Internal Fixation

Internal fixation of proximal humerus, clavicle, and glenoid fractures — anatomical restoration, hardware selection, and management of osteoporotic bone.

Overview

Internal fixation serves as a definitive treatment option across various fracture patterns, with efficacy heavily dependent on patient risk profiles and surgical technique. In elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures, routine internal fixation reduces hospital mortality from 50% to less than 20% and improves functional outcomes [5]. For Hoffa fractures, the choice of internal fixation pattern for Letenneur type I injuries depends on the surgeon and is not recommended for all cases [3]. Similarly, large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2].

Outcomes vary significantly by anatomical site and specific technique. A novel technique for posterior internal fixation of acetabular fractures offers superior outcomes and fewer complications compared to similar internal fixation techniques [4]. In tibial pilon fractures, neither internal plating nor definitive external fixation has proven to be more effective overall, given the high complication rate [7]. For comminuted distal humerus fractures, primary external fixation with second-staged ORIF demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation [9].

When internal fixation is precluded, external fixation provides viable alternatives. External fixation as definitive treatment for the anterior ring component of APC injuries is not inferior to internal fixation when internal fixation is precluded [1]. Plate fixation is reliable and safe for humeral shaft fractures when indications for operative treatment are met [16], and acceptable results can be achieved for difficult humeral shaft fractures provided the correct principles of fixation are carefully followed [11]. The well-established clinical principles of secure internal fixation, placement of cancellous bone about the site of non-union, and adequate additional external support remain the best guidelines for treatment [21]. Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique [6]. Additionally, the use of a metaphyseal locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction [22].

Anatomy & Pathophysiology

Osseous

Proximal Humerus: The biomechanical literature for proximal humerus fracture implants is diverse and heterogeneous [54]. Modified minimally invasive reduction osteosynthesis system (MIROS) fixation for Neer 2 and 3-Part proximal humeral fractures provides adequate fracture stability and permits early shoulder motion [67]. This approach results in satisfactory functional and radiologic outcomes with fewer complications [67]. Regarding implant design, the use of proximal pegs in anatomical locking plates for proximal humeral fractures did not significantly affect postoperative shoulder functional outcomes [76], though it may reduce operative time [76]. Three-part humeral head fractures treated with a definite construct of blocked threaded wires allow only micromovements that do not cause humeral head rotation and translation [35].

Clavicle: Hook plate and superolateral locking plate with coracoclavicular suture fixation constructs offer superior biomechanical stability for distal third clavicle fractures with coracoclavicular ligament disruption [40]. These constructs for distal third clavicle fractures potentially reduce complications associated with subacromial hardware [40]. The clinical relevance of biomechanical studies on surgical fixation of midshaft clavicle fractures may be arguable because they do not investigate the effect of tissue adaptation over time [71].

Scapula and Proximal Ulna: A minimally invasive approach combined with a novel anatomical locking plate provides a biomechanical basis to guide the clinical treatment of scapular body fractures [63]. Appreciating the subtleties of proximal ulna anatomy and biomechanics can lead to improved clinical outcomes [45].

Glenoid and Instability: An all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation restores glenoid bone defects and preserves normal shoulder anatomy in recurrent anterior shoulder instability [62]. The advantage of the Latarjet procedure for open shoulder repair of osseous glenoid defects is particularly evident at 60° of glenohumeral abduction [75].

Other Osseous Deformities: Patients with Sprengel deformity treated surgically maintain improved shoulder function and appearance in long-term studies [69].

Ligamentous

Acromioclavicular Joint: Emerging concepts regarding horizontal and rotational instability and scapular biomechanics are foundational for improving treatment outcomes in acromioclavicular joint injuries [51]. Generations of suspensory fixation with internal brace for Rockwood grade V acromioclavicular joint injuries demonstrate biomechanical noninferiority with no significant differences in dynamic creep, translation, displacement, or stiffness [72].

Rotator Cuff and Subscapularis: Both open and arthroscopic repair of anterosuperior rotator cuff tears with subscapularis involvement significantly improve shoulder function [52]. Both open and arthroscopic repair of anterosuperior rotator cuff tears with subscapularis involvement are relatively safe procedures [52].

Shoulder Stability Mechanics: The shoulder can be viewed as an industrial crane, introducing a 'suspensory cascade' model where the coracohumeral ligament acts as a sensory organ to provide stability and control [65]. There is no single procedure that reliably treats every patient with anterior shoulder instability [74]. Surgical methods for anterior shoulder instability must be adapted to the specific pathomorphology of the patient rather than converting a neuromuscular problem into a purely mechanical one [74].

Vascular & Neural

Pectoralis Major Function: The pectoralis major muscle is not necessary for normal shoulder function but is required for athletics or strenuous activity [70].

Kinematics

Proximal Humerus Nailing: Biomechanical results regarding the safe distance between humerus shaft fracture and distal locking screws in antegrade nailing should be confirmed with clinical studies [56].

Classification

Anterior Pelvic Ring (APC): External fixation is not inferior to internal fixation for long-term patient-reported outcomes in the anterior ring component of APC injuries when internal fixation is precluded [1].

