Aims. The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures. Methods. A retrospective, multicentre registry-based study was undertaken. Between 1 January 2016 and 31 December 2019, data for 24,919 patients from 100 hospitals were collected in the Registry for Geriatric Trauma. This information was queried and patient groups with and without concomitant injury were compared using linear and logistic regression models. In addition, we analyzed the influence of the different types of additional injuries. Results. A total of 22,602 patients met the inclusion criteria. The overall prevalence of a concomitant injury was 8.2% with a predominance of female patients (8.7% vs 6.9%; p < 0.001). Most common were fractures of the ipsilateral upper limb. Concomitant injuries resulted in prolonged time-to-surgery (by 3.4 hours (95 confidence interval (CI) 2.14 to 4.69)) and extended length of stay in hospital by 2.2 days (95% CI 1.74 to 2.61). Mortality during the admission was significantly higher in the concomitant injury group (7.4% vs 5.3%; p < 0.001). Additionally, walking ability and quality of life were reduced in these patients at discharge. More patients were discharged to a nursing home instead of their own home compared to patients without additional injuries (25.8% vs 30.3%; p < 0.001). Conclusion. With a prevalence of 8.2%, the appearance of a concomitant injury is common in elderly patients with hip fracture. These patients are at a greater risk for death during the admission, longer hospital stays, and delayed surgery. This knowledge is clinically important for all who are involved in the treatment of proximal femur fractures. Cite this article: Bone Joint J 2021;103-B(9):1526–1533

Aims. The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI). Methods. From posteroanterior digital radiographs of healed DRFs in 398 female patients aged 70 years or older, and 32 unfractured control wrists, the relationships of RI, quantifiably, to four linear measurements made perpendicular to reference distal radial shaft (DRS) and ulnar shaft (DUS) axes were analyzed: 1) DRS to radial aspect of ulnar head (DRS-U); 2) DUS to volar-ulnar corner of distal radius (DUS-R); 3) DRS to proximal capitate (DRS-PC); and 4) DRS to DUS (interaxis distance, IAD); and, qualitatively, to the distal ulnar fracture, and its intersection with the DUS axis. Results. In the study (fracture) and control groups, respectively, the mean values were: RI, 17.2° (SD 7.2°; -7° to 35°) and 25.6° (SD 2.6°; 21° to 30°); DRS-U, 13.5 mm (SD 1.7; 4.9 to 20.8) and 15.3 mm (SD 0.72; 13.8 to 16.3); DUS-R, 13.4 mm (SD 2.1; 4.8 to 18.5) and 12.0 mm (SD 0.99; 9.7 to 13.9); DRS-PC (positive value radial to DRS, negative value ulnar), 0.14 mm (SD 5.4; -10.9 to 22.7) and -6.1 mm (SD 1.6; -10.6 to -2.3); and IAD, 25.3 mm (SD 2.5; 17.6 to 31.1) and 27.1 mm (SD 1.5; 24.5 to 31.0). All means were significantly different between the study and control groups. RI correlated strongly with DRS-PC. Ulnar styloid fracture intersection with the DUS axis, reflective of ulnar translation of both radial and ulnar shafts, was associated with significantly lower RI. Conclusion. After DRF, the relationship of the proximal capitate to the DRS axis in the coronal plane correlates with the final radial inclination. Additionally, ulnar styloid intersection with the DUS axis is associated with even lower radial inclination. DRF reduction should seek to restore the normal coronal relationship of both radial and ulnar shafts to their distal counterparts. Cite this article: Bone Joint J 2023;105-B(6):688–695

