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Fractures

Proximal humerus, humeral shaft, clavicle, and scapula fractures — epidemiology, mortality risk in elderly populations, and trauma management.

210 citationsUpdated Sep 2026

Overview¶

Fracture management aims to determine optimal treatment for individual injuries and enable comparison of therapeutic efficacy [8]. Treatment follows basic principles of maintaining length, alignment, and immobilization [210]. Operation is often contra-indicated if a fracture can be held without it, as non-operative management may heal faster with fewer complications [210]. For proximal humerus fractures, nonoperative treatment remains the mainstay, although operative treatment has increased over the last decade [6]. Indications for surgical intervention remain controversial, with recent evidence suggesting no long-term differences in outcomes between surgical and nonsurgical cohorts for many patient populations [41, 47]. Surgical fixation and arthroplasty offer specific benefits for displaced fractures or younger patients [47]. The choice between intramedullary and locking plate fixation should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations [202]. More randomized controlled trials are needed to definitively recommend intramedullary nailing over locking plate fixation due to observed heterogeneity [48].

For midshaft clavicle fractures, nonsurgical management is reliable, but surgical options are increasingly favored for displaced fractures to improve union rates and functional outcomes [51]. Clear-cut indications for surgery exist for overlapping of fracture fragments ≥ 15% or cranio-caudal displacement ≥ 2.3 cm [53], as well as for overlapping ≥ 13% associated with displacement ≥ 2 cm [53]. Stable distal clavicular fractures should be treated nonoperatively, whereas surgery is indicated in unstable Type Ila distal clavicular fractures [211]. The Tightrope device is advocated as the sole method of fixation for lateral end clavicle fractures [9]. Scapular fractures lack agreement on surgical indications and clear comparative evidence on outcomes [36]. A specific radiographic measurement technique should be utilized if fracture deformity warrants surgical consideration and to adequately compare data across studies for extra-articular scapular fractures [199]. Due to the rarity of displaced glenoid fractures, only multicenter studies extending over long periods of time will lead to accurate definition of the results and prognoses associated with operatively treated fractures [10].

Surgical treatment for humeral shaft fractures is generally reserved for specific indications such as open fractures, polytrauma, or failure of nonoperative management [44]. When indications for operative treatment are met, plate fixation is reliable and safe [55]. For pathologic fractures of the long bones, treatment strategies depend on fracture risk and expected survival [54]. Surgery is indicated for actual pathological fractures or high-risk impending fractures [54], while radiotherapy is indicated for small lesions without fracture risk [54]. A pathologic fracture may no longer be an absolute contraindication for limb salvage surgery in patients with osteosarcoma [24]. Indications for surgical management of calcaneus fractures remain controversial and depend on fracture pattern, patient demographics, and surgeon experience [209]. Open fractures should be excluded as an entry criterion in future clinical trials regarding infection in multiply injured patients [203]. The high rate of surgical complications associated with external fixation of pelvic fractures increases the morbidity associated with the fracture and may interfere with definitive management [213]. It is too early to integrate standardized screening of fractures into treatment guidelines for generalized convulsive seizures and status epilepticus until the effect of such screening is investigated [3].

Anatomy & Pathophysiology¶

Scapular Architecture¶

The scapula attaches to the axial skeleton via the clavicle at the acromioclavicular and sternoclavicular joints [66]. Enveloped in multiple muscle layers and separated from the chest wall by thin gliding fibro-fatty tissue, it allows smooth excursion over the thorax [66]. The scapular body is triangular in anteroposterior view, with its base superior and apex inferior [66]. The glenoid connects to the flat body via the scapular neck, from which the hook-shaped coracoid process curves forwards on the superior surface [66]. The scapular spine arises from the posterior surface and terminates in the flattened acromion, which also curves forwards [66].

Bony mass distribution is highly uneven, concentrating in the glenoid, the scapular neck (including the coracoid base), and the lateral border of the body [66]. Two bony pillars transmit compressive forces from the glenoid fossa: the lateral pillar connects the inferior glenoid border to the inferior angle, while the spinal pillar arises from the central glenoid and continues medially into the scapular spine base [66]. These pillars, connected by a markedly thinner medial border, form the biomechanical body of the scapula [66]. The superior angle and adjacent supraspinous fossa serve as muscle surfaces but do not transmit compressive forces [66]. The weakest bone, only a few millimeters thick, lies primarily in the central infraspinous fossa [66]. The weakest circumferential area is the spinomedial angle, where the scapular spine meets the medial border; most scapular body fractures pass through this angle [66]. Fracture lines also frequently occur in the central part of the scapular spine [66].

The scapula spans ribs two through seven and serves as an attachment for 17 muscles [82]. It is anteverted approximately 30 degrees relative to the body, while the glenoid is retroverted approximately 5 degrees relative to the scapular body [82]. The acromion possesses three ossification centers: the metacromion (base), mesoacromion (middle), and preacromion (tip) [67]. Failure of fusion results in os acromiale [67]. The coracoid process originates the coracobrachialis muscle and short head of the biceps tendon, while the pectoralis minor inserts onto its medial aspect [67]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [67].

In humans, the scapula is suspended by muscles alone and has shifted caudally from the cervical position seen in lower animals [76]. Broadening of the infraspinatus fossa has shifted the vector of muscle pull from the axillary border to the glenoid fossa, enhancing the infraspinatus and teres minor as depressors and external rotators of the humeral head [76]. The acromion has enlarged compared to pronograde animals, reflecting the deltoid’s increasing role in shoulder function [76]. The broader deltoid attachment on the acromion and its more distal humeral insertion have increased its mechanical advantage [76]. The coracoid process has increased in size over time; at 90 degrees of abduction, its extension over the glenohumeral joint mechanically limits anterior humeral translation relative to the glenoid [76].

Proximal Humerus Anatomy¶

The proximal humerus comprises four main parts: the humeral head, greater tuberosity (GT), lesser tuberosity (LT), and humeral shaft [64]. The articular head is spherical with a diameter of 37 to 57 mm [64]. The most superior portion of the articular surface averages 8 mm above the GT [64]. Humeral version averages 29.8 degrees (range 10 to 55 degrees) [64]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [64]. The bicipital groove lies between the GT and LT, serving as a pathway for the long head of the biceps; its distal aspect is internally rotated relative to the proximal portion [64]. The anatomic neck is located at the junction of the articular surface and tuberosities, while the surgical neck represents an indistinct metadiaphyseal junction below the tuberosities but above the shaft [64]. Fractures involving the anatomic neck carry a worse prognosis than other proximal humeral fractures due to potential disruption of the humeral head’s vascular supply and subsequent avascular necrosis [64].

The GT is located posterior-superiorly relative to the shaft and serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [64]. The LT is located anteriorly and serves as the attachment site for the subscapularis tendon [64]. The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [67]. It is retroverted 30 degrees relative to the transepicondylar axis of the humerus [82]. The neck-shaft angle measures an average of 135 degrees, with the humeral head retroverted an average of 30 degrees [65]. The average neck-shaft angle is also cited as 45 degrees (±5 degrees), with a range of 30 to 50 degrees [79]. The articular surface is essentially spherical, with an arc of approximately 160 degrees covered by cartilage [79]. The radius of curvature is approximately 25 mm, slightly larger in men than in women [79]. The superior margin of the articular surface is normally 8 to 10 mm superior to the top of the GT [79].

The distance from the lateral base of the coracoid process to the lateral margin of the GT is the lateral humeral offset [79]. A significant decrease in this offset reduces lever arms for the deltoid and supraspinatus, weakening abduction and impairing function [79]. Conversely, a significant increase causes excessive soft tissue tension, resulting in loss of motion and likely accelerating polyethylene wear [79]. Humeral articular malposition of more than 4 mm leads to increased subacromial contact [79]. An offset of 8 mm in any direction significantly decreases passive range of motion [79]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [79].

The proximal humerus has three ossification centers: for the GT, LT, and humeral head [71]. The humeral head center is usually present at birth [71]. The GT center appears by 1 to 3 years of age, and the LT center by 5 years [71]. The ossification center remains separated from the shaft by the proximal humeral physis, which closes by 14 to 17 years in girls and 16 to 18 years in boys [71]. Humeral retroversion averages 65 degrees in infants and young children, gradually decreasing to adult values by 11 years of age [71]. Eighty percent of subsequent humeral growth comes from the proximal physis, accounting for approximately 40% of total upper extremity growth [71]. Less than 75% of proximal humeral growth occurs before 2 years of age, while more than 85% occurs by 8 years [71]. The periosteum is thicker and stronger in the posteromedial portion compared to the often thin anterolateral portion [71]. This anatomy explains the tendency of proximal humeral metaphyseal fracture fragments to penetrate the anterolateral periosteum [71]. The transverse humeral ligament is an important stabilizer of the biceps tendon [82].

Vascular Supply and Nerves¶

The proximal humerus receives blood supply from the anterior and posterior humeral circumflex branches of the third division of the axillary artery [64]. The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [64]. The anterior humeral circumflex artery (AHCA) arises from the axillary artery at the inferior border of the subscapularis [64]. It provides vascular inflow to the humeral head via its terminal anterolateral branch, the artery of Laing (arcuate artery) [64]. The ascending branch of the AHCA courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and GT [64]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [64]. Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [64].

The primary blood supply to the humeral head is through the ascending branch of the AHCA, which penetrates the head at the bicipital groove and becomes the arcuate artery [65]. The anterolateral ascending branch of the AHCA provides this primary supply [67]. It travels proximally in the lateral aspect of the intertubercular groove, with its terminal intraosseous portion entering at the proximal aspect of the groove as the arcuate artery [67]. Fractures of the anatomic neck have a poor prognosis due to complete disruption of the head’s blood supply [65]. Surgical neck fractures are common and typically preserve the head’s blood supply [65]. More recent quantitative assessment shows that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [71]. This explains the exceedingly low rate of osteonecrosis associated with anterior shoulder dislocations [71].