Clavicle Fractures: Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2]. Surgical treatment with locked plate fixation in type IIB2 clavicle fractures according to Robinson Classification can be the first treatment choice with better cosmetics, lower complication rate, and better outcomes [57].

Hoffa Fractures: The choice of internal fixation pattern for Letenneur type I Hoffa fractures depends on the surgeon and is not recommended for all cases [3].

Tibial Pilon: Neither internal plating nor definitive external fixation has proven to be more effective overall for total fractures of the tibial pilon, which have a high complication rate [7].

Knee Chondral Fragments: Primary fixation can be accomplished for isolated chondral fragments in the knee that have historically been considered 'unsalvageable' [8].

Distal Humerus: Primary external fixation with second-staged ORIF for comminuted distal humerus fractures demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation [9].

Humeral Shaft: Percutaneous fixation for humeral shaft fractures is questioned, with suggestions that complications could have been potentially avoidable with conventional debridement, lavage, and stabilization with methods such as external fixation [20].

Proximal Humerus: The MTM-classification for proximal humeral fractures does not deliver reproducible results despite covering a wide spectrum of fracture types [50]. A simple classification of multifocal humeral fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment [55]. A new classification of impacted proximal humerus fractures based on morpho-volumetric evaluation of humeral head bone loss with a 3D model provides a useful synoptic framework for identifying complex fracture patterns [68].

Shoulder Reconstruction: Open reduction and internal fixation with screw and plate can be done to fixate fragmented fractures in shoulder reconstruction using fibular strut graft insertion [64].

Other Considerations: The Operative Manual of Ilizarov Techniques provides detailed descriptions of the Ilizarov external fixator, including ring assembly, connections, and pin-bone fixation [41].

Clinical Presentation

The clinical presentation of fractures requiring internal fixation varies significantly by anatomical site and patient demographics, necessitating precise diagnostic and therapeutic strategies. In elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures, routine internal fixation reduces hospital mortality from 50% to less than 20% and improves functional outcomes [5]. For skeletally mature patients aged fifty years or less with femoral neck fractures, early accurate reduction and fixation are critical to prevent adverse sequelae [18].

Acute Trauma Patterns: * Clavicle Fractures: Large-scale randomized studies are required to define indications and results for various internal fixation techniques [2]. * Acromioclavicular Dislocation: Both coracoclavicular reconstruction and hook plate fixation for acute unstable dislocations yield excellent functional outcomes [13]. * Distal Humerus: Primary external fixation with second-staged ORIF for comminuted fractures demonstrates higher complication rates and significantly greater loss of extension compared with initial definitive internal fixation [9]. * Humeral Shaft: The use of percutaneous fixation for bridge plate osteosynthesis is questioned; complications may have been avoidable with conventional debridement, lavage, and stabilization via external fixation [20]. * Medial Humeral Condyle: Early diagnosis, accurate reduction, and internal fixation are essential in children to avoid growth disturbance, articular incongruence, and functional disability [14].

Complex Articular and Periarticular Injuries: * Hoffa Fractures: The choice of internal fixation pattern for Letenneur type I Hoffa fractures depends on the surgeon and is not recommended for all cases [3]. * Acetabular Fractures: A novel technique for posterior internal fixation offers superior outcomes and fewer complications compared to similar internal fixation techniques [4]. * Femur Fractures: Rigid internal fixation for supracondylar-intercondylar femur fractures permits early functional rehabilitation and decreases the incidence of malunion, non-union, and loss of fixation [12]. * Humeral Head Fractures: Functional and radiologic outcomes for complex fractures treated with blocked threaded wires are similar between percutaneous fixation and locking plates, but major complications are lower after percutaneous treatment [15]. * Knee Chondral Fragments: Primary internal fixation can be accomplished for isolated chondral fragments without osseous attachment, which have historically been considered 'unsalvageable' [8]. * Radial Head: Future research on isolated Type-II radial-head fractures should focus on suitably powered prospective studies with consistent fixation techniques to better understand the impact of patient factors and modifiable risk factors on clinical outcomes [19].

General Principles and Complications: * Tibial Pilon: The complication rate for total fractures of the tibial pilon is high, and neither internal plating nor definitive external fixation has proven to be more effective overall [7]. * Locked Plates: The clinical performance of locked plates generally has been good, but several unique complications have been noted [17]. * Periplate Osteosynthesis: Further research is needed to determine any complications related to plate on plate osteosynthesis for periplate fracture fixation [10]. * Distal Tibia: Intramedullary nailing, percutaneous plating, and external fixation are effective options for nonarticular distal tibia fractures depending on specific fracture characteristics and soft-tissue status [39]. * LCP External Fixation: LCP external fixation is an unconventional alternative to traditional external fixation that may be of benefit in carefully selected cases of fractures and nonunions, though it is not without its own unique set of complications requiring close clinical and radiological follow-up [37].

Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique [6]. External fixation as definitive treatment for anterior ring component of APC injuries yields similar patient-reported outcomes at long-term follow-up compared to internal fixation [1].

Investigations

Plain radiography: Standard radiographs (ap/outlet), particularly in internal rotation, may miss nearly half of screw cut outs of the proximal humerus [92].

