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Bone Fractures

Proximal humerus, clavicle, and scapular fractures — management of high-energy trauma and age-related fragility fractures.

Overview

Proximal humerus fractures are frequently managed nonsurgically with success, though indications for surgical intervention remain controversial [1]. In contrast, midshaft clavicle fractures present clearer surgical thresholds. Surgery is indicated when fragment overlap is ≥ 15% or cranio-caudal displacement is ≥ 2.3 cm [24]. Overlap ≥ 13% associated with displacement ≥ 2 cm also constitutes a clear-cut indication for operative treatment [24]. Plate osteosynthesis should always be considered for mid-shaft clavicle fractures [9].

Adolescent mid-shaft clavicular fractures behave differently; nonunion is exceptionally rare following nonoperative management, and relative indications for surgery in adults do not appear applicable to this population [26]. Scapular fracture management lacks consensus, with little agreement on surgical indications and no clear comparative evidence on outcomes between surgical and nonsurgical management [15]. Operative treatment of ipsilateral scapular neck and clavicle fractures is safe and yields predictably good results [6].

Atypical tensile-sided femoral neck stress fractures may not require surgery if individualized treatment based on location and severity is feasible [2]. The Tightrope device is advocated as a sole fixation method for lateral end clavicle fractures [3]. For complex bony deficiencies, such as those in recurrent anterior glenohumeral instability, various treatment options and techniques exist [72]. Bone transport techniques are effective for posttraumatic bone defects, with indications based on defect size and location, though no single technique is universal [73]. External fixation remains an essential tool for fracture non-unions, with indications being refined as outcome understanding improves [19]. Large-scale randomized studies are needed to further assess indications and results for various internal fixation techniques for clavicle fractures [62].

Anatomy & Pathophysiology

Osseous

Scapular Fractures: Operative treatment of ipsilateral scapular neck and clavicle fractures is safe and yields predictably good results [6]. A minimally invasive approach combined with a novel anatomical locking plate provides a biomechanical basis for the clinical treatment of scapular body fractures [65].

Clavicle Fractures: Plate fixation for displaced midshaft clavicular fractures does not improve shoulder function, general symptoms, or decrease limitations compared with nonoperative treatment in a sling [87]. After malunion of displaced clavicular shaft fractures, translations of the superior and inferior angles of the scapula are variable in magnitude and direction, and on average translate substantially less than the acromion [86].

Proximal Humerus Fractures: A novel biomechanical model distinguishes between different mechanisms of injury and resulting fracture configurations in proximal humeral fractures [76]. A blocked threaded wire construct for three-part humeral head fractures is biomechanically valid, allowing only micromovements insufficient to cause humeral head rotation or translation [39]. The modified minimally invasive reduction osteosynthesis system (MIROS) fixation for Neer 2 and 3-part proximal humeral fractures provides adequate fracture stability, permits early shoulder motion, and results in satisfactory functional and radiologic outcomes with fewer complications [69]. Results of percutaneous fixation for complex humeral head fractures depend on the biomechanical construct used [88]. Tuberosity fixation in reverse fracture arthroplasty has higher primary stability with a 135° humeral inclination than with a 155° inclination, though transferability and clinical relevance require verification with clinical studies [79]. Varus and antecurvatum proximal humerus deformities as small as 15 degrees are associated with statistically significant alterations in glenohumeral joint mechanics in proximal humeral fracture malunion [82].

Floating Shoulder: Surgical intervention is not required for most patients with floating shoulder injuries, and treatment should be individualized based on patient assessment and understanding of pathoanatomy [77].

Ligamentous & Soft Tissue

Distal Clavicle & Coracoclavicular Ligament: Hook plate and superolateral locking plate with coracoclavicular suture fixation constructs offer superior biomechanical stability and potentially reduce complications associated with subacromial hardware in distal third clavicle fractures with coracoclavicular ligament disruption [45]. Arthroscopic-assisted surgery for Neer Type 2 fractures of the distal clavicle allows for total recovery of shoulder function without device migration or acromioclavicular joint lesions [85]. A single anterior-to-posterior clavicle tunnel has similar biomechanical properties to the 2-tunnel technique for coracoclavicular ligament reconstruction [89].

Rotator Cuff: Both open and arthroscopic repair of anterosuperior rotator cuff tears with subscapularis involvement significantly improve shoulder function and are relatively safe procedures [57].

