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Fracture Management

Elbow & forearm fractures: fixation principles, non-union risk factors, and strategies to minimize re-operation rates.

Overview

Treatment selection for pediatric femoral shaft fractures depends on age, fracture pattern, associated injuries, and family factors to minimize complications and optimize outcomes [1]. Effective management of malunited fractures requires careful patient selection with detailed clinical and radiographic evaluation and a thorough understanding of available treatment options [2]. The method selected for operative treatment of metacarpal and phalangeal shaft fractures must be tailored to the characteristics of the fracture and individualized to the patient to achieve optimal outcomes [7]. Surgical intervention may not be required for all atypical tensile-sided femoral neck stress fractures if the fracture location and severity allow for individualized treatment [6].

Operative treatment, particularly intramedullary nailing, is indicated for unstable tibial shaft fractures to minimize treatment failures and avoid secondary procedures [22]. The AAOS Clinical Practice Guideline for hip fractures in older adults includes 16 recommendations and three option statements to assist orthopaedic surgeons and qualified physicians managing patients older than 55 years [9]. Surgery should be performed as soon as possible after femoral neck fractures to reduce mortality rates in patients undergoing bipolar hemiarthroplasty [54]. The choice of specific surgical management for femoral neck fractures in the geriatric population should be based on fracture stability and patient factors such as age, function, and bone quality [55].

Current evidence on femoral head fractures covers indications, variant patterns, surgical approaches, and outcomes [53]. The optimal surgical approach for open reduction and internal fixation of intra-articular distal humeral fractures remains controversial [58]. Large, randomised trials are needed to guide the management of complex proximal humeral fractures [4].

Anatomy & Pathophysiology

Osseous Articulations and Stability

Elbow function requires recognition of the complex articulations of the humerus, radius, and ulna [43]. Optimal outcomes for coronoid fractures and traumatic elbow instability are founded upon concentric reduction of the elbow [67]. Placement of a distal humeral hemiarthroplasty implant causes a small but significant alteration in elbow joint kinematics, regardless of implant size [42].

Ligamentous and Dynamic Stabilizers

Ligaments and dynamic stabilizers play a critical role in elbow stability [43]. Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity [66].

Distal Biceps Insertion Mechanics

The trough technique for distal biceps repair results in a significant decrease in the moment arm of a 60° supinated forearm [87]. The trough technique for distal biceps repair results in a significant reduction in radial tuberosity height [87].

Classification

Pediatric Capitellar Fractures: A classification system is proposed to guide treatment and prognosis for these injuries [10].

Open Fractures: The classification of open fractures directs the surgeon’s attention to the presence and extent of injury variables [16].

Stress Fractures: Stress fractures are classified as low-risk or high-risk injuries [25]. Low-risk stress fractures generally respond to activity modification [25]. High-risk stress fractures have a propensity to develop into chronic injuries and require more aggressive treatment [25].

Monteggia-like Lesions: Correct identification, classification, and understanding of Monteggia-like lesions using CT scans, followed by appropriate surgical treatment addressing all injury components, can achieve good to excellent mid-term results [26].

Olecranon Stress Fractures: A new classification system for olecranon stress fractures in baseball players is based on the origin and direction of the fracture plane [31]. This classification is strongly influenced by the age at symptom onset [31].

Coronal Shear Fractures of the Distal Humerus: Dubberley's classification is useful for describing coronal shear fractures of the distal humerus and selecting the surgical approach [33]. Unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation according to Dubberley's classification [33].

Periprosthetic Fractures: The Unified Classification System (UCS) proposes a rational approach to treatment for periprosthetic fractures regardless of the bone broken or joint involved [30]. The UCS aims to improve understanding and consistency in reporting periprosthetic fractures [30]. The UCS for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts [49]. Three distinct fracture modes were characterized morphologically in periprosthetic fractures after hip resurfacing arthroplasty [41]. Osteonecrosis was identified as the most frequent cause of fracture-related failures in periprosthetic fractures after hip resurfacing arthroplasty [41].

Hip Fractures: Deep learning models have shown great potential in assisting clinicians with the accurate diagnosis and classification of hip fractures [36].

Other Considerations: Effective management of malunited fractures requires careful patient selection with detailed clinical and radiographic evaluation [2]. Effective management of malunited fractures requires a thorough understanding of available treatment options that continue to evolve [2] [2]. Identifying patients who require centralized care versus those who can be treated in a regional centre can improve the management of pathological fractures [13]. Outcomes for capitellum fractures are unclear due to multiple classification systems and a literature consisting of small case series without comparative groups [34].

Clinical Presentation

Treatment selection for pediatric femoral shaft fractures depends on age, fracture pattern, associated injuries, and family factors [1]. Recent advances in diagnosis and treatment of pediatric pelvic, hip, and femur fractures aim to minimize morbidity and maximize recovery potential [32]. Management of pediatric phalanx fractures is based on injury severity, with nondisplaced fractures treated via splint immobilization and unstable, displaced fractures requiring surgical management [21].