CT: Preoperative CT scans may improve surgical planning for patellar fractures by identifying secondary fracture lines poorly visualized on radiographs [93].

Other Considerations: Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques for clavicle fractures [2]. Advances in understanding fracture patterns, imaging, exposure techniques, fixation, and rehabilitation have improved patient outcomes for distal humerus fractures [81].

Treatment

Non-Operative

Non-operative management remains the standard of care for most humeral shaft fractures, achieving union rates exceeding 90% [66]. For nondisplaced pediatric tibial eminence fractures, nonsurgical management is appropriate, whereas displaced variants require arthroscopic reduction and fixation [42]. In cases of established non-union of non-operatively treated displaced olecranon fractures, continued non-operative treatment remains a viable option [34]. Similarly, undisplaced inferior angle of scapula fractures exhibit variable outcomes when managed nonoperatively [60]. For incomplete atypical femoral fractures related to bisphosphonate treatment, non-operative treatment is not reliable; prophylactic intramedullary nailing should be considered if the patient experiences intractable pain [53].

Operative

Indications: Internal fixation is indicated for difficult humeral shaft fractures when correct principles are followed [11], and plate fixation is reliable and safe when operative indications are met [16]. For acute humerus fractures, Ender nailing is reserved for fractures recalcitrant to closed reduction and immobilization or in non-compliant patients [58]. In elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures, routine internal fixation reduces hospital mortality from 50% to less than 20% and improves functional outcomes [5]. For adolescent diaphyseal forearm fractures, open reduction and internal fixation may be preferred as patients approach skeletal maturity, though insufficient data exists to recommend one strategy over another [30]. External fixation as definitive treatment is not inferior to internal fixation for long-term patient-reported outcomes in the anterior ring component of APC injuries when internal fixation is precluded [1].

Surgical Approach / Technique: Operative management of humeral shaft fractures includes open reduction and internal fixation through various exposures, intramedullary nail fixation, and external fixation [27]. For posterior acetabular fractures, a novel technique for posterior internal fixation offers superior outcomes and fewer complications compared to similar techniques [4]. Primary fixation can be accomplished for isolated chondral fragments without osseous attachment in the knee, which were historically considered unsalvageable [8]. For distal tibial shaft fractures, external fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complications, good functional results, and no local soft tissue irritation or need for implant removal [44]. Transarticular fixation is highly successful in achieving union, stability, and pain relief in a single operation for non-union of supracondylar femur fractures [83].

Implant Selection: The Locking Compression Plate (LCP) revolutionizes internal fixation but requires adapted surgical techniques and new thinking to avoid failures [29]. Anatomically precontoured locking compression plates for Schatzker II tibial plateau fractures improve radiological and clinical outcomes compared to conventional implants, which are associated with more pronounced articular subsidence and higher valgus angulation [49]. For proximal humeral fractures, no single fixation method is a panacea; the choice of implant must be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [48]. Closed reduction and external fixation of proximal humeral fractures combines percutaneous pinning advantages with improved fixation strength in osteoporotic bone using long threaded pins and a dedicated external fixator [32]. Linking lateral ends of fixation wires with an external fixator increases the stiffness and strength of constructs for percutaneous fixation of proximal humeral fractures [47]. For intertrochanteric fractures, the implant device plays the major role in fixation stability, while reduction positions exert only a minor influence [38]. For proximal humerus intramedullary nailing, no compelling evidence exists to suggest one technique over another compared to locking plate fixation [28]. The use of a locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate reduction [22]. For Letenneur type I Hoffa fractures, the choice of internal fixation pattern depends on the surgeon and is not recommended for all cases [3].

Adjuncts: The AO philosophy has evolved from rigid mechanical fixation to a biological approach emphasizing preservation of local blood supply and minimally invasive techniques, leading to improved clinical outcomes and reduced complications such as nonunion and infection [31]. The well-established clinical principles of secure internal fixation, placement of cancellous bone about the site of non-union, and adequate additional external support remain the best guidelines for treatment [21]. Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique [61]. The incidence of non-union in femoral neck fractures can be decreased by accurate reduction, accurately placed adequate internal fixation, and carefully supervised postoperative care [61].

Revision: Total elbow arthroplasty (TEA) serves as a salvage procedure for failed internal fixation of elbow fractures, leading to significant improvements in pain and function [23]. Clavicle fixation for delayed and non-union is a cost-effective intervention, although functional outcomes are worse compared to patients that unite with non-operative management [59].

Other Considerations: Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2]. The use of regional anaesthesia during operative repair of long bone fracture nonunion was associated with no significant difference in functional outcome scores or pain levels at all post-operative time points [82]. Arthrodesis of the ankle in patients with rheumatoid arthritis often allows the patient to maintain their level of functional activity, but should not be expected to improve it [86].

