Fracture Fixation

Femoral neck, intertrochanteric, and subtrochanteric fractures — implant selection for unstable patterns and IMN vs extramedullary fixation.

Overview

A thorough understanding of fracture types, treatment principles, and fixation devices is paramount for managing complex periprosthetic femoral fractures [1]. Reduction and internal fixation remains the preferred treatment method for displaced femoral neck fractures [2]. For open blast pelvis fractures, minimal internal fixation is advocated [4]. Internal fixation also serves as an effective option in select clinical circumstances, where successful healing and avoidance of complications are largely determined by surgical technique [5].

Acceptable results can be achieved with internal fixation for difficult humeral shaft fractures, even when closed treatment remains the method of choice for most fractures [11]. Achieving these outcomes requires that correct principles of fixation are carefully followed [11]. Plate fixation is reliable and safe for humeral shaft fractures when indications for operative treatment are met [17]. Current evidence is insufficient to recommend an optimal method of internal fixation when comparing fixed angle devices versus multiple cancellous screws [6]. High-quality randomised, controlled trials are needed to study this comparison [6].

External fixation is an essential tool in the management of fracture non-unions [3]. Indications for external fixation in non-union management are refined as understanding of outcomes improves [3]. Common indications for dual-implant fixation include nonunion treatment and comminuted fractures with bone loss [13]. Neither internal plating nor definitive external fixation has proven to be more effective overall for total fractures of the tibial pilon [24]. The complication rate for total fractures of the tibial pilon is high [24].

The use of the Fixion nailing system is associated with minimal complications and very good functional outcomes in tibial shaft fractures OTA types A and B [21]. The Fixion nailing system is indicated for tibial shaft fractures OTA types A and B [21]. Further evidence is needed to specify indications for fixation versus primary transfixation in osteoporotic trimalleolar ankle fractures [57]. Future research is required to identify patients who benefit from arthroscopic-assisted surgery in the management of trimalleolar ankle fractures [57].

Anatomy & Pathophysiology

Osseous Geometry and Morphology

Hip geometry in Arctic populations suggests a delicate balance that differs from European data [51]. Femoral neck fractures in young and middle-aged adults exhibit morphological diversity and complexity [78]. The contralateral uninjured hip is an excellent indicator of the initial lesser trochanter size and biomechanical rotation [36].

Biomechanics of Fixation

The insertion of a dynamic hip screw requires assessment of the native angle of the femoral neck [61]. Fixation of the femoral head with a helical blade was biomechanically superior to fixation with a standard sliding hip screw in a cadaveric, unstable intertrochanteric hip fracture model [68]. The Femoral Neck System (FNS) has excellent biomechanical properties and shows significantly higher overall construct stability compared to cannulated compression screws in younger patients [71]. However, the biomechanical performance of the FNS is fracture-type-dependent, necessitating angle-specific optimisation [72]. Treatment of femoral neck fractures with the Femoral Neck System (FNS) contributes to improved hip joint function, with biomechanical research confirming its structural stability and advantages in resisting femoral head varus [65]. Conversely, the Femoral Neck System demonstrated failure at the subtrochanteric femur in a synthetic femoral biomechanical model [73]. Single and double lag screw implants demonstrated a significantly different migration resistance in surrogate specimens under gait loading simulation with the HIPS model [79].

Complications and Risk Factors

Intraoperative mechanical injury of the femoral neck or malpositioning of the femoral component may lead to changes in loading patterns resulting in acute and chronic biomechanical femoral neck fractures [22]. The ratio between the screw distance and femoral neck width on lateral radiography is a reliable predictor of femoral head necrosis [64]. Optimization of screw trajectories, particularly through broader screw spacing facilitated by a navigation system, is a promising strategy for improving the local biomechanical environment and reducing the likelihood of femoral head necrosis [64]. Cerclage femoral wiring for prophylactic purposes during hip arthroplasty does not confer a significant biomechanical advantage over non-wiring techniques [67].

Imaging and Simulation

If an anteriorly placed hip screw is not seen to be breaching the articular surface on a view taken in internal rotation, the screw is definitely not in the joint, whereas external rotation may give a false impression of adequate placement [77]. Robust simulation of macro and micro-scale events allows the testing of novel new designs in simulations far more complex than conventional biomechanical testing will allow [76].

Classification

A thorough understanding of fracture types is paramount for managing periprosthetic femoral fractures [1]. Periprosthetic femoral fractures occur at different rates at different times depending on the method of fixation [9]. A new classification system for interprosthetic femoral fractures showed adequate inter-observer reproducibility [34].

AO/OTA: The revised 2018 AO/OTA classification simplified the previous classification of intracapsular femoral neck fractures but remains unreliable with only fair interobserver reliability [42]. Additional studies are required to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures [46]. Fracture classification was the main determinant for the use of the trochanteric stabilizing plate in a study of 20,902 trochanteric fractures [37].

Segmental Tibial: Type-I segmental tibial fractures are the easiest to treat, while Type-II and Type-III fractures require firm fixation due to increased risks of complications [19].

Coronoid Process: A radiographic classification of coronoid process fractures has prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures [15].

Multifocal Humeral: A simple classification of multifocal humeral fractures is suggested to help surgeons choose the most suitable type of synthesis for surgical treatment [32].