The brachial plexus is prone to injury during proximal humeral fractures, dislocations, or traction [71]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [71]. It is a terminal branch of the posterior cord of the brachial plexus, arising just proximal to the coracoid process [70]. The nerve passes beneath the conjoined tendon anterior to the subscapularis, 3 to 5 mm medial to the musculotendinous junction [70]. It is adjacent to the inferior capsule before entering the quadrilateral space posteriorly [70]. Within the quadrangular space, the axillary nerve splits into anterior and posterior branches [70]. The anterior and middle deltoid muscles receive sole innervation from the anterior branch [70]. Posterior deltoid innervation varies: supply is from the anterior branch only in 2.3% of cases, from the posterior branch in 8.5%, and from both branches in 89.1% [70]. The posterior branch supplies the teres minor muscle and terminates as the superior lateral brachial cutaneous nerve [70].

In the anterior deltopectoral approach, the axillary nerve can be palpated by sweeping a finger inferiorly across the subscapularis muscle tendon interface [70]. In the anterolateral deltoid splitting approach, the nerve crosses approximately 5 cm inferior to the anterolateral acromial corner [70]. Shoulder abduction brings the axillary nerve closer to the acromion landmark [70]. In the posterior deltoid splitting approach, the axillary nerve is approximately 7 cm from the posterior acromial corner [70]. The radial nerve is commonly injured in humeral shaft fractures, particularly at the junction of the middle and distal third (Holstein-Lewis fracture) [65]. An axillary nerve injury from proximal humeral fracture or fracture-dislocation results in deltoid paralysis and anesthesia over the “badge” region at the lateral proximal arm [65].

The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to the ligament [67]. Entrapment of the suprascapular nerve at this ligament causes denervation of both the supraspinatus and infraspinatus [67]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [67]. Entrapment, traction, or compression at this notch causes denervation of the infraspinatus [67]. The suprascapular artery passes superior to the superior transverse scapular ligament, and the nerve passes inferior to it through the notch [82]. At the spinoglenoid notch, both the artery and nerve are inferior to the inferior transverse scapular ligament [82].

Glenohumeral Joint and Stability¶

The glenoid is a convex structure of shallow depth shaped like an inverted pear [64]. It articulates with the humeral head and serves as the attachment for the labrum and joint capsule [64]. The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure imparting stability to the shoulder girdle [64]. The rotator cuff, subacromial bursa, and subdeltoid bursa pass underneath this arch [64]. Displaced proximal humeral fractures can impede normal movement of structures under the arch, causing impingement and disrupting normal glenohumeral motion [64]. In proximal humeral fractures, the subdeltoid and subacromial bursae can become thickened and fibrotic, forming adhesions that limit normal glenohumeral motion [64].

The shoulder joint comprises four articulations: sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic [80]. The glenohumeral joint depends on static and dynamic stabilizers for movement and stability [79]. The rotator cuff stabilizes the joint while allowing greater freedom of motion and fixes the fulcrum of the upper extremity against which the deltoid contracts [79]. The rotator cuff must act simultaneously and synergistically with the deltoid muscle for normal function [79]. Bony anatomy contributes little to stability, having been compared to a golf ball on a tee [80]. The glenoid is encircled by the labrum, composed of dense fibrocartilaginous tissue, which increases the socket depth by 50% around the humeral head [80]. The glenoid articular surface and labrum combine to create a socket approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [80]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically [80].

Classification¶

General Principles and Goals¶

The ultimate goal of any fracture classification scheme is to allow for the determination of the best treatment for each individual fracture and to enable comparison of the efficacy of various treatment methods on a particular fracture [8]. A precise classification of fracture type at the time of diagnosis identifies a smaller subset of patients that require follow-up [1]. The classification of open fractures is important because it directs the attention of the treating surgeon to the presence and extent of injury variables [86]. Understanding the classification and grade of stress fractures and their implications on return-to-play decisions is key to optimal care of the athlete [128]. A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment [88].

AO/OTA¶

The fundamental principle of the comprehensive classification of fractures of long bones is the division of all fractures of a bone segment into three types (A, B, C), each divided into three groups, and further subdivided into three subgroups [42]. The AO classification system arranges fracture types in an ascending order of severity according to morphologic complexities, treatment difficulties, and prognosis [42]. In the AO classification, A1 indicates the simplest fracture with the best prognosis and C3 indicates the most difficult fracture with the worst prognosis [42]. The OTA fracture classification distinguishes between extra-articular (type A), partial articular (type B), and complete articular (type C) injuries and accounts for fracture complexity [250]. A study demonstrated significant interobserver variation in coding long bone fractures using the AO classification system, with only 32 per cent of individual codings agreeing with the final consensus [122]. The classification of fracture severity in children should be done in only two categories that distinguish between simple and wedge/complex fractures [98].

Neer¶

The Neer classification is a useful management tool, but accurate delineation of fracture pattern requires better imaging modalities [37]. Observer agreement on the classification of displaced four-part fractures according to the Neer system is low (slight to moderate) [90]. More complex fractures, including those with higher Neer classification scores, developed pseudosubluxation at higher rates than simpler fracture patterns [119].

Gustilo–Anderson¶

The Gustilo-Anderson classification has been the mainstay of open fracture classification since it was first described in 1976 [245]. Gustilo described three broad categories (I-III) based on the extent of soft-tissue injury and the size of corresponding skin wounds [245]. Type I open fractures are defined as clean injuries with a skin wound < 1 cm and a simple fracture pattern [245]. Type II open fractures have skin wounds > 1 cm, with minimal soft-tissue injury and no flaps or avulsions [245]. The type III classification was revised in 1984 into types III-A, B, and C, stratified according to the degree of need for local coverage and evidence of neurovascular compromise [245]. Type III-C is defined as an open fracture with associated vascular injury requiring repair [245]. The Gustilo classification has met with scrutiny regarding limited inter-observer reliability, with as little as 60% concordance between observers [245].

Other Considerations¶

Existing classification systems for complex extremity fractures are inadequate and lack therapeutic recommendations [62]. Existing classification systems for ballistic fractures are inadequate because they fail to account for soft-tissue injury, anatomical location, and joint involvement [83]. The problem with proximal humerus fractures is understanding the images of complex fractures, not the classification system [11]. Three-dimensional reconstructions improve the reliability, but not the accuracy, of fracture classification and characterization for distal humeral fractures [19]. Although the MTM-classification covers a wide spectrum of fracture types, the precise topographic and morphological description is not delivering reproducible results [73]. A 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 [140]. A new classification of impacted proximal humerus fractures based on morpho-volumetric evaluation provides a useful synoptic framework for identifying complex fracture patterns [93, 94]. The classification of complex 4-part humeral fractures consists of 6 groups divided into 15 subgroups of calcar fracture patterns [84]. The four-segment classification for displaced proximal humeral fractures is based on the presence or absence of displacement of one or more of the four major segments rather than the level of the fracture or mechanism of injury [236]. A new 'unified' classification of open fractures based on Gustilo and OTA schemes has good validity, reliability, and acceptability, and has the potential to replace all other existing classification systems [63]. The Orthopaedic Trauma Association Board of Directors has charged the Classification Committee with designing a multi-centre study to assess reliability, validity, and ideal usage of the open fracture classification [105]. A knowledge of injury mechanisms and careful clinical and radiologic examinations are essential to determine the proper diagnosis of scapular fractures [2]. Scapular fractures are caused by different mechanisms of varying violence and are often associated with other injuries involving the ipsilateral extremity or other parts of the body [2]. A comprehensive classification of craniofacial fractures divides the region into three units and distinguishes lateral and central fractures [81]. A novel classification system for fragility fractures of the pelvic ring is based on morphological criteria and corresponds with the degree of instability [103]. There is no universally accepted method of classification for distal femur fractures, though all classifications distinguish among extra-articular, intra-articular, and isolated condylar lesions [250]. Anatomic fracture classifications for distal femur fractures fail to address conditions commonly associated with supracondylar femur fractures that influence treatment or outcome [250]. All acromial fractures in a study of nonoperative treatment following reverse shoulder arthroplasty were classified according to the Levy classification [238].

Clinical Presentation¶

History and Initial Assessment¶

A comprehensive history and physical examination are essential when a patient presents with a fragility fracture to evaluate the mechanism of injury and identify secondary contributing factors [5]. Fracture stability and anatomic location significantly guide operative versus non-operative decision-making in these cases [5]. In pediatric patients with upper-limb fractures from dog bites, a high index of suspicion derived from the history, coupled with careful clinical examination, alerts the clinician to the possibility of an underlying fracture [28]. Extremity fractures are common in patients with traumatic brain injury and are frequently missed; appropriate evaluation allows for prompt diagnosis and optimal treatment [110]. The incidence of fractures missed on initial examination in patients admitted for trauma is at least 7.5 per cent [111].

Diagnostic Modalities and Missed Fractures¶

Bone scan is an effective method for detecting missed fractures in patients with multiple severe traumas and can be used reliably as a screening test [31]. Awareness of the double line sign may help detect clinically or radiographically missed or occult fractures of the proximal humerus, facilitating adequate therapy and obviating extra financial costs from unnecessary additional examinations [92]. Although nearly half of first rib stress fractures in baseball players were initially missed, careful review of radiographs detected most cases with high accuracy and excellent interobserver reliability [17].

Pathological and Special Populations¶

The diagnosis of a pathological fracture can be a trap; the surgeon must be suspicious and carefully scrutinize every X-ray image [4]. If radiographic appearances are reassuringly benign in children with pathological fractures, biopsy can be delayed until conservative fracture management is completed [15]. A high index of suspicion leads to early diagnosis in pathological fractures caused by primary hyperparathyroidism [117]. When faced with a fracture in a previously abnormal bone, one should think ahead to the possible results for both the fracture and the previous abnormality [39].