Glenoid & Instability: Glenohumeral contact patterns depend on the amount of glenoid retroversion and posterior labral and/or bony glenoid integrity [71]. Correcting excessive glenoid retroversion in combination with posterior glenoid bone grafting improves glenohumeral contact pressures in a cadaveric posterior instability model [71]. Iliac crest bone graft augmentation of the anterior glenoid improves anterior glenohumeral stability [74]. Mapping of glenoid bone loss in recurrent anterior shoulder instability reveals specific deficit patterns that can influence biomechanical models and surgical reconstruction [78]. Hill-Sachs lesions are not created at the time of dislocation but occur after the arm comes to equilibrium at a low abduction angle in a cadaveric model [75]. Secondary displacement after closed reduction of greater tuberosity fracture associated with shoulder dislocation is common and significantly associated with SF-IF involvement and greater critical shoulder angle [90].

Classification

Non-union: Defined as a fracture where reparative processes have ceased [8]. Diagnosis requires clinical, roentgenographic, and histological criteria [8].

MTM-classification: Covers a wide spectrum of proximal humeral fracture types [11]. However, its precise topographic and morphological description does not deliver reproducible results [11].

HGLS classification: A reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems [40].

New classification of impacted proximal humerus fractures: Based on morpho-volumetric evaluation of humeral head bone loss with a 3D model, this system provides a useful synoptic framework for identifying complex fracture patterns [33]. A variant based on a 3D model similarly provides a useful synoptic framework for identifying complex fracture patterns [34].

New classification system for proximal humeral fractures: Emphasizes qualitative aspects and showed high reliability when based on a standardized imaging protocol including computed tomography scans [38]. Distinct fracture morphologies in greater tuberosity fractures likely have implications for pathophysiology and surgical technique [14]. A technique for viewing 3D images is suggested to maximize their usefulness in the context of proximal humeral fracture classification [50].

Simple classification of multifocal humeral fractures: Suggested to help surgeons choose the most suitable type of synthesis for surgical treatment [32].

New classification based on displacement of four major segments: Adequate for sorting lesions and correlating roentgen appearance with fracture type, specifically regarding the head, lesser tuberosity, greater tuberosity, and shaft [47]. The frequency of each type of injury in this new classification of proximal humeral fractures is presented [50].

Modified Neer classification: The extra-lateral distal clavicle fracture pattern is recommended to be added as a type IIC fracture [41].

AO/OTA classification: For glenoid fractures, groups are related to the fragmented articular surface area and the number of fragments [49]. The mechanism of injury is related to the AO/OTA classification group for glenoid fractures [49].

Periprosthetic fractures: Around the shoulder, these involve detailed review of epidemiology, risk factors, classification, and management [51].

Clinical Presentation

Clavicle fractures represent the most common fracture type, with the middle third being the most frequent site of injury [44]. Plate osteosynthesis should always be considered for mid-shaft clavicle fractures [9]. For lateral end clavicle fractures, the Tightrope device is advocated as a sole method of fixation [3]. In cases of sternoclavicular hyperostosis with pathological clavicle fracture, patient symptoms improve significantly following fracture healing [35].

Proximal humerus fractures are frequently managed nonsurgically [1]. Indications for surgical intervention remain controversial [1]. Distinct morphologies of the greater tuberosity likely influence pathophysiology and surgical technique [14]. Minimal displacement (<3 mm) in greater tuberosity fractures does not worsen clinical outcomes or symptom duration [7]. The MTM-classification for proximal humeral fractures fails to deliver reproducible results for precise topographic and morphological description [11].

Humeral shaft fracture patterns, locations, and patient risk factors may predict poor outcomes with nonoperative management [5]. Earlier operative intervention is recommended when such risk factors are present [5]. Pediatric shoulder injuries are generally easy to diagnose and treat nonoperatively, as pediatric fractures remodel rapidly [43].

Stress fractures of the radius diaphysis in skeletally immature wrestlers are often subtle or undetectable on plain radiographs, requiring a high index of suspicion for diagnosis [12]. Atypical tensile-sided femoral neck stress fractures may not require surgical intervention if fracture location and severity allow for individualized treatment [2].