Effective management of malunited fractures requires careful patient selection with detailed clinical and radiographic evaluation [2]. Proper treatment of femoral shaft nonunions begins with appropriate diagnosis, workup, and identification of risk factors followed by a multidisciplinary approach to treatment [15].

Isolated stable radial head fractures: Routine primary nonoperative management provides a satisfactory outcome for the majority of patients [3]. Capitellar fractures: Success depends on an early diagnosis by keeping a high index of suspicion and timely management [5]. Complex proximal humeral fractures: There is a need for large, randomised trials to guide management [4].

Atypical tensile-sided femoral neck stress fractures: Surgical intervention may not be required in all cases if the fracture location and severity allow for individualized treatment [6]. Unstable tibial shaft fractures: Operative treatment, particularly intramedullary nailing, is indicated to minimize treatment failures and avoid secondary procedures [22]. Metacarpal and phalangeal shaft fractures: The method selected for operative treatment must be tailored to the characteristics of the fracture and individualized to the patient [7].

Posterior tibial plateau fractures: Fracture morphology, trauma mechanism, and soft-tissue injury are key factors determining the treatment strategy and outcome [39]. Distal humerus fractures: Advances in understanding fracture patterns, imaging, exposure techniques, fixation, and rehabilitation have improved patient outcomes [19].

Hip fractures in older adults: The AAOS Clinical Practice Guideline includes 16 recommendations and three option statements to assist orthopaedic surgeons managing patients older than 55 years [9]. Tailored fracture management and optimized cardiovascular care could improve survival in elderly patients receiving hemiarthroplasty for femoral neck fractures [8].

Open fractures: The classification is important because it directs the attention of the treating surgeon to the presence and extent of injury variables [16]. Pathological fractures: Identifying patients who require centralized care, as opposed to those who can be adequately treated in a regional centre, can improve management [13]. Traumatic pelvic ring fractures during pregnancy: Management requires a multidisciplinary approach, with treatment strategies varying based on fracture stability and gestational age [17].

Spontaneous bilateral femoral neck fractures: Early diagnosis of those associated with low serum vitamin D could have been helpful to avoid further displacement of the fracture and surgical treatment [18]. Bisphosphonate-associated atypical femoral fractures: The local incidence is in line with published figures, but medical management and identification of these fractures may be suboptimal [37].

Investigations

Plain radiography: Routine primary management of isolated stable radial head fractures provides satisfactory outcomes for the majority of patients [3]. For acute transverse patellar fractures associated with weightlifting, evaluation with radiographic examination is indicated [86]. In the context of minimally displaced acetabular fractures, a fracture step-off of ≥2 mm is a strong predictor for a poor clinical and radiographic result at 10 years if treated nonoperatively [90].

MRI: The 2025 international foot and ankle sports consensus recommends MRI for nondisplaced Jones fractures [56]. MRI-based examination is useful in all symptomatic elderly patients whose plain radiographic findings reveal isolated greater trochanter fractures [68]. All patients with isolated edema in the femoral neck without a fracture line on the initial MRI had resolution with nonoperative treatment and did not have fracture progression toward surgical fixation [79]. Ultrasound and MRI are helpful in evaluating acute brachialis rupture and monitoring its resolution [82].

CT: The 2025 international foot and ankle sports consensus recommends CT for comminuted or displaced Jones fractures [56] and reached unanimous agreement on indications for minimally invasive techniques [56] and the use of adjunctive bone grafting for Jones fractures [56]. Preoperative CT scans may improve surgical planning for patellar fractures by identifying secondary fracture lines poorly visualized on radiographs [62]. With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved for Monteggia-like lesions of the elbow [26]. Indirect reduction using a simple quadrilateral frame in the application of distal tibial LCP allows for soft tissue assessment and CT scanning [89].

Bone scan: Evaluation with bone scan is indicated for acute transverse patellar fractures associated with weightlifting [86].

Other Considerations: Treatment selection for pediatric femoral shaft fractures depends on age, fracture pattern, associated injuries, and family factors [1]. Effective management of malunited fractures requires careful patient selection with detailed clinical and radiographic evaluation [2]. There is a need for large, randomised trials to guide management of complex proximal humeral fractures [4]. The success of management of a capitellar fracture depends on an early diagnosis by keeping a high index of suspicion and timely management [5]. Surgical intervention for atypical tensile-sided femoral neck stress fractures may not be required in all cases if the fracture location and severity allow for individualized treatment [6]. A classification of pediatric capitellar fractures guides treatment and prognosis [10]. Proper treatment of femoral shaft nonunions begins with appropriate diagnosis, workup, and identification of risk factors followed by a multidisciplinary approach to treatment [15]. Early diagnosis of spontaneous bilateral femoral neck fractures associated with low serum vitamin D could have been helpful to avoid further displacement and surgical treatment [18]. Advances in understanding fracture patterns, imaging, exposure techniques, fixation, and rehabilitation have improved patient outcomes for distal humerus fractures [19].