Malignant and Metastatic Fractures: Management of malignant pathological fractures necessitates careful diagnostic work-up, preoperative investigation, planning, and multidisciplinary input from specialists in radiology, pathology, oncology, trauma, and orthopaedics [101]. Patient workup for metastatic long bone fractures must be thorough and appropriate for the clinical context [112]. If a definitive diagnosis cannot be made based on a thorough history, physical examination, laboratory tests, and radiographic evaluation for metastatic long bone fractures, a biopsy should be performed and a histologic diagnosis must be made before fracture fixation [112]. In patients with a history of cancer, a newly diagnosed osseous lesion cannot be assumed to be part of the same pathologic process [112]. Primary bone lymphoma is a rare entity that can present as a pathological fracture and is often misdiagnosed initially [127].

Seizure-Related Fractures: As long as the effect of standardized screening of fractures is not investigated, it is too early to integrate such a screening into treatment guidelines for fractures from generalized convulsive seizures and status epilepticus [3].

Specific Fracture Patterns and Locations¶

Scapular and Glenoid Fractures: Scapular fractures are often associated with other injuries involving not only the ipsilateral extremity but also other parts of the body [2]. These fractures can be difficult to diagnose, leading to missed or delayed diagnoses [74]. Diagnosis of acute glenoid fractures requires plain radiographs and CT scans, while management is dictated by fracture morphology, displacement, and associated injuries [12]. Functional results are limited regardless of the fracture management for scapular spine fractures after reverse shoulder arthroplasty, and no clear preoperative risk factors were identified [123].

Proximal Humerus and Greater Tuberosity: Management of proximal humerus fractures is challenging as 50% of fractures are displaced, requiring hospitalization in half the cases, yet surgery is only performed in one out of five [99]. Nonoperative treatment remains the mainstay for most proximal humerus fractures; however, operative treatment has increased over the last decade [6]. All fractures of unstable proximal humeral fractures treated with a locking plate and fibular strut allograft healed clinically and radiologically [7]. Techniques for complex proximal humerus fractures with diaphyseal extension can result in good clinical outcomes despite the complexity of this fracture pattern [40].

The appropriate evaluation of greater tuberosity fracture dislocations is predicated on the treating surgeon’s ability to identify the injury in a timely fashion and have a complete and thorough understanding of the fracture pattern [115]. Aside from a focused history, physical exam and imaging remain the mainstays of diagnosis for greater tuberosity fracture dislocations [115]. Minimal fracture displacement (<3 mm) of the greater tuberosity does not worsen the clinical outcome or duration of symptoms [116]. Distinct fracture morphologies of the greater tuberosity are likely to have implications in terms of pathophysiology and surgical technique [125].

Other Upper Extremity and Pediatric Fractures: Fracture should be suspected in patients who present with pain postoperatively following reverse total shoulder arthroplasty, and workup should include plain radiographs and computed tomographic scan if indicated [22]. Treatment of acromial fractures depends on the fracture location, displacement, and patient factors and includes both non-surgical management and surgical fixation [26]. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management of humeral shaft fractures, and earlier operative intervention may be recommended [18].

Most pediatric fractures can be treated on an outpatient basis, with only 1 of 18 fractures requiring hospitalization or observation [35]. The prognosis is favourable across fracture types and circumstances of occurrence for fractures in children younger than 18 months [16]. A precise classification of fracture type at the time of diagnosis would identify a smaller subset of patients that require follow-up in children [1].

Complications and Emergency Care: A high rate of fracture complications was observed with internal fixation for collocated burn and fracture injury, despite undergoing management within 24 h of presentation [114]. Air splints are recommended for emergency treatment, pathological fractures, and situations requiring x-ray transparency, with no complications observed after twenty-four hours of use [124].

Investigations¶

Plain radiography: Radiographs remain the mainstay for fracture assessment, although interpretation is challenging with experimental studies documenting a roughly 30% error rate [241]. Clinicians and radiologists agreed on the presence or absence of fracture or dislocation in 897 of 1011 cases (89 per cent) [243]. The standard shoulder series includes a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [148]. At least two X-ray views should be obtained for shoulder imaging: an anteroposterior view in the plane of the glenoid and an axillary projection with the arm in abduction [107]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration [148]. The axillary view is necessary for evaluating glenohumeral joint instability and may detect occult, locked posterior shoulder dislocation [148]. The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs [148]. Normal acromiohumeral distance is 7 to 14 mm, and normal coracoclavicular distance is 1.1 to 1.3 cm [148].

The first key view is the anteroposterior (AP) in the plane of the scapula taken so that the x-ray beam passes through the glenohumeral joint [14]. This view shows the superoinferior position of the humeral head relative to the glenoid, the presence of osteophytes on the humeral head and glenoid, narrowing of the joint space, the degree of medial displacement of the humerus in relation to the lateral acromial line, the quality of the humeral and glenoid bone, the presence of loose bodies, and whether there is humeral head collapse or deformity [14]. The second key view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula and oriented so that both the spinoglenoid notch and the scapular neck are visible [14]. This view shows a different perspective of the humeral anatomy, the amount of glenoid bone, the shape of the glenoid, its version in relation to the plane of the scapula, and the relationship of the humeral head to the glenoid fossa [14]. This is referred to as the “truth view” because it demonstrates the glenohumeral relationships in the functional position of elevation, in contrast to CT scans which are taken with the arm in the adducted position [14].

When taken properly, standardized anteroposterior and axillary views indicate the thickness of the cartilage space between the humerus and the glenoid, relative positions of the humeral head and the glenoid, presence of osteophytes, degree of osteopenia, and extent of bony deformity and erosion [14]. Since arthritis usually involves the central aspect of the humeral head, joint space narrowing is most evident on the truth view as opposed to images made with the arm at the side [14]. The axillary truth view also shows posterior subluxation or “functional decentering” that is not evident in images taken with the arm at the side [14]. The degree of posterior subluxation can be measured as (1) the position of the center of the humeral head in relation to the plane of the scapula, (2) the position of the center of the humeral head in relation to the glenoid face, or (3) the point of contact of the humeral articular surface on the glenoid articular surface [14]. The point of contact is preferred because it reflects the degree of centering of the net humeral joint reaction force on the glenoid; malcentering of this force leads to posterior instability, posterior glenoid wear, and “rocking horse” loosening of prosthetic glenoid components [14].

Radiographs were shown to provide incomplete information about the fracture pattern in scapula fractures, and advanced imaging caused a change in classification into a segment more likely to be considered for surgical care [228]. If a plain radiograph does not reveal a fracture, CT may be useful for bilateral simultaneous glenoid fractures [216]. In a systematic review of posterior shoulder dislocations, a missed initial diagnosis was reported in 73% of patients (150) due to the lack of an axillary view, Y view, or computed tomography (CT) imaging [156]. Of 150 patients with missed initial diagnosis of posterior shoulder dislocation, almost all (147/150 or 98%) had only AP or lateral views of the shoulder [156]. When the axillary or Y-view radiographs were made subsequently, the diagnosis of posterior dislocation was confirmed in 100% of patients [156]. Delayed diagnosis of subacromial, supracoracoid dislocation of the acromioclavicular joint with ipsilateral clavicle fracture is likely if careful examination of the patient's radiographs is not performed [291].

For pediatric patients, a precise classification of fracture type at the time of diagnosis would identify a smaller subset that require follow-up [1]. If radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed in children with pathological fractures [15]. Additional radiographs did not alter management or contribute positively to clinical outcomes in pediatric clavicle fractures, supporting a standardized protocol involving imaging only at the initial radiographic evaluation for children aged 8 years or younger [277]. Repeat radiographic assessment 2-3 weeks post-injury is supported prior to making definitive treatment decisions for completely displaced adolescent clavicle fractures [280]. Once clavicle fractures are healed, further radiographic imaging does not provide any notable information [294]. Radiologists were found to classify displaced comminuted midshaft clavicular fractures more reliably than surgeons, with substantial intra-observer and inter-observer agreement after viewing the fractures on two-plane radiography [274]. Even under laboratory conditions, the information gained from plain radiographs is not sufficient to accurately predict the strength of a healing fracture [276].

Careful review of radiographs detected most first rib stress fracture cases with high accuracy and excellent interobserver reliability, although nearly half were initially missed [17]. The imaging evaluation of a patient in whom a stress reaction or fracture is clinically suspected should begin with high-resolution radiographs of the area in question [237]. A heightened awareness and serial roentgenographic studies are necessary to demonstrate the evolution of multiple stress fractures in rheumatoid arthritis [60]. The paper defines non-union as a fracture where reparative processes have ceased and outlines clinical, roentgenographic, and histological criteria for diagnosis [287]. Postoperative x-ray films showed excellent reduction of the fracture and appropriate placement of the screw in arthroscopic internal fixation of coracoid fractures [282]. All fractures healed clinically and radiologically in unstable proximal humeral fractures treated with a locking plate and fibular strut allograft [7]. We recommend close follow-up with serial radiographs for the first several weeks to allow for optimal treatment of delayed migration of greater tuberosity fractures associated with anterior shoulder dislocation [270]. Fracture should be suspected in patients who present with pain postoperatively after reverse total shoulder arthroplasty, and workup should include plain radiographs and computed tomographic scan if indicated [22]. Appropriate views on radiographs are essential for the diagnosis of facial fractures [271]. The problem is understanding the images of complex fractures, not the classification system [11].

CT: Computed tomography (CT) is helpful for planning fracture surgery and shoulder joint replacement [107]. CT imaging is frequently used to evaluate fractures of the shoulder, to assess for bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [144]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [148]. Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics for distal humerus fractures [248]. Dual-energy CT combines the advantages of conventional CT (good visualisation of bone matter) and MRI (medullary cavity and visualisation of occult fractures) [249]. A CT scan is essential in all patients with displaced inferior ramus fractures to examine the posterior ring in detail [268]. Insufficiency fracture is best diagnosed by 'thinking of it' and subsequently establishing the diagnosis by CT [285].