Diagnosis of non-union relies on clinical, roentgenographic, and histological criteria, defined as a fracture where reparative processes have ceased [8]. For distal tibia fractures, diagnosing union based on radiographs at 3 months is only moderately reliable and accurate, though it possesses a high negative predictive value [16]. A systematic approach to evaluating fracture union incorporates patient symptoms, signs, immune status, endocrine status, and various diagnostic tests to determine intervention timing and nature for compromised healing [4].

Failure to properly diagnose, reduce, and immobilize carpal navicular (scaphoid) fractures is directly responsible for delayed union or non-union [36]. Ultrasonography may provide greater accuracy in phalanx fracture diagnostics by revealing small avulsed bony fragments missed on radiographs, particularly in children [18]. Trapezoid fractures may be underdiagnosed; computed tomography is recommended over plain radiography alone when clinical suspicion exists [13].

Increasingly sophisticated imaging and modeling lead to slight but significant improvements in diagnostic performance and interobserver agreement on distal humerus fracture characteristics [20]. Specific clinical and radiological 'red flags' should increase suspicion of associated vascular injury in proximal humeral fractures with vascular compromise [42]. Early diagnosis and appropriate combined orthopaedic and vascular intervention are facilitated by recognizing these red flags [42].

Investigations

Plain radiography: Many proximal humerus fractures can be successfully treated nonsurgically [1], though indications for surgical intervention remain controversial [1]. For trapezoid fractures, plain radiography alone is insufficient; computed tomography is recommended when clinical suspicion exists due to the risk of underdiagnosis [13]. Diagnosis of distal tibia fracture union via radiographs at 3 months post-injury is only moderately reliable and accurate, yet it possesses a high negative predictive value [16]. In skeletally immature wrestlers, stress fractures of the radius diaphysis are often subtle or undetectable on plain radiographs, requiring a high index of suspicion [12]. Medial end clavicle fractures have a higher incidence than previously considered and can be difficult to diagnose by less experienced practitioners on plain radiographs; a low threshold for senior review or additional imaging is advised [94]. For completely displaced adolescent clavicle fractures, repeat radiographic assessment 2–3 weeks post-injury is supported prior to definitive treatment decisions [84]. Adequate initial radiologic investigation for proximal humeral fractures can be achieved using three plain films obtained at 90° to each other [98].

Computed tomography: CT represents the gold standard for diagnosing odontoid fractures in geriatric patients alongside conventional radiographs [80]. It is valuable for diagnosing atlantal arch fractures causing atlanto-axial instability when plain radiographs are inconclusive [83]. Increasingly sophisticated imaging and modeling with CT leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics for distal humerus fractures [20]. Interobserver agreement for proximal humerus fracture classification is best when fractures are classified using CT scans [96]. Three-dimensional CT reconstruction provides adequate radiologic investigation for proximal humeral fractures, particularly for arthroscopic treatment of malunion of a head-splitting proximal humeral fracture [98].

Magnetic resonance imaging: Rapid limited-sequence MRI of the pelvis identified femoral neck fractures not diagnosed on thin-cut high-resolution CT in 12% of patients with femoral shaft fractures [81].

Ultrasound: Ultrasonography may provide greater accuracy in diagnosing phalanx fractures by revealing small avulsed bony fragments missed on radiographs, and is beneficial in diagnosing occult phalanx fractures, especially in children [18]. Sonographic bridging callus serves as an early predictor of fracture union [92]. A repeatable technique for assessing sonographic bridging callus has been established with assessed agreement between blinded reviewers [92].

Other Considerations: Non-union is defined as a fracture where reparative processes have ceased, diagnosed using clinical, roentgenographic, and histological criteria [8]. Surgical intervention for atypical tensile-sided femoral neck stress fractures may not be required if fracture location and severity allow for individualized treatment [2]. Scapular spine fractures can achieve radiological union around 3 months with significant pain reduction and functional improvement [97]. Proximal humeral bone resorption after total shoulder arthroplasty with an uncemented rectangular stem is a radiographic phenomenon without significant impairment of function or need for revision within 5 years after surgery [93]. Classification of proximal humerus fractures according to pattern recognition is associated with high intraobserver and interobserver agreement [96].

Treatment

Non-Operative Management

Many proximal humerus fractures are successfully treated nonsurgically [1], although indications for surgical intervention remain controversial [1]. Conservative management for nondisplaced or minimally displaced proximal humeral fractures involves initial immobilization followed by a rehabilitation program [58]. In patients aged 60 years or older with displaced 2-part proximal humerus fractures, a multicenter randomized controlled trial demonstrated no significant difference in clinical outcomes at 2 years between surgical and non-operative treatment [66]. For humeral shaft fractures, fracture pattern, location, and identifiable patient risk factors may predict poor outcomes with nonoperative management, suggesting earlier operative intervention in these cases [5].