Complications

Infection (PJI): Periprosthetic joint infection remains a formidable challenge with incidence rates of 0.4% to 2% after primary total knee replacement, with the absolute number of cases projected to increase significantly due to the growing volume of arthroplasties [107]. In open fractures of the tibia treated with the Lottes nail, the infection rate was 6% [117]. For comminuted distal humerus fractures, primary external fixation with second-staged ORIF demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation [9]. Earlier conversion from external fixator to intramedullary nail in tibial fractures reduced infection rates [24]. A sequential protocol involving a short period of external fixation followed by delayed intramedullary nailing for open tibial shaft fractures minimized colonization of the pin tracks, yielded excellent results, and had a low rate of infection [122]. A 1-stage secondary nailing procedure after external fixation for tibial shaft fracture appears feasible and does not increase infection risk if external fixation pin site infection is excluded [97]. There was no difference in general complications or infection rates between patients treated with C-clamp/external fixation and those without for unstable pelvic fractures, although the adjusted odds of death were 32% lower in the C-clamp/external fixation group [120].

Instability: In the Latarjet procedure for chronic anterior shoulder instability, screw fixation was associated with lower rates of recurrent instability but greater reoperations due to irritation or pain after surgery compared to cortical buttons [25, 116]. Total elbow arthroplasty is a salvage procedure for failed internal fixation of elbow fractures, leading to significant improvements in pain and function [23].

Thromboembolism: Thromboembolic disease is a feared complication in patients who sustain trauma to the involved lower extremity and have a history of deep venous thrombosis and previous arthrodesis of the hip [110].

Other Considerations: External fixation as definitive treatment for anterior ring component of APC injuries yields similar patient-reported outcomes at long-term follow-up compared to internal fixation [1]. Routine use of internal fixation in elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures reduced hospital mortality from 50% to less than 20% and improved functional outcomes [5]. The complication rate for total fractures of the tibial pilon is high, and neither internal plating nor definitive external fixation has proven to be more effective overall [7]. Primary external fixation with second-staged ORIF for comminuted distal humerus fractures demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation [9]. Locking plate fixation has yet to prove clinical superiority in any anatomic site for which good-quality comparative analyses are available [106]. The S3 plate for proximal humerus fractures has a very low revision rate, with union seen in most fractures by 6 months [111]. Patients with bridge plates for complex elbow instability often require a second surgery for removal and experience high rates of general complications because of the complexity of their condition [112]. Early fracture stabilization may reduce recurrence of fat embolism and the fat embolism syndrome [113]. Displaced Neer Type IIB distal-third clavicle fractures treated with plate fixation and additional screw augmentation for coracoclavicular instability had an early postoperative complication rate of 25% and a 100% rate of secondary surgery due to removal of the CC screw [114]. The incidence of refracture following implant removal after bone union in midshaft clavicle fractures is underestimated, with severe comminute fractures and unsatisfactory reduction during primary surgery identified as risk factors [115]. Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating [118]. The operative treatment of mid-shaft clavicular non-unions is safe and reliable, with a predictably high rate of union and low incidence of complications [119]. Percutaneous Knowles pinning for intracapsular femoral neck fractures is associated with low morbidity, mortality, and infection rates compared to primary prosthetic replacement [121]. Results of meta-analyses comparing minimally invasive plating versus open reduction and plate fixation or intramedullary nailing for humeral shaft fractures are limited by problems inherent in the primary studies, including poor reporting of randomization protocols, possible attrition bias, and reporting bias [123]. Methodological flaws remain to be addressed in future meta-analyses in orthopaedic surgery to continue increasing the quality of the orthopaedic literature [125]. Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2]. A novel technique for posterior internal fixation of acetabular fractures offers superior outcomes and fewer complications compared to similar internal fixation techniques [4]. Further research is needed to determine any complications related to plate on plate osteosynthesis for periplate fracture fixation [10]. Future research should focus on suitably powered prospective studies with consistent fixation techniques to better understand the impact of patient factors and modifiable risk factors on clinical outcomes for isolated type-II radial-head fractures [19].

Recovery

Light activity (weeks): Early mobilization is a cornerstone of recovery for many fixation strategies. Rigid internal fixation of supracondylar-intercondylar femur fractures permits early functional rehabilitation [12]. Minimally invasive external fixation of proximal humerus fractures allows for early but gentle postoperative mobilization [46]. In polytrauma patients with long bone fractures, application of damage control principles with proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation yields good clinical results [33]. For isolated low-energy ulnar shaft fractures, early mobilization without external immobilization or internal fixation is the recommended treatment [36].

Full activity (months): Return to function varies by injury pattern and fixation method. Retrograde intramedullary nailing (RTEN) for mid-shaft clavicle fractures may allow for shorter immobilization and earlier rehabilitation compared to antegrade nailing, though clinical studies are needed to confirm superiority [43]. Titanium elastic nail (TEN) fixation significantly accelerates return to sport, reduces season loss, and enhances early functional and psychological recovery in adolescent athletes engaged in high-demand sports [95]. Extra-articular dorsal plate fixation of Lisfranc injuries in athletes demonstrates improvement in postoperative patient reports of function [99]. Screw fixation in the Latarjet procedure for chronic anterior shoulder instability is associated with lower rates of recurrent instability but higher rates of reoperation compared to cortical buttons [25].

