Clavicle fractures are very common and comprise 2.6% to 5% of all fractures in adults, with midshaft injuries accounting for almost 75% of all fracture types. Clavicle fractures typically occur when an axial load is applied to the bone, generally in the form of a sudden point load to the apex of the shoulder. When these fractures displace, the proximal fragment is usually pulled superiorly by the sternocleidomastoid muscle while the distal fragment is pulled laterally by the weight of the arm. Most minimally displaced clavicular or nondisplaced fractures can be managed non-surgically simply by placing the arm in a sling. In these instances, the malunion and nonunion rates are very low.
However, when midshaft clavicular fractures present with complete displacement or significant shortening, the risk of nonunion is significantly higher with conservative management. Surgical decision making is a matter of debate. Currently, the only absolute indications for surgical treatment of clavicular fractures include open fractures and injuries associated with evolving skin compromise. Relative indications for internal fixation and open reduction of midshaft clavicular fractures include injuries with 15 to 20 mm of shortening, fractures with significant comminution, completely displaced fractures, floating shoulder injuries that involve a concomitant glenoid neck fracture, painful non-unions, and midshaft clavicular fractures in some multisystem trauma cases.
Depending on fracture morphology, either open or closed reduction and intramedullary orthopedic pin fixation or open reduction and bone plate fixation can be performed and these quality implants can be supplied by Orthopedic implants Manufacturers. Biochemically, both methods provide similar repair strength for middle-third clavicle fractures. After hardware removal, clavicles previously treated with intramedullary fixation were shown to be stronger than those treated with bone plate fixation. Clinically, internal fixation and open reduction of clavicular fractures have shown marked success for the union in a relatively expected time frame with low complications.
Intramedullary fixation offers the benefit of smaller scars and lower refracture potential but also bears the potential risk of hardware prominence and a little higher incidence of nonunion. General principles for a successful surgical outcome involve minimizing soft tissue disruption and periosteal stripping as much as possible during exposure, achieving an anatomic reduction, and preventing wound complications and hardware irritation as much as possible with suitable soft tissue hardware coverage. Either dynamic compression plates (DCP) or locked plating constructs can be used, depending on bone quality and fracture type. In general, the orthopedic bone plate is placed on the anteroposterior, or tension side, of the clavicle to result in the most biochemically sound construct.
A fibula fracture refers to a break in the fibula bone. A forceful impact, such as landing after a high jump or any impact to the outer part of the leg, can cause a fracture. Even spraining or rolling an ankle puts stress on the fibula bone, which can lead to a fracture.
Types of Fibula Fracture
Fractures in Fibula can happen at any point on the bone and can differ in type and severity. Types of fibula fracture include:
- Lateral malleolus fractures occur when the fibula is fractured at the ankle
- Fibular head fractures occur at the upper end of the fibula at the knee
- Avulsion fractures happen when a small chunk of bone that is attached to a ligament or tendon is pulled away from the main part of the bone
- Stress fractures describe a condition where the fibula is injured as the result of repetitive stress, such as hiking or running
- Fibular shaft fractures occur in the mid-portion of the fibula after an injury such as a direct blow to the area
- Fibular shaft fractures occur in the mid-portion of the fibula after an injury like a direct blow to the area
- A fibula fracture can be because of several tough injuries. It is commonly associated with a rolled ankle but can also be because of a fall, awkward landing, or a direct blow to the outer ankle or lower leg.
Fibula fractures are most common in sports, especially those that involve jumping, running, or quick changes of direction such as football, basketball, and soccer.
Symptoms
Swelling, pain, and tenderness are some of the most common signs and symptoms of a fractured fibula. Other signs and symptoms include:
- Incapability to bear weight on the injured leg
- Bruising or bleeding in the leg
- Visible deformity
- Coldness and numbness in the foot
- Tender to the touch
Diagnosis
People who have injured their leg and are facing any of the symptoms should consult a doctor for diagnosis. The following steps occur during the process of diagnosis:
- Physical examination: A thorough examination will be conducted, and the doctor will look if there are any deformities
- X-ray: These are used to see the fracture and know if a bone has been displaced
- Magnetic resonance imaging (MRI): This type of test provides a more detailed scan and can generate detailed pictures of the soft tissues and interior bones
Computerized tomography (CT), bone scans, and other tests may be ordered to make a more precise diagnosis and judge the severity of the fibula fracture.