Undisplaced inferior angle scapula fractures exhibit variable outcomes when treated nonoperatively [21]. There is little agreement on surgical indications for scapular fractures, and no clear comparative evidence exists regarding outcomes for surgically versus nonsurgically managed cases [15]. Nonsurgical management remains the treatment of choice for nondisplaced midshaft clavicle fractures [68]. Closed, non-surgical reduction maneuvers are generally ineffective in improving or maintaining alignment of clavicle fractures and should not be attempted [48]. Nonsurgical treatment of distal clavicle fractures results in a significantly high nonunion rate (33.3%) but yields acceptable functional outcomes, making it a potential first-line option after appropriate counseling [52].

Non-union prevention depends largely on the application of well-established sound principles of fracture management, as non-unions often result from a combination of adverse situations [55]. External fixation serves as an essential tool in managing fracture non-unions, with indications being refined as understanding of outcomes improves [19]. Judicious use of bone morphogenic protein (BMP) in certain clinical scenarios may revolutionize the management of non-unions and delayed unions [54]. Mesenchymal stem cells (MSC) represent a potential adjunct therapy for patients with non-union fractures [63]. Prospective, randomised, double-blind, placebo-controlled trials demonstrate the clinical efficacy of ultrasound in accelerating fracture healing [37]. 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 treating nonunions with low-intensity pulsed ultrasound (LIPUS) [56].

Operative Management

Indications: Surgical treatment with plate osteosynthesis should always be considered for mid-shaft clavicle fractures [9]. Clear-cut indications for surgery include overlapping of fracture fragments ≥ 15% or cranio-caudal displacement ≥ 2.3 cm in midshaft clavicle fractures [24]. Surgery is also indicated for overlapping ≥ 13% associated with displacement ≥ 2 cm in midshaft clavicle fractures [24]. Surgical intervention may be required for severe displacement, neurovascular compromise, or specific fracture patterns in clavicle fractures [68]. Operative treatment of ipsilateral fractures of the scapular neck and clavicle is safe and yields predictably good results [6].

Surgical Approach / Technique: The authors advocate the use of the Tightrope device as the sole method of fixation in treating lateral end clavicle fractures [3]. For displaced lateral-third clavicle fractures (Neer type II), the best functional outcomes with clavicle hook plate fixation occur with plate removal before 6 months postoperatively, provided the fracture has healed [27]. Careful frequent radiographic examination during the initial 3 months of fracture healing is recommended to assess the acromion in patients with clavicle hook plates, especially in those with comorbidities or medication history leading to osteopenia [61]. Open reduction–internal fixation for acromial spine fractures after reverse total shoulder arthroplasty was not shown to be clinically superior despite a limited complication rate [53]. Acromial spine fractures after reverse total shoulder arthroplasty correlate with worse postoperative outcomes regardless of treatment method [53].

Implant Selection: The available evidence suggests that there are no differences in treatment effects between plating and intramedullary pinning for midshaft clavicle fractures, but plating is associated with more side effects [60].

Complications

Proximal Humerus: Surgical intervention for proximal humerus fractures involves controversial indications [1]. Locking-plate fixation in patients over 60 is associated with a high complication rate [59]. Higher complication and failure rates for this fixation method are observed in older patients and those with more complex fractures [59].

Lateral Condyle Humerus: Long-term complications of lateral condyle humerus fractures are permanent in nature [23]. Forty percent of lateral condyle humerus fracture cases do not reach satisfactory outcomes even after long follow-up until the end of bone growth [23]. Lateral condylar fractures of the humerus in children have a higher rate of nonunion with K-wire fixation [29].

Clavicle: Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures [67]. Patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures [67]. Hook plate fixation of acute displaced lateral clavicle fractures has no long-term complications addressed to the use of the plate at mid-term [17]. An all-suture technique for fixation of unstable displaced distal clavicle fracture showed low complications and a high level of union after 1 year of follow-up [22]. Stabilisation of vertical unstable distal clavicular fractures (Neer 2b) using locking T-plates and suture anchors did not see complications such as non-union or instability [64]. Close follow-up of nonoperatively treated clavicle fractures is warranted due to displacement related to patient position and progressive displacement in the peri-injury period [28].