Complete recovery / outcome plateau (months): Long-term outcomes are generally favorable with appropriate fixation. External fixation as definitive treatment for anterior ring component of APC injuries yields similar patient-reported outcomes at long-term follow-up compared to internal fixation [1]. Anatomical locking plates provide favorable functional outcomes at a minimum of 10 years postoperatively for proximal humerus fractures [103]. Plate augmentation for aseptic femoral shaft nonunion after intramedullary nailing results in a good rate of consolidation, good functional recovery, and a low incidence of complications [104]. A treatment protocol for ipsilateral femoral neck and shaft fractures produces excellent results with all fractures uniting and good long-term functional outcomes [105]. Clinical or functional recovery for triquetrum fractures usually occurs long before roentgenographic evidence of bony union is demonstrated [98].

Rehabilitation protocol: Specific protocols depend on the stability of the fixation. Firm fixation after medullary nailing of fresh femur fractures is required to allow the patient to walk without additional support [80]. Efforts at osteosynthesis for proximal humerus fractures should aim for anatomic fracture fixation that resists displacement, with a stable shoulder and healed tuberosities as the primary goal in the immediate and early recovery phase [87]. The best functional outcomes for clavicle hook plate fixation in displaced lateral-third clavicle fractures occur when the plate is removed before 6 months postoperatively, provided the fracture has healed [100]. Earlier conversion from external fixator to intramedullary nail in tibial fractures reduces infection rates [24].

Functional milestones: Various fixation methods achieve high levels of functional restoration. Routine use of internal fixation in elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures reduced hospital mortality from 50% to less than 20% and improved functional outcomes [5]. Functional return is achieved in all survivors of intertrochanteric and subtrochanteric hip fractures treated with the Ender method who could walk at the time of injury, with no non-unions reported [84]. Primary fixation allows for the salvage of isolated chondral fragments in the knee that have historically been considered unsalvageable [8]. Both plate fixation and elastic stable intramedullary nailing (ESIN) return patients to pre-injury functional levels at one year for completely displaced midshaft clavicle fractures, but plate fixation provides a faster recovery period in comminuted fractures [78]. Suture-button fixation in arthroscopic Latarjet procedures eliminates the need for hardware removal, maintains a low instability recurrence rate, and supports excellent return to pre-injury activity levels [79]. Dual plating of displaced midshaft clavicle fractures offsets higher initial hardware costs through greater health utility via lower reoperation rates and improved patient quality of life [88]. A direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilization, and functional outcomes at early follow-up compared to an indirect anterolateral approach [108]. Arthrodesis of the knee by double-plating results in uniform clinical success with only one failure, which resolved after a second plating procedure [109].

Other Considerations: Patient selection and timing influence recovery trajectories. Routine use of internal fixation in elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures reduced hospital mortality from 50% to less than 20% and improved functional outcomes [5]. Screw fixation in the Latarjet procedure for chronic anterior shoulder instability is associated with lower rates of recurrent instability but higher rates of reoperation compared to cortical buttons [25].

