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The centers of rotation of the elbow during a flexion/extension arc all lie within this tight axode Precise wire placement is essential. Anatomically, the axis landmarks are slightly anterior and distal to the medial epicondyle, and just distal to the lateral epicondyle. The wire is placed on one of these points, confirmed fluoroscopically, and advanced slowly with repeated imaging. It must follow the axis. On the lateral view it should be central within the capitellum and trochlea.For a unilateral hinge, the wire need be advanced from lateral to medial only far enough to ensure a perfectly coaxial location and adequate stability. For a fixator with bilateral hinges, the wire must be exposed both medially and laterally.Once the hinges are securely attached to the external fixator structure, the guide wire will be removed. The patient is positioned with the arm abducted and elbow extended on a radiolucent hand table. The C-arm is positioned above the arm table and is rotated approximately 60 degrees from the vertical A fluoroscopic view along the axis of rotation of the elbow. The medial supracondylar ridge (white arrows) is 27% from the posterior humeral border. The periphery of the capitellum (black arrows) is concentric with the trochlea over a 90 degree anterior and distal arc. The center of rotation is the center of these arcs (x) The first humeral pin is inserted free hand. Note that the position of the lateral epicondyle and eventual hinge location (arrow) was marked to help locate the correct position for the humeral pins The axis wand is attached to a humeral pin and a long free pin is used to help orient the wand to the rotation axis. This pin is not drilled into the bone An intra-operative fluoroscopic view of an unstable elbow shows the typical radiographic appearance of the axis landmarks of the distal humerus and the positioning of the axis wand The wand has been locked in position and the circular hinge is precisely oriented to the wand by a pin wh
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