5 - Atlas of Reference Positions PDF

Atlas for the Insertion of Transosseous
Element Reference Positions 5

Leonid Nikolaevich Solomin, Roman Nikolaevich Inyushin,
Pavel Nikolaevich Kulesh, Maxim Vasil’evich Andrianov,
Dmitry Alexandrovich Mykalo, Nikolay Fedorovich
Fomin, Sergey Valerjevich Majkov,
and Konstantin Andreevich Ukhanov
The atlas of positions for the correct insertion of transosseous Reference positions (RP) for transosseous element inser-
elements utilizes the coordinate system of MUDEF (Chap. 4). tion are indicated at each level with an arrow. RPs are located
Each limb segment is divided into eight principal levels, and where soft-tissue displacement is at a minimum during
each level is marked by 12 positions. movement of the adjacent joint (the method for defining RPs
The major blood vessels and nerves at each level are is described in Chap. 35). Thus, the designation and use of
grouped into special zones designated by the letters A, B, C, RPs allows: (a) the avoidance of damage to the principal ves-
and D. Due to the characteristically variable anatomy, and sels and nerves, (b) a reduction in the incidence of pin-
taking into consideration the possible changes in surface induced joint stiffness, and (c) a reduction in the incidence of
anatomy following displacement of the bone fragments, the infectious complications (pin-tract infection).
areas adjacent to the vessels and nerves are considered con- Diagrams of the anatomic-functional sections for each
traindicated positions for the insertion of transosseous pins segment are shown below. Note that RPs are not located at
or wires. all levels but they are located symmetrically across a bone;
Of the 12 positions, those remaining after disallowing the for example, positions 3 and 9, 1 and 7, 6 and 12, etc. It is
contraindicated positions are considered safe positions; they possible to insert a wire at the projection of the positions
allow the insertion of transosseous elements without damage given, and to insert a half-pin using part of any recommended
to the principal vessels and nerves. position. Where there is no second (symmetrically located)
position, only a half-pin should be used. More detailed
information about the choice of transosseous elements is
presented in Chap. 7.
L.N. Solomin, M.D., Ph.D. (*) The images of the recommended transosseous elements
R.R. Vreden Russian Research Institute of Traumatology are accompanied by their MUDEF designations. As the angle
and Orthopedics, Professor of Surgery Chair, Medical Faculty of half-pin insertion is defined by the requirements to achieve
of Saint Petersburg State University, 8 Baykova Str., optimum biomechanics in a particular clinical situation, in
St. Petersburg 195427, Russia
e-mail: solomin.leonid@gmail.com the submitted schemes the actual digital values of the inser-
tion angles of the half-pins are not specified.
R.N. Inyushin, M.D., Ph.D.
Department of Orthopedics, City Polyclinic No 25, Solodarnosti Str., 1, The acupuncture points and classic meridians are shown
St. Petersburg 193312, Russia in Fig. 5.1. The upper extremities are crossed by the follow-
P.N. Kulesh, M.D., Ph.D. • D.A. Mykalo, M.D., Ph.D. • S.V. Majkov ing meridians: lung (P), large intestine (GI), triple energizer
Department of Orthopedics, R.R. Vreden Russian Research (TR), small intestine (IG), heart (C), and pericardium (MC).
Institute of Traumatology and Orthopedics, 8 Baykova Str., The lower extremities are crossed by the following meridi-
St. Petersburg 195427, Russia ans: stomach (E), liver (F), spleen (Rp), kidneys (R), bladder
M.V. Andrianov, M.D., Ph.D. (V), and gallbladder (VB).
Department of Orthopedics, City Adult Outpatient Department No 6, The atlas shows the projections of the acupuncture points
Elizarov Str., 32, Build. 2, St. Petersburg 192148, Russia
and meridians on the skin. The zones where the levels are
N.F. Fomin, M.D., Ph.D. crossed by the meridians are designated in the section dia-
Department of Surgery, Kirov Military Academy,
Lebedeva Str., 6, St. Petersburg 199106, Russia grams according to the recommendations of [80]. The coinci-
dences of levels and the acupuncture points are designated
K.A. Ukhanov
Central Regional Hospital, Urotskogo Str., 1, according to the French system of transcription. Only the des-
Gatchina 188300, Russia ignations in letters correspond to the crossing of a level by a
L.N. Solomin (ed.), The Basic Principles of External Skeletal Fixation Using the Ilizarov and Other Devices, 63
DOI 10.1007/978-88-470-2619-3_5, © Springer-Verlag Italia 2008, 2012
64 L.N. Solomin et al.
a b
Fig. 5.1 (a, b) Meridian diagrams according to [86]
meridian. Where the safe positions and RPs are identified, the in order to achieve correct placement of the fixation ele-
projections of the acupuncture points and meridians are not ments. In cases of angular deformity, shortening, or dyspla-
shown because the meaning of a transosseous element pass- sia of the extremity, the ability to define the contraindicated
ing through a reflex zone is still a matter of controversy positions is enhanced by adjunctive studies such as comput-
[80–85]. erized tomography, MRI, and angiography.
The diagrams shown in the atlas are oriented in the ana- Figures for the following sections were taken from the
tomic-topographic norm. Prior to transosseous element 2005 electronic Atlas for Insertion of Transosseous Element
insertion, both elimination of the severe displacement of “Reference Positions” (http://rniito.org/solomin/download/
bone fragments and restoration of the limb axis are required atlas-engl.zip and http://ortho-suv.org).
5 Atlas for the Insertion of Transosseous Element Reference Positions 65
5.1 Upper Arm
Leonid Nikolaevich Solomin and

Roman Nikolaevich Inyushin
The figures show sections at each of the principal levels

(I–VIII) of the upper arm. In the anatomic functional sec-
tions of the upper arm, the thick arrows designate the posi-
tions at which soft-tissue displacement is minimal for all
movements of the shoulder and elbow joints: flexion, exten-
sion, abduction, rotation. The thin arrows designate the posi-
tions at which soft-tissue displacement is minimal for most
movements: flexion, extension, abduction.
Of 93 positions, 60 (64.5%) are safe positions as defined
according to MUDEF (positions 2–4 at level I are not consid-
ered due to anatomic constraints). In the humerus, there are
29 RPs (31.2%) for transosseous element insertion. The
insertion of K-wires is prudent and safe only at levels III,
IV,V,VII, and VIII.
On the humerus there are three Yin meridians with a
centrifugal direction of energy, those of the lung (P), heart
(C), and pericardium (MC). There are three Yang meridians
with a centripetal direction of energy, those of the large
bowel (GI), triple energizer (TR), and small bowel (IG).
The meridians on the humerus are represented by 22 active
points.
Level I (Figs. 5.2, 5.3, and 5.4)

Contraindicated positions: 3, 4
Safe positions: 1, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions: 8, 9, 10, 11
Comments. Only console transosseous elements can be used in the projection of positions 8, 9, and
10. The use of positions 8, 10, and 11 is optimal at this level because the transosseous elements will
minimally restrict soft-tissue displacement with shoulder joint motion.
11 12 1
2 A
a.axilaris; v.axilaris
10 n.medianus; n.ulnaris; n.radialis
GI
9 3
8 Tr
Fig. 5.2 4
IG
7 6 5
Fig. 5.3
The transosseous elements recommended for use at humeral level I are I,8; I,10; and I,11.
I,11 12
I,10
9 3
I,9
I,8
Fig. 5.4
Level II (Figs. 5.5, 5.6, and 5.7)

Contraindicated positions: 1, 2, 3, 4
Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 7, 8, 9,
and 10. The use of positions 8, 10, and 11 is optimal at this level because the transosseous elements
will minimally restrict soft-tissue displacement relative to the shoulder during motion of the gle-
nohumeral joint.
11 12 1
P
A
a.brachialis
2
10 v.brachialis
n.medianus
n.ulnaris
B
GI MC n.radialis
9 3
C
C n.musculo-cutaneus
Tr
Fig. 5.5
D
8 4 v.cephalica
IG
7 6 5
Fig. 5.6
The transosseous elements recommended for use at humeral level II are II,8; II,9; II,10; and II,11.
12
II,11
II,10
9 3
II,9
II,8
Fig. 5.7
Level III (Figs. 5.8, 5.9, and 5.10)

Safe positions: 2, 6, 7, 8, 9, 10, 11, 12
Reference positions: 9, 10, 11
10, and 11. The radial nerve lies close to the humerus in the projection of positions 4 and 5. The place-
ment of console transosseous elements at positions 10 and 11 should perforate only the anterolateral
cortical plate. The use of positions 9, 10, and 11 is optimal at this level because the transosseous ele-
ments will minimally impede soft-tissue displacement to the shoulder during motions of the gle-
nohumeral and (to a lesser degree) to the elbow joints.
12 1
11 P
A
a.brachialis
v.brachialis
10 n.medianus
2 n.ulnaris
MC2 n.cutaneus antebrachii medialis
n.cutaneus brachii medialis
v.basilica
GI C
9 3 B
n.radialis
Fig. 5.8 a.profunda brachii
C
n.musculo-cutaneus
4
8
IG
Tr13
7 6 5
Fig. 5.9
The transosseous elements recommended for use at humeral level III are III,9; III,10; and III,11.
12
III,11
III,10
9 3
III,9
Fig. 5.10
Level IV (Figs. 5.11, 5.12, and 5.13)

Contraindicated positions: 1, 3, 5, 6, 7
Safe positions: 2, 4, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 9, 11,
and 12. The close disposition of the radial nerve to the humeral bone in the projection of positions 5
and 6 suggests that in the projection of positions 11 and 12 console transosseous elements should be
used that perforate only the anterior cortical plate. The use of positions 8, 9, 10, and 11 is optimal at
this level because in this case the transosseous elements will minimally impede soft-tissue displace-
ment relative to the shoulder during motions of the adjacent joints.
11 12 P3 1
A
MC a.brachialis
2 v.brachialis; v.basilica
n.medianus; n.ulnaris
10
n.cutaneus antebrachii medialis
n.cutaneus brachii medialis
a.collateralis ulnaris superior
B
9 3 n.radialis
C a.profunda brachii
Fig. 5.11
GI14
C
n.musculo-cutaneus
8
4
IG
Tr
7 6 5
Fig. 5.12
The transosseous elements recommended for use at humeral level IV are IV,8; IV,9; IV,10; and IV,11.
IV,11 12
IV,10
9 3
IV,9
IV,8
Fig. 5.13
Level V (Figs. 5.14, 5.15, and 5.16)

Contraindicated positions: 1, 2, 3, 7, 8, 9
Safe positions: 4, 5, 6, 10, 11, 12
Reference positions: 4, 5, ,10
Comments. The use of positions 4, 10, and 11 is optimal at this level because the transosseous ele-
ments will minimally interfere with soft-tissue displacement relative to the shoulder during motions of
the adjacent joints.
11 12 1
P
A
a.brachialis
MC 2 v.brachialis; v.basilica
n.medianus; n.ulnaris
10
B
n.radialis
9 3 a.profunda brachii
GI C
C
n.musculo-cutaneus
Fig. 5.14
8
4
Tr13 IG
7
5
6
Fig. 5.15
The transosseous elements recommended for use at humeral level V are V,4; V,5; V,6; V,10; and V,4-10.
12
9 3
V,4−10
V,6
6
V,5
Fig. 5.16
Level VI (Figs. 5.17, 5.18, and 5.19)

Safe positions: 1, 4, 5, 6, 7, 8, 11
8. The use of positions 4, 7, and 8 is recommended at this level because the transosseous elements will
minimally impinge on the soft-tissue displacement relative to the shoulder during motions of the gle-
nohumeral and (to a lesser degree) elbow joints.
11 12 1 A
P a.brachialis
v.brachialis
n.medianus
v.basilica
2 n.cutaneus antebrachii medialis
MC
10
B
n.ulnaris
C2
9 3
C
Gl13 n.radialis
Fig. 5.17
a.profunda brachii
IG
8
Tr 4 D
n.musculo-cutaneus
7 6 5
Fig. 5.18
The transosseous elements recommended for use at humeral level VI are VI,4; VI,7; and VI,8.
12
9 3
VI,8
VI,4
VI,7 6
Fig. 5.19
Level VII (Figs. 5.20, 5.21, and 5.22)