MRI: Magnetic resonance imaging (MRI) is useful to identify osteonecrosis of the humeral head, or a bone tumour [107]. MRI can also identify labral tears and rotator cuff tears, although the accuracy for these latter two is enhanced by combining the scan with arthrography [107]. MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [144]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of the joint surfaces [144]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [144]. Traditional magnetic resonance imaging (MRI) is a diagnostic tool to complement both physical examination and standard radiographs in the management of patients with anterior shoulder instability [136]. Magnetic resonance (MR) accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [136]. The acquired multi-planar imaging allows for the detailed evaluation of the glenoid, labrum, joint capsule, and rotator cuff in different planes [136].

MRI did not appreciably change the estimation of fracture displacement compared to radiography in acute greater tuberosity proximal humeral fractures [220]. MRI is an imperative tool for operative planning in pathological fractures; however, we recommend against the routine use of MRI to diagnose pathological fractures in oncological patients [222]. MRI examination of the pelvis was found to be superior in detecting undislocated fractures in a cohort of patients with a high incidence of osteoporosis compared to CT and clinical examination [284].

Arthrography: Arthrography involves injection of contrast agent in conjunction with either an MRI or CT scan, enhancing imaging of the joint to enable better identification of normal structures and pathology involving the joint surfaces [144]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [144]. When MRI or MR arthrography is contraindicated (eg, pacemaker, vascular clips), CT arthrography is indicated [144]. Magnetic resonance arthrography (MRA) refers to MRI of a joint that has been injected with an intra-articular contrast agent such as diluted gadolinium or saline solution [136]. By distending the joint capsule, the cartilage, ligaments, and labrum are outlined with contrast, increasing the sensitivity for detecting tears and other lesions [136]. In a meta-analysis of the diagnostic test accuracy of MRA compared to MRI for the detection of glenoid labral injuries, MRA had greater diagnostic test accuracy than MRI (MRA sensitivity 88% and specificity 93% vs. MRI sensitivity 76% and specificity 87%) [136]. Abduction and external rotation (ABER) of the arm is an alternative position that is utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [136]. The sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of the MRA in neutral position and more effective in identifying Perthes lesions [136]. MRAs can also demonstrate a patulous capsule on the coronal, sagittal, and axial imaging in patients with multidirectional instability [136]. MRAs can be helpful in evaluating lesions of the rotator interval and other associated findings as well that may ultimately affect the eventual surgical plan [136]. The presence of glenoid dysplasia, increased capsular cross-sectional area, and increased glenoid retroversion have all been found to be associated with increased posterior labral tears and symptomatic instability [136]. Glenoid retroversion was significantly increased in patients with symptomatic posterior labral tears but there was no significant association between instability and increased humeral head subluxation [136]. The diagnosis of multidirectional instability is a clinical one, and as such, the need for expensive and/or invasive imaging should be weighed against the information that will be gained from these studies [136].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [107]. It can also be useful in guiding injections or barbotage (aspirating calcific deposits in the rotator cuff) [107]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [144]. It can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [144]. It can also be used to measure the subacromial space and detect atrophy of rotator cuff muscles [144]. Additionally, as a result of providing images in real-time, ultrasonography can evaluate impingement in various positions and motions [144]. Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [144]. The most commonly performed joint examination using ultrasonography is the shoulder examination [91]. Accuracy depends on the skill of the scanner operator and an awareness of pitfalls that are encountered [91].

Bone scan: Bone scintigraphy is an important adjunct to the early diagnosis of stress fracture, as it can demonstrate lesions earlier than conventional roentgenograms [281].

Other Considerations: The purpose of imaging of the shoulder is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient [14]. Unless a specific research protocol is in place, the temptation to “overimage” should be resisted, obtaining only the scans or reconstructions that are necessary for the care of the patient [14]. Although CT scans may offer a few degrees of increased precision in the measurement of glenoid version, we are not convinced that this precision improves the quality of the surgery or the clinical outcome [14]. Standardized plain films are almost always sufficient to garner the information needed and, as described below, there is information that can be gathered from properly taken plain films that cannot be obtained from CT scans [14]. Proper radiographic technique is as important as proper surgical technique to achieve the desired outcome, so we always take time to ensure that our radiograph technologists know what we are seeking in the images [14].

As shoulder surgeons we use imaging to help establish the diagnosis, plan surgery, and evaluate the change in patients' shoulder anatomy with time [134]. A robust approach to imaging the shoulder needs to recognize that (1) the shoulder is a three-dimensional structure that cannot be represented by a single planar view, (2) critical relationships—such as the degree of centering of the humeral head—change with the position of the arm, (3) shoulder pathology may be found in a large number of different bones and soft tissues, and (4) overlying and superimposed structures as well as metallic implants may complicate imaging the structures of interest [134]. It is possible to spend a lot of time, money, and radiation dosage on imaging; thus surgeons need to develop a judicious approach that yields the information necessary to treat the patient while avoiding the tendency to "over-image" [134]. The authors advocate the use of the Tightrope device as the sole method of fixation in treating lateral end clavicle fractures [9]. Existing literature relies on small case series and expert opinions, highlighting the need for further research to establish optimal treatment strategies for periprosthetic humeral fractures after shoulder arthroplasty [29].

Treatment¶

General Principles¶

Nonoperative fracture treatment remains the most common method of fracture management, although its role has changed significantly during the last 40 to 50 years [21]. Historically, nonoperative management was the only method of fracture management until about 1750 [87]. The concentration of severe injuries into specialized trauma centers has caused surgeons to overestimate the role of operative treatment in the full spectrum of fractures [87]. A comprehensive history and physical exam are important to evaluate the mechanism of injury and identify secondary factors that contribute to the injury in patients presenting with a fragility fracture [5]. The ultimate goal of any fracture classification scheme is to allow for determination of the best treatment of each individual fracture and the ability to compare efficacy of various treatment methods on a particular fracture [8]. Fracture classification as it is currently used still varies across the spectrum of injury from one anatomic area to another and is mostly applied through a nonsystematic approach [120]. There are currently no clinical practice guidelines for acute pain management in musculoskeletal injury or surgery [154]. The Orthopedic Trauma Association is currently in progress with creating a set of clinical practice guidelines for pain management [154].

Non-Operative¶

Nonoperative treatment remains the mainstay for most proximal humerus fractures [6]. Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults [187]. Nonsurgical treatment of proximal humerus fractures is not simply “benign neglect” and requires frequent follow-up examination and imaging [223]. Fracture realignment in nonsurgical proximal humerus treatment is facilitated with sitting erect imaging, which allows the weight of the arm to offset muscle forces about the shoulder [223]. Indications for nonsurgical treatment of proximal humerus fractures include minimal displacement, impacted displaced fractures, medical comorbidities, osteoporosis, low functional demand, and low outcome expectations [223]. One-part proximal humerus fractures are treated non-operatively with sling immobilization and enjoy almost universally good or excellent outcomes [224]. Patients with one-part proximal humerus fractures are instructed to remain in the sling for a period of 3 to 5 days depending on the level of their post-injury pain [224]. Early pendulum exercises are instructed for one-part proximal humerus fractures to improve the range of motion and limit capsular retraction [224]. Strengthening exercises for one-part proximal humerus fractures are initiated after the second follow-up appointment, approximately 6 to 8 weeks post-injury, after obtaining standard radiographs confirming appropriate healing [224]. The results of the nonoperative treatment of three- and four-part proximal humerus fractures are satisfactory even in elderly patients [194]. In case of nondisplaced or minimally displaced proximal humerus fractures, a conservative treatment consisting of initial immobilization and a rehabilitation program will be chosen [200]. Non-operative treatment is advocated for the majority of non-displaced and minimally displaced isolated tuberosity fractures of the proximal humerus with generally good outcomes [205]. For most long bone fractures in osteopetrosis, non-operative treatment works well [204]. In general, non-displaced clavicle fractures are treated conservatively [95]. Closed, non-surgical reduction maneuvers are not effective in improving or maintaining alignment of clavicle fractures and should generally not be attempted [168]. Non-operative management of midshaft clavicle fractures consisted of a broad arm sling to immobilise and support the shoulder joint for two weeks, as well as complete avoidance of contact sport for at least 3 months in adolescents [142]. Patients allocated to nonoperative care for displaced midshaft clavicle fractures received a standard sling for 6 weeks [186]. Most patients with nonoperatively managed displaced midshaft clavicle fractures were advised to begin "out of sling" activities after 3 weeks [186]. At 3 months, patients with nonoperatively managed displaced midshaft clavicle fractures were allowed pre-injury levels of activity excluding all contact sports [186]. At six months, patients with nonoperatively managed displaced midshaft clavicle fractures were allowed unrestricted activities [186]. For patients assigned to nonoperative treatment for displaced midshaft clavicle fractures, follow-up started at the day of inclusion [157]. During the first 2 weeks of nonoperative treatment for displaced midshaft clavicle fractures, patients used a sling and were advised to perform non-weight-bearing pendulum exercises after instruction by a physiotherapist [157]. After 6 weeks of nonoperative treatment for displaced midshaft clavicle fractures, full range of motion was permitted and strengthening exercises were started [157]. Patients in the non-operative group for displaced proximal humerus fractures are immobilised in a sling for 2 weeks before starting self-exercises and instructed physiotherapy [179]. Patients in the nonoperative group for acute Neer type III and IV proximal humeral head fractures were immobilized in a sling for two weeks before beginning self-exercise and physiotherapy [219]. Nonoperative treatment of upper extremity fractures in children consisted of splinting or casting at the discretion of the treating surgeon [232]. Torus fractures can be safely and effectively treated with removable splints or braces [161]. Treatment for upper extremity stress fractures is predominantly nonoperative, involving relative rest and activity modification, with most fractures healing uneventfully [182]. Treatment decision making for high-risk stress fractures should be based on radiographic findings with less consideration given to symptom severity [146]. The immediate goal of treatment of a high-risk stress fracture is to avoid progression and get the fracture to heal [146]. Treatment of a high-risk stress fracture typically requires either complete elimination of loading of the site or surgical stabilization [146]. If an incomplete fracture is present on plain films with evidence of fracture on MRI or CT in a high-risk location, immobilization and strict non-weight bearing is indicated [146]. Worsening symptoms or radiographic evidence of fracture progression despite nonoperative treatment is an indication for surgical fixation of high-risk stress fractures [146]. Undisplaced scapular fractures have a variable outcome when treated nonoperatively [150]. A conservative treatment seems sufficient for other fracture types of the coracoid process [207]. Conservative treatment is sufficient in non-displaced type A post-operative periprosthetic humeral fractures associated with reverse total shoulder arthroplasty [96]. As long as the effect of standardized screening of fractures is not investigated, it is too early to integrate such a screening into treatment guidelines for bone fractures from generalized convulsive seizures and status epilepticus [3].

