Summary The Skeletal Dynamics Humeral Plating Set consists of the following systems: Distal Humerus Plating System (this page) Midshaft Humerus Plating System The Skeletal Dynamics Humeral Fixation Set contains bone plates for the repair of distal and midshaft humerus fractures. Included in the set are bone screws, K-Wires, and specialized instrumentation. Related Implants Distal Humerus Plates Medial Direct Plate Lateral Direct Plate Lateral Capitellar Plate Lateral Helical Plate Supracondylar Plate with extension for distal fractures Humeral Shaft Plates Midshaft Narrow Plate Midshaft Broad Plate Indications Distal humerus fractures Distal humerus nonunion Distal humerus osteotomies Anatomy Osteology elbow is a hinged joint articular surface is in 6 degrees of valgus 5 degrees of external rotation 30 degrees of flexion trochlea articulates with sigmoid notch allows for flexion and extension capitellum articulates with proximal radius allows for forearm rotation Muscles common flexors (originate from medial epicondyle) pronator teres flexor carpi radialis palmaris longus FDS FCU common extensors (originate from lateral epicondyle) anconeus ECRL ECRB extensor digitorum comminus EDM ECU Ligaments medial collateral ligament anterior bundle originates from distal medial epicondyle inserts on sublime tubercle primary restraint to valgus stress at the elbow from 30-120° tight in pronation lateral collateral ligament originates from distal lateral epicondyle inserts on crista supinatorus stabilizer against posterolateral rotational instability tight in supination Nerves ulnar nerve resides in the cubital tunnel in a subcutaneous position posterior to the medial condyle radial nerve anatomic landmarks in the spiral groove 15cm proximal to distal humeral articular surface 10cm from the medial edge of the olecranon 7.5cm from the lateral edge of the olecranon 3.9 cm (two finger-breadths) proximal to the triceps aponeurosis runs between brachioradialis and brachialis proximal to elbow posterior antebrachial cutaneous nerve (PABCN) branches in the posterior arm divides into PIN and superficial radial nerve at the level of the radial head Blood supply intraosseous and extraosseous blood supplies that may be compromised by the injury Approach A posterior incision, including exposure of the ulna via an olecranon osteotomy. Technique (Posterior Approach with Olecranon Osteotomy) Exposure Make a posterior incision. Use caution to identify and release the ulnar nerve. Expose the ulna for an olecranon osteotomy. Preparing olecranon osteotomy Place a 3 hole Proximal Ulna Plate on the surface of the proximal ulna. Make a narrow incision, parallel to the tendon fibers and through the triceps insertion, to apply the home-run tab onto the surface of the olecranon. Note the presence of osteophytes on the olecranon, Osteophytes may prevent plate from sitting flush with bone. Drill through the center of the gliding hole using the 2.7mm x 50mm Drill Bit. Using the appropriate scale of the depth gauge, measure then insert a 3.5mm compression screw and tighten with the T-10 Driver. Drill through the home-run tab using the 2.7mm x 80mm Drill Bit. Using the appropriate scale on the metaphyseal side of the depth gauge, measure and insert a 3.5mm compression screw (multi-thread compression) and tighten with a T-10 to reduce the plate to the ulna. With the plate firmly on the ulna, drill the two olecranon screw holes using the 2.7mm x 50mm Drill Bit. The plate will be used as a template to direct the osteotomy placement and restore original ulnar anatomy during closing. Remove the Proximal Ulna Plate. Apply the osteotomy cutting guide with the grooved side facing the bone and insert a 3.5mm compression screw in the gliding slot. Position the proximal edge of the cutting guide level with the two predrilled olecranon screw holes. Further secure the cutting guide by inserting a 2.0mm K-Wire in either the proximal or distal guide wire hole. Tighten the 3.5mm compression screw to prevent vibrational loosening while cutting. Olecranon osteotomy Perform the olecranon osteotomy using a blade with minimum dimensions of 12mm wide and 15mm long. Remove the olecranon guide and complete the osteotomy using a saw or osteotome. Fracture exposure Reflect the olecranon and triceps proximally, exposing the fracture. Reduction Articular fragment Debride the fracture sites and reduce articular fragments. Column Reduce the articular portion to the humeral shaft using 1.5mm K-Wires. The K-Wire in each column should be placed as posterior and close to the midline as possible to prevent interference during Trochlea Compression Screw insertion. Release soft tissue from the