Aims. Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria. Methods. Data from 11,270 patients with PFFs, treated surgically (osteosyntheses, n = 6,435; endoprostheses, n = 4,835) at Austrian hospitals within a one-year period (January to December 2021) was retrieved from the Leistungsorientierte Krankenanstaltenfinanzierung (Achievement-Oriented Hospital Financing). The 30-day and one-year readmission rates were reported. Readmission risk for any complication, as well as general medicine-, internal medicine-, and surgery/injury-associated complications, and factors associated with readmissions, were investigated. Results. The 30-day and one-year readmission rates due to any complication were 15% and 47%, respectively. The 30-day readmission rate (p = 0.001) was higher in endoprosthesis than osteosynthesis patients; this was not the case for the one-year readmission rate (p = 0.138). Internal medicine- (n = 2,273 (20%)) and surgery/injury-associated complications (n = 1,612 (14%)) were the most common reason for one-year readmission. Regardless of the surgical procedure, male sex was significantly associated with higher readmission risk due to any, as well as internal medicine-associated, complication. Advanced age was significantly associated with higher readmission risk after osteosynthesis. In both cohorts, treatment at mid-sized hospitals was significantly associated with lower readmission risk due to any complication, while prolonged length of stay was associated with higher one-year readmission risks due to any complication, as well as internal-medicine associated complications. Conclusion. Future health policy decisions in Austria should focus on optimization of perioperative and post-discharge management of this vulnerable patient population. Cite this article: Bone Jt Open 2024;5(4):294–303

Background. Disruption of the normal relationship between the proximal tibia and fibula is seen in a number of different conditions such as skeletal dysplasias and post-infective deformity, as well as the consequence of lengthening procedures. Radiographic indices for the tibio-fibular relationship at the ankle have been described, but no similar measures have been reported for the proximal articulation. Aim. The purpose of this study was to investigate the normal radiographic relationship between the proximal tibia and fibula in children to determine the normal range and variation. Methods. Our radiology database was used to identify a sample of 500 normal anteroposterior radiographs of paediatric knees. All radiographs were reviewed by a single observer. The distance from the corner of the lateral tibial plateau to both the proximal tibial (PT) and fibular physes (PF) were measured, and a ratio of the two calculated (PF/PT). The process was repeated with a sample of 100 radiographs by the same observer, and a second independent observer in order to calculate intra-and inter-observer reliability. Results. The age range of patients in this study was 4–16 years, with mean age 12.7. The mean PF/PT ratio was 1.7 (standard deviation 0.2, range 1.3–2.0). Intra-observer reliability was 100% and inter-observer reliability was 97.8%. Conclusion. The results of this study demonstrate that in the normal paediatric knee, there is a consistent relationship between the position of the proximal tibial and fibular physes, with a small range of variation. The PF/PT ratio is a simple and reliable way of assessing the relationship between the proximal tibia and fibula in children, using a standard anteroposterior radiograph. This ratio could be very useful in the diagnosis and planning of surgical management of a number of different causes of tibial and fibular deformities in children

The Gamma nail is frequently used in unstable peri-trochanteric hip fractures. We hypothesised that mechanical failure of the Gamma nail was associated with inadequate proximal three-point fixation. We identified a consecutive series of 299 Gamma nails implanted in 299 patients over a five-year period, 223 of whom fulfilled our inclusion criteria for investigation. The series included 61 men and 162 women with a mean age of 81 years (20 to 101). Their fractures were classified according to the Modified Evans’ classification and the quality of fracture reduction was graded. The technical adequacy of three points of proximal fixation was recorded from intra-operative fluoroscopic images, and technical inadequacy for each point was defined. All patients were followed to final follow-up and mechanical failures were identified. A multivariate statistical analysis was performed, adjusting for confounders. A total of 16 failures (7.2%) were identified. The position of the lag screw relative to the lateral cortex was the most important point of proximal fixation, and when inadequate the failure rate was 25.8% (eight of 31: odds ratio 7.5 (95% confidence interval 2.5 to 22.7), p < 0.001). Mechanical failure of the Gamma nail in peri-trochanteric femoral fractures is rare (< 1%) when three-point proximal fixation is achieved. However, when proximal fixation is inadequate, failure rates increase. The strongest predictor of failure is positioning the lateral end of the lag screw short of the lateral cortex. Adherence to simple technical points minimises the risk of fixation failure in this vulnerable patient group. Cite this article: Bone Joint J 2013;95-B:825–30

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions. There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection. The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants. We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement

Early mortality in patients with hip fractures due to bony metastases is unknown. The aim was to quantify 30 and 90-day mortality in patients with metastatic hip fractures and identify markers associated with early death. Consecutive patients referred to orthopaedics with a metastatic proximal femoral fracture/impending fracture over a six-year period were compared to a matched control group of non-malignant hip fractures. Minimum follow-up was 1 year and data was analysed using the student´s t-test (significance p<0.05). From Jan 2010-Dec 2015, 163 patients were referred with metastatic proximal femoral lesions. 90-day mortality was three times higher than controls (44% 71/163 vs. 12% 4/33, p<0.01). Mean time from referral to surgery was longer in impending versus completed fractures (11 and 4 days respectively, p<0.05). Multiple biochemical markers were associated with early mortality in the metastatic group. Patients who died early were more likely to demonstrate low haemoglobin and albumin, and high c-reactive protein, platelets, urea, alkaline phosphatase and calcium (p<0.05). Several biochemical markers associated with early mortality reached clinical and statistical significance. These markers were combined into a score out of 7 and indicated a higher early mortality in metastatic patients compared to controls. Patients with a score of 5–6/7 were 31 times more likely to die within 90 days versus controls. This scoring system could be utilised to predict early mortality and guide management. The average delay to surgery of 4 days (completed) and 11 days (impending fractures) identifies a window to intervene and correct these abnormalities to improve survival

Proximal femoral fractures remain the most common reason for admission to hospital following orthopaedic injury, with an annual cost of £1.7 billion to the National Health Service and social care services. Fragility fractures of the hip in the elderly are a substantial cause of mortality and morbidity. Revision surgery for any cause carries a higher morbidity, mortality, healthcare- and social economic burden. Which patients suffer failed surgery and the reasons for failure have not been established. The aim of this study was to determine which patients are at risk of failed proximal femoral fracture surgery, the mechanism and cause fo failed surgery and modifiable patient factors associated with failure of hip fracture surgery. From prospectively collected data of 795 consecutive proximal femoral fractures admitted between July 2007 and July 2008, all peri-operative and post-operative complications were identified. 55 (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age (p=0.01), smoking (p=0.01) and cannulated screw fixation (p<0.01). Cannulated screw fixation was associated with a 30.9% complication rate. Mechanical cause was the most common reason for cannulated screw failure. Hip hemiarthroplasty most commonly failed by infective causes. Inter-trochanteric and subtrochanteric fracture fixation had very low failure rates. Surgical complication was not found to be associated with an increased mortality but a post-operative medical complication (21.8%) was associated with higher rate of mortality at 4-years (78.5%) and shorter time to mortality. (Median time 0.16 years (95% CI 0.00–0.33)

Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures

Aims. The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up. Patients and Methods. Of the original 250 trial participants, 176 consented to extended follow-up and were sent postal questionnaires at three, four and five years after recruitment to the trial. The Oxford Shoulder Score (OSS; the primary outcome), EuroQol 5D-3L (EQ-5D-3L), and any recent shoulder operations and fracture data were collected. Statistical and economic analyses, consistent with those of the main trial were applied. Results. OSS data were available for 164, 155 and 149 participants at three, four and five years, respectively. There were no statistically or clinically significant differences between operative and non-operative treatment at each follow-up point. No participant had secondary shoulder surgery for a new complication. Analyses of EQ-5D-3L data showed no significant between-group differences in quality of life over time. Conclusion. These results confirm that the main findings of the PROFHER trial over two years are unchanged at five years. Cite this article: Bone Joint J 2017;99-B:383–92

Introduction. The proximal femur fracture in children is rare. Furthermore osteoporotic fracture associated with bone tumor make it difficult to decide the proper management method. The treatment plan should include both the treatment of the fracture and management of the condition responsible for the fracture. However, the reported literatures are rare and vary. Hypothesis. We identified the results of treatment associated with pathologic fracture of proximal femur in children. Material and Method. We retrospectively reviewed 56 patients who had fracture associated with benign bone femur between May 25th, 1995 and Jan. 14th, 2012. The patients’ mean age was 11.7(2–20) years old and follow-up duration was 55.3(5–132) months. Results. Fifty-six children with pathologic proximal femur fracture due to benign tumor were treated by various methods. Surgery consisted with combination of curettage, graft and internal fixation. We had 13(23%) complication. 6(11%) of them was related with fracture and 7(12%) of them was related with tumor. In six, malunion and shortening due to varus deformity developed after follow-up. In seven, recurrence was treated by curettage and internal fixation. There is no case of nonunion. Discussion and Conclusion. To manage the osteoporotic fracture of proximal femur in children, a thorough understanding of the risks associated with it is essential for decision making of increasing successful results