Treatment

Treatment selection for pediatric femoral shaft fractures depends on age, fracture pattern, associated injuries, and family factors to minimize complications and optimize outcomes [1]. Invasive primary treatment of children's both-bone diaphyseal forearm fractures prevents re-displacement, and the need for re-operation of severe fractures was less common in the invasive treatment group than in the non-invasive treatment group [61]. Management of pediatric phalanx fractures is based on injury severity, with nondisplaced fractures treated via splint immobilization and unstable, displaced fractures requiring surgical management, preferably closed reduction and percutaneous pinning [21]. A classification of pediatric capitellar fractures guides treatment and prognosis [10]. The success of management of capitellar fractures depends on early diagnosis by keeping a high index of suspicion and timely management [5].

Effective management of malunited fractures requires careful patient selection with detailed clinical and radiographic evaluation and a thorough understanding of available treatment options [2]. Conservative treatment may be considered for anteromedial coronoid facet fractures under strict preconditions, especially for nondisplaced subtype 1 and 2 fractures, as these show satisfactory functional outcomes when treated nonoperatively [38]. Routine primary nonoperative management of isolated stable radial head fractures provides a satisfactory outcome for the majority of patients, with few requiring further intervention for persisting complaints [3]. Delayed excision is a viable option for patients with a fracture of the radial head in whom non-operative management fails or late symptoms develop [52]. A patient treated nonoperatively despite complete non-union of a radial neck fracture achieved a good functional outcome at 16 months with no pain, avascular necrosis, or head collapse [70].

The role of non-operative management for pelvic and acetabular fractures is not defined, and the problem of late posterior pain in patients with a pelvic fracture is incompletely solved [59]. Management of traumatic pelvic ring fracture during pregnancy requires a multidisciplinary approach, with treatment strategies varying based on fracture stability and gestational age [17]. There is currently no high-quality evidence to guide the optimal treatment method for a Bennett's fracture [48]. Arthroscopically assisted percutaneous osteosynthesis of displaced transverse patellar fractures with figure-eight wiring through paired cannulated screws is not indicated for severely comminuted fractures [45].

There is a need for large, randomised trials to guide management of complex proximal humeral fractures [4]. Nonsurgical management of proximal humerus fractures decreased during the study period [64]. Tailored fracture management and optimized cardiovascular care could improve survival in elderly patients receiving hemiarthroplasty for femoral neck fractures [8]. The AAOS Clinical Practice Guideline for Management of Hip Fractures in Older Adults includes 16 recommendations and three option statements to assist orthopaedic surgeons and qualified physicians managing patients older than 55 years with hip fractures based on the best current available evidence [9]. The AAOS guideline for Management of Hip Fractures in the Elderly provides evidence-based principles to improve the standard of care for hip fracture patients [57].

In the management of Pauwels type III femoral neck fractures in young patients, Femoral Neck System (FNS) demonstrates clinical efficacy comparable to 4 cannulated compression screws (CCSs) [50]. Computerized navigation for the internal fixation of femoral neck fractures may provide better mechanical stability and improved fracture outcome [46]. Fracture risk during primary total hip arthroplasty increases in patients younger than 50 and older than 80 years, females, American Society of Anesthesiologists grade 3 to 5, and indications other than primary osteoarthritis [51].

The method selected for operative treatment of metacarpal and phalangeal shaft fractures must be tailored to the characteristics of the fracture and individualized to the patient to achieve optimal outcome [7]. Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery [63]. Low and high body mass index and lower numbers of screws in the articular segment are risk factors for non-union of distal humeral fractures in the elderly [69]. Non-union is associated with poor clinical outcomes in distal humeral fractures in the elderly [69]. Other fracture-recovery outcomes were similar when comparing teriparatide with risedronate after pertrochanteric hip fracture [11].

Complications

Infection: Ninety-day follow-up is inadequate for postoperative surveillance and diagnosis of fracture-related infections in patients with open long-bone fractures [12].

Periprosthetic fracture: Geriatric hip fractures continue to have high short-term morbidity and mortality [20]. A hip fracture has a long-term impact on health-related quality of life (HRQOL) and is a strong predictor of worsened physical health [24]. Approximately 1 in 6 patients live at least 10 years following a hip fracture [28]. Tailored fracture management and optimized cardiovascular care could improve survival in elderly patients receiving hemiarthroplasty for femoral neck fractures [8].