Treatment
Treatment for a fibula fracture can differ and depends greatly on how severe the break is. A fracture is classified as closed or open.
Open fracture (compound fracture)
In an open fracture, either a deep wound exposes the bone through the skin or the bone pokes through the skin and can be seen.
An open fracture is mostly the result of a high-energy trauma or direct blow, such as a motor vehicle collision or fall. This kind of fracture can also occur indirectly such as with a high-energy twisting type of injury.
The force needed to cause these types of fractures means that patients will often receive additional injuries. Some injuries could be potentially life-threatening.
According to the American Academy of Orthopedic Surgeons, there is 40% to 70% rate of associated trauma elsewhere within the body.
Doctors will treat open fibula fractures immediately and look for any other injuries. Antibiotics will be administered to avoid infection. A tetanus shot will also be given if it is essential.
The wound will be cleaned thoroughly, examined, stabilized, and then covered so that it can heal properly. An open reduction and internal fixation with bone screws and bone plates may be essential to stabilize the fracture. If the bones are not uniting, a bone graft may be essential to promote healing. Orthopedic implants such as Bone plates and bone screws can be accessible from orthopedic instruments suppliers.
Closed fracture (simple fracture)
In a closed fracture, the bone is broken, but the skin is left intact
The goal of treating closed fractures is to put the bone back in place, control the pain, give the fracture time to heal, prevent complications, and return to the normal function. Treatment begins with the elevation of the leg. Ice is used to relieve the pain and lessen the swelling.
If no surgery is required, crutches are used for mobility and a cast, brace, or walking boot is recommended while healing takes place. Once the area has healed, persons can stretch and strengthen weakened joints with the help of a physical therapist.
There are two main kinds of surgery if a patient requires them:
- Closed reduction involves realigning the bone back to its original position without the need to make an incision at the site of fracture
- Open reduction and internal fixation realign the fractured bone to its original position using hardware such as bone screws, orthopedic plates, and rods
The ankle will be placed into a cast or fracture boot until the process of healing is complete.
Clavicle (collarbone) fractures make up 44% to 66% of all fractures of shoulder. A doctor can often diagnose a clavicle fracture during a physical evaluation, but X-rays and other tests are often recommended. The fracture may also require surgical intervention when Orthopaedic or trauma Implant may be used to fix the fracture.
Diagnosing Clavicle Fractures
X-rays can help determine the extent and location of the injury. At times it is essential to distinguish between a clavicle fracture and an injury to the joint at the top of the shoulder, called the acromioclavicular joint. A CT scan may also be required for more detailed images.
During the physical examination, the physician may do the following tasks:
- Note areas of tenderness
- Observe skin discoloration
- Look for deformities
- Address any open wounds
- Palpate or touch the shoulder blade and ribs to determine if there is an accompanying injury
- Listen to the lungs with a stethoscope, and observe differences in breathing
- Evaluate the shoulder’s range of motion
A doctor may conduct a neurological examination to make sure that motor functions and sensation are normal. The clavicle is located near a series of nerves found based in the shoulder and neck called the brachial plexus. Injury to the brachial plexus is uncommon but can happen with a clavicle break.
The physician will also ask about the medical history of patient, how the injury occurred, and any symptoms associated with it.
Common Causes and Risk Factors of Clavicle Breaks
They may be caused by:
- An athletic event resulting in a fall or direct hit. Clavicle fractures related to sports are commonly seen in children and young adults. Caution is advised when playing contact sports- including rugby, football, and hockey- and when participating in “extreme” sports where falls can happen- such as skateboarding and biking.
- A fall on the shoulder or an extended arm.
- A direct hit to the shoulder in a collision of motor vehicle.
Falling on the shoulder is the common cause of clavicle fractures.
Risk factors for clavicle breaks include:
- Young age, reaching a high point between the ages of 10 and 19. The clavicle is not entirely developed until about 20 years of age.
- Advanced age in both females and males over the age of 70.
- The onset of osteopenia, which is the early stage of reduced bone maps that can eventually lead to osteoporosis.
While certain people are at greater risk for a clavicle fracture, they can affect any person.
Nonsurgical Treatment for a Clavicle Fracture
Nonsurgical treatment for a broken clavicle can include the following:
- A wrap or arm sling is typically worn after the break occurs. This helps to prevent arm movement as the collarbone recovers.