Other Considerations: Reduction and internal fixation is the preferred treatment method for displaced femoral neck fractures [2]. External fixation is an essential tool in the management of fracture non-unions [3]. An alternative fixation device should be considered for unstable per-, inter-, and subtrochanteric fractures of the proximal femur with missing posteromedial support [7]. The Fixion nailing system is associated with minimal complications and very good functional outcomes in OTA types A and B tibial shaft fractures [21]. Intraoperative mechanical injury of the femoral neck or malpositioning of the femoral component may lead to changes in loading patterns resulting in acute and chronic biomechanical femoral neck fractures after hip resurfacing arthroplasty [22].

Clinical Presentation

A thorough understanding of fracture types is paramount for managing periprosthetic femoral fractures [1]. Risk factors and fracture patterns for these injuries vary depending on the method of fixation [9], and fractures occur at different rates at different times based on that same fixation method [9].

For displaced femoral neck fractures, the integrity of the posterior retinaculum is relevant to clinical assessment [2]. Atypical tensile-sided femoral neck stress fractures may not require surgical intervention if the fracture location and severity allow for individualized treatment [38]. Early diagnosis of spontaneous bilateral femoral neck fractures associated with low serum vitamin D levels could have avoided further displacement [16].

Proper treatment of femoral shaft nonunions begins with appropriate diagnosis, workup, and identification of risk factors [31]. Treatment selection for pediatric femoral shaft fractures depends on age, fracture pattern, associated injuries, and family factors [28].

Type-I segmental tibial fractures are the easiest to treat, while Type-II and Type-III fractures require firm fixation due to increased risks of complications [19]. Fractures of the talus without displacement have a good prognosis with complete function restored after adequate immobilization [20].

Delayed presentation is a clinical challenge in neglected acetabular fractures [33]. Fractures of the capitate are diagnosed and reported with undeserved rarity, requiring a higher index of suspicion for recognition [18]. Failure to diagnose, reduce, and immobilize carpal navicular (scaphoid) fractures properly is directly responsible for delayed union or non-union [30].

Investigations

Plain radiography: A radiographic classification of coronoid process fractures has prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures [15]. Diagnosis of distal tibia fracture union based on radiographs 3 months after injury is only moderately reliable and accurate but has a high negative predictive value [85]. Despite deformity, cases with a wedge effect following intramedullary hip screw fixation of intertrochanteric proximal femur fractures demonstrated radiographic fracture union [96]. Anatomical reduction and fixation of the posterior wall of the acetabulum with a plate and screws did not restore the pattern of loading to pre-injury levels [101].

MRI: Early diagnosis of spontaneous bilateral femoral neck fractures associated with low serum vitamin D levels could help avoid further displacement and surgical treatment [16]. MRI can identify a subgroup of elderly patients with occult Garden I and II femoral neck fractures sustained after trauma [95]. MRI is a reasonable option for patients with isolated greater trochanter fractures on plain radiographs, as 90% of cases had occult extension into the intertrochanteric region [98]. Insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures were often overlooked on radiographs but successfully identified and treated by internal fixation using MRI [100].

CT: An algorithm for acute scaphoid fractures recommends MRI or CT for negative radiographs, conservative management for non-displaced fractures, and internal fixation for displaced or proximal fractures [23]. Preoperative CT scans may improve surgical planning for patellar fractures by identifying secondary fracture lines poorly visualized on radiographs [91]. Computed tomography permits a more adequate assessment of the size of the fracture gap and the rotatory alignment of fracture fragments compared with plain radiography for spiral tibia fractures [94].

Other Considerations: A higher index of suspicion is required for the recognition and treatment of capitate fractures, which are diagnosed and reported with undeserved rarity [18]. Modern imaging technology does not appear to miss clinically significant occult hip fractures [84]. Urgent open reduction for the Edinburgh variant of a talar body fracture requires adequate imaging to plan the approach and potential fixation [87]. Non-union is defined as a fracture where reparative processes have ceased, with clinical, roentgenographic, and histological criteria for diagnosis [93]. Sonographic bridging callus is a reliable early predictor of fracture union, detecting bridging earlier than radiographs [99].

Treatment

Non-Operative

Closed treatment remains the method of choice for most humeral shaft fractures, with nonsurgical management using functional bracing achieving union rates greater than 90% [63]. Non-operative management is often contra-indicated for forearm fractures if the fracture can be held without operation, as non-operative management may heal faster with fewer complications [59]. Non-operative management remains a viable treatment option for non-osteoporotic patients with Garden I femoral neck fractures, who have a risk of secondary displacement close to 10% [56]. Non-operative treatment is not a reliable way of treating incomplete atypical femoral fractures related to bisphosphonate treatment; prophylactic intramedullary nailing should be considered if the patient is in intractable pain [60].

Operative

Indications: Reduction and internal fixation are the preferred treatment methods for displaced femoral neck fractures, supported by evidence regarding posterior retinaculum integrity [2]. Internal fixation is recommended for displaced or proximal acute scaphoid fractures [23]. Dual-implant fixation is commonly indicated for nonunion treatment and comminuted fractures with bone loss in distal femur fractures [13]. Only fractures recalcitrant to closed reduction and immobilization or fractures in non-compliant patients should be considered for Ender nailing of acute humerus fractures [47].

Surgical Approach / Technique: Fracture size is the most important factor guiding the selection of surgical approach and fixation technique in Hoffa fractures [26]. Surgical treatment of atypical acetabular fractures with an independent acetabular roof fragment (three-column fractures) is difficult; a combined surgical approach (anterior followed by posterior) may provide the best reduction, especially for subtype 1 [29]. Single-provider emergency fracture management techniques can be efficient, reproducible, safe, and successful in level 1 trauma practice [103]. Minimally invasive finger fracture management relies on patient perception of pain to ensure motion does not exceed the stability of the fracture reduction construct [109].