Safe positions: 1, 3, 5, 6, 7, 8, 9
Comments. Only console transosseous elements can be used in the projection of positions 5, 6, and 8.
The use of positions 3, 8, and 9 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the shoulder during motions of the elbow joint.
11 12 1
A
P a.brachialis
MC
v.brachialis
v.basilica
2
10
Gl C
B
n.ulnaris
a.collateralis ulnaris
9 3 C
n.radialis
a.collateralis radialis
Fig. 5.20
D
n.musculo-cutaneus
8 Tr11
IG 4
7 6 5
Fig. 5.21
The transosseous elements recommended for use at humeral level VII are VII,3; VII,8; VII,9; and
VII,3-9.
12
VII,3−9
9 3
VII,8
Fig. 5.22
Level VIII (Figs. 5.23, 5.24, and 5.25)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10
Comments. Positions 5, 6, and 7 are conditionally safe because the use of transosseous elements in
the olecranon will lead to a limitation of elbow-joint motion. Only console transosseous elements can
be used in the projection of position 8. The use of positions 3, 4, 8, and 9 is best at this level because
the transosseous elements will minimally impede the soft-tissue displacement relative to the shoulder
during motions of the elbow joint.
11 12 1
A
a.brachialis
v.v.brachialis
2
10 v.basilica
P5 MC3 n.mediamus
C3 a.collateralis ulnaris inferior
B
Gl12 n.ulnaris
9 3
IG8 C
n.radialis
Tr10 a.collateralis radialis
Fig. 5.23
D
8 4 n.musculo cutaneus
E
7 6 5
Fig. 5.24
The transosseous elements recommended for use at humeral level VIII are VIII,3; VIII,4; VIII,8;
VIII,9; and VIII,3-9.
12
VIII,3−9
9 3
VIII,8 VIII,4
Fig. 5.25
5.2 Ulna
Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh
The figures show sections through the forearm at each of the

principal levels (I–VIII) relative to the ulna in the mid-posi-
tion (between pronation and supination, see pages 75–82), in
supination (see pages 83–90), and in pronation (see pages
91–98), respectively.
Our studies have demonstrated that physiological move-
ments in the radioulnar joints (forearm rotation) do not
exceed 12–140°: 65° ± 5° for supination and pronation.
Evaluation at level VIII showed that the ulna and radius are
placed strictly in the frontal plane. The noted position of the
radius relative to the ulna is represented in the diagrams.
We also determined that 77% of the positions are safe
positions for the insertion of transosseous elements. To pro-
vide functional rotation alone during fixation treatment, there
are only 26 RPs (30%), indicated by arrows. The positions
that provide only free flexion and extension in the elbow and
radiocarpal joints (33% of the positions) are indicated by a
thickened projection lines.
Wires inserted at six distal levels (the goal of which is to
change the spatial orientation of the bone fragments) must
later be changed to half-pins inserted in the orientation; these
are indicated by arrows.
On the forearm there are three Yin meridians with a cen-
trifugal direction of energy, those of the lung (P), heart (C),
and pericardium (MC). There are three Yang meridians with
a centripetal direction of energy: those of the bowel (GI),
triple energizer (TR), and intestine (IG). The meridians on
the forearm are represented by 27 active points.
In accordance with MUDEF, transosseous elements in the
radius are enclosed in parentheses. Note that (VIII,12-6)
VIII,12-6 and VIII,6-12(VIII,6-12) designate the same wire
inserted at level VIII through both bones, but in the first case
the wire is inserted from the radial side and in the second
from the ulnar side.
5.2.1 Ulna, Mid-Position
Level I (Ulna, mid-position) (Figs. 5.26, 5.27, and 5.28)

Contraindicated positions: 1, 3, 12
Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11
Reference positions: 4, 5, 6, 7, 8, 9, 10
Reference positions with safe rotation: 4, 5, 6, 7, 8, 9, 10
9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level. The transosseous elements will mini-
mally impinge on the soft tissues relative to the ulna during motions of the elbow and radioulnar joints.
11 12 1 A
a.radialis
v.radialis
a.ulnaris
GI11 P5 v.ulnaris
n.medianus
2 B
MC3 n.radialis
10
(r.superficialis et r.profundus)
C
n.ulnaris
C3
9 3
Fig. 5.26 Tr
IG8
8
4
7 6 5
Fig. 5.27
The transosseous elements recommended for use at ulnar level I are I,4; I,5; I,5(I,5); I,6; I,7; I,8; I,9;
I,10; and I,4-10.
12
1,9
9 3
1,4−10
1,8
1,6 1,5
1,7 6
Fig. 5.28
Level II (Ulna, mid-position) (Figs. 5.29, 5.30, and 5.31)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
and 9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the tran-
sosseous elements will minimally impinge on the soft tissues relative to the ulna during motions of the
elbow and radioulnar joint.
11 12 1 A
a.radialis
v.radialis
n.radialis (r.superficialis)
GI10
P
B
2 n.radialis (r.profundus)
10
MC C
n.ulnaris
Fig. 5.29 9 3 D
Tr n.medianus
C
a.ulnaris
v.ulnaris
IG
8
4
7 6 5
Fig. 5.30
The transosseous elements recommended for use at ulnar level II are II,4; II,5; II,6; II,6(II,6); II,7;
II,8; II,9; II,10; and II,4-10.
12
II,9
9 3
II,8
I,4−10
II,7 II,6 II,5
Fig. 5.31
Level III (Ulna, mid-position) (Figs. 5.32, 5.33, and 5.34)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions: 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions with safe rotation: 4, 5, 6, 7, 8
Comments. Only console transosseous elements can be used in the projection of positions 7 and 8.
The use of positions 4, 5, 6, 7, and 8 is optimal at this level because in this case the transosseous ele-
ments will minimally impinge on the soft-tissue displacement relative to the ulna during motions of the
elbow and radioulnar joint. The insertion of transosseous elements in the projection of positions 3, 9,
10, 11, and 12 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
n.radialis (r.superficials)
P
GI9
B
2
n.medianus
MC
10
Tr C
a.ulnaris
v.ulnaris
Fig. 5.32
D
9 3
C n.ulnaris
IG
8
7 6 5 4
Fig. 5.33
The transosseous elements recommended for use at the ulnar level III are III,3; III,4; III,5; III,6;
III,6(III,6); III,7; III,8; III,9; III,10; III,11; III,3-9; III,4-10; III,5-11; III,6-12(III,6-12); and (III,12)III,12.
12
(III,6−12)III,6−12
III,3−9
9 3
III,8
III,4−10
III,7 III,5−11
Fig. 5.34
Level IV (Ulna, mid-position) (Figs. 5.35, 5.36, and 5.37)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions with safe rotation: 5, 6, 7
9. The use of positions 5, 6, and 7 is optimal at this level because in this case the transosseous elements
will minimally impinge on the soft-tissue displacement relative to the ulna during motions of the
elbow and radioulnar joint, and during forearm rotation. The insertion of transosseous elements in the
projection of positions 4, 8, 9, and 10 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
P
GI
2 B
n.medianus
10
Tr C
MC a.ulnaris
v.ulnaris
Fig. 5.35 n.ulnaris
C
9 3
IG
4
7 6 5
Fig. 5.36
The transosseous elements recommended for use at ulnar level IV are IV,4; IV,5; IV,6; IV,6(IV,6);
IV,7; IV,8; IV,9; IV,10; and IV,4-10.
12
IV,9
9 3
IV,8
IV,4−10
IV,7 IV,6 IV,5
Fig. 5.37
Level V (Ulna, mid-position) (Figs. 5.38, 5.39, and 5.40)

Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions: 5, 6, 7, 8, 9, 10, 11, 12
The use of positions 5, 6, 7 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and radi-
oulnar joints and during forearm rotation. The insertion of transosseous elements in the projection of
positions 8, 9, 10, 11, and 12 will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
P6
GI7
2
B
10 MC n.medianus
C
Fig. 5.38 a.ulnaris
v.ulnaris
9 3
C n.ulnaris
IG7
4
7 6 5
Fig. 5.39
The transosseous elements recommended for use at ulnar level V are V,5; V,5-11; V,6; V,6-
12(V,6-12); V,6(V,6); V,7; V,8; V,9; V,10; V,11; and (V,12)V,12.
12
(V,12−6)V,12−6
V,10
V,9
9 3
V,8
V,7 V,5−11
6
Fig. 5.40
Level VI (Ulna, mid-position) (Figs. 5.41, 5.42, and 5.43)

Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11, 12
The use of positions 5, 6, and 7 is optimal at this level because in this case the transosseous elements
will minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and
radioulnar joint and during forearm rotation. The insertion of transosseous elements in the projection
of positions 8, 9, 10, 11, and 12 will provide free flexion and extension in the joints adjacent to the
forearm, but will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
GI
P 2
B
10
n.medianus
Tr6
Fig. 5.41 MC C
Tr7 a.ulnaris
9 3 v.ulnaris
n.ulnaris
C
IG
4
7 6 5
Fig. 5.42
The transosseous elements recommended for use at ulnar level VI are VI,5; VI,5-11; VI,6;
VI,6(VI,6); VI,6-12(VI,6-12); VI,7; VI,8; VI,9; VI,10; VI,11; and (VI,12)VI,12.
12
(VI,12−6)VI,12−6
VI,10
VI,9
9 3
VI,8
VI,7 VI,5−11
Fig. 5.43
Level VII (Ulna, mid-position) (Figs. 5.44, 5.45, and 5.46)

Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions with safe rotation: 6, 7
The use of positions 6 and 7 is optimal at this level because the transosseous wires will minimally
impede the soft-tissue displacement relative to the ulna with range of motion in the elbow, and to the
radioulnar joints during forearm rotation. The insertion of transosseous elements in the projection of
positions 5, 8, 9, 10, 11, and 12 will provide free flexion and extension in the radiocarpal joint, but will
limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
B
GI n.medianus
2
C
10 P
a.ulnaris
Tr5 v.ulnaris
n.ulnaris
Fig. 5.44 MC6
9 3
IG C4
8
4
7 6 5
Fig. 5.45
The transosseous elements recommended for use at ulnar level VII are VII,5; VII,5-11; VII,6;
VII,6-12(VII,6-12); VII,6(VII,6); VII,7; VII,8; VII,9; VII,10; VII,11; and (VII,12)VII,12.
12
(VII,12−6)VII,12−6
VII,10
VII,9
9 3
VII,8
VII,7 VII,5−11
6
Fig. 5.46
Level VIII (Ulna, mid-position) (Fig. 5.47, 5.48, and 5.49)

Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
Reference positions: 6, 7, 8, 11, 12
Reference positions with safe rotation: 6
Comments. Only console transosseous elements can be used in the projection of positions 7, 8, 9
and 10. The use of position 6 is optimal at this level, as the transosseous elements will minimally inter-
fere with soft-tissue displacement relative to the ulna with elbow and radioulnar forearm rotation. The
insertion of transosseous elements in the projection of positions 7, 8 and 12 will allow unimpeded
flexion and extension at the radiocarpal joint, but will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
GI
P8 B
2 n.medianus
10
Tr4 MC C
a.ulnaris
v.ulnaris
9 3 n.ulnaris
Fig. 5.47
C6
IG5
8
4
7 6 5
Fig. 5.48
The transosseous elements recommended for use at ulnar level VIII are VIII,6; VIII,6-12(VIII,6-12);
VIII,6(VIII,6); VIII,7; VIII,8; and (VIII,12)VIII,12.
VII,11 12
(VIII,12−6)VIII,12−6
9 3
VIII,8
VIII,7
Fig. 5.49
5.2.2 Ulna, Supination
Level I (Ulna, supination) (Figs. 5.50, 5.51, and 5.52)

Safe positions: 2, 4, 5, 6, 7, 8, 9, 10, 11
9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because the transosseous elements
will minimally impinge on the soft tissues relative to the ulna during motions of the elbow and the
radioulnar joint.
11 12 1
A
P5 a.radialis
v.v.radialis
a.ulnaris
v.v.ulnaris
MC3 n.medianus
10
2
B
GI11 n.radialis
C3
9 3 C
Fig. 5.50 n.ulnaris
Tr
IG8
8 4
7 6 5
Fig. 5.51
I,10; and I,4-10.
12
I,9
9 3
I,8 I,4-10
I,7 I,6 I,5

6
Fig. 5.52
Level II (Ulna, supination) (Figs. 5.53, 5.54, and 5.55)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
sosseous elements will minimally impinge on the soft tissues relative to the ulna during motions of the
elbow and the radioulnar joint.
11 12 1
A
a.radialis
P v.radialis
n.radialis
(r.superficialis)
MC
2
10 GI10 B
C
n.radialis (r.profundus)
C
n.ulnaris
Fig. 5.53 9 3
Tr
D
n.medianus
IG a.ulnaris
v.ulnaris
8
4
7 6 5
Fig. 5.54
II,8; II,9; II,10; and II,4-10.
12
II,9
9 3
II,8 II,4−10
II,7 II,6 II,5
Fig. 5.55
Level III (Ulna, supination) (Figs. 5.56, 5.57, and 5.58)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10
and 8. The use of positions 4, 5, 6, 7, and 8 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the ulna during motions of the
elbow and the radioulnar joint. The insertion of transosseous elements in the projection of positions 3,
9, and 10 will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
P n.radialis
MC (r.superficialis)
B
2
10 n.medianus
C C
a.ulnaris
v.ulnaris
GI9
Fig. 5.56 9 3
D
Tr n.ulnaris
IG
8
4
7 6 5
Fig. 5.57
The transosseous elements recommended for use at ulnar level III are III,3; III,4; III,5; III,5(III,5);
III,6; III,7; III,8; III,9; III,10; III,3-9; and III,4-10.
12
III,3−9
9 3
III,8 III,4−10
III,7 III,6 III,5