Key Evidence

• [Paper] External fixation as definitive treatment is not inferior when internal fixation is precluded. (10.1016/j.injury.2020.05.037)
• [L4] Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques. (10.1016/j.otsr.2016.11.007)
• [L5] However, the choice of internal fixation pattern depends on the surgeons and is not recommended for all cases. (10.1016/j.injury.2017.03.044)
• [L4] Compared to similar internal fixation techniques, it offers superior outcomes and fewer complications. (10.1186/s13018-025-06049-8)
• [L4] Routine use of internal fixation in elderly, poor-risk patients reduced hospital mortality from 50 per cent to less than 20 per cent and improved functional outcomes. (10.2106/00004623-195638060-00011)
• [L5] Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique. (10.5435/jaaos-d-23-01256)
• [Paper] The complication rate is high and neither internal plating nor definitive external fixation has proven to be more effective overall. (10.1016/j.otsr.2013.06.016)
• [L4] Primary fixation can be accomplished for what have been historically considered 'unsalvageable' fragments. (10.1177/2325967117696281)
• [L3] Primary external fixation with second-staged ORIF demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation. (10.1007/s00402-017-2792-x)
• [L4] Further research is needed to determine any complications related to this type of fixation. (10.1177/2325967120s00043)
• [L4] While closed treatment remains the method of choice for most fractures, acceptable results can be achieved with internal fixation, even for difficult fractures, provided the correct principles of fixation are carefully followed. (10.2106/00004623-198668030-00018)
• [L4] Rigid internal fixation permits early functional rehabilitation of the patient and decreases the incidence of malunion, non-union, and loss of fixation. (10.2106/00004623-198971010-00015)
• [L3] Both fixations yielded excellent functional outcomes. (10.1186/s12891-021-03978-3)
• [L4] Early diagnosis, accurate reduction, and internal fixation are important to avoid growth disturbance, articular incongruence, and functional disability. (10.2106/00004623-198062070-00016)
• [L3] The functional and radiologic outcomes obtained with percutaneous fixation or locking plates are similar; however, the percentage of major complications after percutaneous treatment is lower. (10.1016/j.jse.2018.06.034)
• [L4] When indications for operative treatment are met, plate fixation is reliable and safe. (10.2106/jbjs.rvw.n.00119)
• [L5] The clinical performance of locked plates generally has been good, but several unique complications have been noted. (10.5435/00124635-200806000-00007)
• [L4] Early accurate reduction and fixation should be pursued in all patients in this age group. (10.2106/00004623-198567080-00018)
• [L5] Future research should focus on suitably powered prospective studies with consistent fixation techniques to better understand the impact of patient factors and modifiable risk factors on clinical outcomes. (10.2106/jbjs.rvw.17.00010)
• [L4] The authors question the use of percutaneous fixation in these types of fractures and suggest that complications could have been potentially avoidable with conventional debridement, lavage, and stabilisation with methods such as external fixation. (10.1016/j.injury.2004.11.013)
• [L4] The well-established clinical principles of secure internal fixation, placement of cancellous bone about the site of non-union, and adequate additional external support remain the best guidelines for treatment. (10.2106/00004623-198163080-00028)
• [Paper] Clinical outcomes show that the use of locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction. (10.1016/j.injury.2016.11.031)
• [Abstract] TEA is a salvage procedure for failed internal fixation, leading to significant improvements in pain and function. (10.1016/j.jse.2007.02.051)
• [L4] Surgeons should strongly consider the necessity of external fixation for these fractures, as earlier conversion reduced infection rates. (10.5435/jaaos-d-21-00857)
• [L3] However, despite lower rates of recurrent instability reoperations were more common following screw fixation. (10.1016/j.jse.2020.01.023)
• [L5] Both patients achieved radiological union around 3 months with significant pain reduction and functional improvement. (10.1016/j.jseint.2023.09.001)
• [L5] Operative management includes open reduction and internal fixation through a variety of exposures, intramedullary nail fixation, and external fixation. (10.1016/j.jse.2017.10.028)
• [L5] Compared with other fixation strategies, such as locking plate fixation, no compelling evidence exists to suggest one technique over another. (10.1016/j.jse.2015.11.016)
• [L5] The Locking Compression Plate (LCP) is a new implant revolutionizing internal fixation that requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications. (10.1016/j.injury.2003.09.026)
• [L3] There is insufficient data to recommend one strategy over the other, although open reduction and internal fixation may be preferred as patients approach skeletal maturity. (10.1016/j.injury.2018.08.023)
• [L5] The AO philosophy evolved from a focus on rigid mechanical fixation to a biological approach emphasizing preservation of local blood supply and minimally invasive techniques, which has led to improved clinical outcomes and reduced complications such as nonunion and infection. (10.2106/00004623-200306000-00029)
• [L5] The technique was developed to combine the advantages of traditional percutaneous pinning with improved fixation strength in osteoporotic bone through the use of long threaded pins and a dedicated external fixator. (10.5435/jaaos-d-17-00721)
• [Paper] Good clinical results can be expected in patients with long bone fractures if the principles of damage control are applied and complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation. (10.1016/j.injury.2017.04.016)
• [L4] Continued non-operative treatment is an option for patients who present with an established non-union. (10.1111/j.1758-5740.2012.00194.x)
• [Abstract] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jse.2022.01.037)
• [L4] Early mobilization without external immobilization or internal fixation is recommended as the treatment of choice for these low-energy injuries. (10.2106/00004623-198365030-00007)
• [L4] LCP external fixation is an unconventional alternative to traditional external fixation that may be of benefit in carefully selected cases of fractures and nonunions, though it is not without its own unique set of complications requiring close clinical and radiological follow-up. (10.1186/1749-799x-5-19)