Implant Selection: A thorough understanding of fracture types, treatment principles, and fixation devices is paramount for managing complex periprosthetic femoral fractures [1]. Current evidence is insufficient to recommend an optimal method of internal fixation between fixed angle devices and multiple cancellous screws, highlighting the need for high-quality randomised, controlled trials [6]. The implant device plays the major role in fixation stability, while reduction positions exert only a minor influence in stable fixation of intertrochanteric fractures [45]. Using the proper fixation and implant can achieve reliable fixation and good functional recovery in traumatic periprosthetic femoral fractures after total hip arthroplasty [39]. Treatment principles for periprosthetic fractures after total knee arthroplasty depend on the bone location, status of implant fixation, bone stock, and available implant types [50]. An alternative fixation device should be considered for unstable per-, inter-, and subtrochanteric fractures of the proximal femur with missing posteromedial support due to fixation failure risks of the LCP proximal femoral plate [7]. A new dynamic locking plate device may represent an advance in the treatment of difficult and common intracapsular hip fractures [12]. Salvage of failed internal fixations of intertrochanteric femoral fractures with properly selected implants and profound techniques can lead to valuable surgical strategies and satisfactory clinical outcomes [43].

Surgical Approach / Technique (Specific Fixation Modalities): Plate fixation is reliable and safe for humeral shaft fractures when indications for operative treatment are met [17]. Acceptable results can be achieved with internal fixation for difficult humeral shaft fractures, provided correct principles of fixation are carefully followed [11]. Internal fixation remains an effective option in select clinical circumstances for orthopaedic trauma, with successful healing and complication avoidance largely determined by surgical technique [5]. Dual plating is indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult [44]. Dual plating is contraindicated in severely comminuted fractures requiring extensive dissection [44]. Transarticular fixation is highly successful in achieving union, stability, and pain relief in non-union of supracondylar fractures of the femur [90].

External Fixation: External fixation is an essential tool in the management of fracture non-unions, with indications being refined as understanding of outcomes improves [3]. External fixation facilitates safe and accurate reduction without major surgical complications and may offer an additional option for treating unstable pelvic fractures when used with spinopelvic fixation in a lateral position [27]. Minimal internal fixation is advocated for the management of open blast pelvis fractures [4].

Pain Management: The use of regional anaesthesia during operative repair of long bone fracture nonunion is associated with no significant difference in functional outcome scores or pain levels at all post-operative time points [70]. Patients undergoing hip fracture surgery with spinal anaesthesia had significantly lower rates of short-term complications than those undergoing hip fracture repair with general anaesthesia [92]. Management of hip fracture pain with fascia iliaca compartment blockade (FICB) does not markedly decrease short-term mortality [105].

Adjuncts: NSAID use may outweigh the potential risk of non-unions in the first week after fracture or for simple well-stabilized fractures, as patient benefit of reduced pain and addiction risk currently outweighs risks until Level 1 evidence is available [107].

Setting of Care: Surgical treatment of fragility hip and pelvic fractures improves fracture stability, achieves better pain relief, and allows earlier mobilization [108].

Complications

Periprosthetic fracture: Internal fixation of periprosthetic femoral fractures requires a thorough understanding of fracture types, treatment principles, and fixation devices [1]. Current evidence is insufficient to recommend an optimal method of internal fixation, highlighting the need for high-quality randomised, controlled trials [6]. Periprosthetic femoral fractures occur at different rates at different times depending on the method of fixation [9]. Further research is needed to determine complications related to plate-on-plate osteosynthesis for periplate fracture fixation [10]. The annual incidence of periprosthetic fractures remained relatively stable throughout the study period [144], but periprosthetic fractures will continue to increase in prevalence and compromise successful surgery, requiring concerted efforts to capture the totality of fractures in registries and optimize care pathways [145]. There are greater incidences of periprosthetic joint infections and overall reoperations following early periprosthetic femur fractures compared to late fractures after total hip arthroplasty [128]. The incidence of periprosthetic proximal femoral fractures after primary total hip arthroplasty is generally lower than after revision total hip arthroplasty [134]. 13% of patients with Vancouver C periprosthetic femur fractures required a reoperation within 2 years, most commonly for infection or nonunion [126]. Plating of periprosthetic greater trochanter fractures is associated with a high incidence of reoperation (20%) within the first 2 years, as well as a high rate of nonunion (39%) and hardware failure (28%) [133].

Thromboembolism: The incidence of deep vein thrombosis (DVT) in patients with femoral neck fracture is relatively high and associated with many risk factors [104]. Deep-vein thrombosis developed in approximately 15 per cent of patients following major pelvic fracture [106]. Patients undergoing surgical treatment for lower limb pathological fracture due to malignancy are at increased risk of DVT or death due to pulmonary embolism (PE) under current general thromboprophylaxis regimens [111]. Preoperative DVT is not very prevalent following elderly femoral neck fractures but occurs with a certain proportion in the uninjured extremity, necessitating more attention [112]. Patients presenting with hip fractures are at high risk of developing DVT and PE [113]. Despite a not-so-high prevalence rate of DVT in the general population with intertrochanteric fracture, particular attention should be paid to those involved in associated risk factors [120]. There is a substantial risk of venous thromboembolic disease in patients with a fracture about the hip, regardless of whether or not they have had an operation, and this risk increases if the time to presentation is delayed [131]. Intramedullary fixation for intertrochanteric fractures was associated with an increased risk of pulmonary complications, deep vein thrombosis, and transfusion compared to extramedullary fixation [125].