Other Considerations: Treatment selection for pediatric femoral shaft fractures depends on age, fracture pattern, associated injuries, and family factors to minimize complications [1]. Effective management of malunited fractures requires careful patient selection with detailed clinical and radiographic evaluation [2]. Routine primary nonoperative management of isolated stable radial head fractures provides a satisfactory outcome for the majority of patients, with few requiring further intervention for persisting complaints [3]. Other fracture-recovery outcomes were similar between teriparatide and risedronate groups after pertrochanteric hip fracture [11]. Closed fracture and regular follow-up were determining factors for better functional outcomes in distal femur fractures treated by open reduction and internal fixation [14]. Short and long-term outcomes of traumatic hip dislocation are largely driven by the time from injury to reduction and associated injuries [23]. Low-risk stress fractures generally respond to activity modification, while high-risk fractures have a propensity to develop into chronic injuries [25]. Patient characteristics, the nature of the fracture, and the experience of the treating orthopaedic surgeon must be considered when choosing among nonsurgical treatment, percutaneous fixation, open reduction and internal fixation, and immediate or delayed arthroplasty for acetabular fractures in the elderly [27]. A longer duration between surgical fixation and the first adverse event before stabilization of the fracture site may be a risk factor for revision surgery in older female patients with low bone mass treated with a femoral neck system versus multiple cannulated screws for Pauwels classification type II femoral neck fractures [35]. Prophylactic titanium elastic nailing following femoral lengthening reduces the risk for secondary interventions after regenerate fractures [72]. Fractures occurred in 12% of cases in the cohort study on prophylactic titanium elastic nailing following femoral lengthening [72]. People with a history of wrist fracture can potentially benefit from early-stage hypertension control, although a history of fracture overall may not directly cause hypertension [75]. True compression plates apply continuous force to accelerate healing, distinguishing them from early devices that merely coapted fragments [91]. A sound knowledge of the natural history of fibrodysplasia progressiva ossificans allowed treating surgeons to effectively use a serendipitous osteotomy for a humeral fracture, with bony union virtually guaranteed [92].

Recovery

Light activity (weeks): The mean time for a tibial fracture to heal is 18 weeks, with 13.8% of patients requiring longer than 25 weeks to achieve healing [95]. For distal radius fractures, there is a linear relationship between surgical delay and declining radiographic outcomes, where each day's delay progressively compromises fracture alignment [94].

Full activity (months): Geriatric hip fractures continue to have high short-term morbidity and mortality [20]. Although mortality is high after hip fracture, surviving patients experience measurable gains in function and well-being in the 3 years after the fracture [47]. A hip fracture has a long-term impact on health-related quality of life (HRQOL) and is a strong predictor of worsened physical health [24]. Approximately 1 in 6 patients live at least 10 years following a hip fracture [28].

Complete recovery / outcome plateau (months): Short and long-term outcomes for traumatic hip dislocation are largely driven by the time from injury to reduction and associated injuries [23]. Other fracture-recovery outcomes were similar between teriparatide and risedronate in patients with pertrochanteric hip fractures [11]. The success of pulsed electromagnetic fields for treating tibial delayed unions and nonunions is not associated with specific fracture or patient-related variables and cannot be clearly considered a time-dependent phenomenon [93].

Rehabilitation protocol: Treatment selection for pediatric femoral shaft fractures depends on age, fracture pattern, associated injuries, and family factors to minimize complications and optimize outcomes [1]. Routine primary nonoperative management of isolated stable radial head fractures provides a satisfactory outcome for the majority of patients, with few requiring further intervention for persisting complaints [3]. Successful management of capitellar fractures depends on early diagnosis via a high index of suspicion and timely management [5]. Closed fracture status and regular follow-up were determining factors for better functional outcomes in distal femur fractures treated with open reduction and internal fixation using a distal femur locking plate [14].

Functional milestones: Patient characteristics, the nature of the fracture, and the experience of the treating orthopaedic surgeon must be considered when choosing among nonsurgical treatment, percutaneous fixation, open reduction and internal fixation, and immediate or delayed arthroplasty for acetabular fractures in the elderly [27].

Other Considerations: A 90-day follow-up period after management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes [12].