- Pain medication, typically nonsteroidal anti-inti-inflammatory drugs such as ibuprofen or naproxen, can be taken to reduce pain.
- Physical therapy exercises will be recommended once the collarbone starts to mend. The patient will start with mild movements to ease stiffness. More intense exercises will be added after the recovery of bone.
Surgical Treatment for a Clavicle Fracture
Clavicle surgery may be required if the fractured pieces of bone are not in their anatomical and correct location. (The medical term for this is a displaced fracture). In these cases, the bones need to be secured and moved to heal properly. Bone plates, bone screws, and pins are often used during the surgical process. Rehabilitation after surgery includes exercises that can be done at home or with a physical therapist.
Cervical or spine implants are orthopedic devices orthopedic surgeons use to decompress and stabilize the spine. These devices are implanted either from the front (anterior) of the spine or from the back (posterior). Information about anterior implants starts below.
The Aims Of Cervical Spine Surgery Include:
- Reduce pressure on the nerve(s) by decompression (for instance, surgically removing tissues pushing on a nerve).
- Stabilize the cervical spine by fusing 2 or more cervical vertebrae together.
Anterior Cervical Approach Implants
Interbody Cage or Spacers: Cages and spacers are placed between 2 vertebrae. Their purpose is to:
- Keep space between vertebrae (if space gets so narrow, nerve roots may be pinched).
- Preserve spinal alignment (for instance, a healthy neck has a specific curve; a spacer can facilitate restoring this curve).
- Promote spinal fusion (for instance, join (fuse) 2 or more vertebrae together).
Cages are available in various sizes and shapes; some are cylinder-shaped, and others are box-shaped. Cages are placed or fit into the spine between vertebrae. Usually, cages are made from bone, metal, plastic, or carbon fiber. Bone chips (autograft, allograft, other bone graft alternatives, or other bone growth stimulating materials (for instance, demineralized bone matrix) can be packed into the cage. During the months after surgery, the hope is the cage will allow and improve fusion between the vertebrae above and below. Fusion increases spine stability.
Spacers are solid devices and bone cannot be packed inside. A spacer is utilized to facilitate restoring or correct spine alignment.
Anterior cervical plates are attached to the front of 2 or more vertebrae. Bone plates help to:
- Increase the stability of the cervical spine immediately after surgery.
- Increase the chances for a successful solid fusion.
- Stabilize the cervical spine while healing.
- Help to reduce the time the patient can need wearing a cervical collar after surgery.
Plates are made with screw holes through which bone screws are positioned into the adjacent (to be fused) vertebral bodies to anchor the plates into an accurate place. Both plates and screws are available in various sizes and designs. Most plates are made from metal (mostly titanium); some are produced from plastics. Certain newer plates are manufactured from composite substances that dissolve after fusion happens. Some designs of the plate are self-compressing to help promote spinal fusion.
Artificial Cervical Discs
Spine surgeons of the world have an interest in cervical artificial discs to treat degenerative disease. It’s believed keeping movement between vertebrae is better than spinal fusion. Early studies report cervical artificial discs can help slow down the process or prevent adjacent level disc degeneration. The process is called disc arthroplasty. Artificial discs are produced from various materials. Some designs are all plastics and metal composites and other metal. There are numerous ongoing, and some finished, FDA trials of artificial discs underway in the United States. Devices are being cleared for sale and implantation as the studies show safety and efficacy compared to fusion in selected cases.
Conclusion
If your surgeon suggests cervical surgery, you may be encouraged that cervical decompression and stabilization processes are some of the most successful operations spine surgeons perform presently. Patients often have a rapid recovery and quickly return to activities of everyday living with marked improvement of their symptoms.
Siora Surgicals has launched its new orthopedic product range of spine surgery implants or cervical implants which includes Variable Angle Cervical Locking Plate and Cervical Locking Screws in titanium.
A fibula fracture occurs when there is an injury in the leg to one of the two bones of the leg. The leg (the segment between the ankle and knee) is made up of two bones. The larger bone, the tibia, carries most of the weight of the body). The smaller bone, the fibula, is located on the outside part of the leg.
The Fibula
The fibular bone starts just below the knee joint on the outside of the leg and extends all the way down to the ankle joint. The bone is a thin, long bone, hollow in its center. While the bone does little to support the body weight, it is a critical site of attachment for ligaments at both the ankle and knee joint and is also connected to the tibia by a thick ligament called the syndesmosis.