Other Considerations: Minimal fracture displacement (<3 mm) of the greater tuberosity does not worsen the clinical outcome or duration of symptoms with non-operative treatment [7]. 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 [2].

Recovery

A systematic approach to evaluating fracture union, incorporating patient symptoms, signs, immune and endocrine status, and various diagnostic tests, can help surgeons determine the timing and nature of interventions for compromised fracture healing [4]. The uninterrupted progression of biological events in conjunction with a favourable mechanical environment remains the hallmark of successful fracture healing [31].

Light activity (weeks):

Evidence does not provide specific week ranges for light activity, desk work, or driving.

Full activity (months):

Evidence does not provide specific month ranges for manual work, sport, or full ROM/strength return.

Complete recovery / outcome plateau (months):

Evidence does not provide specific month ranges for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol:

For displaced lateral-third clavicle fractures treated with hook plate fixation, the best functional outcomes occur with plate removal before 6 months postoperatively, provided the fracture has healed [27]. Close follow-up of nonoperatively treated clavicle fractures is warranted due to displacement related to patient position and progressive displacement in the peri-injury period [28].

Functional milestones:

Evidence does not provide validated PROM trajectories or outcome-measure benchmarks (e.g., Constant, ASES, WOMAC).

Other Considerations:

Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended [5]. Minimal fracture displacement (<3 mm) does not worsen the clinical outcome or duration of symptoms in minimally displaced fractures of the greater tuberosity treated non-operatively [7]. Undisplaced scapular inferior angle fractures have a variable outcome when treated nonoperatively [21].

Nonunion is exceptionally rare following nonoperative management of adolescent mid-shaft clavicular fractures, and relative indications for surgical intervention in adults do not appear to be applicable to adolescents [26]. Hook plate fixation of acute displaced lateral clavicle fractures yields excellent mid-term results with no long-term complications attributable to the plate [17]. An all-suture technique for fixation of unstable displaced distal clavicle fractures showed low complications and a high level of union after a 1-year follow-up in a pilot study [22]. Results of surgical treatment for unstable distal clavicular fractures were more problematic in the delayed group despite a high rate of union [103].

Long-term complications of lateral condyle humerus fractures are permanent in nature, with 40% of cases not reaching satisfactory outcomes even after long follow-up until the end of bone growth [23]. Data suggest a higher rate of nonunion with K-wire fixation for lateral condylar fractures of the humerus in children, though prospective, randomized trials with long-term follow-up are required to confirm these findings [29]. An eighty-four-year follow-up on a patient with an ununited fracture of the lateral condyle of the humerus is believed to be the longest follow-up on record of a fracture, verified by history and roentgenography [25].

Double-plating of proximal humeral fractures yields good clinical mid- to long-term results in complex and highly unstable fractures [70]. Fractures of the proximal humerus follow characteristic patterns [105]. The progression of ossification during the first 3 months was a significant predictor of successful nonoperative treatment and complete union in osteochondritis dissecans of the humeral capitellum [102].

Union of an ununited long-bone fracture is achieved surgically in four basic steps: host bone preparation, bone-graft application, fixation, and postoperative care [30]. Union occurred in all patients treated with iliac inlay-on-edge bone graft, with protracted healing time in only two cases [104]. The treatment of non-union of fractures in the United States during the 19th century progressed from primitive methods involving setons and caustics to the modern use of bone grafts by the end of the century [10].

