Elbow Plating System Surgical Technique Acumed® is a global leader of innovative orthopaedic and medical solutions. We are dedicated to developing products, service methods, and approaches that improve patient care. Acumed® Elbow Plating System Designed in conjunction with Shawn W. O’Driscoll, MD, PhD, the Elbow Plating System is engineered to address fractures of the distal humerus, olecranon, and coronoid. The Elbow Plating System includes precontoured, indication-specific plates and a low-profile Olecranon Plate design with anatomic curvature and instrumentation to aid with plate and screw insertion. This system also includes the Hexalobe Screw System with variable angle Tap-Loc® Technology for the Medial and Lateral Distal Humerus Plates. Acumed offers Posterolateral Plates in addition to Medial and Lateral Distal Humerus Plates to provide multiple plating solutions for elbow fracture management. Indications for Use: ⊲ Fractures of the distal humerus, olecranon, and coronoid ⊲ Osteotomies of the olecranon Definition Warning Indicates critical information about a potential serious outcome to the patient or the user. Indicates instructions that must be followed in order to ensure the proper use of Caution the device. Note Indicates information requiring special attention. Acumed® Elbow Plating System Surgical Technique Table of Contents System Features . 2 Instrument Overview . 6 Surgical Technique Overview . 8 Surgical Techniques . 12 Olecranon Plate . 12 Olecranon Plate Osteotomy Cutting Jig . 16 Distal Humerus Plate . 18 Posterolateral Plate . 24 Coronoid Plate . 27 Ordering Information . 30 Acumed® Elbow Plating System Surgical Technique System Features Plates and Screws Olecranon Plates Coronoid Plates Posterolateral Distal HumerusPlates Hexalobe Screws Lateral Column Plates Medial Column Plates 2 Acumed® Elbow Plating System Surgical Technique System Features [continued] Key Plate Features ⊲ Plate lengths range from 3-hole to 15-hole ⊲ 3-hole plate offers fixation of olecranon osteotomies and (65 mm–100 mm in shaft length) fractures where a longer plate is not necessary ⊲ Extended Plates are now offered in two lengths ⊲ Left and right specific plates are designed to provide (90 mm and 130 mm) anatomic fit, both proximally and distally along the ulnar shaft Olecranon Plate K-wire holes are included in the plates to facilitate provisional plate fixation Holes in the buttress portion of the plate are designed to allow screws to capture fragments Coronoid Plate Locking screws in the Offset screw hole is intended Standard Plates are designed to help capture fractures of to avoid collision with one the sublime tubercle another, regardless of screw length selection K-wire holes and prongs are provided for provisional fixation Posterolateral Distal Humerus Plate Limited-contact design Locking screws may be used in the distal holes Cluster of distal screws, angled distally and divergent from one another, is designed to allow the plate to sit more proximally to avoid potential impingement on the olecranon and to capture fracture fragments Proximal taper is engineered to minimize stress concentrations Long screws in the Lateral Column Plate are designed to interdigitate with screws from the Medial Column Plate, providing a parallel construct for the stabilization of distal humerus fractures Medial and Lateral Plates The Acumed Elbow Plating System was the first to offer precontoured, parallel distal humerus plates. 3 Acumed® Elbow Plating System Surgical Technique System Features [continued] Key Screw, Instrumentation, and Tray Features Screws ⊲ The 3.0 mm and 3.5 mm screws are offered in lengths from 8 mm−65 mm, providing more options than previous generations ⊲ 2.7 mm screws with a smaller diameter head allow clustering of screws in selected regions ⊲ Hexalobe screws are Type II anodized Driver interface is intended to minimize screw stripping Instrumentation Cutting flute design is intended to facilitate screw insertion, particularly with longer screws A radiolucent targeting guide targets the four clustered 2.7 mm proximal screws in the plate Trays ⊲ All-metal screw caddy design eliminates the use of plastic. The screw caddy lid is removable for ease of use ⊲ Retractable handles in the screw caddy are designed to aid in removing the caddy from the tray ⊲ Windows are on the sides and top of the system tray, so that contents can be viewed without opening and disassembling the tray 4 Acumed® Elbow Plating System Surgical Technique System Features [continued] Tap-Loc® Technology The Acumed Tap-Loc technology is designed to be used only with the Medial and Lateral Distal Humerus Plates to insert locking screws with up to 20 degrees of angulation. Quick Release Instrumentation provides an efficient way to switch from 3.5 mm to 3.0 mm plate taps T-Handle Provides control when tapping plate holes 3.5 mm and 3.0 mm Plate Tap Sizes Color-coded taps accommodate the screw diameters provided in the system Laser Mark Indicates maximum tapping depth Tapping Threads Allow