Nonunion / Malunion: Internal fixation with a dynamic locking plate for intracapsular hip fractures resulted in 8 non-unions and 4 cases of avascular necrosis, with a revision rate of 15% (11 out of 74 patients) [117]. 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 femoral neck system versus multiple cannulated screws fixation for Pauwels classification type II femoral neck fractures [118]. A systematic review and meta-analysis identified specific risk factors associated with nonunion following surgically managed, traumatic, diaphyseal fractures [146]. Infected non-union is a devastating complication requiring complex reconstruction surgery with unpredictable outcomes [147]. Implant-associated mycobacterium tuberculosis infection following surgical management of fractures resolved in all patients, with 14 achieving fracture union [129]. Open fractures of the tibia treated with the Lottes nail had an infection rate of 6 per cent, delayed union rate of 16 per cent, and malunion rate of 4 per cent [140].

Infection (PJI): The complication rate for total fractures of the tibial pilon is high, and neither internal plating nor definitive external fixation has proven to be more effective overall [24]. Earlier conversion from external fixator to intramedullary nail in tibial fractures reduces infection rates [25].

Other Considerations: Primary arthroplasty demonstrates lower revision surgery rates and equivalent postoperative mortality compared to internal fixation for valgus-impacted and nondisplaced femoral neck fragility fractures, particularly in patients with posterior tilt greater than 20 degrees [110]. Primary arthroplasty has emerged as a viable treatment option for nondisplaced femoral neck fractures in the elderly, particularly in the presence of factors predisposing to fixation failure [116]. There is a role for cementless primary stems in hip arthroplasty for late fixation failures of intertrochanteric fractures [121]. Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in elderly patients [122]. Primary bone-grafting after closed reduction eliminates the disadvantages of metallic fixation and osteotomy by more surely preventing aseptic necrosis and neck resorption while maintaining better hip function [123]. The short-term survivorship of conversion hip arthroplasty after surgical treatment of an intertrochanteric fracture is excellent regardless of the original fracture fixation method [124]. Locking plate fixation has yet to prove clinical superiority in any anatomic site for which good-quality comparative analyses are available [137]. A large claims-based study of real-world fracture-healing outcomes is needed to provide guidance for randomized clinical trials that can test biological risk factors for nonunion more rigorously [138]. The pooled estimate of effect size for heal rate was 82% (95% CI: 77-87%) for any anatomical site and fracture age of at least 3 months when treated with low-intensity pulsed ultrasound [139]. Routine use of internal fixation in elderly, poor-risk patients with intertrochanteric and subtrochanteric fractures reduced hospital mortality from 50 per cent to less than 20 per cent and improved functional outcomes [141]. More randomised controlled trials are needed to definitively recommend locking plate versus intramedullary nail for specific proximal humeral fracture patterns due to observed heterogeneity [142]. Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating [143]. Percutaneous Knowles pinning is a safe, simple, and reasonably effective method of treatment for most non-pathological intracapsular hip fractures, citing low morbidity, mortality, and infection rates compared to primary prosthetic replacement [148].

Recovery

Internal fixation facilitates early functional rehabilitation and stable osteosynthesis, which permits early postoperative function [49, 115]. Rigid internal fixation decreases the incidence of malunion, non-union, and loss of fixation [49]. Restoration of limb length, rotation, and axial alignment with stable fixation and early motion produces uncomplicated fracture healing and a return to normal function for most patients [114].

Light activity (weeks): Screw fixation for certain fractures of the phalanges and metacarpals allows early range-of-motion exercises and full recovery of motion [52]. The aim of treatment for coronal plane partial articular fractures of the distal femoral condyle is to obtain anatomical reduction and rigid fixation in order to allow early mobilisation and restoration of function [40]. Interference screw fixation in Schatzker type III tibial plateau fractures allows for fast patient mobilization and recovery [132].

Full activity (months): Good clinical results can be expected in patients with long bone fractures if the principles of damage control are applied and complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation [41]. Earlier conversion from external fixation to intramedullary nailing reduces infection rates [25]. Patients with healed fractures without complications of intracapsular femoral neck fractures treated with cannulated screw fixation were functioning well more than sixty months after the fracture [81]. Functional return was achieved in all survivors of intertrochanteric and subtrochanteric hip fractures treated by the Ender method who could walk at the time of injury, with no non-unions reported [75]. A treatment protocol for ipsilateral femoral neck and shaft fractures produced excellent results with all fractures uniting and good long-term functional outcomes [88]. Cephalomedullary nails for ipsilateral neck and shaft fractures of the femur resulted in union of both fractures and excellent or good functional outcome in all but 1 of 35 cases [82]. Medial augmentation plating for aseptic distal femoral nonunions is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes [130]. Patients treated with interfragmentary positional screw in minimally invasive plate osteosynthesis for simple distal femur fractures can be expected to return to their normal lives earlier as union is achieved in a shorter time, though functional differences were not seen in follow-ups [97].