6
Fig. 5.58
Level IV (Ulna, supination) (Figs. 5.59, 5.60, and 5.61)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10
and 8. The use of positions 5, 6, and 7 is optimal at this level because in this case the transosseous ele-
ments will minimally impede soft-tissue displacement relative to the ulna during motions of the elbow
and the radioulnar joint. The insertion of transosseous elements in the projection of positions 3, 4, 8,
9, and 10 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
n.radialis
(r.superficialis)
P
MC B
2 n.medianus
10
C
C
GI
a.ulnaris
v.ulnaris
Fig. 5.59 n.ulnaris
9 3
Tr IG
8 4
7 6 5
Fig. 5.60
The transosseous elements recommended for use at ulnar level IV are IV,3; IV,4; IV,5; IV,5(IV,5);
IV,6; IV,7; IV,8; IV,9; IV,10; IV,3-9; and IV,4-10.
12
IV,10−4
IV,9−3
9 3
IV,8
IV,5
IV,7 IV,6
6
Fig. 5.61
Level V (Ulna, supination) (Figs. 5.62, 5.63, and 5.64)

Safe positions: 3, 4, 5, 6, 7, 8, 9, 10
and 8. The use of position 6 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and the
radioulnar joint and during forearm rotation. The insertion of transosseous elements in the projection
of positions 3, 4, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints
but will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
n.radialis (r.superficials)
MC
10 P6 B
2 n.medianus
C
C
GI7 a.ulnaris
Fig. 5.62
v.ulnaris
9 3 n.ulnaris
IG7
Tr
4
8
7 6 5
Fig. 5.63
The transosseous elements recommended for use at ulnar level V are V,3; V,4; V,4(V,4); V,5; V,6;
V,7; V,8; V,9; (V,10)V,10; V,3-9; and V,4-10(V,4-10).
12
(V,10−4)V,10−4
V,9−3
9 3
V,8
V,5
V,7 V,6
6
Fig. 5.64
Level VI (Ulna, supination) (Figs. 5.65, 5.66, and 5.67)

Safe positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
7. The use of position 6 is optimal at this level because in this case the transosseous elements will mini-
mally impede soft-tissue displacement relative to the ulna during motions of the elbow and the radi-
oulnar joint and during forearm rotation. The insertion of transosseous elements in the projection of
positions 3, 4, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints
11 12 1
A
a.radialis
v.radialis
10 MC
P 2 B
n.medianus
C
GI C
Fig. 5.65 a.ulnaris
9 3 v.ulnaris
IG n.ulnaris
Tr7
Tr6
4
8
7 6 5
Fig. 5.66
The transosseous elements recommended for use at ulnar level VI are VI,3; VI,4; VI,4(VI,4); VI,5;
VI,6; VI,7; VI,8; VI,9; (VI,10)VI,10; VI,3-9; and VI,4-10(VI,4-10).
12
(VI,10−4)VI,10−4
VI,3−9
9 3
VI,8
VI,5
VI,7
VI,6
6
Fig. 5.67
Level VII (Ulna, supination) (Figs. 5.68, 5.69, and 5.70)

Safe positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
Reference positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
positions 2, 3, 4, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints
11 12 1 A
a.radialis
v.radialis
B
10
medianus
P MC6
2
C
C4 a.ulnaris
GI v.ulnaris
n.ulnaris
9 3
IG
Fig. 5.68 Tr5
8
7 6 5
Fig. 5.69
The transosseous elements recommended for use at ulnar level VII are VII,2; VII,3; VII,4; VII,4(VII,4);
VII,5; VII,6; VII,7; VII,8; VII,9; (VII,10)VII,10; VII,2-8; VII,3-9; and VII,4-10(VII,4-10).
12
(VII,10−4)VII,10−4
VII,9−3
9 3
VII,8−2
VII,7 VII,5
VII,6
6
Fig. 5.70
Level VIII (Ulna, supination) (Figs. 5.71, 5.72, and 5.73)

Safe positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
positions 2, 3, 4, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints
11 12 1
A
a.radialis
v.radialis
10
P6 B
MC 2
C n.medianus
C
Fig. 5.71 GI7 a.ulnaris
9 3 v.ulnaris
IG7 n.ulnaris
Tr
8
7 6 5
Fig. 5.72
The transosseous elements recommended for use at ulnar level VIII are VIII,2; VIII,3;
VIII,4; VIII,4(VIII,4); VIII,5; VIII,6; VIII,7; VIII,8; VIII,9; (VIII,10)VIII,10; VIII,2-8; VIII,3-9; and
VIII,4-10(VIII,4-10).
12
VIII,9−3
9 3
VIII,8−2
VIII,5
VIII,7
VIII,6
6
Fig. 5.73
5.2.3 Ulna, Pronation
Level I (Ulna, pronation) (Figs. 5.74, 5.75, and 5.76)

Safe positions: 2,4,5, 6, 7, 8, 9, 10, 11
9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the tran-
sosseous elements will minimally impede soft-tissue displacement relative to the ulna during motions
of the elbow and the radioulnar joint.
11 12 1
A
a.radialis
P5 v.v.radialis
GI11
a.ulnaris
v.v.ulnaris
n.medianus
2
10
MC3
B
n.radialis
9 3
Fig. 5.74 Tr C
C3 n.ulnaris
IG8
8
7 6 5 4
Fig. 5.75
I,10; and I,4-10.
12
I,9
9 3
I,8
I,4−10
I,7 I,5
I,6
6
Fig. 5.76
Level II (Ulna, pronation) (Figs. 5.77, 5.78, and 5.79)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
sosseous elements will minimally impede soft-tissue displacement relative to the ulna during motions
of the elbow and the radioulnar joint.
11 12 1
A
GI10 a.radialis
P v.radialis
n.radialis (superficialis)
2 B
a.radialis (r.profundus)
10 MC
C
n.ulnaris
Fig. 5.77 9 3
Tr C D
n.medianus
a.ulnaris
v.ulnaris
8
IG
7 6 5 4
Fig. 5.78
II,8; II,9; II,10; and II,4-10.
12
II,9
9 3
II,8
II,4−10
II,7 II,6
II,5
6
Fig. 5.79
Level III (Ulna, pronation) (Figs. 5.80, 5.81, and 5.82)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
Reference positions with safe rotation: 4, 5, 6, 7, 8, 9
9. The use of positions 4, 5, 6, 7, 8, and 9 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the ulna during motions of the
elbow and the radioulnar joint. The insertion of transosseous elements in the projection of position 10
will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
GI9 n.radialis (r.superficialis)
B
2
n.medianus
P C
10
a.ulnaris
v.ulnaris
Fig. 5.80
MC D
9 3 n.ulnaris
Tr
8 IG
C
7 6 5 4
Fig. 5.81
The transosseous elements recommended for use at ulnar level III are III,4; III,5; III,6; III,7;
III,7(III,7); III,8; III,9; III,10; and III,4-10.
12
9 3
III,8
III,4−10
III,7 III,6 III,5
6
Fig. 5.82
Level IV (Ulna, pronation) (Figs. 5.83, 5.84, and 5.85)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 7, 8 and
9. The use of positions 5, 6, and 7 is optimal at this level because in this case the transosseous elements
will minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and
the radiocarpal joints and during forearm rotation. The insertion of transosseous elements in the pro-
jection of positions 4, 8, 9, 10, and 11 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
GI
2 B
n.medianus
10 C
P
a.ulnaris
v.ulnaris
Tr
n.ulnaris
Fig. 5.83 9 3
MC
IG
8 C
7 6 5 4
Fig. 5.84
The transosseous elements recommended for use at ulnar level IV are IV,4; IV,5; IV,6; IV,7;
IV,7(IV,7); IV,8; IV,9; IV,10; IV,11; IV,4-10; and IV,5-11.
12
IV,10−4
IV,9
9 3
IV,8
IV,7
IV,6 IV,5−11
6
Fig. 5.85
Level V (Ulna, pronation) (Figs. 5.86, 5.87, and 5.88)

Safe positions: 1, 5, 6, 7, 8, 9, 10, 11, 12
10. The use of position 6 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and radio-
carpal joints and during forearm rotation. The insertion of transosseous elements in the projection of
positions 1, 5, 7, 8, 9, and 10 will limit forearm rotation.
11 12 1 A
a.radialis,
v.radialis,
GI7 n.radialis
(r.superficialis)
2
P6 B
10 n.medianus
Tr
C
a.ulnaris
Fig. 5.86 v.ulnaris
9 3 n.ulnaris
MC
IG7
8 C
4
7 6 5
Fig. 5.87
The transosseous elements recommended for use at ulnar level V are (V,1)V,1; V,5; V,6; V,7; V,7-
1(V,7-1); V,7(V,7); V,8; V,9; and V,10.
12
(V,1−7)V,1−7
V,10
V,9
9 3
V,8
V,6 V,5
Fig. 5.88
Level VI (Ulna, pronation) (Figs. 5.89, 5.90, and 5.91)

Safe positions: 1, 5, 6, 7, 8, 9, 10, 11, 12
positions 1, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints but
11 12 1 A
a.radialis
v.radialis
Tr6
2
Tr7 GI B
n.medianus
10
P C
a.ulnaris
v.ulnaris
Fig. 5.89 9 3 n.ulnaris
IG
MC
C
8
4
7 6 5
Fig. 5.90
The transosseous elements recommended for use at ulnar level VI are (VI,1)VI,1; VI,5; VI,6; VI,7;
VI,7-1(VI,7-1); VI,7(VI,7); VI,8; VI,9; and VI,10.
12
(VI,1−7)VI,1−7
VI,10
VI,9
9 3
VI,8
VI,6 VI,5
Fig. 5.91
Level VII (Ulna, pronation) (Figs. 5.92, 5.93, and 5.94)

Safe positions: 1, 2, 5, 6, 7, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 9 and
positions 2, 5, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints but
11 12 1 A
a.radialis
v.radialis
2 B
Tr5
GI n.medianus
10
C
P a.ulnaris
v.ulnaris
n.ulnaris
9 3
Fig. 5.92
MC6
IG
C
8
7 6 5
Fig. 5.93
The transosseous elements recommended for use at ulnar level VII are (VII,2)VII,2; VII,5; VII,6;
VII,7; VII,8; VII,8-2(VII,8-2); VII,8(VII,8); VII,9; and VII,10.
12 (VII,1−7)VII,1−7
VII,10
VII,9
9 3
VII,8
VII,6 VII,5
Fig. 5.94
Level VIII (Ulna, pronation) (Figs. 5.95, 5.96, and 5.97)