Operative¶

Indications: Operative treatment for proximal humerus fractures has increased over the last decade [6]. Indications for surgical treatment of proximal humerus fractures include young, high-demand patients, elderly patients with high expectations, cooperative patients, displaced unstable nonimpacted fractures, fracture-dislocations, and adequate bone quality [223]. Displaced or unstable proximal humerus fractures will be managed operatively [200]. Displaced isolated tuberosity fractures of the proximal humerus may require arthroscopically assisted fixation or open/percutaneous reduction and internal fixation depending on fracture type and patient factors [205]. Surgical management is reasonable for long bone fractures in osteopetrosis in certain circumstances such as fracture neck and shaft of femur, Coxa Vara, and failure of conservative treatment [204]. Surgical options are increasingly favored for displaced midshaft clavicle fractures to improve union rates and functional outcomes [51]. For active and younger patients with midshaft clavicle fractures, surgical treatment is favoured due to the short time of rehabilitation, the return to sport activities, and the high non-union rate after conservative treatment [208]. Surgical treatment should always be considered when facing displaced mid-shaft clavicle fractures [206]. Indications for acute fixation of adolescent displaced lateral-end clavicle fractures are open fractures, vascular injury, or skin compromise [142]. In displaced adolescent lateral-end clavicle fractures without open fracture, vascular injury, or skin compromise, operative management was selectively undertaken under patient and parental wishes at the discretion of the consultant surgeon following a discussion in clinic [142]. This study further supports the role of non-operative treatment for teenagers with completely displaced clavicle fractures, with nearly perfect outcomes reported bringing into question the role of acute operative management of these fractures given its associated risks and costs [143]. Treatment for acromial fractures depends on the fracture location, displacement, and patient factors and includes both non-surgical management and surgical fixation [26]. As the results from the review of the literature indicate, the more medial the fracture of the base of the acromion after reverse shoulder arthroplasty, the worse the prognosis with non-operative treatment [173]. Treatment strategies for pathological fractures of the long bones depend on fracture risk and expected survival, with surgery indicated for actual fractures or high-risk impending fractures and radiotherapy for small lesions without fracture risk [54].

Surgical Approach / Technique: While closed treatment remains the method of choice for most humeral shaft fractures, acceptable results can be achieved with internal fixation, even for difficult fractures, provided the correct principles of fixation are carefully followed [171]. Interlocking nailing should be used with caution when managing acute non-pathological humeral shaft fractures as there is a high incidence of non-union [130]. Only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for Ender nailing of acute humerus fractures [162]. Dual plating is still indicated for certain cases of femoral shaft fractures, particularly old ununited fractures where intramedullary nailing is difficult [141]. Dual plating for femoral shaft fractures is contraindicated in severely comminuted fractures requiring extensive dissection [141]. Closed reduction and percutaneous pinning for proximal humerus fractures has limited indications based on simple fracture pattern, patient compliance, and surgeon experience, primarily reserved for the pediatric population [223]. Contraindications for closed reduction and percutaneous pinning of proximal humerus fractures include dislocations, metaphyseal comminution/diaphyseal extension, severe osteoporosis, or head-split fracture [223]. When properly stabilized, intraoperative humerus fractures during revision reverse shoulder arthroplasty do not substantially influence overall final outcomes [174]. The technique of percutaneous posterior fixation for unstable pelvic ring fractures is reliable and reproducible, leading to fracture union and excellent functional outcomes after 4 years' follow-up [49]. Seven criteria are sufficient to rule out any relevant pelvic fracture in blunt trauma patients [172]. The decision making of the type and timing of treatment for a patient with multiple system trauma and fractures should be undertaken in a collaborative manner and involve all members of the multidisciplinary team [160]. Life-threatening and limb-threatening injuries, including massive hemorrhage from a pelvic fracture or multiple long bone fractures, complete arterial injury in an extremity, and compartment syndromes, are addressed emergently [160]. Open fractures should be débrided in the operating room within the first 24 hours [160]. Mechanically unstable spine, pelvis, acetabulum, and proximal and diaphyseal femur fractures benefit from provisional or definitive stabilization, ideally performed within the first 36 hours after injury [160].

Implant Selection: Open reduction and plate fixation reduces the rate of nonunion and is associated with better functional outcomes compared with nonoperative treatment for displaced midshaft clavicular fractures [181]. The improved outcomes of open reduction and plate fixation for displaced midshaft clavicular fractures appear to result from the prevention of nonunion [181]. Conservative modality for mid-shaft clavicle fractures is associated with higher rates of non-union and delayed healing [163]. The advantages of intramedullary fixation for clavicle fractures include a smaller incision that can be more cosmetically appealing, less soft tissue dissection, less hardware prominence, and easier surgical removal of the hardware as compared with plates and screws [225]. Intramedullary fixation for clavicle fractures has inconsistent results compared with fixation using plates and screws and is not as commonly used [225]. Contraindications to the use of intramedullary fixation for clavicle fractures include significant comminution, very small canal diameter, and lateral third clavicle fractures [225]. Surgical fixation of isolated acromion fractures is reported to be effective in achieving fracture union and safe to the patient [137]. Although the locked plate device provides exceptional fixation stability for proximal humerus fractures, its indication must be scrutinized for each individual patient, taking the extent of trauma/fracture and age into consideration and carefully weighing it against other forms of treatment [38]. No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [166]. More RCTs are needed to definitively recommend locking plate over intramedullary nail for specific fracture patterns of proximal humeral fractures due to observed heterogeneity [48]. Randomized controlled trials and cost analyses are necessary to determine the optimal treatment method for complex proximal humerus fractures [175]. These techniques using intramedullary allograft fibula can result in good clinical outcomes despite the complexity of proximal humerus fractures with diaphyseal extension [40]. The results of proximal humeral fractures treated with an intramedullary cage and plate demonstrate similar fracture healing, clinical improvement, and complication rates compared with conventional ORIF with screws and a side plate [183].

Other Considerations: A valid comparison between operative and nonoperative treatment cannot be made for any scapular fracture type due to low numbers, high variability, and methodological limitations [167]. Operative treatment for displaced scapular fractures in patients 65 years of age and older is safe and can yield good functional results and return to function [170]. Most patients with open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle regained normal function of the shoulder soon after the injury [23]. While surgical fixation and arthroplasty offer specific benefits for displaced proximal humerus fractures or younger patients, recent evidence suggests no long-term differences in outcomes between surgical and nonsurgical cohorts for many patient populations [47]. Nonoperative treatment has been traditionally reserved for patients who were either too ill to undergo surgery or who had extremely limited functional demands for proximal humerus fractures [218]. The functional results of nonoperative treatment for proximal humerus fractures are almost universally poor [218]. In a review of the literature, only 5% of patients undergoing nonoperative treatment for proximal humerus fractures could expect satisfactory results [218]. Greater pain and inferior function were shown in patients managed nonoperatively for proximal humerus fractures when compared with those treated with internal fixation or hemiarthroplasty [218]. The risk of severe complication with conservative management of proximal humerus fractures is minimal [218]. Nonunion or malunion of the tuberosities occurs in almost all cases of nonoperative treatment for proximal humerus fractures [218]. Patients who have pre-existing malunion or nonunion who undergo revision to a hemiarthroplasty tend to have poor functional outcomes when compared with patients who are managed with immediate surgery for proximal humerus fractures [218]. The best functional outcomes for clavicle hook plate fixation of displaced lateral-third clavicle fractures occur with plate removal before 6 months postoperatively, provided the fracture has healed [188]. Post-operatively for clavicle fractures, the arm is maintained in a sling and pendulum exercises are permitted [225]. At 2 weeks post-operatively for clavicle fractures, the sutures are removed, the sling is discontinued, and unrestricted range of motion exercises are permitted [225]. Strengthening and resisted exercises for clavicle fractures may begin when clinical and radiographic signs of healing are present, usually at 6 to 8 weeks post-operatively [225]. Return to sports for clavicle fractures may take place at 3 to 4 months post-operatively, depending on the activity involved [225]. Fragility fractures in the geriatric population necessitate management of both the acute injury and underlying osteoporosis [14].

Complications¶

Infection and Nonunion¶

Postoperative surveillance for open long-bone fractures requires follow-up beyond 90 days, as this interval is inadequate for detecting complications, particularly in research contexts [20]. Despite advances in treatment, rates of surgical site infection and delayed union or nonunion remain high at one year and have not substantially improved from historical rates spanning several decades [59]. The rate of nonunion following operative treatment of long-bone fractures is 9.4% [180]. In tibial shaft fractures, the incidence of delayed union correlates with injury severity: 2% for minor severity injuries (undisplaced or angulated), 11% for moderate severity injuries (completely displaced), and 60% for major severity injuries (major comminution or major wound) [299].

Mortality and Morbidity¶

Mortality following open pelvic fracture remains high despite the evolution of trauma management over the last two decades [58]. For fragility proximal humerus fractures, mortality at one year is universally high regardless of risk factors [197].