Complete recovery / outcome plateau (months): Clinical or functional recovery usually occurs long before roentgenographic evidence of bony union is demonstrated in fractures of the triquetrum [102]. In fractures without displacement, the prognosis is good with complete function restored after adequate immobilization [20]. Select nonoperatively treated Vancouver B1 fractures had infrequent need for unplanned surgery, high union rate, and return to their preinjury ambulation status [89]. Zone 1 fifth metatarsal fractures are treated non-operatively with good outcomes [135]. Moderate levels of disability and reduced quality of life reported by participants 12 months after a displaced fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year [119].

Rehabilitation protocol: The risk of mortality for intertrochanteric fracture patients far exceeds the 1-year risk of a secondary procedure, emphasizing the focus on rehabilitation [55]. A systematic approach to fragility fracture care aims to restore function and prevent subsequent fractures without further delay [53].

Key Evidence

• [Paper] A thorough understanding of fracture types, treatment principles, and fixation devices is paramount for managing these complex fractures. (10.1016/j.injury.2007.02.050)
• [Paper] This evidence supports reduction and internal fixation as the preferred treatment method for these fracture types. (10.1016/j.injury.2008.07.024)
• [Paper] External fixation is an essential tool in the management of fracture non-unions, with indications being refined as understanding of outcomes improves. (10.1016/j.injury.2019.03.053)
• [L4] We advocate an approach of minimal internal fixation in the management of these fractures. (10.1016/j.injury.2012.06.020)
• [L5] Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique. (10.5435/jaaos-d-23-01256)
• [L4] Current evidence is insufficient to recommend an optimal method of internal fixation, and this review demonstrates the need for high-quality randomised, controlled trials to study this problem. (10.1016/j.injury.2014.12.008)
• [L4] An alternative fixation device should be considered in these challenging fracture scenarios. (10.1007/s00402-010-1074-7)
• [L3] The study identifies risk factors and fracture patterns, noting that fractures occur at different rates at different times depending on the method of fixation. (10.1302/0301-620x.98b4.37203)
• [L4] Further research is needed to determine any complications related to this type of fixation. (10.1177/2325967120s00043)
• [L4] While closed treatment remains the method of choice for most fractures, acceptable results can be achieved with internal fixation, even for difficult fractures, provided the correct principles of fixation are carefully followed. (10.2106/00004623-198668030-00018)
• [L4] The authors conclude that this new fixation device might represent an advance in the treatment of this difficult and common fracture. (10.1302/0301-620x.95b10.31511)
• [L5] Common indications for dual-implant fixation include nonunion treatment and comminuted fractures with bone loss. (10.5435/jaaos-d-24-01222)
• [L4] The proposed radiographic classification had prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures. (10.2106/00004623-198971090-00011)
• [L4] Early diagnosis could have been helpful to avoid further displacement of the fracture and surgical treatment. (10.1016/j.arth.2008.01.309)
• [L4] When indications for operative treatment are met, plate fixation is reliable and safe. (10.2106/jbjs.rvw.n.00119)
• [L4] The injury has been diagnosed and reported with undeserved rarity, and a higher index of suspicion would lead to the recognition and treatment of more of these fractures. (10.2106/00004623-196244080-00003)
• [L4] Type-I fractures are the easiest to treat, while Type-II and Type-III fractures require firm fixation due to increased risks of complications. (10.2106/00004623-198163080-00014)
• [L4] In fractures without displacement, the prognosis is good with complete function restored after adequate immobilization. (10.2106/00004623-194830030-00020)
• [Paper] The use of the Fixion nailing system, where indicated, is associated with minimal complications and very good functional outcomes in fractures OTA types A and B. (10.1016/j.injury.2008.01.022)
• [L4] Intraoperative mechanical injury of the femoral neck or malpositioning of the femoral component may lead to changes in loading patterns resulting in acute and chronic biomechanical femoral neck fractures. (10.2106/jbjs.h.01113)
• [L4] The review presents an algorithm for diagnosis and treatment, recommending MRI or CT for negative radiographs, conservative management for non-displaced fractures, and internal fixation for displaced or proximal fractures. (10.1302/2058-5241.5.190025)
• [Paper] The complication rate is high and neither internal plating nor definitive external fixation has proven to be more effective overall. (10.1016/j.otsr.2013.06.016)
• [L4] Surgeons should strongly consider the necessity of external fixation for these fractures, as earlier conversion reduced infection rates. (10.5435/jaaos-d-21-00857)
• [L5] Fracture size is the most important factor guiding the selection of surgical approach and fixation technique. (10.1016/j.injury.2018.11.034)
• [L4] External fixation facilitates safe and accurate reduction without major surgical complications and may offer surgeons an additional option for the treatment of such fractures. (10.1016/j.otsr.2021.103008)
• [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] Surgical treatment of these fractures is difficult; thus a combined surgical approach (anterior followed by posterior) may provide the best reduction, especially for subtype 1. (10.1016/j.otsr.2022.103209)
• [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)
• [Paper] A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment. (10.1016/j.injury.2013.10.010)
• [L3] Despite delayed presentation, ORIF achieved satisfactory anatomical and functional results in most cases. (10.1186/s13018-025-06298-7)