Key Evidence

  • [L5] Treatment selection depends on age, fracture pattern, associated injuries, and family factors to minimize complications and optimize outcomes. (10.5435/jaaos-d-22-00415)
  • [L4] Routine primary nonoperative management of these fractures provides a satisfactory outcome for the majority of patients, with few patients requiring further intervention for persisting complaints. (10.2106/jbjs.m.01354)
  • [L1] There is a need for large, randomised trials to guide management of these fractures. (10.1111/j.1758-5740.2010.00075.x)
  • [L4] The success of management of a capitellar fracture depends on an early diagnosis by keeping a high index of suspicion and timely management. (10.1016/j.jse.2016.01.034)
  • [L4] Surgical intervention may not be required in all cases if the fracture location and severity allow for individualized treatment. (10.1177/0363546503262195)
  • [L5] The method selected must be tailored to the characteristics of the fracture and individualized to the patient to achieve optimal outcome. (10.5435/00124635-200003000-00005)
  • [L3] Tailored fracture management and optimized cardiovascular care could improve survival. (10.1186/s12891-025-08620-0)
  • [L1] The guideline includes 16 recommendations and three option statements to assist orthopaedic surgeons and qualified physicians managing patients older than 55 years with hip fractures based on the best current available evidence. (10.5435/jaaos-d-22-00125)
  • [L4] A classification of pediatric capitellar fractures is proposed, guiding treatment and prognosis. (10.2106/jbjs.16.01393)
  • [L2] Other fracture-recovery outcomes were similar. (10.2106/jbjs.15.01217)
  • [L3] Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes. (10.1097/corr.0000000000001911)
  • [L4] Identifying patients who require centralized care, as opposed to those who can be adequately treated in a regional centre, can improve the management of patients with pathological fractures. (10.1302/0301-620x.100b10.bjj-2018-0239.r1)
  • [L3] Closed fracture and regular follow up were determining factors for better functional outcomes. (10.1186/s13018-024-05054-7)
  • [L5] Proper treatment of femoral shaft nonunions begins with appropriate diagnosis, workup, and identification of risk factors followed by a multidisciplinary approach to treatment. (10.5435/jaaos-d-24-01391)
  • [L5] The classification of open fractures is important because it directs the attention of the treating surgeon to the presence and extent of injury variables. (10.5435/00124635-200305000-00008)
  • [L4] Management requires a multidisciplinary approach, with treatment strategies varying based on fracture stability and gestational age. (10.1530/EOR-23-0164)
  • [L4] Early diagnosis could have been helpful to avoid further displacement of the fracture and surgical treatment. (10.1016/j.arth.2008.01.309)
  • [L3] Geriatric hip fractures continue to have high short-term morbidity and mortality. (10.5435/jaaos-d-21-01055)
  • [L5] Management is based on injury severity, with nondisplaced fractures treated via splint immobilization and unstable, displaced fractures requiring surgical management, preferably closed reduction and percutaneous pinning. (10.5435/jaaos-d-16-00199)
  • [L5] Operative treatment, particularly intramedullary nailing, is indicated for unstable fractures to minimize treatment failures and avoid secondary procedures. (10.2106/00004623-199410000-00021)
  • [L5] Short and long-term outcomes are largely driven by the amount of time from injury to reduction and associated injuries. (10.5435/jaaos-d-23-01013)
  • [L3] A hip fracture has a long-term impact on HRQOL and is a strong predictor of worsened physical health. (10.1186/1471-2474-11-226)
  • [L5] Stress fractures are classified as low-risk or high-risk injuries; low-risk fractures generally respond to activity modification, while high-risk fractures have a propensity to develop into chronic injuries and require more aggressive treatment. (10.5435/00124635-200011000-00002)
  • [L3] With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. (10.1302/0301-620x.100b2.bjj-2017-0398.r2)
  • [L5] Patient characteristics, the nature of the fracture, and the experience of the treating orthopaedic surgeon must be considered when choosing among nonsurgical treatment, percutaneous fixation, open reduction and internal fixation, and immediate or delayed arthroplasty. (10.5435/jaaos-d-15-00510)
  • [L3] Approximately 1 in 6 patients live at least 10 years following a hip fracture. (10.2106/jbjs.24.00379)
  • [L5] The Unified Classification System proposes a rational approach to treatment regardless of the bone broken or joint involved, aiming to improve understanding and consistency in reporting periprosthetic fractures. (10.1302/0301-620x.96b6.34040)
  • [L4] This study presents a new classification system for the different types of OSFs based on the origin and direction of the fracture plane, which is strongly influenced by the age at symptom onset. (10.1177/0363546514528099)
  • [L4] The study confirms the utility of the Dubberley classification in describing the fracture and selecting the surgical approach. (10.1016/j.jse.2025.05.033)
  • [L4] The article summarizes the existing body of evidence on capitellum fractures, noting that outcomes are unclear due to multiple classification systems and a literature consisting of small case series without comparative groups, and proposes areas for future study. (10.1177/1558944719878817)
  • [L3] A longer duration between surgical fixation and the first adverse event before stabilization of the fracture site may be a risk factor for revision surgery. (10.1186/s12891-024-07179-6)
  • [L4] The model has shown great potential in assisting clinicians with the accurate diagnosis and classification of hip fractures. (10.1302/0301-620x.107b2.bjj-2024-0791.r1)
  • [L4] The local incidence of atypical femoral fractures is in line with published figures; however, medical management and identification of these fractures may be suboptimal. (10.1186/s12891-017-1392-9)
  • [L4] Conservative treatment may be considered under strict preconditions, especially for nondisplaced subtype 1 and 2 fractures, as these fractures show satisfactory functional outcomes when treated nonoperatively. (10.1016/j.jse.2020.09.008)
  • [L5] Fracture morphology, trauma mechanism, and soft-tissue injury are key factors determining the treatment strategy and outcome. (10.1016/j.injury.2020.09.011)