• [L5] Intramedullary nailing, percutaneous plating, and external fixation are effective options depending on specific fracture characteristics and soft-tissue status. (10.5435/00124635-200607000-00003)
• [L5] These constructs offer superior biomechanical stability in our model and potentially reduce complications associated with subacromial hardware. (10.1016/j.xrrt.2025.100645)
• [L5] This book fulfills the definition of its title by providing detailed descriptions of the Ilizarov external fixator, including ring assembly, connections, and pin-bone fixation, making it an important addition to the library of orthopaedic surgeons interested in external fixation. (10.2106/00004623-199509000-00029)
• [L5] Nondisplaced fractures are amenable to nonsurgical management, while displaced fractures are managed with arthroscopic reduction and fixation. (10.5435/00124635-201007000-00002)
• [L5] This suggests RTEN may allow for shorter immobilization and earlier rehabilitation with a lower risk of fixation failure, though clinical studies are needed to confirm superiority. (10.1186/s12891-025-08426-0)
• [L2] External fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication, good functional result, and no local soft tissue irritation or implant removal. (10.1007/s00264-014-2294-1)
• [L5] Appreciating the subtleties of proximal ulna anatomy and biomechanics can lead to improved clinical outcomes. (10.5435/00124635-201303020-00004)
• [L5] The external fixator system allows early but gentle postoperative mobilisation. (10.1186/s12891-024-07977-y)
• [L5] Linking the lateral ends of fixation wires with an external fixator increased the stiffness and strength of the constructs. (10.2106/jbjs.j.00815)
• [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. (10.1016/j.injury.2010.10.016)
• [Paper] The data demonstrate a more pronounced articular subsidence and a higher valgus angulation secondary to the internal fixation with conventional implants. (10.1016/j.injury.2020.07.012)
• [L4] Although the MTM-classification covers a wide spectrum of fracture types, the precise topographic and morphological description is not delivering reproducible results. (10.1186/1471-2474-9-21)
• [L5] By exploring emerging concepts and strategies regarding horizontal and rotational instability and scapular biomechanics, the article aims to lay the foundation for future studies aimed at improving treatment outcomes and patient management. (10.1016/j.jseint.2023.11.018)
• [L3] Both techniques significantly improved shoulder function and are relatively safe procedures. (10.1016/j.jse.2019.09.035)
• [L2] Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. (10.1302/0301-620x.99b3.bjj-2016-0276.r2)
• [L4] The biomechanical literature was found to be both diverse and heterogeneous. (10.1186/s12891-015-0627-x)
• [Paper] A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment. (10.1016/j.injury.2013.10.010)
• [L5] These biomechanical results, although very promising, should be confirmed with clinical studies. (10.1186/s12891-025-08711-y)
• [L3] Surgical treatment with locked plate fixation in type IIB2 clavicle fractures according to Robinson Classification can be the first treatment choice with better cosmetics, lower complication rate, and better outcomes. (10.1177/2325967114s00265)
• [L3] However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment. (10.2106/00004623-198769040-00013)
• [L3] Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management. (10.1177/1758573221990367)
• [L4] Undisplaced fractures have a variable outcome when treated nonoperatively. (10.1016/j.jse.2015.11.007)
• [L4] The incidence of non-union can be decreased and many aspects of the unsolved fracture can be resolved by accurate reduction, accurately placed adequate internal fixation, and carefully supervised postoperative care. (10.2106/00004623-196244050-00006)
• [L4] This technique restores glenoid bone defects and preserves the normal shoulder anatomy. (10.1016/j.arthro.2020.10.036)
• [L5] The study provided a biomechanical basis to guide the clinical treatment of scapular body fractures. (10.1186/s13018-024-04905-7)
• [Case_report] Open reduction and internal fixation with screw and plate can be done to fixate fragmented fractures. (10.1177/2325967125s00053)
• [L5] The article argues that the shoulder should be viewed as an industrial crane to better understand its biomechanics, introducing a 'suspensory cascade' model where the coracohumeral ligament acts as a sensory organ to provide stability and control. (10.1136/jisakos-2019-000294)
• [L5] Nonsurgical management with functional bracing is the standard of care for most humeral shaft fractures, achieving union rates >90%. (10.5435/jaaos-20-07-423)
• [L3] It is a minimally invasive procedure that provides adequate fracture stability and permits early shoulder motion, with satisfactory functional and radiologic outcomes and fewer complications. (10.1186/s12891-025-08600-4)
• [L5] The new classification provides a useful synoptic framework for identifying complex fracture patterns. (10.1016/j.jse.2020.02.022)
• [L5] Recent long-term studies indicate that patients treated surgically maintain improved shoulder function and appearance. (10.5435/jaaos-20-03-177)
• [L2] The clinical relevance of the biomechanical studies may be arguable since none investigate the effect of tissue adaptation over time. (10.1016/j.injury.2018.02.017)
• [L5] This study demonstrated biomechanical noninferiority of all four construct groups with respect to each other, with no significant differences in dynamic creep, translation, displacement, or stiffness. (10.1016/j.jse.2024.06.020)
• [L5] There is no single procedure that reliably treats every patient with anterior shoulder instability; surgical methods must be adapted to the specific pathomorphology of the patient rather than converting a neuromuscular problem into a purely mechanical one. (10.1177/17585732231224699)
• [L5] The advantage of the Latarjet procedure is particularly evident at 60° of glenohumeral abduction. (10.1177/0363546508326714)
• [L3] The use of proximal pegs did not significantly affect postoperative shoulder functional outcomes, although it may reduce operative time. (10.1186/s12891-025-08917-0)
• [L1] Both methods return patients to their pre-injury functional levels at one year, but plate fixation provides a faster recovery period in comminuted fractures compared to ESIN. (10.1302/0301-620x.99b8.bjj-2016-1318.r1)
• [L4] There was no need for hardware removal after suture-button fixation, with a low instability recurrence rate and excellent return to pre-injury activity level. (10.1016/j.arthro.2018.11.012)
• [L4] The main requisite is that after the operation fixation should be so firm that the patient can walk without any additional support. (10.2106/00004623-195133030-00013)