Functional Outcomes and Deformity¶

Long-term outcomes are related to the severity of the bone and soft-tissue injury and the quality of the reduction, with more severe injuries having a poorer outcome [27]. Fractures that are significantly displaced can result in adverse healing and long-term functional consequences and should therefore be considered for ORIF [43]. In patients aged 10 to 18 years with clavicle fractures, shortening of the fracture had a small negative effect on the outcome [32]. At final follow-up, most clinical and patient-reported outcomes were significantly better in patients with 2-part proximal humerus fractures than in patients with 3- or 4-part fractures [52]. Worse outcomes were associated with increased fracture displacement in acromial fractures following reverse shoulder arthroplasty [50]. High energy fracture events and an adult aged patient group were associated with higher rates of adverse clinical outcome in midshaft clavicle fractures [192]. Obesity had a negative influence on lower extremity long bone fracture in-hospital outcomes [158].

Pathological and Secondary Fractures¶

Patients who have any type of fragility fracture have a notable risk of subsequent fractures within 3 years, especially hip fractures [293]. Fractures occurred in 12% of cases following femoral lengthening, and the rate of secondary interventions was markedly reduced with prophylactic titanium elastic nailing [242]. The natural history of osteoporosis pseudoglioma syndrome suggests the osteopenic process stabilizes with age, necessitating prophylaxis and diligent care of fractures and deformities [46].

Surveillance and Diagnosis¶

A precise classification of fracture type at the time of diagnosis would identify a smaller subset of patients that require follow-up [1]. As long as the effect of standardized screening of fractures is not investigated, it is too early to integrate such a screening into treatment guidelines for generalized convulsive seizures and status epilepticus [3]. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms [45].

Recovery¶

General Prognosis and Long-Term Outcomes: Long-term outcomes for distal tibial pilon fractures correlate with the severity of bone and soft-tissue injury and the quality of reduction, with more severe injuries yielding poorer results [27]. In children younger than 18 months, fractures carry a favourable prognosis across all fracture types and circumstances of occurrence [16]. For proximal humeral fractures, long-term functional deficits persist following locked plating [177], with function remaining moderate and plateauing after one year [102]; persistent symptoms in surviving patients can be predicted as early as one year post-injury [308]. Two years after hip fracture, health-related quality of life remains below normal regarding physical function, role-physical, and social function [198]. Similarly, two years after vertebral fracture, health-related quality of life is significantly lower across all domains, both physical and mental [198]. Functional outcome for open pelvic fractures is usually fair to good, with the long-term outlook determined by concomitant injuries [178]. In combined femoral and tibial shaft injuries, all fractures healed within 15 months, and functional end results were excellent in the majority of surviving patients (89 per cent) [191].

Specific Fracture Sites: For clavicle fractures in patients aged 10 to 18 years, shortening of the fracture had a small negative effect on outcome [32]. Age at injury affects recovery from conservatively treated clavicle fractures, with 33 per cent of patients over 20 years still symptomatic three months post-fracture [302]. Following reverse shoulder arthroplasty for acromial fractures, 55% of patients achieved the MCID at mid-term follow-up, with worse outcomes associated with increased fracture displacement [50]. Clinical and patient-reported outcomes at final follow-up were significantly better in patients with 2-part proximal humerus fractures compared to those with 3- or 4-part fractures treated with an intramedullary nail [52]. Mid-term follow-up demonstrates satisfying results for severe displaced fractures in elderly patients treated with RSA [169]. The locking plate provides satisfactory functional outcomes after mid-term follow-up in patients with displaced proximal humerus fractures [189]. Fracture fixation with the PHILOS showed good to excellent longer-term results in three fourths of patients, with outcomes partially still improving after the first postoperative year [201]. Hemiarthroplasty for severe proximal humerus fractures yields better results in younger patients, while fracture severity and timing of operation do not appear to affect the outcome [305]. When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions for displaced midshaft clavicle fractures [196]. At 6-month follow-up in 17 patients treated with the MultiLoc nail, the mean Constant score was 66.1 points, and radiographically all fractures had healed [309]. Following conversion from external fixation to plate fixation in humeral shaft fractures, 15 of 17 fractures united with an average time to healing of 11.1 weeks [312]. All fractures healed uneventfully at 19 weeks on average without failure following helical plate fixation for comminuted fractures of the proximal and middle one-third of the humerus [315].

Surveillance, Complications, and Monitoring: Ninety days of follow-up is inadequate for surveillance of fracture-related infections in patients with open long-bone fractures, especially for research purposes, and 12 months of follow-up is preferable [307]. Long-term follow-up is required for physeal fractures to monitor for growth arrest and deformities [176]. Normally healing fractures show an increase of 3 per cent per month in dynamic bone scanning, whereas delayed unions show less than half that amount [304]. Due to the rarity of displaced fractures, only multicenter studies extending over long periods of time will lead to accurate definition of the results and prognoses associated with operatively treated fractures [10]. The success of pulsed electromagnetic fields for tibial delayed unions and nonunions is not associated with specific fracture or patient-related variables and cannot be clearly considered a time-dependent phenomenon [298].