Key Evidence

  • [L4] Surgical intervention may not be required in all cases if the fracture location and severity allow for individualized treatment. (10.1177/0363546503262195)
  • [L4] The authors advocate its use for these challenging fractures. (10.1177/1758573220964807)
  • [L5] A systematic approach to evaluating fracture union, incorporating patient symptoms, signs, immune and endocrine status, and various diagnostic tests, can help surgeons determine the timing and nature of interventions for compromised fracture healing. (10.5435/jaaos-20-05-273)
  • [L5] Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. (10.1016/j.jse.2017.10.028)
  • [L4] Operative treatment of these complex fractures is safe and yields predictably good results. (10.2106/00004623-199407000-00024)
  • [L4] Minimal fracture displacement (<3 mm) does not worsen the clinical outcome or duration of symptoms. (10.1016/j.jse.2013.01.033)
  • [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)
  • [L4] For this reason, such surgical treatment should always be considered when facing this particular fracture group. (10.1016/j.injury.2020.10.085)
  • [L5] The treatment of non-union of fractures in the United States during the 19th century progressed from primitive methods involving setons and caustics to the modern use of bone grafts by the end of the century. (10.2106/00004623-197355080-00014)
  • [L4] Although the MTM-classification covers a wide spectrum of fracture types, the precise topographic and morphological description is not delivering reproducible results. (10.1186/1471-2474-9-21)
  • [L4] A high index of suspicion is required to diagnose these fractures because they are often subtle or undetectable on plain radiographs. (10.1016/j.jhsa.2012.01.040)
  • [L4] These fractures may be underdiagnosed, and computed tomography is recommended over plain radiography alone in case of clinical suspicion. (10.1016/j.jhsa.2012.02.046)
  • [L4] These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique. (10.1302/0301-620x.96b5.32362)
  • [L5] However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. (10.5435/jaaos-20-03-130)
  • [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)
  • [L4] At mid term the results are excellent and no long term complications can be addressed to the use of the plate. (10.1186/1749-799x-7-2)
  • [L4] Ultrasonography may provide greater accuracy in fracture diagnostics by revealing small avulsed bony fragments missed on radiographs and can be beneficial in diagnosing occult fractures, especially in children. (10.1016/j.jhsa.2015.02.022)
  • [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)
  • [L1] Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics. (10.1016/j.jse.2012.01.009)
  • [L4] Undisplaced fractures have a variable outcome when treated nonoperatively. (10.1016/j.jse.2015.11.007)
  • [L4] This pilot study showed low complications and a high level of union after a follow-up of 1 year. (10.1016/j.xrrt.2022.01.005)
  • [L2] Long-term complications of lateral condyle humerus fractures seem to be permanent in nature, with 40% of cases not reaching satisfactory outcomes even after long follow-up until the end of bone growth. (10.1007/s00402-018-2934-9)
  • [Paper] There is a clear-cut indication for surgery in patients with overlapping of fracture fragments ≥ 15% or cranio-caudal displacement ≥ 2.3 cm, as well as in those with overlapping ≥ 13% associated with displacement ≥ 2 cm. (10.1007/s00264-009-0850-x)
  • [L5] This is believed to be the longest follow-up on record of a fracture, both by history and also by roentgenographic verification. (10.2106/00004623-197355020-00015)
  • [L3] Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. (10.1302/0301-620x.103b5.bjj-2020-1929.r1)
  • [L4] The best functional outcomes occur with plate removal before 6 months postoperatively, provided the fracture has healed. (10.1016/j.jse.2011.07.020)
  • [L2] Close follow-up of nonoperatively treated clavicle fractures is warranted. (10.1016/j.jse.2018.01.004)
  • [L3] The data suggest a higher rate of nonunion with K-wire fixation, though prospective, randomized trials with long-term follow-up are required to confirm these findings. (10.1302/0301-620x.100b3.bjj-2017-0814.r1)
  • [L5] Union of an ununited long-bone fracture is achieved surgically in four basic steps: host bone preparation, bone-graft application, fixation, and postoperative care. (10.2106/00004623-196547010-00016)
  • [Paper] The uninterrupted progression of biological events in conjunction with a favourable mechanical environment remains the hallmark of successful fracture healing. (10.1016/j.injury.2016.10.008)
  • [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)
  • [L5] The new classification provides a useful synoptic framework for identifying complex fracture patterns. (10.1016/j.jse.2020.02.022)
  • [Abstract] The new classification provides a useful synoptic framework for identifying complex fracture patterns. (10.1016/j.jse.2022.01.040)
  • [Case_report] The patient's symptoms improved significantly following fracture healing. (10.1016/j.injury.2003.10.012)