  • [L4] Three distinct fracture modes were characterized morphologically, with osteonecrosis identified as the most frequent cause of fracture-related failures. (10.2106/jbjs.h.01113)
  • [L5] This study showed a small but significant alteration in elbow joint kinematics with placement of a distal humeral hemiarthroplasty implant, regardless of implant size. (10.1016/j.jse.2014.02.011)
  • [Paper] However, it is not indicated for severely comminuted fractures. (10.1007/s00402-010-1241-x)
  • [L3] It may provide better mechanical stability and improved fracture outcome. (10.2106/jbjs.e.00137)
  • [L2] Although mortality is high, surviving patients experience measurable gains in function and well-being in the 3 years after the fracture. (10.5435/jaaos-d-19-00530)
  • [L4] Overall there is currently no high-quality evidence to guide us to the optimal treatment method for a Bennett's fracture. (10.1177/1753193416642691)
  • [L4] The Unified Classification System (UCS) for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts. (10.1302/0301-620x.96b11.34214)
  • [L3] In the management of Pauwels type III femoral neck fractures in young patients, FNS demonstrates clinical efficacy comparable to CCSs. (10.1186/s13018-025-05461-4)
  • [L3] Fracture risk increases in patients younger than 50 and older than 80 years, females, American Society of Anesthesiologists grade 3 to 5, and indications other than primary osteoarthritis. (10.1016/j.arth.2019.06.062)
  • [L4] Delayed excision is a viable option for patients with a fracture of the radial head in whom non-operative management fails or late symptoms develop. (10.2106/00004623-198668050-00005)
  • [L4] The purpose of this review was to summarize current evidence on femoral head fractures regarding indications, variant patterns, surgical approaches, and outcomes. (10.5435/jaaos-d-23-01121)
  • [L3] The authors recommend performing surgery as soon as possible after the fracture to reduce mortality rates. (10.1016/j.arth.2009.06.019)
  • [L5] The consensus process reached unanimous agreement with respect to the use of MRI for nondisplaced fractures, the use of CT for comminuted or displaced fractures, indications for minimally invasive techniques, and use of adjunctive bone grafting. (10.1002/ksa.70241)
  • [L1] The guideline provides evidence-based principles to improve the standard of care for hip fracture patients. (10.5435/jaaos-d-14-00432)
  • [L4] The optimal approach for surgical management of these fractures remains controversial. (10.1016/j.jse.2011.06.020)
  • [L5] The early functional results appear favorable; however, the role of non-operative management is not defined, and the problem of late posterior pain in patients with a pelvic fracture is incompletely solved. (10.2106/00004623-198668080-00035)
  • [L3] Invasive primary treatment seemed to prevent re-displacement and the need for re-operation of severe fractures was less common in the invasive treatment group than in the non-invasive treatment group. (10.1016/j.injury.2012.08.032)
  • [L5] Preoperative CT scans may improve surgical planning by identifying secondary fracture lines poorly visualized on radiographs. (10.2106/jbjs.20.01478)
  • [L4] Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. (10.1016/j.xrrt.2021.10.001)
  • [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. (10.1016/j.jhsa.2020.03.022)
  • [L5] Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity. (10.1016/j.jse.2023.11.001)
  • [L5] Optimal outcomes are founded upon concentric reduction of the elbow. (10.1016/j.jseint.2023.03.020)
  • [L4] MRI-based examination is useful in all symptomatic elderly patients whose plain radiographic findings reveal isolated GT fractures. (10.1186/s12891-018-2193-5)
  • [L3] Non-union is associated with poor clinical outcomes. (10.1177/17585732221131923)
  • [Case_report] The patient was treated nonoperatively despite complete non-union and achieved a good functional outcome at 16 months with no pain, avascular necrosis, or head collapse. (10.1111/j.1758-5740.2010.00080.x)
  • [L3] Fractures occurred in 12% of cases, and the rate of secondary interventions was markedly reduced. (10.1186/1471-2474-14-302)
  • [L3] Although history of fracture overall may not directly cause hypertension, people with a history of wrist fracture can be potentially benefitted from hypertension control at the early stage. (10.1186/s12891-015-0544-z)
  • [L4] All patients with isolated edema in the femoral neck without a fracture line on the initial MRI had resolution with nonoperative treatment and did not have fracture progression toward surgical fixation. (10.2106/jbjs.17.01593)
  • [Letter] Ultrasound and MRI are helpful in evaluating this injury and monitoring its resolution. (10.1016/j.jse.2013.01.016)
  • [L4] Evaluation with radiographic examination or bone scan is indicated, and reduction of training load may prevent acute fracture. (10.1177/03635465010290021901)
  • [L5] The trough technique resulted in a significant decrease in the moment arm of a 60° supinated forearm and a significant reduction in radial tuberosity height. (10.2106/jbjs.n.01221)
  • [Paper] This approach provides good fracture stability, allows for soft tissue assessment and CT scanning, and minimizes surgical trauma. (10.1016/j.injury.2005.02.023)
  • [L2] A fracture step-off of ≥2 mm is a strong predictor for a poor clinical and radiographic result at 10 years. (10.2106/jbjs.15.01154)
  • [Case_report] A sound knowledge of the natural history of this condition allowed the treating surgeons to effectively make use of a serendipitous osteotomy, meaning that nursing care becoming easier for the patient because bony union of the fracture was virtually guaranteed. (10.1177/1758573215598498)
  • [L3] Its success is not associated with specific fracture or patient related variables and it couldn't be clearly considered a time-dependent phenomenon. (10.1186/1749-799x-7-24)
  • [L3] A linear relationship was identified between surgical delay and declining radiographic outcomes, highlighting that each day's delay progressively compromises fracture alignment. (10.1177/17531934251379171)
  • [Paper] The mean time for a tibial fracture to heal is 18 weeks, with 13.8% of patients requiring longer than 25 weeks to achieve healing. (10.1016/j.otsr.2019.10.010)