Aims. A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults. . Methods. A cost utility analysis from the NHS perspective was performed. Differences between surgical and non-surgical treatment groups in costs and quality adjusted life years (QALYs) at two years were used to derive an estimate of the cost effectiveness of surgery using regression methods. . Results. Patients randomised to receive surgical intervention accumulated mean greater costs and marginally lower QALYs than patients randomised to non-surgery. The surgical intervention cost a mean of £1758 more per patient (95% confidence intervals (CI) £1126 to £2389). Total QALYs for the surgical group were smaller than those for non-surgery -0.0101 (95% CI -0.13 to 0.11). The probability of surgery being cost effective was less than 10% given the current NICE willingness to pay at a threshold of £20 000 for an additional QALY. The results were robust to sensitivity analyses. Discussion. The results suggest that current surgical treatment is not cost effective for the majority of displaced fractures of the proximal humerus involving the surgical neck in the United Kingdom’s NHS. Take home message: The results of this trial do not support the trend of increased surgical treatment for patients with displaced fractures of the proximal humerus involving the surgical neck within the United Kingdom NHS. Cite this article: Bone Joint J 2016;98-B:152–9

Alpine ski sports changed rapidly in the last decade. Complex fractures of the proximal tibia, typically seen in high energy trauma, has been seen more frequently and more often related to alpine skiing. The aim of our study was to identify reasons for proximal tibia fracture in alpine skiing and observe the outcome. All patients with proximal tibia fractures related to alpine skiing, which were treated in our two trauma centers were included. The patients received a questionnaire at the emergency department, dealing with accident details and the skiing habits. The fractures were classified according to the AO fracture classification scheme. The follow up was performed at least one year after trauma with the Lysholm, the Tegner activity, as well as the WOMAC VAS Score. Between 2007 and 2010 a total of 188 patients with proximal tibia fractures caused by alpine skiing were treated. 43 patients had a type A, 96 patients a type B and 49 a type C injury. The incidence was increasing over the period continuously. The main trauma mechanism was an accident without a third party involvement with an increased rotational and axial compression impact. All outcome scores were related to fracture severity with significant worse results for the type C fractures. In conclusion, proximal tibia fractures are an increasing and serious injury during alpine skiing. Further technical progress in skiing material should focus on these knee injuries in future

We have reviewed retrospectively 80 patients who were treated for traumatic fractures of the femur with a Grosse-Kempf nail to assess the incidence and causes of persisting pain in the proximal thigh. At a mean of 21 months after operation 33 patients had residual pain severe enough to interfere with their lifestyle or mobility. This was in the region of the scar on the greater trochanter in three-quarters of the patients. Only four showed no radiological abnormality. There was nonunion of the fracture in two, Paget’s disease in one, breakage of the nail in two and prominence of the proximal locking screw in five, although we found no correlation between prominence of the nail and pain. There was a strong relationship between pain and heterotopic ossification at the proximal end of the implant; this was present in 64% of the patients with pain as compared with those without pain (p < 0.001, Mann-Whitney U test). Of the 80 patients, 27 had the implant removed after 18 months, 17 of them because of pain. In six of these 17, the pain was not relieved. Prominence of the nail proximally was not associated with pain, but protuberance of laterally-based proximal locking screws caused problems. We found a strong association between heterotopic bone formation and pain, but it is uncertain whether this is the true cause or merely an indication of some other factor such as traumatic damage to the glutei during insertion of the nail. Removal of the implant does not always cure such pain

Title. 3D distribution of cortical bone thickness in the proximal humerus, implications for fracture management. Introduction. CT imaging is commonly used to gain a better understanding of proximal humerus fractures. the operating surgeon however has a limited capacity to evaluate the internal bone geometry from these clinical CT images. our aim was to use clinical CT in a novel way of accurately mapping cortical bone geometry in the proximal humerus. we planned to experimentally define the cortico-cancellous border in a cadaveric study and use CT imaging software to map out cortical thickness distribution in our specimens. Methodology. With ethical approval we used fifteen fresh frozen human proximal humeri. These were stripped of all soft tissue and transverse CT images taken with a GE VCT Lightspeed scanner. The humeral heads were then subsequently resected to allow access to the methaphyseal area. Using currettes, cancellous bone was removed down to hard cortical bone. Another set of CT images of the reamed specimen were then taken. Using Mimics imaging software[Materialise, Leuven] and a CAD interface, 3-matic [Materialise, Leuven], we built 3D model representations of our intact and reamed specimens. We first had to define an accurate CT density threshold for visualising cortical contours. We then analysed cortical thickness distribution based on that experimented threshold. Results. we were able to statistically determine the CT threshold, in Hounsfield Units, that represents the cortico-cancellous interface in the proximal humerus. Our 3D colour models provide an accurate depiction of the distribution of cortical thickness in the proximal humerus. Discussion/Conclusions. Our Hounsfield value for the cortico-cancellous interface in the proximal humerus agrees with a similar range of 400 to 800 HU reported in the literature for the proximal femur. Knowledge of regional variations in cortical bone thickness has direct implications for basic science studies on osteoporosis and its treatment, but is also important for the orthopaedic surgeon since our decision for treatment options is often guided by local bone quality