Key Evidence¶

[Paper] A precise classification of fracture type at the time of diagnosis would identify a smaller subset of patients that require follow-up. [1] (10.3109/17453674.2013.789731)
[L4] As long as the effect of standardized screening of fractures is not investigated, it is too early to integrate such a screening into treatment guidelines. [3] (10.1111/epi.14738)
[Paper] The diagnosis of a pathological fracture can be a trap; the surgeon must be suspicious and carefully scrutinize every X-ray image. [4] (10.1016/j.otsr.2015.05.010)
[L4] [5] (10.1007/s11914-018-0443-y)
[L5] Nonoperative treatment remains the mainstay for most fractures; however, operative treatment has increased over the last decade. [6] (10.1016/j.xrrt.2026.100809)
[Paper] All fractures healed clinically and radiologically. [7] (10.1007/s00264-015-2950-0)
[L5] The ultimate goal of any classification scheme is to allow for determination of the best treatment of each individual fracture, and subsequently the ability to compare efficacy of various treatment methods on a particular fracture. [8] (10.1016/j.ocl.2008.05.002)
[L4] The authors advocate its use for these challenging fractures. [9] (10.1177/1758573220964807)
[L4] Due to the rarity of displaced fractures, only multicenter studies extending over long periods of time will lead to accurate definition of the results and prognoses associated with operatively treated fractures. [10] (10.2106/00004623-199274020-00019)
[L4] The problem is understanding the images of complex fractures, not the classification system. [11] (10.1016/j.jse.2005.02.014)
[L5] Diagnosis requires plain radiographs and CT scans, while management is dictated by fracture morphology, displacement, and associated injuries. [12] (10.5435/jaaos-d-20-00252)
[L4] If radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. [15] (10.1016/j.injury.2006.07.040)
[L4] The prognosis is favourable across fracture types and circumstances of occurrence. [16] (10.1016/j.otsr.2012.11.004)
[L3] Although nearly half of fractures were initially missed, careful review of radiographs detected most cases with high accuracy and excellent interobserver reliability. [17] (10.1177/2325967126s00531)
[L5] Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. [18] (10.1016/j.jse.2017.10.028)
[L3] Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes. [20] (10.1097/corr.0000000000001911)
[L4] Fracture should be suspected in patients who present with pain postoperatively, and workup should include plain radiographs and computed tomographic scan if indicated. [22] (10.1016/j.ocl.2021.03.006)
[L4] Most patients regained normal function of the shoulder soon after the injury. [23] (10.2106/00004623-199407000-00024)
[L1] Therefore, a pathologic fracture may no longer be an absolute contraindication for limb salvage surgery. [24] (10.1097/corr.0000000000002687)
[L4] Treatment depends on the fracture location, displacement, and patient factors and includes both non-surgical management and surgical fixation. [26] (10.21037/aoj.2018.12.03)
[L5] A high index of suspicion from the history coupled with a careful clinical examination should alert the clinician to the possibility of an underlying fracture. [28] (10.1016/0020-1383(96)00039-3)
[L2] Existing literature relies on small case series and expert opinions, highlighting the need for further research to establish optimal treatment strategies for these challenging fractures. [29] (10.1530/eor-2024-0053)
[L4] Bone scan is an effective method of detecting missed fractures among patients with multiple severe traumas and can be used reliably as a screening test. [31] (10.1016/j.otsr.2014.09.015)
[L4] However, shortening of the fracture had a small negative effect on the outcome. [32] (10.1097/bpo.0000000000000082)
[L3] Most pediatric fractures can be treated on outpatient basis, with only 1 of 18 fractures requiring hospitalization or observation. [35] (10.1097/bpo.0000000000000595)
[L5] However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. [36] (10.5435/jaaos-20-03-130)
[L4] The Neer classification is a useful management tool but accurate delineation of fracture pattern requires better imaging modalities. [37] (10.1007/s00590-008-0325-6)
[L4] Although the device provides exceptional fixation stability, its indication must be scrutinized for each individual patient, taking the extent of trauma/fracture and age into consideration and carefully weighing it against other forms of treatment. [38] (10.1097/bot.0b013e318169ef2a)
[L5] When faced with a fracture in a previously abnormal bone, one should think ahead to the possible results, both for the fracture and for the previous abnormality. [39] (10.1016/0020-1383(77)90005-5)
[L4] These techniques can result in good clinical outcomes despite the complexity of this fracture pattern. [40] (10.1097/bot.0b013e31829a346d)
[L4] Fractures that are significantly displaced can result in adverse healing and long-term functional consequences and should therefore be considered for ORIF. [43] (10.5435/00124635-199501000-00004)
[L5] Surgical treatment is generally reserved for specific indications such as open fractures, polytrauma, or failure of nonoperative management. [44] (10.1016/j.jse.2010.11.030)
[L3] After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms. [45] (10.1007/s00590-021-03099-6)
[L5] While surgical fixation and arthroplasty offer specific benefits for displaced fractures or younger patients, recent evidence suggests no long-term differences in outcomes between surgical and nonsurgical cohorts for many patient populations. [47] (10.5435/jaaos-d-24-01073)
[L1] More RCTs are needed to definitively recommend one over the other for specific fracture patterns due to observed heterogeneity. [48] (10.1186/s13018-015-0242-4)
[L4] The technique is reliable and reproducible, leading to fracture union and excellent functional outcomes after 4 years' follow-up. [49] (10.1016/j.otsr.2017.07.024)
[L3] Overall, 55% of patients achieved the MCID at mid-term follow-up, and worse outcomes were associated with increased fracture displacement. [50] (10.1016/j.jse.2022.01.132)
[L4] While nonsurgical management is reliable for many fractures, surgical options are increasingly favored for displaced fractures to improve union rates and functional outcomes. [51] (10.5435/jaaos-d-17-00442)
[L3] However, at final followup most clinical and patient-reported outcomes were significantly better in patients with 2-part fractures than in patients with 3- or 4-part fractures. [52] (10.1016/j.jseint.2024.03.018)
[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. [53] (10.1007/s00264-009-0850-x)
[L5] Treatment strategies for pathological fractures of the long bones depend on fracture risk and expected survival, with surgery indicated for actual fractures or high-risk impending fractures and radiotherapy for small lesions without fracture risk. [54] (10.1302/2058-5241.1.000008)
[L4] When indications for operative treatment are met, plate fixation is reliable and safe. [55] (10.2106/jbjs.rvw.n.00119)
[Paper] Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. [58] (10.1016/j.injury.2020.02.096)
[L3] Despite current treatment approaches, the rates of surgical site infection and delayed union/nonunion following treatment of open fractures remain high at 1 year and are not substantially improved from historical rates spanning several decades. [59] (10.2106/jbjs.24.01055)
[L5] A heightened awareness and serial roentgenographic studies are necessary to demonstrate the evolution of these fractures. [60] (10.2106/00004623-196749070-00017)
[L5] Existing classification systems for complex extremity fractures are inadequate and lack therapeutic recommendations. [62] (10.1016/j.injury.2009.10.039)
[L4] The new 'unified' classification of open fractures has good validity, reliability and acceptability, and has the potential to replace all other existing classification systems. [63] (10.1016/j.injury.2018.06.007)
[L4] Although the MTM-classification covers a wide spectrum of fracture types, the precise topographic and morphological description is not delivering reproducible results. [73] (10.1186/1471-2474-9-21)
[L4] The system divides the craniofacial region into three units and distinguishes lateral and central fractures. [81] (10.1016/s0020-1383(02)00119-5)
[Paper] Existing classification systems for ballistic fractures are inadequate because they fail to account for soft-tissue injury, anatomical location, and joint involvement. [83] (10.1016/j.injury.2004.10.023)
[L4] The classification consists of 6 groups divided into 15 subgroups of calcar fracture patterns. [84] (10.1007/s12306-012-0195-2)
[L5] The classification of open fractures is important because it directs the attention of the treating surgeon to the presence and extent of injury variables. [86] (10.5435/00124635-200305000-00008)
[Paper] A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment. [88] (10.1016/j.injury.2013.10.010)
[L4] Observer agreement on the classification of displaced four-part fractures according to the Neer system is low (slight to moderate), which challenges the clinical approach to these fractures and poses a problem for the interpretation and generalisation of results from future randomised trials. [90] (10.1007/s00264-008-0591-2)
[L4] Awareness of this sign may be of help in detecting clinically or radiographically missed or occult fractures, thus facilitating initiation of adequate therapy and obviating extra financial costs due to unnecessary additional examinations. [92] (10.1007/s00330-006-0331-1)
[L5] The new classification provides a useful synoptic framework for identifying complex fracture patterns. [93] (10.1016/j.jse.2020.02.022)
[Abstract] The new classification provides a useful synoptic framework for identifying complex fracture patterns. [94] (10.1016/j.jse.2022.01.040)
[L4] In general, non-displaced fractures are treated conservatively. [95] (10.1007/s00068-019-01122-4)
[Paper] Conservative treatment is sufficient in non-displaced type A post-operative fracture. [96] (10.1007/s00264-015-2972-7)
[L4] Our findings suggest that the classification of fracture severity in children should be done in only two categories that distinguish between simple and wedge/complex fractures. [98] (10.1080/17453670710013753)
[L2] Management is challenging as 50% of fractures are displaced, requiring hospitalization in half the cases, yet surgery is only performed in one out of five. [99] (10.1016/j.otsr.2012.05.013)
[L5] The management of malignant pathological fractures necessitates careful diagnostic work-up, preoperative investigation, planning and multidisciplinary input from specialists in the fields of radiology, pathology, oncology, trauma and orthopaedics. [101] (10.1016/j.injury.2015.07.028)
[L4] Long-term function after locking plate fixation is moderate and plateaus after one year. [102] (10.1016/j.jseint.2026.101683)
[L4] Based on an analysis of 245 consecutive patients, the authors propose a novel classification system for fragility fractures of the pelvic ring that is based on morphological criteria and corresponds with the degree of instability. [103] (10.1016/j.injury.2013.06.023)
[L5] The Orthopaedic Trauma Association Board of Directors has charged the Classification Committee with designing a multi-centre study to collect enough data to assess reliability, validity, and ideal usage of the open fracture classification. [105] (10.1016/j.injury.2012.12.016)
[L4] Extremity fractures in patients with traumatic brain injury are common and often missed; appropriate evaluation allows prompt diagnosis and optimal treatment. [110] (10.5435/00124635-199809000-00005)
[L4] The incidence of fractures missed on the initial examination of patients admitted to hospital as the result of trauma is at least 7.5 per cent. [111] (10.1016/0020-1383(73)90005-3)
[L5] [112] (10.5435/jaaos-22-02-90)
[L4] We observed a high rate of fracture complications with internal fixation, despite undergoing management within 24 h of presentation. [114] (10.1016/j.injury.2014.07.027)
[L5] [115] (10.1016/j.xrrt.2023.07.007)
[L4] Minimal fracture displacement (<3 mm) does not worsen the clinical outcome or duration of symptoms. [116] (10.1016/j.jse.2013.01.033)
[L5] A high index of suspicion will lead to an early diagnosis in this uncommon cause of pathological fractures. [117] (10.1016/s0020-1383(01)00134-6)
[L4] More complex fractures, including those requiring operative intervention and those with higher Neer classification scores, developed pseudosubluxation at higher rates than simpler fracture patterns. [119] (10.1016/j.jseint.2022.01.013)
[L4] The study demonstrated significant interobserver variation in coding long bone fractures using the AO classification system, with only 32 per cent of individual codings agreeing with the final consensus. [122] (10.1016/0020-1383(93)90282-b)
[L4] Functional results are limited regardless of the fracture management, and no clear preoperative risk factors were identified. [123] (10.1016/j.jse.2018.06.007)
[L4] They are recommended for emergency treatment, pathological fractures, and situations requiring x-ray transparency, with no complications observed after twenty-four hours of use. [124] (10.2106/00004623-196446080-00013)
[L4] These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique. [125] (10.1302/0301-620x.96b5.32362)
[Case_report] Primary bone lymphoma is a rare entity that can present as a pathological fracture and is often misdiagnosed initially; early diagnosis and multimodal treatment including chemotherapy, radiotherapy, and surgical reconstruction can lead to complete remission and functional recovery. [127] (10.1016/j.xrrt.2023.12.008)