tip of the medial and lateral epicondyles, and any osteophytes present, to expose for plate application. Plate selection Select the first plate (medial or lateral). If necessary, contour to optimize fit using bending instruments. If using bending pliers, a Locking Cap can be applied temporarily to prevent deformation of the distal hole. Shaft fixation Position the plate such that the epicondylar screw hole (2nd node on the plate) is located on the apex of the epicondyle. First, fix the plate to the proximal fragment. Using the HPS Drill Guide, drill through the chosen FreeFix® slot using the 2.7mm x 50mm Drill Bit. Using the FreeFix® scale of the depth gauge, measure then insert a 3.5mm compression screw (FreeFix® Compression) for fixation to the humeral shaft. Distal fragment fixatiion Provisionally secure the articular portion to the shaft by inserting, through the Epicondylar Node, a 2.7mm provisional Smooth Peg or a 2.0mm K-Wire as follows If a 3.5mm Metaphyseal Screws will be later used for final fixation, use a 2.7mm Drill Bit to drill through the Epicondylar Holes and insert the Smooth Pegs with the T-10 Driver. If using 2.7mm Metaphyseal Screws for final fixation, insert the 2.0mm AIMing Guide into the pre-loaded Drill Guide and drill through the Epicondyle with a 2.0mm K-Wire. Repeat for the second plate TiBeam® canal preparation Use the Trajectory Guide to insert the 1.5mm x 229mm K-Wire through the most distal holes of the medial and lateral plates via the Bushing Sleeve. Measure length using marks on the Bushing Sleeve or a standard Depth Gauge (from plate to plate). If impingement occurs, replace the temporary fixation K-Wire as needed. Ensure the Trajectory Guide is fully seated in the distal holes. Measurement Guide on the thumb screw should start at 0mm and be used only for micro-adjustments. Select a male TiBeam® component by rounding length down to nearest 5mm. (e.g., 68mm → 65mm) Overlay component on bone to confirm sizing. Optional: use Distal Trochlea Compression Screws in distal holes instead of TiBeam® Drill with 2.7mm x 80mm drill bit. Measure using Metaphyseal Scale on the Depth Gauge. Drill over the K-Wire through both plates using the 3.7mm x 80mm Cannulated Drill Bit. Drill from the opposite direction of K-Wire insertion for easier access. Prepare for the female TiBeam® component by drilling over the K-Wire using the 4.0mm x 20mm Stop Drill in the same direction as initial insertion. TiBeam® Assembly Use Trochlea Compression Screw Insertion Tool to push out the trochlea K-Wire. Place Female Trochlea Compression Screw on the tool tip to protect internal threads. With T-10 Driver, insert the female TiBeam® component while pulling the Insertion Tool until fully seated. Remove the Insertion Tool and insert the male TiBeam®. TiBeam® Compression With both drivers in place, engage the male and female components and compress the trochlea fragments. Confirm TiBeam® engagement and compression with fluoroscopy. Trochlea support screws - medial plate Remove the provisional fixation from the Epicondylar Holes and perform final fixation with the chosen Screws. For 3.5mm screws Drill with 2.7mm x 80mm Drill Bit through the Thread-In Drill Guide, measure with Depth Gauge, insert correct 3.5mm Metaphyseal Screw For 2.7mm screws Drill with 2.0mm x 80mm Drill Bit, measure with Depth Gauge, insert correct 2.7mm Metaphyseal Screw Starting with the third hole of the medial plate, work proximally to finish inserting all Metaphyseal Screws Repeat for lateral side. Diaphyseal function Fill the remaining holes in the humeral shaft FreeFix® slots with 3.5mm locking or compression screws using the HPS or 3.5mm Thread-In Drill Guide, and 2.7mm x 50mm Drill Bit. When reduction is complete, insert a Locking Cap into each distal node to create a fixed TiBeam® construct. Closure Once fixation is complete, reduce the olecranon and apply the Proximal Ulna Plate. Use the Home-Run Screw to ensure compression across the osteotomy site. Fill all the screw holes for optimal fixation. Technical specifications Lateral Capitellar: 70mm, 100mm, 130mm, 160mm Lateral Direct: 85mm, 115mm Lateral Helical: 85mm, 115mm, 145mm, 175mm Medial Direct: 75mm, 105mm, 135mm, 165mm Screws Metaphyseal and Diaphyseal Specific Screw Options Screw Options TiBeam® Male (40mm - 80mm construct lengths) Female (40mm - 80mm construct lengths) Distal Trochlea Compression 20mm - 80mm lengths Compression/ Locking Screw 2.7mm & 3.5mm Compression (10mm - 70mm lengths) 2.7mm & 3.5mm Locking (10mm - 70mm lengths) 3.0mm Polyaxial Locking (10mm - 70mm lengths) FREEFIX® Compression/ Locking 3.5mm Compression (14mm - 44mm lengths) 3.5mm Locking (14mm - 44mm lengths)