surgeons to tap the plate after drilling, creating threads in the plate and bone for locking screw insertion Tap Trajectory Guide Follows the drill path for accurate tap angle and screw placement 5 Acumed® Elbow Plating System Surgical Technique Instrument Overview 8" Bone Reduction Forceps Bone Reduction Forceps, 5.25 Reduction Forceps With Medium Ratcheting (MS-1280) (MS-45300) Serrated Jaw Driver Handle (PL-CL04) (80-0663) 2.8 mm Drill Guide Cannula Targeted Drill Guide 2.3 mm Drill Guide Cannula Plate Holder Assembly (PL-28CLAMP) (PL-CLAMP) (80-0624) (PL-2030) Plate Bender, large Offset Drill Guide 2.8 mm/3.5 mm Thin 2.0 mm/2.3 mm Narrow (PL-2045) (PL-2095) Drill Guide Drill Guide (PL-2196) (80-0628) 2.8 mm Hexalobe Locking 2.3 mm Locking Drill Guide 2.0 mm Hexalobe Locking Drill Periosteal Elevator Drill Guide 6–65 mm 6–65 mm Guide 4–32 mm (MS-46212) (80-0668) (80-0622) (80-0621) Depth Gauge 6–65 mm .035 x 5.75 STT Guide Wire, .062 x 5.75 STT Guide Wire, 2.0 mm Quick Release Drill (80-0623) Titanium Titanium (80-0318) (WT-0906STT) (WT-1606STT) 15 mm Hohman Retractor Sharp Hook CO/CA Countersink (MS-46827) (PL-CL06) (PL-2080) 6 Acumed® Elbow Plating System Surgical Technique Instrument Overview [continued] Plate Tap for 3.5 mm Screw Plate Tap for 3.0 mm Screw T15 Stick Fit Hexalobe Driver T8 Stick Fit Hexalobe Driver (80-0661) (80-0659) (80-0760) (80-0759) 2.3 mm Quick Release Drill 2.8 mm Quick Release Drill Bone Tap for 2.7 mm Bone Tap for 3.0 mm (80-0627) (80-0387) Hexalobe Screws Non-locking Screws (80-0625) (80-0626) 3.5 mm x 5" Quick Release Drill 3.5 mm Cortical Screw 2.0 mm Depth Probe 2.3 mm Depth Probe (MS-DC35) Bone Tap (80-0643) (80-0664) (MS-LTT35) Quick Release T-Handle Olecranon Plate Osteotomy Olecranon Plate Proximal Locking Bolt: M4 (MS-T1212) Cutting Jig Targeting Guide (80-0652) (80-0653) (80-0654) Targeting Guide 70 mm Tension Band Pin 90 mm Tension Band Pin Tension Band Pin Snapper Locking Bolt: 10-32 (30-0098) (30-0099) (80-0411) (80-2164) 2.0 mm x 9" ST Guide Wire .062" x 6" Guide Wire .045" x 6" ST Guide Wire Plate Tack (WS-2009ST) (WS-1607ST) (WS-1106ST) (PL-PTACK) 7 Acumed® Elbow Plating System Surgical Technique Surgical Technique Overview Fracture Reduction Provisional Wire Nonlocking Distal Proximal Locking and Plate Placement Placement Screw Placement Screw Placement Olecranon Plate Surgical Technique Pre-Drill Provisional Fixation Screw Holes Create Osteotomy Olecranon Osteotomy Cutting Jig Surgical Technique Plate Placement Articular Fragment and Provisional Reduction Fixation Screw Placement Compress Column Distal Humerus Plates Surgical Technique 8 Acumed® Elbow Plating System Surgical Technique Fracture Site Final Screw Postoperative Compression Placement Protocol Tap Distal Plate Insert Proximal Postoperative Holes Insert Distal Screws Locking Screws Protocol 9 Acumed® Elbow Plating System Surgical Technique Surgical Technique Overview [continued] Distal Screw Plate Placement Fixation and Articular Fragment and Provisional Initial Proximal Supracondylar Reduction Fixation Screw Placement Compression Posterolateral Plate Surgical Technique Plate Placement Fracture Fragment and Provisional Initial Central Fixation Fixation Nonlocking Screw Coronoid Fixation Coronoid Plates Surgical Technique 10 Acumed® Elbow Plating System Surgical Technique Insert Proximal Postoperative Locking Screws Protocol Insert Remaining Postoperative Locking Screws Protocol 11 Acumed® Elbow Plating System Surgical Technique Olecranon Plate Surgical Technique Shawn W. O’Driscoll, MD, PhD Figure 1 Technical Objectives for Locking Olecranon Plates: ⊲ Each screw should be as long as possible ⊲ Locking screws should interlock to provide a stable “fixed angle” structure inside the bone fragment ⊲ Plate should buttress against anterior pull of elbow flexors ⊲ Plate should provide stable fixation of the ulnar shaft ⊲ Plate should be applied with compression across the fracture ⊲ Plate must be strong and stiff enough to resist bending before union occurs Fracture Reduction and 1 Plate Placement Attach the Olecranon Plate Proximal Targeting Guide (80-0654) to the Olecranon Plate (70-03XX) with the Locking Bolt: M4 (80-0652). Flex the elbow 90 degrees, reduce the fracture, and apply the plate. The prongs in the proximal end of the plate should penetrate the triceps tendon and provide provisional fixation. These prongs are not intended to compress the tendon and a gap between the plate and the bone should be visible on X-ray. Note: Plates designed for use on the left arm are blue. Plates designed for use on the right arm are green. Note: Using the Extended Olecranon Plate (70-03XX) requires splitting the triceps tendon. Figure 2 Provisional Wire Placement 2 If a locking screw is to be utilized in the most proximal hole of the plate, thread the 2.3 mm Locking Drill Guide 6–65 mm (80-0622) into the plate hole. A 2.0 mm x 9" ST K-wire (WS-2009ST) is drilled through the locking drill guide and across the fracture site, penetrating the anterior metaphyseal cortex.