• [L4] The new classification system for interprosthetic femoral fractures showed adequate inter-observer reproducibility. (10.1016/j.injury.2017.04.008)
• [L5] The contralateral uninjured hip is an excellent indicator of the initial lesser trochanter size and biomechanical rotation. (10.5435/jaaos-d-17-00505)
• [L3] Fracture classification was the main determinant for TSP use. (10.1186/s13018-020-02163-x)
• [L4] Surgical intervention may not be required in all cases if the fracture location and severity allow for individualized treatment. (10.1177/0363546503262195)
• [L4] Using the proper fixation and implant can achieve a reliable fixation and good functional recovery. (10.1186/s42836-021-00089-1)
• [L4] The aim of treatment is to obtain anatomical reduction and rigid fixation in order to allow early mobilisation and restoration of function. (10.1302/0301-620x.95b9.30656)
• [Paper] Good clinical results can be expected in patients with long bone fractures if the principles of damage control are applied and complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation. (10.1016/j.injury.2017.04.016)
• [L4] The revised 2018 AO/OTA classification simplified the previous classification of intracapsular fracture but remain unreliable with only fair interobserver reliability. (10.1186/s12891-022-05007-3)
• [L4] Salvage of failed internal fixations of IT fractures with properly selected implants and profound techniques can lead to the formulation of valuable surgical strategies and provide patients with satisfactory clinical outcomes. (10.1186/s12891-020-03593-8)
• [L4] Dual plating is still indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection. (10.2106/00004623-196345020-00026)
• [L5] Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures. (10.1007/s11999-013-2834-9)
• [L3] However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment. (10.2106/00004623-198769040-00013)
• [L4] Rigid internal fixation permits early functional rehabilitation of the patient and decreases the incidence of malunion, non-union, and loss of fixation. (10.2106/00004623-198971010-00015)
• [L4] Treatment principles depend on the bone the fracture is located, the status of the implant fixation, bone stock, and the type of implants available. (10.5435/jaaos-d-22-00701)
• [L4] Our findings differed from European data and suggest a delicate balance in hip geometry in Arctic populations. (10.1186/s13018-021-02482-7)
• [L4] The technique allows early range-of-motion exercises and full recovery of motion, though traditional methods are preferred for most other fractures. (10.2106/00004623-197658040-00010)
• [Paper] The authors call for the implementation of a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures without further delay, emphasizing the urgent need for improved acute multidisciplinary care, rapid secondary prevention, and ongoing post-acute care. (10.1016/j.injury.2018.06.032)
• [L5] The risk of mortality for these patients far exceeds the 1-year risk of a secondary procedure and we should be focusing our efforts and research on fracture prevention, perioperative optimization, and rehabilitation. (10.2106/jbjs.22.00771)
• [Paper] Non-operative management appears to remain a viable treatment option for non-osteoporotic patients with Garden I femoral neck fractures with a risk of secondary displacement close to 10%. (10.1007/s00402-014-2139-9)
• [L4] Further evidence is needed to specify indications for fixation versus primary transfixation in osteoporotic patients, and future research is required to identify patients who benefit from arthroscopic-assisted surgery. (10.1302/2058-5241.6.200138)
• [L2] Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. (10.1302/0301-620x.99b3.bjj-2016-0276.r2)
• [Paper] The insertion of a dynamic hip screw requires assessment of the native angle of the femoral neck. (10.1016/j.injury.2003.12.010)
• [L5] Nonsurgical management with functional bracing is the standard of care for most humeral shaft fractures, achieving union rates >90%. (10.5435/jaaos-20-07-423)
• [L3] The optimization of screw trajectories, particularly through broader screw spacing facilitated by a navigation system, emerges as a promising strategy for improving the local biomechanical environment and reducing the likelihood of femoral head necrosis. (10.1186/s13018-024-05243-4)
• [L3] The treatment of femoral neck fractures with FNS is superior and contributes to improved hip joint function, with biomechanical research confirming its structural stability and advantages in resisting femoral head varus. (10.1186/s12891-024-07863-7)
• [L5] Cerclage femoral wiring for prophylactic purposes during hip arthroplasty does not confer a significant biomechanical advantage over non-wiring techniques. (10.1186/s42836-025-00331-0)
• [L5] This study demonstrated that fixation of the femoral head with a helical blade was biomechanically superior to fixation with a standard sliding hip screw in a cadaveric, unstable intertrochanteric hip fracture model. (10.1016/j.injury.2006.06.008)
• [L3] In this cohort, the use of regional anaesthesia during operative repair of long bone fracture nonunion was associated with no significant difference in functional outcome scores or pain levels at all post-operative time points. (10.1016/j.injury.2019.01.013)
• [L3] FNS has excellent biomechanical properties and shows significantly higher overall construct stability. (10.1186/s13018-021-02517-z)
• [Paper] The biomechanical performance of the FNS is fracture-type-dependent, necessitating angle-specific optimisation. (10.1186/s12891-026-09591-6)
• [L5] The Femoral Neck System demonstrated failure at the subtrochanteric femur in this synthetic femoral biomechanical model. (10.5435/jaaos-d-25-00469)
• [L4] Functional return was achieved in all survivors who could walk at the time of injury, with no non-unions reported. (10.2106/00004623-197658050-00004)
• [Paper] Robust simulation of macro and micro-scale events allows the testing of novel new designs in simulations far more complex than conventional biomechanical testing will allow. (10.1016/j.injury.2012.10.023)