While the fibula is a significant bone, it is possible to extract much of the bone for surgical procedures where the bone is needed elsewhere in the body. When these grafting procedures are performed, people can function very normally, despite missing a large part of the fibula bone.
Types of Fibula Fractures
There are several types of injury to the fibula bone. For this discussion, I will divide them into more manageable topics:
- Fibula fractures that occur due to injury to the ankle joint
- Fibula fractures that occur in conjunction with tibia fractures
- Stress fractures of the fibula
These are not the only types of injury that can occur to the fibula but account for the majority of cases of injury to the fibula bone. By far the most common are injuries that occur when the ankle joint is damaged. Typically, the ankle buckles or is twisted and the fibula is injured as part of the injury.
Symptoms
As mentioned, fibula fractures can occur in association with injuries to the ligaments, other bones, tendons, and tendons around the knee and ankle. The most common symptoms related to the fibula fracture include:
- Pain directly over the fibula bone (outside of the leg)
- Swelling in the fracture part
- Bruising over the injury site
Diagnosis of a fibular fracture can typically be done with an x-ray image. Other imaging studies such as CT scan or MRI are typically not necessary, but there are some situations where a fibular fracture may not show up on a regular x-ray. These conditions include injuries such as stress fractures. Your physician will examine the injury site, the ankle and knee joints for associated injuries which may impact the treatment of the fibular fracture.
Ankle Injuries
Fibula fractures typically occur as part of an ankle injury. Whenever a fibula fracture is found, the ankle joint should be examined for an injury that can be possible.
The most common kind of fracture to occur to the fibula bone is an isolated injury to the end of the fibula bone at the level of the ankle joint. These injuries occur in a similar manner to a badly sprained ankle, and mostly the injury can be treated similarly to a badly sprained ankle.
Fracture Of The Greater Tuberosity: Mechanism Of Fracture
This type of fracture occurs in the following cases of direct and indirect injury.
In cases of a direct injury, the patient falls with the arm in an abducted position. Here, the force is transmitted in an upward direction along the humerus (the long bone in the upper arm). The greater tuberosity encroaches against the acromion process which further leads to the upper end of the humerus fracture.
In other cases, such fractures can occur due to an indirect injury which usually happens before the epiphyseal union. Sudden contraction of the supraspinatus muscle (supraspinatus is a relatively small muscle of the upper back) can produce separation of the greater tuberosity. In the adult age group, the same contracting force the supraspinatus muscle can lead to tearing of the supraspinatus tendon. Our company manufactures Locking Distal Humerus Plate Medial Side 2.7 / 3.5mm for distal humerus fracture.
Diagnosis
Proper diagnosis is very important in all kinds of fractures. Some of the common symptoms that patients often complaints include pain and swelling around the shoulder area. Also, the abduction movement is painful, restricted, or absent X-ray diagnosis or Radiological evidence substantiates the fracture.
While going through the X-ray diagnosis, two views should be taken. Further, the amount of parting of the greater tuberosity must be considered cautiously.
The lesion in case of fracture of the upper end of the humerus can be of the following five types.
I. Fracture without displacement.
II. Nominal displacement of the fragment.
III. Comminuted fracture without displacement.
IV. Under the acromion process, a small piece of bone is pulled upwards
V. Fracture with a coarse displacement of a large piece of bone.
Treatment
In the case of fracture of the upper end of humerus, it is very important to diagnose the condition early and properly. If the condition is not recognized and properly treated, a disability may appear like the abduction disability of the shoulder.
The treatment varies as per the diagnosis. In cases where there is no displacement, a reduction is not required. A simple cuff and collar sling which provides more mobility is useful. Doctors generally prescribe an early exercise of the joints of the limb.
In patients where displacement is there in fracture diagnosis, reduction, as well as maintenance of this reduction of the fracture, is fundamental.
Orthopedic implants experts also use conservative treatment in such cases. In this type of treatment, the affected limb is immobilized in an orthopedic implant like an abduction splint or a plaster spica. It is used to provide an abduction of 30, 60 & 90 degrees. Here, the shoulder is maintained at 90° abduction, 60° external rotation, and 40° forward fixed position. An X-ray of the joint is then done to confirm the reduction. Immobilization or restriction in movement is continued for a period of six weeks.