See Also

References

[1] Treatment of Pediatric Femoral Shaft Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-22-00415

[2] Chapter 10 Malunions. 2021.

[3] Long-Term Outcomes of Isolated Stable Radial Head Fractures. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01354

[4] Conservative versus Operative Management of Complex Proximal Humeral Fractures: A Meta-analysis. Shoulder & Elbow. 2010. DOI: 10.1111/j.1758-5740.2010.00075.x

[5] Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.01.034

[6] Atypical Tensile-Sided Femoral Neck Stress Fractures. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546503262195

[7] Operative Treatment of Metacarpal and Phalangeal Shaft Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200003000-00005

[8] Risk factors associated with mortality in elderly patients receiving hemiarthroplasty for femoral neck fractures. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08620-0

[9] AAOS Clinical Practice Guideline Summary: Management of Hip Fractures in Older Adults. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-22-00125

[10] Capitellar Fractures in Children and Adolescents. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.16.01393

[11] Effects of Teriparatide Compared with Risedronate on Recovery After Pertrochanteric Hip Fracture. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.01217

[12] Ninety-Day Follow-up Is Inadequate for Diagnosis of Fracture-related Infections in Patients with Open Fractures. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000001911

[13] Trends in the surgical treatment of pathological fractures of the long bones. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b10.bjj-2018-0239.r1

[14] Prospective study on functional outcome of distal femur fracture treated by open reduction and internal fixation using distal femur locking plate in Tibebe Ghion Specialized Hospital, Bahirdar, North West Ethiopia. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05054-7

[15] Approach to Femoral Shaft Nonunions: Diagnosis and Management. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01391

[16] Open Fractures: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200305000-00008

[17] Traumatic pelvic ring fracture during pregnancy: a systematic review. EFORT Open Reviews. 2024. DOI: 10.1530/EOR-23-0164

[18] Spontaneous Bilateral Femoral Neck Fractures Associated With a Low Serum Level of Vitamin D in a Young Adult. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.01.309

[19] Chapter 26 Distal Humerus Fracture. 2021.

[20] Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-21-01055

[21] Pediatric Phalanx Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-16-00199

[22] Treatment of unstable fractures of the shaft of the tibia.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199410000-00021

[23] Traumatic Hip Dislocation: Pediatric and Adult Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01013

[24] Two-year changes in quality of life in elderly patients with low-energy hip fractures. A case-control study. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-226

[25] High-Risk Stress Fractures: Evaluation and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200011000-00002

[26] The challenge of Monteggia-like lesions of the elbow. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b2.bjj-2017-0398.r2

[27] Management of Acetabular Fractures in the Elderly. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00510

[28] Patient Factors Associated with 10-Year Survival After Arthroplasty for Hip Fracture. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.24.00379

[30] The Unified Classification System (UCS): improving our understanding of periprosthetic fractures. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b6.34040

[31] Classification of Olecranon Stress Fractures in Baseball Players. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514528099

[32] Chapter 56 Pediatric Pelvis, Hip and Femur Trauma. 2020.

[33] Unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation: a long-term retrospective study according to Dubberley's classification. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.05.033

[34] Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes. HAND. 2019. DOI: 10.1177/1558944719878817

[35] Femoral neck system versus multiple cannulated screws for the fixation of Pauwels classification type II femoral neck fractures in older female patients with low bone mass. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07179-6

[36] Deep learning for automated hip fracture detection and classification. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b2.bjj-2024-0791.r1

[37] Incidence and medical management of bisphosphonate-associated atypical femoral fractures in a major trauma centre: a retrospective observational study. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1392-9

[38] The treatment of anteromedial coronoid facet fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.008

[39] Why address posterior tibial plateau fractures?. Injury. 2020. DOI: 10.1016/j.injury.2020.09.011

[41] Morphologic Analysis of Periprosthetic Fractures After Hip Resurfacing Arthroplasty. The Journal of Bone & Joint Surgery. 2010. DOI: 10.2106/jbjs.h.01113

[42] Hemiarthroplasty of the elbow: the effect of implant size on kinematics and stability. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.02.011

[43] Chapter 27 Fractures of the Proximal Radius and Ulna and Dislocations of the Elbow. 2021.