• [L5] If an anteriorly placed hip screw is not seen to be breaching the articular surface on a view taken in internal rotation, the screw is definitely not in the joint, whereas external rotation may give a false impression of adequate placement. (10.1016/j.injury.2006.12.002)
• [L4] The present study highlights the morphological diversity and complexity within femoral neck fractures in young and middle-aged adults, which allows for more accurate simulation of femoral neck fracture patterns in future biomechanical studies. (10.1186/s12891-024-07207-5)
• [Paper] The single and double lag screw implants demonstrated a significantly different migration resistance in surrogate specimens under gait loading simulation with the HIPS model. (10.1186/1749-799x-4-16)
• [L4] Venting the hip reduces the traction force necessary to arthroscopically visualize and instrument the central compartment of the hip by at least 50%. (10.1016/j.asmr.2023.02.011)
• [L4] Patients with healed fractures without complications were found to be functioning well more than sixty months after the fracture. (10.2106/00004623-199412000-00005)
• [Paper] All but 1 of 35 cases achieved union of both fractures and excellent or good functional outcome. (10.1016/j.injury.2008.08.009)
• [Paper] Modern imaging technology does not appear to miss clinically significant fractures. (10.1016/j.injury.2016.02.020)
• [Paper] Diagnosis of union based on radiographs 3 months after injury is only moderately reliable and accurate but has a high negative predictive value. (10.1016/j.injury.2012.10.034)
• [Case_report] Urgent open reduction should be employed with adequate imaging to plan the approach and potential fixation of the fracture. (10.1186/1749-799x-5-92)
• [L4] The developed protocol produced excellent results with all fractures uniting and good long-term functional outcomes. (10.2106/00004623-198466020-00013)
• [L3] Select nonoperatively treated patients had infrequent need for unplanned surgery, high union rate, and return to their preinjury ambulation status. (10.1016/j.arth.2023.03.069)
• [L4] The procedure described was highly successful in achieving union of the fractured femur, stability, and relief of pain in all patients with one operation. (10.2106/00004623-197961070-00008)
• [L5] Preoperative CT scans may improve surgical planning by identifying secondary fracture lines poorly visualized on radiographs. (10.2106/jbjs.20.01478)
• [L3] Patients who underwent hip fracture surgery with spinal anaesthesia had significantly lower rates of complications than patients who underwent hip fracture repair with general anaesthesia. (10.1016/j.injury.2015.02.002)
• [L5] The paper defines non-union as a fracture where reparative processes have ceased and outlines clinical, roentgenographic, and histological criteria for diagnosis. (10.2106/00004623-196446030-00023)
• [L5] Computed tomography permits a more adequate assessment of the size of the fracture gap and the rotatory alignment of the fracture fragments as compared with plain radiography. (10.2106/00004623-198668050-00029)
• [L5] This multicenter cohort study identifies a subgroup of elderly patients with MRI verified Garden I and II FNFs sustained after trauma, i.e. occult fractures. (10.1186/s12891-022-05088-0)
• [L4] Despite deformity, all cases demonstrated radiographic fracture union. (10.1007/s00402-015-2280-0)
• [L3] Though functional differences were not seen in follow-ups, patients can be expected to return to their normal lives earlier as union is achieved in a shorter time. (10.1016/j.injury.2016.10.034)
• [L2] MRI is a reasonable option for patients presenting with isolated greater trochanter fracture on plain radiographs, as 90% of cases had occult extension into the intertrochanteric region. (10.1186/s12891-015-0857-y)
• [Paper] Sonographic bridging callus is a reliable early predictor of fracture union, detecting bridging earlier than radiographs. (10.1016/j.injury.2019.09.027)
• [L5] Insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures were often overlooked on radiographs but successfully identified and treated by internal fixation using MRI. (10.1007/s00402-011-1358-6)
• [L5] Anatomical reduction and fixation of the fracture with a plate and screws did not restore the pattern of loading to pre-injury levels. (10.2106/00004623-199508000-00007)
• [L4] Clinical or functional recovery usually occurs long before roentgenographic evidence of bony union is demonstrated. (10.2106/00004623-195638020-00012)
• [L5] The authors present examples of previously described and novel single-provider emergency fracture management techniques that they have found efficient, reproducible, safe, and successful in their level 1 trauma practice. (10.5435/jaaos-d-24-00240)
• [L3] The incidence of DVT in patients with femoral neck fracture is relatively high, and there are many related risk factors. (10.1186/s13018-022-02926-8)
• [L1] Management of hip fracture pain with FICB does not markedly decrease short-term mortality. (10.5435/jaaos-d-21-00561)
• [Paper] Until Level 1 evidence in large trials is available, the patient benefit of reduced pain and addiction risk with NSAID use outweighs the potential risk of non-unions, particularly in the first week after fracture or for simple well-stabilized fractures. (10.1016/j.injury.2020.04.028)
• [L4] Surgical treatment of fragility hip and pelvic fractures improves fracture stability, achieves better pain relief and allows earlier mobilization. (10.1016/j.injury.2020.02.066)
• [L5] This technique relies on patient perception of pain to ensure motion does not exceed the stability of the fracture reduction construct. (10.1016/j.hcl.2013.08.014)
• [L4] Primary arthroplasty demonstrates lower revision surgery rates and equivalent postoperative mortality compared to internal fixation, particularly in patients with posterior tilt greater than 20 degrees. (10.5435/jaaos-d-19-00866)
• [L3] Patients who undergo surgical treatment for lower limb pathological fracture due to malignancy are at increased risk of DVT or death due to PE under current general thromboprophylaxis regimens. (10.1186/s12891-018-2141-4)