Aims. The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost. Methods. A detailed inpatient treatment pathway was constructed using semi-structured interviews with 32 members of hospital staff. Its content validity was established through a Delphi panel evaluation. Costs were calculated using time-driven activity-based costing (TDABC) and sensitivity analysis was performed to evaluate the determinants of cost. Results. The mean cost of the different surgical treatments was estimated to be £3282. Although this represented a profit of £1138 against the national tariff, hemiarthroplasty as a treatment choice resulted in a net loss of £952. Choice of implant and theatre staffing were the largest cost drivers. Operating theatre delays of more than one hour resulted in a loss of income. Discussion. Our findings indicate that the national tariff does not accurately represent the cost of treatment for this condition. Effective use of the operating theatre and implant discounting are likely to be more effective cost containment approaches than control of bed-day costs. Take home message: This cost analysis of fractures of the proximal humerus reinforces the limitations of the national tariff within the English National Health Service, and underlines the importance of effective use of the operating theatre, as well as appropriate implant procurement where controlling costs of treatment is concerned. Cite this article: Bone Joint J 2016;98-B:249–59

We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18 709 (£2606.30 to £60.827.10), compared with £8610 (£918.54 to £45 601.30) for uncomplicated cases (p < 0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p < 0.01). Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw

Background. To establish relative fixation strengths of a single lateral locking plate, a double locking plate, and a tibial nail in treatment of proximal tibial extra-articular fractures. Methods. Three groups of composite tibial synthetic bones consisting of 5 specimens per group were included; lateral plating (LP) using a LCP-PLT (locking compression plate-proximal lateral tibia), double plating (DP) using a LCP-PLT and a LCP-MPT (locking compression plate-medial proximal tibia), and intramedullary nailing (IN) using an ETN (expert tibial nail). To simulate a comminuted fracture model, a gap osteotomy measuring 1 cm was cut 8 cm below the joint. For each tibia, a minimal preload of 100N was applied before loading to failure. A vertical load was applied at 25mm/min until tibia failure. Results. For axial loading, fixation strength of DP (14387.3N, SD=1852.1) was 17.5% greater than that of LP (12249.3N, SD=1371.6), and 60% less than that of IN (22879.6N, SD=1578.8) (p<0.001). For ultimate displacement in axial loading, similar results were observed for LP (5.74mm, SD=1.01) and DP (4.45mm, SD=0.96), with a larger displacement for IN (5.84mm, SD=0.99). Conclusion. In biomechanical testing of a comminuted proximal tibial fracture model, DP proved stronger than LP in terms of ultimate strength. IN proved strongest; however, DP may be an acceptable alternative for minimally invasive osteosynthesis, which may be technically difficult to fix using a nail

Secure fixation of displaced proximal fractures of the humerus is a challenging problem. A total of 32 patients with acutely displaced three- or four-part proximal fractures of the humerus were treated by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate. There were 23 women and nine men with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the outcomes were assessed using the Constant score. The mean follow-up was for 11 months (3 to 24). In 31 patients (97%) the fracture united clinically and radiologically at a mean of 10 weeks (8 to 24). The mean Constant score at final review was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients aged more than 60 years (18 patients) with those aged less than 60 years (14 patients) (t-test, p = 0.8443). There was one case each of nonunion, malunion and a broken screw in the elderly population. This plate provides an alternative method of fixation for fractures of the proximal humerus. It provides a stable fixation in young patients with good-quality bone sufficient to permit early mobilisation. Failure of the screws to maintain fixation in the elderly remains a problem