An operation may also be needed in some cases as discussed below.
In the first case, where there is a failure of closed reduction, fixation of the tuberosity by suture or screw may be required.
In some other cases where the fragment is small, it should be excised and the supraspinatus tendon which passes laterally beneath the cover of the acromion is sutured to the humerus.
Lastly, the after-treatment involves the immobilization of the arm in an abduction splint.
Ankle Arthrodesis/fusion is the end-stage procedure for the treatment of ankle arthritis. Other options available for treating arthritis of the ankle is Joint Replacement Surgery. So, when selecting between arthrodesis and replacement as the optimum procedure for a patient the important considerations are-
1) Infrastructure: – Well equipped OT and Trained Staff
2) Availability of Implants: – Total Ankle still not available in India even in December 2019.
3) Patient’s expectations after surgery: – Total Ankle tolerated well in urban lifestyle.
4) The longevity of the Implant: – 85% survivorship at 10 years in the best of the series.
In low demand patients and financially sound Individuals, arthroplasty finds favor as the cost of the surgery is above 8000 US$.
On all the above counts’ Fusion/ Arthrodesis scores over Arthroplasty. It has been proven beyond doubt that ankle fusion does not produce a bad walking pattern, while it takes away the pain from an individual whose life is already severely compromised due to painful arthritis of the ankle.
Ankle Arthrodesis can be done by either open or arthroscopic techniques:
1) Open Technique: – For moderate to severe deformities. Healthy skin is mandatory for open procedures. Various approaches used are Anterior, Lateral, Lateral+medial, Medial & Posterior.
2) Arthroscopic Technique: – For mild deformities i.e. less than 15 degrees of varus or valgus tilt in the coronal plane. Preferred in the presence of compromised skin and diabetic patients.
Fixation Methods: – Screws, Anterior Plate, Lateral Plate
Plates are used to achieve more stiffness of arthrodesis especially in the presence of osteoporosis.
Fixation by 3 compression screws is biomechanically similar to that of plate
( Clifford C, Berg S, McCann K, Hutchinson B, A biomechanical comparison of internal fixation techniques for ankle Arthrodesis. The Journal of Foot Ankle Surgery 2013;54:188-191).
Authors:-
Dr. Kamal Dureja.
Head of Foot & Ankle Surgery Unit,
Max Smart Superspeciality Hospital, Saket
Website: www.drkamaldureja.com
Dr. Shantanu Bhardwaj.
Fellow in Foot & Ankle Surgery,
Max Smart Superspeciality Hospital, Saket
Implants removal belongs to the foremost common elective orthopedic procedures in industrial countries. In an often-cited Finnish study, implant removal contributed to almost 30 percent of all planned orthopedic operations, and 15 percent of all operations of the department.
Controversy exists as to the necessity for routine orthopedic implant removal. In children, it can be essential to remove implants early to avoid disturbances to the growing skeleton, to avoid their bony confinement making later removal technically hard or impossible, and to enable for planned reconstructive surgery after skeletal maturation (for example, in case of hip dysplasia).
In adults, pain, the resumption of strenuous activities or contact sports after fracture healing, soft tissue irritation, as well as the demand of patient are typical indications for removal of the implant in clinical practice. Numerous surgeons will remember patients whose intractable, barely explainable local symptoms and complaints resolved rapidly after the procedure. Though, ortho implant removal needs a second surgical procedure in scarred tissue and poses a risk for re-fractures and nerve damage.
Pain can even get worse after implant removal. In a series of 109 femoral nail removals, a rise in pain and discomfort was noted in 4/58 (7 percent) of all patients with, and 10/51 (20 percent) of all patients without pre-operative signs. Similar observations were made in subjects who had experienced open reduction and internal fixation of ankle fractures.
Corrosion, systemic release of nickel, cobalt, and chromium, and it’s presumed allergic, toxic, and even carcinogenic potential have been related to stainless steel implants. Yet, none of these adverse effects had influentially been confirmed in the clinical setting. Orthopedic fixation devices made from titanium alloy are considered less vulnerable to degradation and safe to be retained in situ, but aluminum and titanium had been traced in serum and hair of 16 out of 46 patients after spinal instrumentation as well.