Safe positions: 1, 2, 6, 7, 8, 9, 10, 11, 12
Reference positions: 2, 6, 7, 8, 9, 10
and 11. The use of position 6 is optimal at this level because in this case the transosseous elements will
minimally impede soft-tissue displacement relative to the ulna during motions of the elbow and the
radiocarpal joints and during forearm rotation. The insertion of transosseous elements in the projection
of positions 2, 7, 8, 9, and 10 will provide free flexion and extension adjacent to the forearm joints but
11 12 1 A
a.radialis
v.radialis
2 n.radialis (r.superficialis)
Tr4 GI B
10 n.medianus
C
a.ulnaris
v.ulnaris
9 3
P8 n.ulnaris
Fig. 5.95 IG5
MC
C6
8
7 6 5
Fig. 5.96
The transosseous elements recommended for use at ulnar level VIII are (VIII,2)VIII,2; VIII,6;
VIII,7; VIII,8; VIII,8-2(VIII,8-2); VIII,8(VIII,8); VIII,9; and VIII,10.
12
VIII,10
VIII,9
9 3
VIII,6
VIII,7
Fig. 5.97
5.3 Radius and pericardium (MC). There are three Yang meridians with a
centripetal direction of energy, those of the large bowel (GI),
Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh the triple energizer (TR), and the small bowel (IG). The
meridians on the forearm are represented by 27 active points.
The figures show sections through the forearm at each of the According to MUDEF, transosseous elements applied to
principal levels (I–VIII) relative to the radius in the mid- the radius are enclosed in parentheses. Note that (VIII,12-6)
position (between pronation and supination, see pages (100– VIII,12-6 andVIII,6-12(VIII,6-12) designate the same wire
107), in supination (see pages 108–115), and in pronation inserted at level VIII through both bones, but in the first case
(see pages 116–123). the wire is inserted from the radial side and in second it is
On the anatomic functional cross-sections of the forearm, inserted from the ulnar side.
the arrows indicate only the safe positions where, following
K-wire or half-pin insertion at that location, complete resto-
ration of rotational forearm function during the fixation
period can be expected. Thickened projection lines indicate
that the insertion of transosseous elements in the designated
locations will allow only the early restoration of flexion and
extension of the elbow and the wrist joint.
Of the 96 positions, 67 (68%) are safe positions as defined
according to MUDEF. Studies of soft-tissue movements rela-
tive to the radius during supination and pronation of the fore-
arm have demonstrated that the safe application of external
fixation elements to the radius is impossible without disturb-
ing rotational function. The insertion of transosseous ele-
ments in this context is possible only at levels VII and VIII
in the projections of 8 positions (8% of possible positions).
These are indicated by arrows. However, there are positions
that allow partial restoration of rotational function during the
fixation period (Table 5.1).
The RPs that allow only flexion and extension of the
elbow and radiocarpal joints and partial rotational function
(47% of total positions) are indicated by thickened projection
lines.
On the forearm there are three Yin meridians with a cen-
trifugal direction of energy, those of the lung (P), heart (C),
Table 5.1 Radius bone positions that allow forearm rotation

Positions partial rotation
Positions for rotation not except: supination Positions for rotation except: supination 30˚, Positions that allow complete
Level 10˚, pronation 10˚ pronation 25˚ rotation
I 8 – –
II – 8 –
III 9, 10, 11, 12 1, 8 –
IV 8, 9, 10 1, 11, 12 –
V 8, 9 10, 11, 12 –
VI – 1, 8, 9, 10, 11, 12 –
VII – 10 1, 11, 12
VIII – 10, 11 1, 12
5.3.1 Radius, Mid-Position
Level I (Radius, mid-position) (Figs. 5.98, 5.99, and 5.100)

Safe positions: 5, 6, 7, 8, 9, 10, 11
9 and 10. The use of positions 5, 6, 7, and 8 is best at this level because the transosseous elements will
minimally impede soft-tissue displacement relative to the radius during elbow range of motion.
11 12 1
A
a.radialis
v.radialis
GI11 P5 2 a.ulnaris
v.ulnaris
10 n.medianus
B
MC3 n.radialis
(superficialis et r.profundus)
C
9 3
n.ulnaris
C3
Fig. 5.98 Tr
8
IG8
4
7 6 5
Fig. 5.99
The transosseous elements recommended for use at radial level I are I,5(I,5); (I,6); (I,7); and (I,8).
12
9 3
(I,8)
(I,6) I,5(1,5)
(I,7)
Fig. 5.100
Level II (Radius, mid-position) (Figs. 5.101, 5.102, and 5.103)

Contraindicated positions: 1, 2, 3, 4, 11, 12
Safe positions: 5, 6, 7, 8, 9, 10
8, 9, and 10. The close approximation of the radial nerve to the radius is demonstrated in the projection
of positions 11 and 12. The use of console transosseous elements in the projection of positions 5 and
6 is safe if the elements perforate only the posterior cortical plate. The use of positions 5, 6, 7, and 8 is
optimal at this level because the elements will only minimally impinge on the soft-tissue displacement
relative to the radius during elbow range of motion.
11 12 1 A
a.radialis
v.radialis
GI10
P
10 B
C
9 3 n.ulnaris
MC
Fig. 5.101 D
n.medianus
8 Tr a.ulnaris
C v.ulnaris
4
IG
7 6 5
Fig. 5.102
The transosseous elements recommended for use at radial level II are (II,5); II,6(II,6); (II,7); and (II,8).
12
9 3
(II,8)
(II,7)
(II,5)
II,6(II,6)
6
Fig. 5.103
Level III (Radius, mid-position) (Figs. 5.104, 5.105, and 5.106)

Safe positions: 1, 5, 6, 7, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used at positions 8, 9, and 10. The use of
positions 1, 5, 6, 7, 8, 9, 10, 11, and 12 is optimal as the transosseous elements will not inhibit soft-
tissue displacements of the radius during elbow range of motion.
11 12 1 A
a.radialis
2 v.radialis
GI9 P
10
B
n.medianus
MC
C
9 3
a.ulnaris
Tr v.ulnaris
D
C
8 n.ulnaris
Fig. 5.104
4
IG
7 6 5
Fig. 5.105
The transosseous elements recommended for use at radial level III are (III,1); (III,1-7); (III,5);
(III,5-11); III,6(III,6); III,6-12(III,6-12); (III,7); (III,8); (III,9); (III,10); (III,11); and (III,12).
(III,11-5) 12 (III,1-7)
(III,10)
(III,9)
9 3
(III,8)
III,6-12(III,6-12)
6
Fig. 5.106
Level IV (Radius, mid-position) (Figs. 5.107, 5.108, and 5.109)

Safe positions: 1, 6, 7, 8, 9, 10, 11, 12
and 11. The use of positions 1, 6, 7, 8, 9, 10, 11, and 12 is optimal at this level, as the transosseous ele-
ments will not inhibit soft-tissue movement with range of motion of the elbow and radiocarpal joint.
11 12 1 A
2
a.radialis
v.radialis
P
GI
B
n.medianus
9 3
MC C
Tr
a.ulnaris
v.ulnaris
C n.ulnaris
8
Fig. 5.107 4
IG
7 6 5
Fig. 5.108
The transosseous elements recommended for use at radial level IV are (IV,1); (IV,1-7); IV,6(IV,6);
IV,6-12(IV,6-12); (IV,7); (IV,8); (IV,9); (IV,10); (IV,11); (IV,12); and (IV,12)IV,12.
(IV,11) 12 (IV,1−7)
(IV,10)
(IV,9)
9 3
(IV,8)
IV,6−12(IV,6−12)
Fig. 5.109
Level V (Radius, mid-position) (Figs. 5.110, 5.111, and 5.112)

Safe positions: 1, 6, 7, 8, 9, 10, 11, 12
and 11. The use of positions 1, 6, 7, 8, 9, 10, 11, and 12 is optimal at this level, as the transosseous
elements will not inhibit soft-tissue movement of the radius with range of motion in the elbow and
radiocarpal joint.
11 12 1 A
2 a.radialis
v.radialis
10
GI7 P6
B
n.medianus
9 3
Tr
MC C
a.ulnaris
v.ulnaris
8 n.ulnaris
C 4
Fig. 5.110
IG7
7 6 5
Fig. 5.111
The transosseous elements recommended for use at radial level V are (V,1); (V,l-7); V,6(V,6);
V,6-12(V,6-12); (V,7); (V,8); (V,9); (V,10); (V,11); (V,12); and (V,12)V,12.
(V,11) 12
(V,10)
(V,9)
9 3
(V,8)
(V,7−1)
V,6−12(V,6−12)
Fig. 5.112
Level VI (Radius, mid-position) (Figs. 5.113, 5.114, and 5.115)

Safe positions: 1, 6, 7, 8, 9, 10, 11, 12
and 11. The use of positions 1, 6, 7, 8, 9, 10, 11, and 12 is optimal at this level, as the transosseous
elements will not impede soft-tissue movement of the radius with range of motion in the elbow and
radiocarpal joint.
11 12 1
2
A
10 a.radialis
v.radialis
GI
P
B
9 3 n.medianus
Tr6
C
a.ulnaris
v.ulnaris
Tr7 n.ulnaris
8 MC
Fig. 5.113 4
C
IG
7 6 5
Fig. 5.114
The transosseous elements recommended for use at radial level V are (VI,1); (VI,l-7); VI,6(VI,6);
VI,6-12(VI,6-12); (VI,7); (VI,8); (VI,9); (VI,10); (VI,11); (VI,12); and (VI,12)VI,12.
(VI,11) 12 (VI,1−7)
(VI,10)
(VI,9)
9 3
(VI,8)
VI,6−12(VI,6−12)
6
Fig. 5.115
Level VII (Radius, mid-position) (Figs. 5.116, 5.117, and 5.118)

Safe positions: 1, 4, 6, 7, 8, 9, 10, 11, 12
11. The use of positions 11 and 12 is optimal at this level, as the transosseous elements will not impede
soft-tissue movement relative to the radius with range of motion in the elbow and radiocarpal joint.
The insertion of transosseous elements in the projection of positions 1, 6, 7, and 10 will, however, limit
forearm rotation.
11 12 1
2 A
10 a.radialis
v.radialis
GI B
n.medianus
P
9 3 C
Tr5 a.ulnaris
v.ulnaris
n.ulnaris
Fig. 5.116 MC6
8
4
IG C4
7 6 5
Fig. 5.117
The transosseous elements recommended for use at radial level VII are (VII,1); (VII,1-7);
VII,6(VII,6); VII,6-12(VII,6-12); (VII,7); (VII,10); (VII,11); (VII,12); and (VII,12)VII,12.
(VII,11) 12 (VII,1−7)
(VII,10)
9 3
VII,6−12(VII,6−12)
6
Fig. 5.118
Level VIII (Radius, mid-position) (Figs. 5.119, 5.120, and 5.121)

Safe positions: 1, 4, 6, 7, 8, 9, 10, 11, 12
Safe positions: 1, 6, 10, 11, 12
11. The use of positions 1 and 12 is optimal at this level, as the transosseous elements will not impede
soft-tissue movements relative to the radius with range of motion in the elbow and radiocarpal joint. The
insertion of transosseous elements in the projection of positions 6, 10, and 11 will limit forearm rotation.
11 12 1
A
a.radialis
v.radialis
2
10
B
GI n.medianus
P8
C
a.ulnaris
9 3 v.ulnaris
Tr4 MC n.ulnaris
Fig. 5.119
8 C6
4
IG5
7 6 5
Fig. 5.120
The transosseous elements recommended for use at radial level VI are (VIII,1); VIII,6(VIII,6);
VIII,6-12(VIII,6-12); (VIII,10); (VIII,11); (VIII,12); and (VIII,12)VIII,12.
(VIII,11) 12 (VIII,1−7)
(VIII,10)
9 3
VIII,6−12(VIII,6−12)
6
Fig. 5.121
5.3.2 Radius, Supination
Level I (Radius, supination) (Figs. 5.122, 5.123, and 5.124)

Forbidden positions: 1, 2, 3, 4
Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
and 10. The close disposition of the radial nerve to the radial bone in the projection of position 1 rec-
ommends that in the projection of position 7 console transosseous elements are used that perforate
only the posterolateral cortical plate. The use of positions 5, 6, 7, 8, and 9 is optimal at this level
because in this case the transosseous elements will minimally impede soft-tissue displacement relative
to the radius during motions of the elbow.
11 12 1
P5 A
2 a.radialis
10 v.radialis
a.ulnaris
MC3 v.ulnaris
n.medianus
9 3
B
GI11 C3 n.radialis
(r.superficialis et r.profoundus)
Fig. 5.122
8 C
Tr 4 n.ulnaris
IG8
7 6 5
Fig. 5.123
The transosseous elements recommended for use at radial level I are I,5(I,5); (I,6); (I,7); (I,8) and (I,9).
12
(I,9)
9 3
(I,8)
(I,7) I,5(I,5)
(I,6)
Fig. 5.124
Level II (Radius, supination) (Figs. 5.125, 5.126, and 5.127)

Forbidden positions: 1, 2, 3, 4, 12
Safe positions: 5, 6, 7, 8, 9, 10, 11
9, and 10. The close disposition of the radial nerve to the radial bone in the projection of position 12
recommends that in the projection of position 6 console transosseous elements should be used that
perforate only the posterior cortical plate The use of positions 5, 6, 7, 8, and 9 is optimal at this level
because in this case the transosseous elements will minimally impede soft-tissue displacement relative
to the radius during motions of the elbow.
11 12 1
A
a.radialis
P 2 v.radialis
10 MC
B
GI10 C
C
9 3 n.ulnaris
D
Fig. 5.125 n.medianus
a.ulnaris
v.ulnaris
8
Tr
4
IG
7 6 5
Fig. 5.126
The transosseous elements recommended for use at radial level II are II,5(II,5); (II,6); (II,7); (II,8);
and (II,9).
12
(II,9)
9 3
(II,8)
(II,7) II,5(II,5)
(II,6)
Fig. 5.127
Level III (Radius, supination) (Figs. 5.128, 5.129, and 5.130)