  • [L1] Prospective, randomised, double-blind, placebo-controlled trials demonstrate its clinical efficacy in accelerating fracture healing. (10.1016/j.injury.2008.01.015)
  • [L3] The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans. (10.1016/j.jse.2015.08.006)
  • [Abstract] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jse.2022.01.037)
  • [L3] The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems. (10.1016/j.jse.2012.09.018)
  • [L4] We recommend that this fracture pattern be added to the current modified Neer classification as a type IIC fracture. (10.1016/j.jse.2020.10.006)
  • [L3] Specific clinical and radiological 'red flags' should increase suspicion of associated vascular injury to facilitate early diagnosis and appropriate combined orthopaedic and vascular intervention. (10.1302/0301-620x.106b8.bjj-2023-1114.r1)
  • [L5] These constructs offer superior biomechanical stability in our model and potentially reduce complications associated with subacromial hardware. (10.1016/j.xrrt.2025.100645)
  • [L4] A new classification based on the displacement of the four major segments (head, lesser tuberosity, greater tuberosity, and shaft) is adequate for sorting lesions and correlating roentgen appearance with fracture type. (10.1097/01.blo.0000198718.91223.ca)
  • [L4] The classification groups are related to the fragmented articular surface area and the number of fragments, and the mechanism of injury is also related to the classification group. (10.1016/j.jse.2015.07.022)
  • [L2] The frequency of each type of injury in this new classification is presented and a technique for viewing 3D images is suggested which maximizes their usefulness. (10.1016/j.jse.2009.03.001)
  • [L4] This article represents a detailed review of the epidemiology, risk factors, classification and management of these complex injuries. (10.1111/j.1758-5740.2011.00147.x)
  • [L1] Nonsurgical treatment resulted in a significantly high nonunion rate (33.3%) but acceptable functional outcomes, making it a potential first-line option after counseling. (10.1007/s00402-010-1196-y)
  • [L4] These fractures correlate with worse postoperative outcomes regardless of treatment method; open reduction–internal fixation was not shown to be clinically superior despite a limited complication rate. (10.1016/j.jse.2018.08.033)
  • [L5] Judicious use of BMP in certain clinical scenarios may revolutionise management of non-unions and delayed unions. (10.1016/j.injury.2006.12.012)
  • [L5] Non-union often results from a combination of adverse situations, and its prevention depends to a great extent on the application of well-established sound principles of fracture management. (10.2106/00004623-196547010-00015)
  • [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)
  • [L3] Both techniques significantly improved shoulder function and are relatively safe procedures. (10.1016/j.jse.2019.09.035)
  • [L5] In case of nondisplaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen, while displaced or unstable fractures will be managed operatively. (10.1016/j.jht.2017.05.005)
  • [L3] Higher complication and failure rates were observed in older patients and more complex fractures. (10.1016/j.jse.2018.11.028)
  • [L1] The available evidence suggests that there are no differences in treatment effects between plating and intramedullary pinning, but plating is associated with more side effects. (10.1016/j.jse.2011.01.018)
  • [L5] They recommend careful frequent radiographic examination during the initial 3 months of fracture healing to assess the acromion, especially in patients with comorbidities or medication history leading to osteopenia. (10.1111/j.1758-5740.2010.00078.x)
  • [L4] Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques. (10.1016/j.otsr.2016.11.007)
  • [L1] MSC is a potential adjunct therapy for patients with non-union fractures. (10.1186/s12891-025-08365-w)
  • [Paper] Complications, such as non-union or instability, were not seen in this group. (10.1016/j.injury.2008.07.021)
  • [L5] The study provided a biomechanical basis to guide the clinical treatment of scapular body fractures. (10.1186/s13018-024-04905-7)
  • [L1] This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. (10.1371/journal.pmed.1002855)
  • [L3] Patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures. (10.1016/j.jse.2016.01.028)
  • [L5] Nonsurgical management remains the treatment of choice for nondisplaced midshaft fractures, while surgical intervention may be required for severe displacement, neurovascular compromise, or specific fracture patterns. (10.1016/j.jse.2011.08.053)
  • [L3] It is a minimally invasive procedure that provides adequate fracture stability and permits early shoulder motion, with satisfactory functional and radiologic outcomes and fewer complications. (10.1186/s12891-025-08600-4)
  • [Abstract] Double-plating of proximal humeral fractures yields good clinical mid- to long-term results in complex and highly unstable fractures. (10.1016/j.jse.2022.01.036)