It is best to surmise that decision to remove an Orthopedic implant should be taken in consultation with the Surgeon who can help evaluate the need, effectiveness, and risks of this common procedure in different clinical settings.
A humerus fracture is a break of the humerus bone within the top arm. Symptoms may include pain, swelling, and bruising.
Types for Humerus Fracture
Shaft –
The plating technique is used when indicated for the treatment of a fracture of the shaft of the humerus. Depending upon bone anatomy, a broad heavy-duty plate or a narrow plate is used if the humerus is very thin. The plate may be placed on the dorsal surface of the humerus or the volar side. Screws should engage a minimum of six cortices per the main fragment. When LIFP is used, a narrow, longer plate is preferred.
The Distal Humerus –
For the fixation of intra-articular fractures of the distal humerus, a 3.5/4.0mm distal humerus extra articular plate or a malleable reconstruction plate is useful. A reconstruction plate is placed posteriorly on the lateral column and medially on the medial column for maximum support. In the case of bone loss two plates, one medial and one on the lateral side, are applied.
The Proximal Humerus –
Proximal humerus locking plate-PHLP are pre-contoured and anatomically shaped plate for the proximal humerus. It has five holes in the section abutting the head.
These locking screw holes are in different angles to improve the fixation. The first two holes are slanting at an angle of 95 to the plate and are inclined slightly upwards; these screws ascend in the head. The next row also has two screw holes that at 90° to the plate and at an angle of 50 to one another, spreading out in the head. The fifth hole is an integrated hole and is set at an angle of 90 to the plate. This portion of the plate is bent upwards such that the screw ascends in the head.
Related Post: Post-Operative Care for Humerus Fracture
The proximal section also has several holes of 2 mm diameter through which sutures are passed to repair and stabilize the rotator cuff. These holes serve as placement points for the aiming block. The block sits on the plate to guide the threaded drill sleeve and subsequently the drill bit to the perfect angle of screw insertion in the humerus head. Hence, the use of the aiming block is mandatory while applying for this plate. In the plate segment abutting the shaft, four integrated screws holes are deployed. These are used to apply the placement of conventional or locking screws.
In the case of tibial shaft fractures associated with a displaced intra-articular fracture of the knee and the ankle, plating is the most commonly adopted technique.
The tibial plateau fracture and the tibial pilon fracture require accurate open reduction and fixation. Buttress plating is almost always necessary to support epiphyseal-metaphyseal fragments. Plating with Indirect reduction techniques is used for such fractures.
Narrow plates are used is employed to fix fractures of the tibial diaphysis. For the convenience of the operator, Plates are usually applied on the subcutaneous surface of the tibia. Plates may also be applied on the lateral surface. It is essential to engage six cortices on either side of the fracture.
Eccentric insertion of a screw on each side of the fracture is recommended to compress a tibial diaphyseal fracture. If the plate is placed in a too anterior or too posterior position or there is comminution of either cortex, placement of a single screw in each fragment tends to act as a fulcrum around which the fragments can rotate. To avoid it, instead of one, two eccentric screws are inserted in each fragment, prior to compression. Two screwdrivers are used at the same time to compress the fracture from both sides. This technique is consistent with biological plating as it limits the extent of surgical exposure and avoids the use of plate holding forceps: both factors help in maintaining bone vitality.
LIFP metaphyseal plate for the lower end of the tibia [LCP tibial plate, Synthes, Paoli] is pre-contoured to meet the shape and thickness requirement of the area and mode of application. Its ballet tip renders it easier to a minimally invasive surgical technique. The thinned plate profile especially takes the peculiarities of the metaphyseal area into account and provides easy contouring of the plate. The long hole helps to optimize the fine-tuning of the reduction in the longitudinal axis. The dense net of integrated holes in the thinned plate area of the distal end covering the malleolar region allows a closer insertion of the screws and therefore, provides a higher purchase with better stability.
The integrated holes provide a choice of dynamic compression and angular stability in the implant. The angulation of the two outermost hole units towards the center of the thinned plate allows a closer juxta-articular plate placement. A single smaller hole is provided to facilitate temporary fixation with a K-wire. The undercuts on the surface abutting bone face maintain good vascularization of the periosteum. Plates with similar designs are available for fractures in the metaphyseal areas that reach into the proximal tibia, the proximal and distal shaft of the humerus, fibula, and proximal and distal radius as well as ulna.
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