Safe positions: 4, 5, 6, 7, 8, 9, 10
8, and 9. The use of positions 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the tran-
sosseous elements will minimally impede soft-tissue displacement relative to the radius during motions
of the elbow.
11 12 1 A
a.radialis
2 v.radialis
P
MC
10 B
n.medianus
C
a.ulnaris
9 3 v.ulnaris
C
D
n.ulnaris
8 GI9
Fig. 5.128
Tr
IG 4
7 6 5
Fig. 5.129
The transosseous elements recommended for use at radial level III are III,5(III,5); (III,6); (III,7);
(III,8), (III,9); and (III,10).
12
(III,9)
9 3
(III,8)
III,5(III,5)
(III,7) (III,6)
6
Fig. 5.130
Level IV (Radius, supination) (Figs. 5.131, 5.132, and 5.133)

Forbidden positions: 1, 2, 3
Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
9. The use of positions 4, 5, 6, 7, 8, 9, 10, and 11 is optimal at this level because in this case the tran-
of the elbow.
11 12 1 A
2 a.radialis
v.radialis
P
MC B
10 n.medianus
C
C a.ulnaris
9 3 v.ulnaris
GI n.ulnaris
8
Fig. 5.131
Tr IG
7 6 5
Fig. 5.132
The transosseous elements recommended for use at radial level IV are (IV,4); (IV,5); (IV,6); (IV,7);
(IV,8); (IV,9); (IV,10); (IV,11); (IV,10-4)IV,10-4; and (IV,11-5).
12
(IV,9)
9 3
IV,4−10(IV,4−10)
(IV,8)
(IV,5−11)
(IV,6)
(IV,7)
6
Fig. 5.133
Level V (Radius, supination) (Figs. 5.134, 5.135, and 5.136)

Safe positions: 1, 4, 5, 6, 7, 8, 9, 10
8, and 9. The use of positions 1, 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the
transosseous elements will minimally impede soft-tissue displacement relative to the radius during
motions of the elbow and the radiocarpal joint.
12
(V,1−7)
9 3
(V,9)
Fig. 5.134 V,4−10(V,4−10)

(V,8)
(V,5)
(V,6)
Fig. 5.135
The transosseous elements recommended for use at radial level V are (V,l); V,4(V,4); (V,5); (V,6);
(V,7); (V,8); (V,9); (V,10); (V,10)V,10; (V,1-7); and (V,10-4)V,10-4.
11 12 1
A
2 a.radialis
v.radialis
MC
10 B
n.medianus
P6
C C
9 3 a.ulnaris
GI7 v.ulnaris
n.ulnaris
IG7
8
Tr
7 6 5
Fig. 5.136
Level VI (Radius, supination) (Figs. 5.137, 5.138, and 5.139)

Safe positions: 4, 5, 6, 7, 8, 9, 10
8, and 9. The use of positions 4, 5, 6, 7, 8, 9, and 10 is optimal at this level because in this case the
transosseous elements will minimally impede soft-tissue displacement relative to the radius during
motions of the radiocarpal joint.
11 12 1 A
2 a.radialis
v.radialis
B
10 P MC n.medianus
C C
a.ulnaris
9 3
v.ulnaris
GI n.ulnaris
8 IG
Fig. 5.137
Tr7 Tr6
7 6 5
Fig. 5.138
The transosseous elements recommended for use at radial level VI are VI,4(VI,4); (VI,5); (VI,6);
(VI,7); (VI,8); (VI,9); (VI,10); (VI,10)VI,10; and VI,4-10(VI,4-10).
12
(VI,9)
9 3
(VI,8)
VI,4−10(VI,4−10)
(VI,7)
(VI,5)
(VI,6)
Fig. 5.139
Level VII (Radius, supination) (Figs. 5.140, 5.141, and 5.142)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
and 9. The use of position 7, 8, 9, 10, and 11 is optimal at this level because in this case the tran-
of the radiocarpal and radioulnar joints. The insertion of transosseous elements in the projection of
positions 4 and 5 will limit forearm rotation.
12 1
11
A
2 a.radialis
v.radialis
10 B
P MC6
n.medianus
C4
GI C
9 3
a.ulnaris
Fig. 5.140 v.ulnaris
n.ulnaris
IG
8 Tr5
7 6 5
Fig. 5.141
The transosseous elements recommended for use at radial level VII are VII,4(VII,4); (VII,5);
(VII,7); (VII,8); (VII,9); (VII,10); (VII,10)VII,10; (VII,11); (VII,10-4)VII,10-4; and (VII,5-11).
12
(VII,9)
9 3
(VII,8)
VII,4−10(VII,4−10)
(VII,7)
(VII,5−11)
Fig. 5.142
Level VIII (Radius, supination) (Figs. 5.143, 5.144, and 5.145)

Safe positions: 4, 5, 6, 7, 8, 9, 10, 11
and 9. The use of position 8, 9, and 10 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the radius during motions of the
radiocarpal and radioulnar joints. The insertion of transosseous elements in the projection of positions
4 and 5 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
v.radialis (r.superficialis)
2
B
n.medianus
10
P6 C
MC
a.ulnaris
C v.ulnaris
n.ulnaris
9 3
Fig. 5.143 GI7
IG7
8 Tr
7 6 5
Fig. 5.144
The transosseous elements recommended for use at radial level VIII are VIII,4(VIII,4); (VIII,5);
(VIII,8); (VIII,9); (VIII,10); (VIII,10)VIII,10; and (VIII,10-4)VIII,10-4.
12
VIII,10−4(VIII,10−4)
(VIII,9)
9 3
(VIII,8)
(VIII,5)
Fig. 5.145
5.3.3 Radius, Pronation
Level I (Radius, pronation) (Figs. 5.146, 5.147, and 5.148)

Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
and 10. The close disposition of the radial nerve to the radial bone in position 1 recommends that in
the projection of position 7 console transosseous elements should be used that perforate only the pos-
terolateral cortical plate. The use of positions 5, 7, 8, and 9 is optimal at this level because in this case
the transosseous elements will minimally impede soft-tissue displacement relative to the radial bone
during motions of the elbow.
11 12 1 a
a.radialis
v.v.radialis
2 a.ulnaris
P5 v.v.ulnaris
GI11
n.medianus
b
10 n. radialis
(r.superficialis et r.profoundus)
MC3
c
9 3 n. ulnaris
Fig. 5.146
8 Tr
C3
IG8 4
7 6 5
Fig. 5.147
The transosseous elements recommended for use at radial level I are I,5(I,5); (I,6); (I,7); (I,8); and (I,9).
12
(I,9)
9 3
(I,8)
(I,7)
(I,6) I,5(I,5)
Fig. 5.148
Level II (Radius, pronation) (Figs. 5.149, 5.150, and 5.151)

Forbidden positions: 1, 2, 3, 4, 11, 12
Safe positions: 5, 6, 7, 8, 9, 10
8, 9, and 10. The close disposition of the radial nerve to the radial bone in the projection of positions
11 and 12 recommends that in the projection of positions 5 and 6 console transosseous elements should
be used that perforate only the posterior cortical plate. The use of positions 5, 6, 7, 8, and 9 is optimal
at this level because in this case the transosseous elements will minimally impede soft-tissue displace-
ment relative to the radial bone during motions of the elbow.
11 12 1 A
a.radialis
GI10 v.radialis
P 2
B
10 n.radialis (r.profundus)
C
MC
n.ulnaris
9 3
D
Fig. 5.149 n.medianus
a.ulnaris
v.ulnaris
8
Tr
C
4
IG
7 6 5
Fig. 5.150
The transosseous elements recommended for use at radial level I are (II,5); II,6(II,6); (II,7); (II,8);
and (II,9).
12
(II,9)
9 3
(II,8)
(II,7)
II,6(II,6) (II,5)
Fig. 5.151
Level III (Radius, pronation) (Figs. 5.152, 5.153, and 5.154)

Safe positions: 6, 7, 8, 9, 10, 11, 12
10, and 11. The use of positions 6, 7, 8, and 9 is optimal at this level because in this case the tran-
sosseous elements will minimally impede soft-tissue displacement relative to the radial bone during
motions of the elbow.
11 12 1 A
a.radialis
v.radialis
GI9
10 B
n.medianus
P C
a.ulnaris
9 3 v.ulnaris
MC D
n.ulnaris
Fig. 5.152
8 Tr
IG C
7 6 5
Fig. 5.153
The transosseous elements recommended for use at radial level I are (III,6); III,7 (III,7); (III,8); and
(III,9).
12
(III,9)
9 3
(III,8)
III,7(III,7)
(III,6)
6
Fig. 5.154
Level IV (Radius, pronation) (Figs. 5.155, 5.156, and 5.157)

Safe positions: 6, 7, 8, 9, 10, 11, 12
9, 10, and 11. The use of positions 6, 7, 8, 9, and 10 is optimal at this level because in this case the
transosseous elements will minimally impede soft-tissue displacement relative to the radial bone dur-
ing motions of the elbow.
11 12 1 A
2 a.radialis
v.radialis
10
GI
B
n.medianus
9 3 C
P a.ulnaris
v.ulnaris
n.ulnaris
Tr
Fig. 5.155 8
4
MC
IG
C
7 6 5
Fig. 5.156
The transosseous elements recommended for use at radial level IV are (IV,6); IV,7 (IV,7); (IV,8);
(IV,9); and (IV,10).
12
(IV,10)
(IV,9)
9 3
(IV,8)
IV,7(IV,7)
(IV,6)
Fig. 5.157
Level V (Radius, pronation) (Figs. 5.158, 5.159, and 5.160)

Safe positions: 1, 2, 3, 7, 8, 9, 10, 11, 12
and 12. The use of positions 1, 2, 3, 7, 8, 9, 10, 11, and 12 is optimal at this level because in this case
the transosseous elements will minimally impede soft-tissue displacement relative to the radial bone
during motions of the elbow and the radiocarpal joint.
11 12 1 A
a.radialis
10 2 v.radialis
GI7 n.radialis (r.superficialis)
B
P6 n.medianus
9 3
C
Tr a.ulnaris
v.ulnaris
n.ulnaris
Fig. 5.158 8 4
MC
IG7
C
7 6 5
Fig. 5.159
The transosseous elements recommended for use at radial level V are (V,1); (V,1)V,1; (V,1-7) V,1-7;
(V,2); (V,2-8); (V,3); (V,3-9); V,7(V,7); (V,8); (V,9); (V,10); (V,11); and (V,12).
(V,11) 12
(V,10) (V,12) (V,2−8)
(V,3−9)
9 3
V,7−1(V,7−1)
6
Fig. 5.160
Level VI (Radius, pronation) (Figs. 5.161, 5.162, and 5.163)

Safe positions: 1, 2, 3, 7, 8, 9, 10, 11, 12
and 12. The use of positions 1, 2, 3, 7, 8, 9, 10, and 11 is optimal at this level because in this case the
transosseous elements will minimally impede soft-tissue displacement relative to the radial bone dur-
ing motions of the radiocarpal joint.
11 12 1 A
a.radialis
10 2 v.radialis
Tr6
GI B
Tr7 n.medianus
9 3 C
P
a.ulnaris
v.ulnaris
n.ulnaris
4
Fig. 5.161 8 MC
IG
7 6 5
Fig. 5.162
The transosseous elements recommended for use at radial level VI are (VI,1); (VI,1)VI,1; (VI,l-7)
VI,l-7; (VI,2); (VI,2-8); (VI,3); (VI,3-9); VI,7(VI,7); (VI,8): (VI,9); (VI,10); and (VI,11).
(VI,11) 12
(VI,10) (VI,2−8)
(VI,3−9)
9 3
VI,7−1(VI,7−1)
6
Fig. 5.163
Level VII (Radius, pronation) (Figs. 5.164, 5.165, and 5.166)

Safe positions: 1, 2, 3, 7, 8, 9, 10, 11, 12
and 12. The use of positions 1, 2, and 3 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the radial bone during motions of
the radiocarpal and radioulnar joints. The insertion of transosseous elements in the projection of posi-
tions 8, 9, 10 will limit forearm rotation.
11 12 1
A
10
2 a.radialis
v.radialis
Tr5
B
GI n.medianus
9 3
C
P a.ulnaris
v.ulnaris
n.ulnaris
Fig. 5.164
4
8
IG
MC6
C
7 6 5
Fig. 5.165
The transosseous elements recommended for use at radial level VII are (VII,1); (VII,1)VII,1;
(VII,2); (VII,2-8); (VII,3); (VII,3-9); (VII,8); (VII,9); and (VII,10).
(VII,11) 12
(VII,10) (VII,2)
(VII,3−9)
9 3
VII,7−1(VII,7−1)
6
Fig. 5.166
Level VIII (Radius, pronation) (Figs. 5.167, 5.168, and 5.169)