[45] Arthroscopically assisted percutaneous osteosynthesis of displaced transverse patellar fractures with figure-eight wiring through paired cannulated screws. Archives of Orthopaedic and Trauma Surgery. 2010. DOI: 10.1007/s00402-010-1241-x

[46] Computerized Navigation for the Internal Fixation of Femoral Neck Fractures. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00137

[47] The Pronounced Impact of Hip Fractures on Psychosocial Well-being. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-19-00530

[48] Management of Bennett’s fractures: a review of treatment outcomes. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416642691

[49] Field testing the Unified Classification System for peri-prosthetic fractures of the pelvis and femur around a total hip replacement. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b11.34214

[50] Femoral neck system (FNS) versus 4 cannulated compression screws (CCSs) in the treatment of young patients with Pauwels type III femoral neck fracture: a retrospective comparative study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05461-4

[51] Risk Factors for Intraoperative Periprosthetic Femoral Fractures During Primary Total Hip Arthroplasty. An Analysis From the National Joint Registry for England and Wales and the Isle of Man. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.06.062

[52] Results of delayed excision of the radial head after fracture.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668050-00005

[53] Femoral Head Fractures: Evaluation, Management, and Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01121

[54] Postoperative Mortality and Factors Related to Mortality After Bipolar Hemiarthroplasty in Patients With Femoral Neck Fractures. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2009.06.019

[55] Chapter 48 Femoral Neck Fractures in the Geriatric Population. 2021.

[56] Jones fractures in elite athletes—2025 international foot and ankle sports consensus and systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70241

[57] Management of Hip Fractures in the Elderly. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00432

[58] Effects of surgical approach on functional outcomes of open reduction and internal fixation of intra-articular distal humeral fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.06.020

[59] Pelvic and Acetabular Fractures.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668080-00035

[61] Complications and radiographic outcome of children's both-bone diaphyseal forearm fractures after invasive and non-invasive treatment. Injury. 2013. DOI: 10.1016/j.injury.2012.08.032

[62] Patellar Fractures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01478

[63] Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery: a systematic review. JSES Reviews, Reports, and Techniques. 2022. DOI: 10.1016/j.xrrt.2021.10.001

[64] Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.03.022

[66] Weakening and factors of medial elbow dynamic stabilizers against elbow valgus laxity after repetitive pitching in high school baseball players. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.11.001

[67] Coronoid fractures and traumatic elbow instability. JSES International. 2023. DOI: 10.1016/j.jseint.2023.03.020

[68] Diagnostic strategy for elderly patients with isolated greater trochanter fractures on plain radiographs. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2193-5

[69] Low and high body mass index and lower numbers of screws in the articular segment are risk factors for non-union of distal humeral fractures in the elderly: A multi-center retrospective study (TRON study). Shoulder & Elbow. 2022. DOI: 10.1177/17585732221131923

[70] Non-Union of Radial Neck Fracture: A Case Report and Review of Literature. Shoulder & Elbow. 2010. DOI: 10.1111/j.1758-5740.2010.00080.x

[72] Prophylactic titanium elastic nailing (TEN) following femoral lengthening (Lengthening then rodding) with one or two nails reduces the risk for secondary interventions after regenerate fractures: a cohort study in monolateral vs. bilateral lengthening procedures. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-302

[75] Association of history of fracture with prehypertension and hypertension: a retrospective case–control study. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0544-z

[79] Femoral Neck Stress Fractures: MRI Risk Factors for Progression. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.01593

[82] Regarding “Acute traumatic brachialis rupture in a young rugby player: a case report” and “Acute brachialis muscle rupture caused by closed elbow dislocation in a professional American football player”. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.016

[86] Acute Transverse Patellar Fracture Associated with Weightlifting. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290021901

[87] The Importance of Preserving the Radial Tuberosity During Distal Biceps Repair. The Journal of Bone and Joint Surgery-American Volume. 2015. DOI: 10.2106/jbjs.n.01221

[89] Indirect reduction using a simple quadrilateral frame in the application of distal tibial LCP—technical tips. Injury. 2005. DOI: 10.1016/j.injury.2005.02.023

[90] Long-Term Survival of the Native Hip After a Minimally Displaced, Nonoperatively Treated Acetabular Fracture. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.01154

[91] Compression bone-plating: historical considerations.. The Journal of Bone and Joint Surgery. American Volume. 1977.

[92] Primum non nocere: a case of a humeral fracture in a patient with fibrodysplasia progressiva ossificans. Shoulder & Elbow. 2015. DOI: 10.1177/1758573215598498

[93] Pulsed electromagnetic fields for the treatment of tibial delayed unions and nonunions. A prospective clinical study and review of the literature. Journal of Orthopaedic Surgery and Research. 2012. DOI: 10.1186/1749-799x-7-24

[94] Radiographic outcomes decline linearly with increased time to surgery in distal radius fractures: A cohort analysis. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251379171

[95] Application of the Radiographic Union Scale for Tibial fractures (RUST): Assessment of healing rate and time of tibial fractures managed with intramedullary nailing. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2019.10.010

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