference are, arthritis has it all covered from whether you do parallel plates or 9090 plates. They also have great instrumentation. One particular instrument I wanted to point out right off the bat is this tooth Kocher, which is a combination of very sharp tips, sort of like your pointed reduction clamps, but it doesn't have a large outward bend to this, so that when you're trying to reduce either the fracture, it doesn't get caught up in your soft tissue. And also it acts a little bit like a line draw, a combo line draw, but also a tooth. Kocher. So it's a very useful tool to help not only reduce your fracture, but also to hold your plate onto the bone after the fracture is reduced. Normally, I would either put the tooth on fracture with the plate, and also usually throw in a tack or two to provisionally hold the plate onto the bone. Typically we'll often start with the oblong hole. So this is a 2.5 drill. All right. So we're going to put a 3.5 cortical screw in. First there is a torque limiter on here. So you could either let it torque limit and or you can finish this off with the screwdriver, go ahead and put in a locking screw distally so all the screw holes can accept either 2.7 or 3.5 screw. They are all variable angle locking, which gives you about a 24 degree cone of variability, and each one of the screws are also take lock screws. The crew lock screws are variable pitch locking screws, so they give some compression and yet they will also lock into the screws. You can measure directly off the drill guide and that can either speed up your surgery. If you don't feel the need to depth gauge, or just to confirm your depth gauge. And there's two lines on the drill. The single line, which you can see here, goes up to about 50mm on the screw. After that, there's a double line that's coming through which you can measure off of for screws that are over 50mm in length. Okay. So this is a 2.7 crew lock screw. Again a crew lock means it's a variable pitch but also has a locking head to it. There is a torque limiter on here. Okay. So at this point we're going to get a provisional x ray just to see if we like the position of the plate on this lateral x ray. You can see the plate is in a really good position. And on the AP or provisional placement of this plate looks great. The screw is not going through olecranon fossa and overall position looks like in a good position. So at this point we can go ahead and fill the rest of the screws quickly. So I'm going to put a 3.5 locking screw. Approximately. As usual, Arthrex gives you many different options depending on your preference. I happen to like to screw in tower, so I can read the measurements of the screw directly off the drill guide, and that just saves me time so that I don't have to depth gauge at the same time after that. So we all know that if you get to 75% across the bone, that the biomechanics of a locking screw is just as strong. So I'm up at about 18 on the other cortex. So this is going to probably put 20 to screw in okay. You're going to put the 3.5 screw in proximally. Again there's a torque limiter on here. I just want to show the variable angle cone guide. So this is a three screw we're putting in the 34 okay. So this is our final AP x ray. What I like is the distal screws allow at least two screws that can go fully across the distal humerus and not go into olecranon fossa. The final lateral x ray shows the plate's well placed on the bone and fits very nicely. Screws are all in good position.

Fracturas del olécranon y del húmero distal

Sistema de placas para fractura de codo