Safe positions: 1, 2, 3, 8, 9, 10, 11, 12
and 12. The use of positions 1, 2, and 3 is optimal at this level because in this case the transosseous
elements will minimally impede soft-tissue displacement relative to the radial bone during motions of
the radiocarpal and radioulnar joints. The insertion of transosseous elements in the projection of posi-
tions 8 and 9 will limit forearm rotation.
11 12 1 A
a.radialis
v.radialis
10
Tr4 GI B
n.medianus
9 3 C
a.ulnaris
P8 v.ulnaris
IG5 n.ulnaris
Fig. 5.167
4
C6 MC
8
7 6 5
Fig. 5.168
The transosseous elements recommended for use at radial level VIII are (VIII,1); (VIII,2); (VIII,2)
VIII,2; (VIII,2-8)VIII,2-8; (VIII,3); (VIII,3-9); VIII,8(VIII,8); and (VIII,9).
12 (VIII,1)
(VIII,3-9)
9 3
VIII,8-2(VIII,8-2)
Fig. 5.169
5.4 Femur

Maxim Vasil’evich Andrianov
The figures show sections through the femur at each of the

principal levels (I–VIII).
Of the 93 positions defined in accordance with MUDEF,
positions 2, 3, and 4 at level I are eliminated due to obvious
anatomic constraints, 68 (73%) are considered safe posi-
tions, and 28 (30%) are identified as RPs for transosseous
element insertion. Wires are used only at levels VI, VII, and
VIII.
On the femur, there are three Yin meridians with a cen-
trifugal direction of energy, those of the liver (F), spleen (Rp)
and kidney (R). There are three Yang meridians with a cen-
tripetal direction of energy, those of the stomach (E), bladder
(V), and gallbladder (VB). The meridians on the femur are
represented by 21 active points.
Level I (Figs. 5.170, 5.171, and 5.172)

Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
and 10. The use of positions 8 and 9 is optimal at this level because the transosseous elements will not
impinge on the soft-tissue movements relative to the femur during range of motion of the hip joint. In
positions 10 and 11, subcutaneous fascial release should be carried out in a proximal direction
(1–1.5 cm).
11 12 E 1 A
a.femoralis
v.femoralis
n.femoralis
10 2 B
n.ischiadicus
9 3
Fig. 5.170
VB
4
8
V
7 6 5
Fig. 5.171
The transosseous elements recommended for use at the femoral level I are I,8; I,9; I,10; and I,11.
12
I,11
I,10
I,9
9 3
I,8
Fig. 5.172
Level II (Figs. 5.173, 5.174, and 5.175)

Contraindicated positions: 1, 2 ,3, 4
Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
and 10. The use of positions 8, 9, 10, and 11 is optimal at this level because the transosseous elements
will not impinge on the soft-tissue movements of the femur during range of motion of the hip joint. In
positions 10 and 11 subcutaneous fascial release should be carried out in a proximal direction
(1–1.5 cm).
11 12 1
E31 A
a.femoralis
v.femoralis
n.femoralis
10 Rp 2
B
n.ischiadicus
F10
9 3
Fig. 5.173 VB
8 R 4
V V
7 6 5
Fig. 5.174
The transosseous elements recommended for use at the femoral level II are II,8; II,9; II,10; and II,11.
12
II,11
II,10
9 3
II,9
II,8
Fig. 5.175

Contraindicated positions: 1, 2 ,3 ,4, 5
Safe positions: 6, 7, 8, 9, 10, 11, 12
10, and 11. The use of positions 9 and 10 is optimal at this level because the transosseous elements will
not interfere with the soft-tissue displacement of the femur during range of motion of the hip and (to a
lesser degree) the knee joint. In positions 10 and11, fasciotomy should be carried out proximally
(1–1.5 cm).
11 12 1 A
E a.femoralis
v.femoralis
2 n.femoralis
Rp
10 B
n.ischiadicus
C
VB a.profunda femoris
F
9 3 v.profunda femoris
Fig. 5.176
R
8
4
V
V36
7 6 5
Fig. 5.177
The transosseous elements recommended for use at the femoral level III are III,8; III,9; and III,10.
12
III,10
III,9
9 3
III,8
Fig. 5.178
Level IV (Figs. 5.179, 5.180, and 5.181)

Safe positions: 1, 6, 7, 8, 9, 10, 11, 12
and 11. The use of positions 8, 9, and 10 is optimal at this level because the transosseous elements will
not impinge on the soft-tissue displacement of the femur during range of motion of adjacent joints.
11 12 1 A
E a.femoralis
v.femoralis
2 n.femoralis
10 B
Rp n.ischiadicus
C
VB a.profunda femoris
9 3 v.profunda femoris
Fig. 5.179 8
R 4
V V
7 6 5
Fig. 5.180
The transosseous elements recommended for use at femoral level IV are IV,8; IV,9; and IV,10
12
IV,10
IV,9
9 3
IV,8
Fig. 5.181
Level V (Figs. 5.182, 5.183, and 5.184)

Safe positions: 1, 2, 6, 7, 8, 9, 10, 11, 12
Reference positions: 8, 9
and 11. The use of positions 8 and 9 is optimal at this level because transosseous elements will not
impinge on the soft-tissue displacement of the femur during range of motion of adjacent joints.
11 12 1
E
A
2 a.femoralis
v.femoralis
10
n.saphenus
Rp11 B
n.ischiadicus
9 3
F
VB31
Fig. 5.182 8
4
R
V
V37
7 6 5
Fig. 5.183
The transosseous elements recommended for use at femoral level V are V,8 and V,9.
12
V,9
9 3
V,8
Fig. 5.184
Level VI (Figs. 5.185, 5.186, and 5.187)

Safe positions: 1, 2, 3, 6, 7, 8, 9, 10, 11, 12
The use of positions 3, 7, 8, and 9 is optimal at this level because the transosseous elements will not impinge
on the soft tissues of the femur during range of motion at the knee and (to a lesser degree) hip joints.
11 12 1
E32 A
2 n.ischiadicus
10 B
a.femoralis
v.femoralis
Rp
C
n.saphenus
9 3
F D
VB32 n.saphena magna
8
Fig. 5.185
4
R
7 6 5
Fig. 5.186
The transosseous elements recommended for use at femoral level VI are VI,3; VI,7; VI,8; VI,9; and
VI,3-9.
12
VI,3−9
9 3
VI,8
VI,7
6
Fig. 5.187

Safe positions: 1, 2, 3, 7, 8, 9, 10, 11, 12
will not cause soft-tissue impingement of the femur during range of motion in the knee joint.
11 12 1
E 2 A
a.poplitea
10 v.poplitea
B
Rp10 n.tibials
n.peroneus communis
9 3
C
n.saphenus
F
VB D
8 n.saphena magna
Fig. 5.188
4
R
V
V
7 6 5
Fig. 5.189
The transosseous elements recommended for use at femoral level VII are VII,3; VII,4; VII,8; VII,9;
and VII,3-9.
12
VII,9−3
9 3
VII,8
VII,4
Fig. 5.190

Safe positions: 1, 2, 3, 4, 8, 9, 10, 11, 12
Comments. Only console transosseous elements can be used in the projection of positions 11, 12
and 1. The use of positions 3, 4, 8, and 9 is optimal at this level because the transosseous elements will
not impede soft-tissue displacements of the femur during range of motion of the knee joint.
11 12 1 A
a.poplitea
v.poplitea
2
E
10
B
n.peroneus communis
Rp
C
9 3 n.saphenus
v.saphena magna
F
VB33
Fig. 5.191 8
4
R
V36
V
7 6 5
Fig. 5.192
The transosseous elements recommended for use at femoral level VIII are VIII,3; VIII,4; VIII,8;
VIII,9; and VIII,3-9.
12
VIII,9−3
9 3
VIII,8
VIII,4
Fig. 5.193
5.5 Tibia

Dmitry Alexandrovich Mykalo
The figures show sections through the tibia at each of the

principal levels (I–VIII).
Of the 96 positions defined in accordance with MUDEF,
75% (72 positions) are designated as safe positions and 49
(51%) as tibial RPs for transosseous element insertion.
On the tibia, there are three Yin meridians with a centrifu-
gal direction of energy, those of the liver (F), spleen (Rp),
and kidney (R).There are three Yang meridians with a cen-
tripetal direction of energy, those of the stomach (E), bladder
(V), and gallbladder (VB). The meridians on the tibia are
represented by 34 active points.
Level I (Figs. 5.194, 5.195, and 5.196)

Safe positions: 1, 2, 3, 4, 5, 9, 10, 11, 12
will not impede soft-tissue displacement of the tibia during range of motion in the knee joint.
11 12 1
2
A
10 a.poplitea
E v.poplitea
n.tibialis
Rp B
9 3 a.peroneus communis
VB34
C
F8 n.saphenus
A v.saphena magna
B
8
Fig. 5.194 R10 4
V40
7 6 5
Fig. 5.195
The transosseous elements recommended for use at level I of the tibia are I,2; I,3; I,9; I,10; and I,3-9.
12
I,10 I,2
I,3−9
9 3
B A
Fig. 5.196
Level II (Figs. 5.197, 5.198, and 5.199)

Safe positions: 1, 2, 3, 4, 5, 9, 10, 11, 12
12. The use of positions 1, 2, 3, 4, 9, and 10 is optimal at this level because the transosseous elements
will minimally impede soft-tissue displacement of the tibia during range of motion in the knee joint.
10 11 12 1 2 A
a.tibialis posterior
E36 v.tibialis posterior
n.tibialis
B
9 3 n.peroneus superficialis
n.peroneus profundus
C
VB C
Rp9
A a.tibials anterior
D
B v.tibials anterior
8
F7 4
D
v.saphena parva
n.cutaneus surae medialis
Fig. 5.197
E
E R
v.saphena magna
7 V55 5 n.suralis
6
Fig. 5.198
The transosseous elements recommended for use at level II of the tibia are II,1; II,2; II,3; II,4; II,9;
II,10; II,3-9; and II,4-10.
12
II,1
II,2
9 3
II,3−9
A D
B
II,4−10
Fig. 5.199

Safe positions: 1, 2, 3, 4, 5, 9, 10, 11, 12
12. The use of positions 1, 2, 3, 4, 9, 10, and 12 is optimal at this level because the transosseous ele-
ments will impede soft-tissue displacement of the tibia during range of motion of the knee joint.
10 11 12 1 2 A
v.tibialis posterior
E
n.tibialis
9 3 B
a.tibialis anterior
RP v.tibialis anterior
B n.peroneus profundus
VB F C
A D
4 v.saphena parva
8 n.cutaneus surae medialis
D
Fig. 5.200 v.saphena magna
R
n.saphenus
V56
7 6 5
Fig. 5.201
The transosseous elements recommended for use at level III of the tibia are III,1; III,2; III,3; III,4;
III,9; III,10; III,12; III,3-9; and III,4-10
12
III,12 III,1 III,2
III,4−10
9 3
III,3−9
A D
Fig. 5.202
Level IV (Figs. 5.203, 5.204, and 5.205)

Safe positions: 1, 2, 3, 4, 5, 9, 10, 11, 12
12. The use of positions 1, 2, 3, 4, 9, 10, 11, and 12 is optimal at this level because the transosseous
elements will not impede the soft-tissue motion of the tibia during range of motion of adjacent joints.
11 12 1 2
10 A
E n.tibialis
B
9 3 a.tibialis anterior
v.tibialis anterior
VB
B
F
C
A D
v.saphena parva
n.cutaneus surae medialis
8
4
R D
Fig. 5.203 n.saphena
v.saphena magna
C
V57
7 6 5
Fig. 5.204
The transosseous elements recommended for use at level IV of the tibia are IV,1;IV,2; IV,3; IV,4;
IV,9; IV,10; IV,11; IV,12; IV,3-9; and IV,4-10.
12
IV,11 IV,12 IV,1
IV,2
IV,4−10
9 3
IV,3−9
Fig. 5.205
Level V (Figs. 5.206, 5.207, and 5.208)

Contraindicated positions: 1, 2, 3, 4, 7, 9, 10, 11, 12
and 12. The use of positions 1, 2, 3, 4, 9, and 12 is optimal at this level because the transosseous ele-
ments will not impede soft-tissue displacement of the tibia during range of motion of adjacent joints.
11 12 1
10 2
E39 A
E n.tibialis
9 3
B
VB35 B a.tibialis anterior
v.tibialis anterior
A Rp7
C
8
VB36 D 4 v.saphena parva
F n.cutaneus surae medialis
D
Fig. 5.206 n.saphenus
v.saphena magna
R
V C
7 6 5
Fig. 5.207
The transosseous elements recommended for use at level V of the tibia are V,1; V,2; V,3; V,4; V,9;
V,12; V,3-9; and V,4-10.
12
V,12 V,1
V,4−10 V,2
9 3
V,3−9
B
Fig. 5.208
Level VI (Figs. 5.209, 5.210, and 5.211)