• [L3] Preoperative DVT is not very prevalent following elderly femoral neck fractures, but with a certain proportion in the uninjured extremity, necessitating more attention. (10.1186/s12891-021-04145-4)
• [L4] Patients presenting with hip fractures are at high risk of developing DVT and PE. (10.1302/2058-5241.1.160034)
• [L5] Restoration of limb length, rotation, and axial alignment with stable fixation and early motion can produce uncomplicated fracture healing and a return to normal function for most patients. (10.5435/00124635-199705000-00005)
• [L4] As a result, primary arthroplasty has emerged as a viable treatment option, particularly in the presence of factors predisposing to fixation failure. (10.5435/jaaos-d-20-00349)
• [L4] Internal fixation with the newly designed implant resulted in only 8 non-unions and 4 patients with avascular necrosis, with a revision rate of 15% (11 out of 74 patients), which is outstanding compared to international literature revision rates of 28-48%. (10.1016/j.injury.2009.12.008)
• [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)
• [L2] This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year. (10.1302/0301-620x.105b7.bjj-2022-1419.r1)
• [L3] Despite without a so high prevalence rate of DVT in a general population with intertrochanteric fracture, particular attention should be paid to those involved in the associated risk factors above. (10.1186/s12891-022-05381-y)
• [L3] However, in late fixation failures, there is a role for cementless primary stems. (10.1186/s12891-022-05223-x)
• [L2] Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. (10.2106/jbjs.22.00088)
• [L4] Primary bone-grafting after closed reduction eliminates the disadvantages of metallic fixation and osteotomy by more surely preventing aseptic necrosis and neck resorption while maintaining better hip function. (10.2106/00004623-194830020-00004)
• [L3] The short-term survivorship of conversion hip arthroplasty after surgical treatment of an IT fracture is excellent regardless of original fracture fixation method. (10.1016/j.arth.2017.06.032)
• [L3] Intramedullary fixation for intertrochanteric fractures was associated with an increased risk of pulmonary complications, deep vein thrombosis, and transfusion compared to extramedullary fixation. (10.5435/jaaos-d-17-00921)
• [L3] Moreover, 13% of patients required a reoperation within 2 years, most commonly for infection or nonunion. (10.1016/j.arth.2021.05.033)
• [L3] There are greater incidences of periprosthetic joint infections and overall reoperations following early periprosthetic femur fractures compared to late fractures after total hip arthroplasty. (10.1016/j.arth.2023.10.037)
• [L4] In all patients, the infection resolved, and in 14 the fractures united. (10.1302/0301-620x.97b9.35227)
• [L4] According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications. (10.1186/s12891-023-06675-5)
• [L3] There is a substantial risk of venous thromboembolic disease in patients who have a fracture about the hip, regardless of whether or not they have had an operation, and that this risk increases if the time to presentation is delayed. (10.2106/00004623-199604000-00012)
• [Paper] The presented technique creates alternative possibilities in Schatzker type III tibial plateau fracture management, causing less soft-tissue trauma than other techniques and allowing for fast patient mobilization and recovery. (10.1016/j.eats.2021.01.014)
• [L4] In this large contemporary series, there was a high incidence of reoperation (20%) within the first 2 years following plating of periprosthetic GT fractures, as well as a high rate of nonunion (39%) and hardware failure (28%). (10.1016/j.arth.2022.07.012)
• [L4] The incidence of periprosthetic proximal femoral fractures (PFF) after primary total hip arthroplasty is generally lower than after revision THA. (10.1007/s00264-015-2721-y)
• [L4] Zone 1 fractures are treated non-operatively with good outcomes, while treatment of Zone 2 and 3 fractures remains controversial and should be individualized. (10.1530/eor-21-0025)
• [L4] Locking plate fixation has yet to prove clinical superiority in any anatomic site for which good-quality comparative analyses are available. (10.1016/j.otsr.2016.11.006)
• [L2] A large claims-based study of real-world fracture-healing outcomes is needed to provide guidance for randomized clinical trials that can test risk factors more rigorously. (10.2106/jbjs.rvw.o.00008)
• [L1] The pooled estimate of effect size for heal rate was 82% (95% CI: 77-87%) for any anatomical site and fracture age of at least 3 months. (10.1016/j.injury.2017.05.016)
• [L4] The rate of infection was 6 per cent, delayed union 16 per cent, and malunion 4 per cent. (10.2106/00004623-198365070-00001)
• [L4] Routine use of internal fixation in elderly, poor-risk patients reduced hospital mortality from 50 per cent to less than 20 per cent and improved functional outcomes. (10.2106/00004623-195638060-00011)
• [L1] More RCTs are needed to definitively recommend one over the other for specific fracture patterns due to observed heterogeneity. (10.1186/s13018-015-0242-4)
• [L3] Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating. (10.1016/j.injury.2017.03.005)
• [L3] The annual incidence of periprosthetic fractures remained relatively stable throughout the study period. (10.1016/j.arth.2020.07.050)
• [L5] Periprosthetic fractures will continue to increase in prevalence and compromise successful surgery, requiring concerted efforts to capture the totality of fractures in registries and optimize care pathways. (10.1302/0301-620x.102b5.bjj-2020-0427)
• [L1] This systematic review and meta-analysis identified specific risk factors associated with nonunion following surgically managed, traumatic, diaphyseal fractures, providing evidence to guide clinical decision-making and patient counseling. (10.1530/EOR-21-0137)
• [Paper] Infected non-union is a devastating complication requiring complex reconstruction surgery with unpredictable outcomes. (10.1016/j.injury.2015.08.009)

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