• [L3] In this cohort, the use of regional anaesthesia during operative repair of long bone fracture nonunion was associated with no significant difference in functional outcome scores or pain levels at all post-operative time points. (10.1016/j.injury.2019.01.013)
• [L4] The procedure described was highly successful in achieving union of the fractured femur, stability, and relief of pain in all patients with one operation. (10.2106/00004623-197961070-00008)
• [L4] Functional return was achieved in all survivors who could walk at the time of injury, with no non-unions reported. (10.2106/00004623-197658050-00004)
• [L3] The relief of pain often will allow the patient to maintain the level of functional activity but should not be expected to improve it. (10.2106/00004623-199274060-00012)
• [L3] Efforts at osteosynthesis should be directed to obtaining anatomic fracture fixation that resists fracture displacement, and a stable shoulder with healed tuberosities should be the primary goal in the immediate and early phase of recovery. (10.1016/j.jse.2007.02.109)
• [L2] Despite its higher initial hardware costs, dual plating appears to offset its added costs with greater health utility via lower rates of reoperation and improved patient quality of life. (10.2106/jbjs.23.00338)
• [Paper] Standard radiographs (ap/outlet), especially in internal rotation, may miss nearly half of screw cut outs. (10.1016/j.injury.2014.05.025)
• [L5] Preoperative CT scans may improve surgical planning by identifying secondary fracture lines poorly visualized on radiographs. (10.2106/jbjs.20.01478)
• [L3] For adolescent athletes engaged in structure- or kinetic-dependent sports with high clavicle functional demand, TEN fixation significantly accelerates return to sport, reduces season loss, and enhances early functional and psychological recovery, while achieving long-term functional outcomes equivalent to conservative treatment. (10.1186/s13018-026-06708-4)
• [Paper] A 1-stage procedure appears feasible and does not increase infection risk if external fixation pin site infection is excluded. (10.1016/j.otsr.2014.10.017)
• [L4] Clinical or functional recovery usually occurs long before roentgenographic evidence of bony union is demonstrated. (10.2106/00004623-195638020-00012)
• [L4] In athletes, extra-articular dorsal plate fixation of the Lisfranc joint demonstrates improvement in postoperative patient reports of function. (10.1177/2325967119s00388)
• [L4] The best functional outcomes occur with plate removal before 6 months postoperatively, provided the fracture has healed. (10.1016/j.jse.2011.07.020)
• [L4] Anatomical locking plates provide favorable functional outcomes at a minimum of 10 years postoperatively. (10.1016/j.jse.2025.06.012)
• [L2] The patients treated with plate augmentation included in this review showed a good rate of consolidation in the femoral shaft nonunions, with good functional recovery and a low incidence of complications. (10.3390/bioengineering9100560)
• [L4] The developed protocol produced excellent results with all fractures uniting and good long-term functional outcomes. (10.2106/00004623-198466020-00013)
• [L4] Locking plate fixation has yet to prove clinical superiority in any anatomic site for which good-quality comparative analyses are available. (10.1016/j.otsr.2016.11.006)
• [L3] This study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach. (10.1016/j.injury.2013.04.024)
• [L4] The procedure resulted in uniform clinical success with only one failure, which resolved after a second plating procedure. (10.2106/00004623-196244010-00020)
• [L4] The authors postulate an association between deep venous thrombosis and previous arthrodesis of the hip in patients who sustain trauma to the involved lower extremity, noting that thromboembolic disease is a feared complication in this specific population. (10.2106/00004623-198971090-00023)
• [L4] The implant has a very low revision rate and union was seen in most fractures by 6 months. (10.1111/j.1758-5740.2011.00144.x)
• [L4] However, patients with bridge plates often require a second surgery for removal and experience high rates of general complications because of the complexity of their condition. (10.1016/j.jse.2024.03.013)
• [Paper] The paper is a collection of German abstracts summarizing pathophysiological mechanisms, clinical incidence, and consequences of fat embolism and the fat embolism syndrome, noting that early fracture stabilization may reduce recurrence. (10.1016/j.injury.2006.08.044)
• [L4] However, considering an early postoperative complication rate of 25% and a 100% rate of secondary surgery due to removal of the CC screw does not seem to justify this technique anymore. (10.1186/s12891-017-1398-3)
• [L3] The incidence of refracture following implant removal after bone union is underestimated, and severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors. (10.1186/s12891-023-06391-0)
• [L3] Screw fixation was associated with a significantly lower rate of recurrences, but greater reoperations due to irritation or pain after surgery. (10.1177/17585732241227206)
• [L4] The rate of infection was 6 per cent, delayed union 16 per cent, and malunion 4 per cent. (10.2106/00004623-198365070-00001)
• [L3] Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating. (10.1016/j.injury.2017.03.005)
• [L4] The technique is safe and reliable, with a predictably high rate of union and low incidence of complications. (10.2106/00004623-198668040-00030)
• [Paper] After adjusting for confounding factors, there was no difference in general complications or infection rates between patients treated with C-clamp/external fixation and those without, although the adjusted odds of death were 32% lower in the C-clamp/external fixation group. (10.1016/j.injury.2019.08.039)
• [L4] This sequential protocol for treatment, which involved a short period of external fixation and thus minimized colonization of the pin tracks, yielded excellent results and a low rate of infection. (10.2106/00004623-199072050-00013)
• [L1] However, the results of this metaanalysis are limited by problems inherent in the primary studies, including poor reporting of randomization protocols, as well as possible attrition bias and reporting bias. (10.1016/j.jse.2016.05.014)
• [L1] Methodological flaws remain to be addressed in future meta-analyses in order to continue increasing the quality of the orthopaedic literature. (10.1302/0301-620x.100b10.bjj-2017-1142.r2)

See Also

• Fractures
• Proximal Humerus Fracture
• Shoulder Instability
• Latarjet Procedure
• Rotator Cuff
• Patient Demographics
• Fracture Fixation
• Clavicle Fracture Fixation
• Bone Fractures

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