Safe positions: 1, 2, 3, 4, 7, 8, 10, 11, 12
and 12. Note the close approximation of the tibialis anterior neuro-vascular bundle to the lateral tibial
shaft at position 9. Thus, console transosseous elements from position 3 should perforate only the
medial cortical plate. Insertion of K-wires in the frontal plane is possible through the anterior third of
the tibia at this level. The use of positions 1, 2, 3, 4, and 12 is optimal at level VI because the tran-
sosseous elements will not impinge on soft-tissue displacement of the tibia during range of motion of
the ankle and (to a lesser degree) the knee.
11 12 1
10 E 2 A
n.tibialis
F
9 B 3 B
a.tibialis anterior
VB37 v.tibialis anterior
Rp n.peroneus profundus
D
C
8 A 4 v.saphena parva
Fig. 5.209 n.suralis
R D
v.saphena magna
n.saphenus
C
V59
7 6 5
Fig. 5.210
The transosseous elements recommended for use at level VI of the tibia are VI,1; VI,2; VI,3; VI,4;
VI,12; and VI,4-10.
12
VI,12 VI,1
VI,4−10 VI,2
9 B 3
VI,3
Fig. 5.211

Safe positions: 1, 2, 3, 4, 7, 8, 9, 10, 12
Comments. Only console transosseous elements can be used in the projection of position 12. The
use of positions 1, 2, 3, 4, 8, and 9 is optimal at this level because transosseous elements will not
impinge on soft-tissue displacements of the tibia during range of motion of the ankle.
11 12 1 2 A
10
E
B n.tibialis
F B
RP v.tibialis anterior
VB39 n.peroneus profundus
D
R8 C
v.saphena parva
8 A 4 n.suralis
R7
D
Fig. 5.212
v.saphena magna
n.saphenus
C
V
7 6 5
Fig. 5.213
The transosseous elements recommended for use at level VII of the tibia are VII,1; VII,2; VII,3;
VII,4; VII,8; VII,9; VII,3-9; VII,4-10; and VII,2-8(2–8).
12
VII,1
9 3
VII,3−9
A VII,4−10
(VII,8−2)VII,8−2
C
Fig. 5.214

Safe positions: 1, 2, 3, 4, 7, 8, 9, 10, 12
Comments. Insertion of transosseous elements at this level is contraindicated at positions 5 and 11.
There is a high risk of injury to the anterior and posterior tibial neurovascular structures with insertion
portals at these locations. The use of positions 1, 2, 3, 4, 8, 9, and 10 is optimal at this level because
the transosseous elements will not impinge on soft-tissue displacement of the tibia during range of
motion of the ankle.
10 11 12 1 2 A
E
B n.tibialis
F B
Rp v.tibialis anterior
VB39 n.peroneus profundus
D C
R8 v.saphena parva
8 4 n.suralis
A
R7
D
Fig. 5.215 v.saphena magna
n.saphenus
C
V
7 6 5
Fig. 5.216
The transosseous elements recommended for use at level VIII of the tibia are VIII,1; VIII,2; VIII,3;
VIII,4; VIII,9; VIII,10; VIII,3-9, VIII,2-8(2–8); and VIII,4-10.
12
VII,1
B
9 3
VII,3−9
VII,4−10
A
C
(VII,8−2)VII,8−2
Fig. 5.217
5.6 Foot
Leonid Nikolaevich Solomin, Nikolay Fedorovich Fomin,

Sergey Valerjevich Majkov, and
Konstantin Andreevich Ukhanov
Fig. 5.218
On p.p. 142–156 sections of the foot are presented 14 cross- displacement are considered have not been identified.
sectional and on p.p. 157–159 - 3 oblique cuts. However, whenever possible, the insertion of transosseous
To date, “reference positions” of the foot, i.e., positions in elements in a projection of positions with tendons should be
which not only the main vessels and nerves but also soft-tissue avoided: formally, they are regarded as “safe positions.”
5.6.1 Cross-Sectional Cuts
I
Level I
Toe a–e: Contraindicated positions:
II Safe positions: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
III
IV
V a b
VI
VII
VIII
IX
XI
XII
XIII
c d
XIV
Fig. 5.219
Fig. 5.220 (a–e)

I Level II
Toe a: Contraindicated positions: 3, 9
II
Safe positions: 1, 2, 4, 5, 6, 7, 8, 10, 11, 12
III
Toe b: Contraindicated positions: 3, 9
IV
V Safe positions: 1, 2, 4, 5, 6, 7, 8, 10, 11, 12
Toe c–e: Contraindicated positions: 3, 9
Safe positions: 1, 2, 4, 5, 6, 7, 8, 10, 11, 12
VI
VII
VIII
IX
a b
XI
XII
XIII
XIV
Fig. 5.221
c d
Fig. 5.222 (a–e)

I Level III
Toe a–e: Contraindicated positions: 2, 3, 4, 8, 9, 10
II
Safe positions: 1, 5, 6, 7, 11, 12
III
IV
V a b
VI
VII
VIII
IX
XI
XII
XIII
c d
XIV
Fig. 5.223
Fig. 5.224 (a–e)

I Level IV
Toe a–b: Contraindicated positions: 2, 3, 4, 8, 9, 10
II
Safe positions: 1, 5, 6, 7, 11, 12
III
Toe c: Contraindicated positions: 2 ,3, 4, 8, 9, 10
IV
V Toe d–e: Contraindicated positions: 2, 3, 4, 8, 9, 10
Safe positions: 1, 5, 6, 7, 11, 12
VI
VII a b
VIII
IX
XI
XII
XIII
XIV
Fig. 5.225
c d
Fig. 5.226 (a–e)

I Level V
a: Contraindicated positions: 2, 5, 7, 10
II
Safe positions: 1, 3, 4, 6, 8, 9, 11, 12
III
b: Contraindicated positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
IV
V Safe positions: 1, 11, 12
c: Contraindicated positions: 2, 3, 4, 5, 6, 7, 8, 9, 10
Safe positions: 11, 12
VI
d: Contraindicated positions: 1, 2, 4, 7, 8, 9, 10
VII
VIII Safe positions: 3, 5, 6, 11, 12
e: Contraindicated positions: 1, 2, 4, 5, 6, 7, 8, 10, 11
IX Safe positions: 3, 8, 9, 12
X
a b
XI
XII
XIII
XIV
Fig. 5.227
c d
Fig. 5.228 (a–e)

I Level VI
a: Contraindicated positions: 6, 8, 9, 10, 11, 12
II
Safe positions: 1, 2, 3, 4, 5, 7
III
b: Contraindicated positions: 3, 4, 6, 7, 8, 9
IV
V Safe positions: 1, 2, 5, 8, 10, 11, 12
c: Contraindicated positions: 5, 6, 9, 10, 12
d: Contraindicated positions: 1, 2, 3, 4, 5, 7, 10
VI
e: Contraindicated positions: 1, 2, 3 ,5
VII
VIII Safe positions: 4, 6, 7, 8, 9, 10, 11, 12
IX
a b
XI
XII
XIII
XIV
Fig. 5.229
c d
Fig. 5.230 (a–e)

I Level VII
a: Contraindicated positions: 1, 6, 8, 9, 11
II Safe positions: 2, 3, 4, 5, 7, 10, 12
III
b: Contraindicated positions: 2, 3, 6, 7, 9
IV
V Safe positions: 1, 4, 5, 8, 10, 11, 12
c: Contraindicated positions: 1, 3, 4, 5, 6, 7, 8, 9
Safe positions: 2, 4, 10, 11, 12
VI
VII d: Contraindicated positions: 1, 2, 4, 5, 6, 7, 9, 10, 12
VIII Safe positions: 3, 5, 7, 8, 11
e: Contraindicated positions: 1, 2, 3, 4
IX Safe positions: 5, 6, 7, 8, 9, 10, 11, 12
X a b
XI
XII
XIII
XIV
Fig. 5.231
c d
Fig. 5.232 (a–e)

I Level VIII
a: Contraindicated positions: 3, 4, 7, 8, 10, 11, 12
II
Safe positions: 1, 2, 3, 4, 5, 6, 9
III
b: Contraindicated positions: 2, 6, 9
IV
V Safe positions: 1, 3, 4, 5, 7, 8, 10, 11, 12
c: Contraindicated positions: 2, 5, 7, 9, 10
Safe positions: 1, 3, 4, 6, 8, 11, 12
VI
d: Contraindicated positions: 3, 4, 6, 10, 11, 12
VII
VIII e: Contraindicated positions: 1, 4
Safe positions: 2, 3, 5, 6, 7, 8, 9, 10, 11, 12
IX
a b
X
XI
XII
XIII
XIV
Fig. 5.233
c d
Fig. 5.234 (a–e)

I Level IX
a: Contraindicated positions: 3, 7, 8, 11
II
Safe positions: 1, 2, 4, 5, 6, 9, 12
III
b: Contraindicated positions: 1, 6 , 7
IV
V Safe positions: 2, 3, 4, 5, 8, 9, 10, 11, 12
c: Contraindicated positions: 2, 3, 5, 6
Safe positions: 1, 3, 4, 7, 8, 9, 10, 11, 12
VI
d: Contraindicated positions: 2, 4, 5
VII
VIII Safe positions: 1, 3, 6, 7, 8, 9, 10, 11, 12
IX
a b
XI
XII
XIII
XIV
Fig. 5.235
c d
Fig. 5.236 (a–d)

I Level X
a: Contraindicated positions: 6, 7, 12
II Safe positions: 1, 2, 3, 4, 5, 8, 9, 10, 11
III
IV
V Safe positions: 2, 3, 5, 7, 8, 9, 10, 11, 12
VI a b
VII
VIII
IX
XI
XII
XIII
XIV
Fig. 5.237
Fig. 5.238 (a, b)

I Level XI
II Safe positions: 2, 4, 6, 8, 9, 10
III
IV
V Safe positions: 2, 3, 5, 7, 8, 9, 10, 11, 12
VI a b
VII
VIII
IX
XI
XII
XIII
XIV
Fig. 5.239
Fig. 5.240 (a, b)
I Level XII
II Safe positions: 1, 3, 4, 6, 8, 9, 10
III
b: Contraindicated positions: 1, 3, 4, 5, 12
IV
V Safe positions: 2, 6, 7, 8, 9, 10, 11
VI a b
VII
VIII
IX
XI
XII
XIII
XIV
Fig. 5.241
Fig. 5.242 (a, b)

I Level XIII
a: Contraindicated positions: 4, 5
II Safe positions: 1, 2, 3, 6, 7, 8, 9, 10, 11, 12
III
b: Contraindicated positions: 3, 4
IV
V Safe positions: 1, 2, 5, 6, 7, 8, 9, 10, 11, 12
VI a b
VII
VIII
IX
XI
XII
XIII
XIV
Fig. 5.243
Fig. 5.244 (a, b)
I Level XIV
Contraindicated positions: None
II Safe positions: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
III
IV
V 1 12 11
VI
VII
VIII
2 10
IX
XI
3 9
XII
XIII
XIV
Fig. 5.245 4 8
5 6 7
Fig. 5.246
III II I 5.6.2 Oblique Cuts
Level I (oblique)
Toe a: Contraindicated positions: 1, 2, 5, 12
Safe positions: 3, 4, 6, 7, 8, 9, 10, 11
Toe b: Contraindicated positions: 1, 2, 12
Safe positions: 1, 3, 4, 5, 6, 7, 8, 9, 10, 11
Toe c: Contraindicated positions: 2, 4
Safe positions: 1, 3, 5, 6, 7, 8, 9, 10, 11, 12
Fig. 5.247
a b
Fig. 5.248 (a–c)

III II I Level II (oblique)

Toe a: Contraindicated positions: 1, 4, 5, 11, 12
Safe positions: 2, 3, 6, 7, 8, 9, 10
Safe positions: 3, 4, 5, 6, 7, 8, 9, 10, 11
Fig. 5.249
a b
Fig. 5.250 (a, b)

III II I Level III (oblique)

Toe a: Contraindicated positions: 1, 2, 5, 11, 12
Safe positions: 3, 4, 6, 7, 8, 9, 10
Safe positions: 4, 5, 6, 7, 8, 9, 10, 11, 12
Fig. 5.251
a b
Fig. 5.252 (a, b)