[Paper] Understanding the classification and grade of stress fractures and their implications on return-to-play decisions is key to optimal care of the athlete. [128] (10.1016/j.csm.2005.08.012)
[L4] The procedure should be used with caution when managing acute non-pathological fractures as there is a high incidence of non-union. [130] (10.1016/0020-1383(96)00056-3)
[L4] This technique is reported to be effective in achieving fracture union and safe to the patient. [137] (10.1097/bot.0000000000000040)
[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. [140] (10.1016/j.jse.2015.08.006)
[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. [141] (10.2106/00004623-196345020-00026)
[L4] [142] (10.1177/17585732221131922)
[L2] This study further supports the role of non-operative treatment for teenagers, with nearly perfect outcomes reported bringing into question the role of acute operative management of these fractures given its associated risks and costs. [143] (10.1177/2325967123s00041)
[L4] Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques. [145] (10.1016/j.otsr.2016.11.007)
[L4] Undisplaced fractures have a variable outcome when treated nonoperatively. [150] (10.1016/j.jse.2015.11.007)
[L1] [157] (10.2106/jbjs.15.01394)
[L4] Overall, these findings suggested that obesity had a negative influence on lower extremity long bone fracture in-hospital outcomes. [158] (10.1186/s12891-025-09349-6)
[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. [162] (10.2106/00004623-198769040-00013)
[L2] Conservative modality is associated with higher rates of non-union and delayed healing. [163] (10.1016/j.injury.2018.04.012)
[L4] No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. [166] (10.1016/j.injury.2010.10.016)
[L4] A valid comparison between operative and nonoperative treatment cannot be made for any fracture type due to low numbers, high variability, and methodological limitations. [167] (10.1097/00005131-200603000-00013)
[L3] Mid-term follow-up shows satisfying results in terms of the treatment of severe displaced fractures in elderly patients with RSA. [169] (10.1186/1471-2474-14-231)
[L4] Operative treatment for displaced fractures in patients 65 years of age and older is safe and can yield good functional results and return to function. [170] (10.1097/bot.0000000000000710)
[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. [171] (10.2106/00004623-198668030-00018)
[L1] Seven criteria are sufficient to rule out any relevant pelvic fracture. [172] (10.1007/s00402-003-0631-8)
[L5] As the results from the review of the literature indicate, the more medial the fracture, the worse the prognosis with non-operative treatment. [173] (10.4103/0973-6042.123531)
[L3] When properly stabilized, these fractures do not substantially influence overall final outcomes. [174] (10.1007/s11999-015-4448-x)
[L3] Randomized controlled trials and cost analyses are necessary to determine the optimal treatment method for such fractures. [175] (10.1097/bot.0000000000000229)
[L4] Long-term functional deficits persist. [177] (10.1007/s11999-011-1935-6)
[L4] Functional outcome was usually fair to good with long-term outlook determined by concomitant injuries. [178] (10.1016/s0020-1383(98)00246-0)
[L2] [179] (10.1136/bmjopen-2018-024916)
[L3] The rate of nonunion after operatively treated long-bone fractures was 9.4%. [180] (10.2106/jbjs.22.01127)
[L1] Open reduction and plate fixation reduces the rate of nonunion and is associated with better functional outcomes compared with nonoperative treatment, but the improved outcomes appear to result from the prevention of nonunion. [181] (10.2106/jbjs.l.00307)
[L5] Treatment is predominantly nonoperative, involving relative rest and activity modification, with most fractures healing uneventfully. [182] (10.1016/j.csm.2005.08.008)
[L4] The results demonstrate similar fracture healing, clinical improvement, and complication rates compared with conventional ORIF with screws and a side plate. [183] (10.1016/j.jse.2021.05.001)
[L3] [186] (10.1097/bot.0b013e3181d8290e)
[L4] Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults. [187] (10.5312/wjo.v5.i5.685)
[L4] The best functional outcomes occur with plate removal before 6 months postoperatively, provided the fracture has healed. [188] (10.1016/j.jse.2011.07.020)
[L4] The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. [189] (10.1007/s00590-010-0655-z)
[L4] All fractures healed within 15 months, and functional end results have been excellent in the majority of the surviving patients (89 per cent). [191] (10.1016/0020-1383(77)90133-4)
[L3] High energy fracture events and an adult aged patient group were associated with higher rates of adverse clinical outcome. [192] (10.1177/2325967119s00381)
[L4] The results of the nonoperative treatment of these fractures are satisfactory even in elderly patients. [194] (10.1097/bot.0b013e318210ea56)
[L1] When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions. [196] (10.1097/bot.0b013e3181c3e505)
[L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. [197] (10.1016/j.jse.2022.03.006)
[L2] However, 2 years after hip fracture, HRQOL was still below normal regarding physical function, role-physical and social function, while after vertebral fracture, scores were still significantly lower for all domains, physical as well as mental. [198] (10.1007/s00198-004-1622-5)
[L4] Therefore, we believe this modality should be utilized if fracture deformity warrants surgical consideration and to adequately compare data across studies. [199] (10.1007/s11999-011-1820-3)
[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. [200] (10.1016/j.jht.2017.05.005)
[L2] Fracture fixation with the PHILOS showed good to excellent longer-term results in three fourths of patients with outcome partially still improving after the first postoperative year. [201] (10.1097/bot.0b013e3181f2b20e)
[L5] The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. [202] (10.1016/j.xrrt.2024.01.001)
[L1] These findings suggest that open fractures should be excluded as an entry criterion in future clinical trials. [203] (10.1016/0020-1383(94)90159-7)
[L4] For most long bone fractures non-operative treatment works well, but surgical management is reasonable in certain circumstances such as fracture neck and shaft of femur, Coxa Vara and failure of conservative treatment. [204] (10.1016/j.injury.2009.02.009)
[L4] Non-operative treatment is advocated for the majority of non-displaced and minimally displaced fractures with generally good outcomes, while displaced fractures may require arthroscopically assisted fixation or open/percutaneous reduction and internal fixation depending on fracture type and patient factors. [205] (10.1016/j.injury.2007.09.022)
[L4] For this reason, such surgical treatment should always be considered when facing this particular fracture group. [206] (10.1016/j.injury.2020.10.085)
[L4] A conservative treatment seems sufficient in other fracture types. [207] (10.1007/s00402-020-03496-2)
[L4] For active and younger patients we would favour a surgical treatment due to the short time of rehabilitation, the return to sport activities and the high non-union rate after conservative treatment. [208] (10.3233/thc-130714)
[L4] Stable fractures should be treated nonoperatively, while surgery is indicated in unstable Type Ila fractures. [211] (10.1016/0020-1383(95)00156-5)
[L3] This high rate increases the morbidity associated with the fracture, and may also interfere with the definitive management. [213] (10.1016/s0020-1383(97)00141-1)
[L5] If a plain radiograph does not reveal a fracture CT may be useful. [216] (10.1016/0020-1383(94)90166-x)
[L5] [218] (10.1016/j.hcl.2007.08.002)
[L1] [219] (10.1016/j.jseint.2026.101617)
[L4] MRI did not appreciably change the estimation of fracture displacement compared to radiography. [220] (10.1177/2325967119851472)
[L3] MRI is an imperative tool for operative planning in pathological fractures; however, we recommend against the routine use of MRI to diagnose pathological fractures in oncological patients. [222] (10.1007/s00402-018-3012-z)
[L4] Radiographs were shown to provide incomplete information about the fracture pattern, and advanced imaging caused a change in classification into a segment more likely to be considered for surgical care. [228] (10.1097/bot.0b013e3182382625)
[L3] [232] (10.1097/corr.0000000000001571)
[L4] [236] (10.2106/00004623-197052060-00001)
[L5] The imaging evaluation of a patient in whom a stress reaction or fracture is clinically suspected should begin with high-resolution radiographs of the area in question. [237] (10.1016/j.csm.2005.08.009)
[L3] [238] (10.1016/j.jse.2021.12.024)
[L4] Radiographs remain the mainstay for fracture assessment, but their interpretation is challenging with experimental studies documenting a roughly 30% error rate. [241] (10.1016/j.rcl.2015.02.013)
[L3] Fractures occurred in 12% of cases, and the rate of secondary interventions was markedly reduced. [242] (10.1186/1471-2474-14-302)
[L4] Clinicians and radiologists agreed on the presence or absence of fracture or dislocation in 897 of 1011 cases (89 per cent). [243] (10.1016/s0020-1383(80)80048-9)
[L5] [245] (10.1302/2058-5241.3.170072)
[L1] Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics. [248] (10.1016/j.jse.2012.01.009)
[L4] DECT thus combines the advantages of conventional CT (good visualisation of bone matter) and MRI (medullary cavity and visualisation of occult fractures). [249] (10.1007/s00402-019-03283-8)
[Paper] A CT scan is essential in all patients with displaced inferior ramus fractures to examine the posterior ring in detail. [268] (10.1007/s00402-014-1993-9)
[L4] Therefore, we recommend close follow-up with serial radiographs for the first several weeks to allow for optimal treatment. [270] (10.1097/bot.0000000000000343)
[L4] Appropriate views on radiographs are essential. [271] (10.1016/0020-1383(94)90184-8)
[L4] Radiologists were found to classify these fractures more reliably than surgeons, with substantial intra-observer and inter-observer agreement after viewing the fractures on two-plane radiography. [274] (10.1016/j.clinimag.2014.07.012)
[L5] Even under laboratory conditions, the information gained from plain radiographs is not sufficient to accurately predict the strength of a healing fracture. [276] (10.1002/jor.1100030211)
[L4] These additional radiographs did not alter management or contribute positively to clinical outcomes, supporting a standardized protocol involving imaging only at the initial radiographic evaluation for children aged 8 years or younger. [277] (10.5435/jaaosglobal-d-26-00031)
[L3] The findings of this study support repeat radiographic assessment 2-3 weeks post-injury prior to making definitive treatment decisions. [280] (10.1177/2325967121s00455)
[L4] Bone scintigraphy is an important adjunct to the early diagnosis of stress fracture, as it can demonstrate lesions earlier than conventional roentgenograms. [281] (10.2106/00004623-197759070-00006)
[L5] Postoperative x-ray films showed excellent reduction of the fracture and appropriate placement of the screw. [282] (10.1016/j.eats.2022.04.001)
[L2] MRI examination of the pelvis was found to be superior in detecting undislocated fractures in a cohort of patients with a high incidence of osteoporosis. [284] (10.1016/j.injury.2014.10.050)
[L4] Insufficiency fracture is best diagnosed by 'thinking of it' and subsequently establishing the diagnosis by CT. [285] (10.1007/s004020050371)
[L5] The paper defines non-union as a fracture where reparative processes have ceased and outlines clinical, roentgenographic, and histological criteria for diagnosis. [287] (10.2106/00004623-196446030-00023)
[L5] Delayed diagnosis is likely if careful examination of the patient's radiographs is not performed. [291] (10.1177/2054270414527281)
[L3] Patients who have any type of fragility fracture have a notable risk of subsequent fractures within 3 years, especially hip fractures. [293] (10.5435/jaaos-d-17-00103)
[L3] Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. [294] (10.5435/jaaos-d-17-00598)
[L3] Its success is not associated with specific fracture or patient related variables and it couldn't be clearly considered a time-dependent phenomenon. [298] (10.1186/1749-799x-7-24)
[L4] [299] (10.1016/0020-1383(72)90022-8)
[L4] The patient's age at the time of injury affected recovery, with 33 per cent of those over the age of 20 years still having symptoms 3 months after sustaining the fracture. [302] (10.1016/0020-1383(88)90006-x)
[L4] Normally healing fractures had an increase of 3 per cent per month and delayed unions less than half that amount. [304] (10.1016/0020-1383(81)90162-5)
[L4] Results are better in younger patients, while fracture severity and timing of operation do not appear to affect the outcome. [305] (10.1067/mse.2002.126615)
[L5] The author concludes that 90 days of follow-up is inadequate for surveillance of fracture-related infections in patients with open long-bone fractures, especially for research purposes, and that 12 months of follow-up would be preferable. [307] (10.1097/corr.0000000000001964)
[L3] Our results suggest that there is a substantial mortality in patients with a proximal humerus fracture, as we have previously reported, and that surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year. [308] (10.1080/17453670510041295)
[L4] At 6-month follow-up in 17 patients, the mean Constant score was 66.1 points, and radiographically all fractures had healed. [309] (10.1007/s00064-011-0085-z)
[L4] Fifteen of 17 fractures united with an average time to healing of 11.1 weeks. [312] (10.1097/bot.0b013e3181c673a6)
[L4] All fractures healed uneventfully at 19 weeks on average without failure. [315] (10.1016/j.injury.2004.03.023)

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