  • [L5] Glenohumeral contact patterns highly depend on the amount of glenoid retroversion and posterior labral and/or bony glenoid integrity. (10.1177/03635465251365497)
  • [L5] The purpose of this summary is to review treatment options as well as indications and techniques to address bony deficiencies. (10.1177/0363546505277074)
  • [L3] Bone transport techniques are effective for posttraumatic bone defects with specific indications based on defect size and location; no single technique is universal. (10.1016/j.otsr.2011.11.002)
  • [L5] This biomechanical study confirms improved anterior glenohumeral stability after iliac crest bone graft augmentation of the anterior glenoid. (10.1016/j.jse.2014.09.018)
  • [L5] In our cadaveric model, Hill-Sachs lesions were not created at the time of dislocation but after the arm came to equilibrium at a low abduction angle. (10.1016/j.jse.2019.09.004)
  • [L5] The novel biomechanical model distinguished between different mechanisms of injury and resulting fracture configurations. (10.1177/1758573218768535)
  • [L4] Surgical intervention is not required for most patients with floating shoulder injuries, and treatment should be individualized based on patient assessment and understanding of pathoanatomy. (10.5435/00124635-200608000-00007)
  • [L4] This finding can influence biomechanical models as well as surgical reconstruction. (10.1016/j.jse.2017.03.022)
  • [L5] However, transferability and clinical relevance of these biomechanical results have to be verified with clinical studies. (10.1016/j.jse.2020.09.009)
  • [L5] Computed tomography represents the gold standard for diagnosis alongside conventional radiographs. (10.1055/a-0989-2791)
  • [L3] Rapid limited-sequence MRI of the pelvis for patients with femoral shaft fractures identified femoral neck fractures that were not diagnosed on thin-cut high-resolution CT in 12% of our patients. (10.2106/jbjs.19.00568)
  • [L5] Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics. (10.5435/jaaos-d-20-00555)
  • [L4] Computed tomographic scanning is valuable for diagnosing this pathology when plain radiographs are inconclusive. (10.2106/00004623-198668080-00024)
  • [L3] The findings of this study support repeat radiographic assessment 2-3 weeks post-injury prior to making definitive treatment decisions. (10.1177/2325967121s00455)
  • [L4] This arthroscopic-assisted surgery allows for total recovery of shoulder function, without the inconvenience of device migration or acromioclavicular joint lesions reported with other procedures. (10.1016/j.arthro.2006.08.028)
  • [L4] The translations of the superior and inferior angles of the scapula are quite variable in magnitude and direction, and on average, these angles translate substantially less than the acromion. (10.1016/j.jse.2012.04.011)
  • [L1] In addition, the procedure does not improve shoulder function or general symptoms, and it does not decrease limitations compared with nonoperative treatment in a sling. (10.2106/jbjs.15.01394)
  • [L3] Results of percutaneous fixation depend on the biomechanical construct. (10.1016/j.jse.2018.06.034)
  • [L5] The single anterior-to-posterior clavicle tunnel had similar biomechanical properties to the 2-tunnel technique. (10.1177/2325967114555478)
  • [L3] Secondary displacement was common after initially well-aligned reductions and was significantly associated with SF-IF involvement and greater critical shoulder angle. (10.1016/j.jse.2025.10.009)
  • [Paper] This is the first study to establish time specific ultrasound fracture findings with a repeatable technique and assess the agreement between blinded reviewers. (10.1016/j.injury.2019.09.027)
  • [L2] This is a radiographic phenomenon without significant impairment of function or need for revision within 5 years after surgery. (10.1016/j.jse.2014.02.024)
  • [L4] They can be difficult to diagnose by less experienced Health Practitioners on plain radiographs and a low threshold for more senior review or additional imaging should be considered. (10.1177/1758573220923122)
  • [L5] Interobserver agreement was best when fractures were classified using CT scans. (10.1016/j.jseint.2022.03.005)
  • [L5] Both patients achieved radiological union around 3 months with significant pain reduction and functional improvement. (10.1016/j.jseint.2023.09.001)
  • [L4] More importantly, this case highlights the need for adequate radiologic investigation, either by use of 3 plain films obtained at 90° to each other or by use of 3-dimensional CT reconstruction. (10.1016/j.jse.2006.08.003)
  • [L4] The progression of ossification during the first 3 months was a significant predictor of successful nonoperative treatment and complete union. (10.1016/j.jseint.2021.01.004)
  • [L3] Despite a high rate of union, the results of treatment in the delayed group were more problematic. (10.1016/j.jse.2009.11.056)
  • [L4] Fractures of the proximal humerus follow characteristic patterns. (10.1016/j.jse.2017.05.014)

See Also

References

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4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.