5.7 Pelvis
Leonid Nikolaevich Solomin
The positions for the insertion of transosseous elements

through the pelvis are determined in accordance with two
main requirements: (1) the safety of the major vessels,
nerves, and intrapelvic structures, and (2) the optimal mor-
phometric parameters (width, height, length, bone density)
to maintain strong fixation of the wires and half-pins.
However, as indicated in Chap. 2, optimal positioning for the
insertion of transosseous elements (the reference positions)
requires consideration of soft-tissue displacement in relation
to the bone during movement of the adjacent joints.
Positions with minimal soft-tissue displacement are asso- Fig. 5.253 An olive wire (1) is inserted into the anterior-upper spine
ciated with a lower risk of pin-induced joint stiffness and of the iliac bone. The shank end of the wire is bent internally at an angle
pin-tract infections. As reference positions for the pelvis of 30–35° and distally at an angle of 40–45°. The wire must pass
have not yet been determined, the “available positions” are through the thick part of the anterior third of the iliac bone and exit at
the junction with the middle part. A second wire (2) is inserted some-
presented below [1, 87–98]. The angles of deviation of the what anterior to the exit point of wire 1, its exit oriented towards the
tail of the transosseous elements relative to the sagittal plane junction between the middle and posterior thirds of the iliac bone crest.
of the body are indicated in the figure legends. The wire is inserted until its end protrudes 30–40 mm. Then, on the
It is necessary to bear in mind that literature recommen- opposite side, next to the soft tissues, a corrugated or bayonet-like
flexural stop block is formed. The shank end is pulled until the stop
dations concerning the angles of insertion of the transosseous block contact is plunged into the bone
elements relative to the “human body axis” are based on the
anatomic-topographic characteristics of the intact pelvis.
However, in practice, they are quite difficult to implement inserted along the inner aspect of the ilium (as for an intrapel-
when there is bone fragment displacement, multiple lesions, vic Novocaine block) to serve as a marker for determining
and obvious soft-tissue edema, and in obese patients. the plane for half-pin insertion. The most ventral half-pin is
The “closed” insertion of transosseous elements facili- inserted into the ilium wing and set back 10 mm from the
tates the use of: (a) probes (needles, wires) to determine the anterior upper spine. The projection of the external border of
limits of the internal and external cortical plates, at the sites the bone diameter can also be indicated by a wire or needle
of insertion and exit, when placing the wires, and (b) marker. Following the skin incision, a conical recess is made
fluoroscopy or X-ray imaging with radio-opaque markers. with the aid of an awl, 5 mm in diameter, to perforate the
In difficult cases, one should resort to open insertion of upper cortical plate. The awl must be inserted set back from
the half-pins. An incision should be made in the soft tissues the crest of the inner margin at a distance equal to one-third
so that the direction of insertion of the transosseous element of its thickness (Fig. 5.257a).
can be controlled visually. In any case, final radiographic For insertion of a half-pin with stepped diameters, a recess
confirmation of the correctness of positioning of the tran- of up to 5 mm is made with a 5-mm awl. Then, in the center
sosseous elements is mandatory. of the recess, a canal of 40–50 mm is made using a flexible
Wires should be inserted through the wing of the ilium 2-mm awl inserted parallel to the inner needle marker. During
(Figs. 5.250 and 5.251). According to [96], the wires should formation of the canal with the awl, resistance from the bone
be inserted not lower than the anterior inferior iliac spine in may be sensed as a slight characteristic crunch, which is an
front, and the posterior inferior iliac spine in back. For half- indirect sign of the absence of perforation of the compact
pin insertion, the crests of the iliac wing, the anterior spines, layer. If the awl is noted to dip, it should be reinserted. The
the supra-acetabular area, the pubic bones and the lateral stepped half-pin is inserted into the formed canal to a depth
masses of the sacrum should be used (Figs. 5.252 and 5.253). of 40–50 mm, so that the part of the half-pin of greater diam-
As mentioned above, the angle of the iliac wing depends eter enters the bone to a depth of 10–20 mm (Fig. 5.254d).
on the degree of displacement of the pelvis half and the sex On the Figs. 5.255–5.261 the tips and tricks of half-pin inser-
of the patient. Therefore, an injection needle or a thin wire is tion are presented.
3 Fig. 5.254 A method for fixing the iliac bone crest using two parallel
pairs of wires was devised by Shevtsov and Tropin of the Russian
Ilizarov Research Center. Wire 1 is a half pin inserted into the anterior-
upper spine, with its exit oriented towards a point situated 3 cm above
the posterior third of the posterior-upper spine of the iliac bone wing.
Wire 2 is inserted 1.5 cm below and set back from wire 1 and parallel to
it. The exit site of wire 2 must be 1.5 cm above the posterior-upper
spine. Wire 3 is inserted at the junction between the anterior and middle
1
thirds of the iliac bone crest at an angle of 35–40° relative to wire 1 and
2 directed towards the posterior-lower spine of the iliac bone. Wire 4 is
inserted 1.5 cm cranially from wire 3 and parallel to it, with its exit
oriented towards the posterior-upper spine. Wires 1 and 4 are inserted at
an angle of 25–40° (the optimal angle being 28°) relative to the sagittal
plane. For wires 2 and 3 the angle of the bend is 25–35° (the optimal
angle being 32°). If the bend angle is greater than the recommended
range the major vessels may be damaged in the area of the sacroiliac
joint. If the bend angle is insufficient, the wires only pass through the
anterior half-round of the iliac bone wing (From [96])
a b
c
d
Fig. 5.255 (a–d) In the anterior third of the iliac bone crest, half pins inserted to a depth of up to 3.5–4 cm along the iliac bone wing parallel
are inserted to a depth of up to 5 cm along the iliac bone wing, bending to the body axis (at an angle of 90° relative to the sagittal axis), with the
the half-pin end cranially at an angle of 40–45° and laterally at an angle shank end bent laterally at an angle 30–35°
of 30–35°. In the middle third of the iliac bone crest, half-pins are
Fig. 5.256 Correct (a) and incorrect (b, c) insertion a b c

of the half-pin (From [99, 100])
a b c d
1/3 5mm
2/3
Fig. 5.257 Insertion of half-pins into the iliac bone wing. (a) Landmark for insertion of the awl. (b) Insertion of a thick awl. (c) Insertion of a thin
awl. (d) Insertion of a half-pin with two diameters (From [101])
Fig. 5.258 (a–c) A half-pin is inserted to a depth a

of 3–3.5 cm into the anterior-upper spine of the
iliac bone after bending the half pin end internally
at an angle of 30–35° and distally at an angle of
30–35°. A half-pin is inserted to a depth of 3–4 cm
into the anterior-lower spine of the iliac bone, with
the tail bent at an angle of 8–10°
c
a b
c d
5−7 mm
Fig. 5.259 Half-pins are inserted 1–1.5 cm above the margin of the (c, d) is controlled fluoroscopically in two projections. The pin is
acetabulum into the supratrochanter area (a, b) at an angle 10–60° rela- inserted 5–7 mm from the inner edge of the pubic bone and 5–7 mm
tive to the frontal plane. Half-pins are inserted in the horizontal plane from the edge of the pubic joint to a depth of 3–4 cm until it is 2–3 mm
3–5 cm more proximally from the projection of the greater trochanter beyond the lower edge of the pubic bone (From [101])
apex to a depth of 4–5 cm. Insertion of the half-pins into the pubic bone
a b
Fig. 5.260 (a–d) A needle is inserted into the posterior third of the inner cortex in ruptures of the sacroiliac joint. A channel is then formed
crest of the iliac bone with the patient lying on his or her side. The parallel to the needle into which a half-pin is inserted until it exits
posterior-upper spines of the iliac bones are identified by palpation and, beyond the edge of the iliac bone. Up to three half-pins may be inserted
at that level, a marker needle is inserted para-osseously along the exter- from the posterior-upper to posterior-lower spine of the iliac bone
nal cortex in fractures of the lateral mass of the sacrum, or along the
Fig. 5.261 In the sacrum, half-pins are inserted to a depth of 1.5 cm

into the upper part of the lateral mass at level S1, i.e., directly through
the crest of the iliac bone and sacroiliac joint
Note After the title of this chapter, all Authors, who have contributed
to the chapter, are listed. The specific authorship of the individual para-
graphs is given after each section title.

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Atlas for the Insertion of Transosseous

Element Reference Positions 5

Fig. 5.1 (a, b) Meridian diagrams according to [86]

5.1 Upper Arm

Leonid Nikolaevich Solomin and

The figures show sections at each of the principal levels

Level I (Figs. 5.2, 5.3, and 5.4)

Level II (Figs. 5.5, 5.6, and 5.7)

Level III (Figs. 5.8, 5.9, and 5.10)

Level IV (Figs. 5.11, 5.12, and 5.13)

Level V (Figs. 5.14, 5.15, and 5.16)

Level VI (Figs. 5.17, 5.18, and 5.19)

Level VII (Figs. 5.20, 5.21, and 5.22)

Level VIII (Figs. 5.23, 5.24, and 5.25)

Leonid Nikolaevich Solomin and Pavel Nikolaevich Kulesh

The figures show sections through the forearm at each of the

5.2.1 Ulna, Mid-Position

Level I (Ulna, mid-position) (Figs. 5.26, 5.27, and 5.28)

Level II (Ulna, mid-position) (Figs. 5.29, 5.30, and 5.31)

Level III (Ulna, mid-position) (Figs. 5.32, 5.33, and 5.34)

Level IV (Ulna, mid-position) (Figs. 5.35, 5.36, and 5.37)

Level V (Ulna, mid-position) (Figs. 5.38, 5.39, and 5.40)

Level VI (Ulna, mid-position) (Figs. 5.41, 5.42, and 5.43)

Level VII (Ulna, mid-position) (Figs. 5.44, 5.45, and 5.46)

Level VIII (Ulna, mid-position) (Fig. 5.47, 5.48, and 5.49)

5.2.2 Ulna, Supination

Level I (Ulna, supination) (Figs. 5.50, 5.51, and 5.52)

I,7 I,6 I,5

Level II (Ulna, supination) (Figs. 5.53, 5.54, and 5.55)

II,7 II,6 II,5

Level III (Ulna, supination) (Figs. 5.56, 5.57, and 5.58)

III,7 III,6 III,5

Level IV (Ulna, supination) (Figs. 5.59, 5.60, and 5.61)

Level V (Ulna, supination) (Figs. 5.62, 5.63, and 5.64)

Level VI (Ulna, supination) (Figs. 5.65, 5.66, and 5.67)

Level VII (Ulna, supination) (Figs. 5.68, 5.69, and 5.70)

Level VIII (Ulna, supination) (Figs. 5.71, 5.72, and 5.73)

5.2.3 Ulna, Pronation

Level I (Ulna, pronation) (Figs. 5.74, 5.75, and 5.76)

Level II (Ulna, pronation) (Figs. 5.77, 5.78, and 5.79)

Level III (Ulna, pronation) (Figs. 5.80, 5.81, and 5.82)

Level IV (Ulna, pronation) (Figs. 5.83, 5.84, and 5.85)

Level V (Ulna, pronation) (Figs. 5.86, 5.87, and 5.88)

Level VI (Ulna, pronation) (Figs. 5.89, 5.90, and 5.91)

Level VII (Ulna, pronation) (Figs. 5.92, 5.93, and 5.94)

Level VIII (Ulna, pronation) (Figs. 5.95, 5.96, and 5.97)

Table 5.1 Radius bone positions that allow forearm rotation

5.3.1 Radius, Mid-Position

Level I (Radius, mid-position) (Figs. 5.98, 5.99, and 5.100)

Level II (Radius, mid-position) (Figs. 5.101, 5.102, and 5.103)

Level III (Radius, mid-position) (Figs. 5.104, 5.105, and 5.106)

Level IV (Radius, mid-position) (Figs. 5.107, 5.108, and 5.109)

Level V (Radius, mid-position) (Figs. 5.110, 5.111, and 5.112)

Level VI (Radius, mid-position) (Figs. 5.113, 5.114, and 5.115)

Level VII (Radius, mid-position) (Figs. 5.116, 5.117, and 5.118)

Level VIII (Radius, mid-position) (Figs. 5.119, 5.120, and 5.121)

5.3.2 Radius, Supination

Level I (Radius, supination) (Figs. 5.122, 5.123, and 5.124)

Level II (Radius, supination) (Figs. 5.125, 5.126, and 5.127)

Level III (Radius, supination) (Figs. 5.128, 5.129, and 5.130)

Level IV (Radius, supination) (Figs. 5.131, 5.132, and 5.133)

Level V (Radius, supination) (Figs. 5.134, 5.135, and 5.136)

Fig. 5.134 V,4−10(V,4−10)