Aims. The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. Methods. We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. Results. Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). Conclusion. This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274–282

Aims. To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. Methods. A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons’ assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen’s kappa and Gwet’s agreement coefficient (AC1). Results. We included 120 fractures in 119 patients. Compared to radiographs, CT increased the sensitivity of detecting unstable trochanteric fractures from 63% to 70% (p = 0.028) and from 70% to 76% (p = 0.004) using AO/OTA and EVJ, respectively. Compared to radiographs alone, CT increased the sensitivity of detecting a large posterolateral trochanter major fragment or a comminuted trochanter major fragment from 63% to 76% (p = 0.002) and from 38% to 55% (p < 0.001), respectively. CT improved intra-rater reliability for stability assessment using EVJ (AC1 0.68 to 0.78; p = 0.049) and for detecting a large posterolateral trochanter major fragment (AC1 0.42 to 0.57; p = 0.031). Conclusion. A preoperative CT of trochanteric fractures increased detection of unstable fractures using the AO/OTA and EVJ classification systems. Compared to radiographs, CT improved intra-rater reliability when assessing fracture stability and detecting large posterolateral trochanter major fragments. Cite this article: Bone Jt Open 2024;5(6):524–531

Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children. We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails. Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome. We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children

Unstable fractures of the forearm in children present problems in management and in the indications for operative treatment. In children, unlike adults, the fractures nearly always unite, and up to 10° of angulation is usually considered to be acceptable. If surgical intervention is required the usual practice in the UK is to plate both bones as in an adult. We studied, retrospectively, 32 unstable fractures of the forearm in children treated by compression plating. Group A (20 children) had conventional plating of both forearm bones and group B (12 children) had plating of the ulna only. The mean age was 11 years in both groups and 23 (71%) of the fractures were in the midshaft. In group B an acceptable position of the radius was regarded as less than 10° of angulation in both anteroposterior (AP) and lateral planes, and with the bone ends hitched. This was achieved by closed means in all except two cases, which were therefore included in group A. Union was achieved in all patients, the mean time being 9.8 weeks in group A and 11.5 weeks in B. After a mean interval of at least 12 months, 14 children in group A and nine in group B had their fixation devices removed. We analysed the results after the initial operation in all 32 children. The 23 who had the plate removed were assessed at final review. The results were graded on the ability to undertake physical activities and an objective assessment of loss of rotation of the forearm. In group A, complications were noted in eight patients (40%) after fixation and in six (42%) in relation to removal of the radial plate. No complications occurred in group B. The final range of movement and radiological appearance were compared in the two groups. There was a greater loss of pronation than supination in both. There was, however, no limitation of function in any patient and no difference in the degree of rotational loss between the two groups. The mean radiological angulation in both was less than 10° in both AP and lateral views, which was consistent with satisfactory function. The final outcome for 23 patients was excellent or good in 12 of 14 (90%) in group A, despite the complications, and in eight of nine in group B (90%). If reduction and fixation of the fracture of the ulna alone restores acceptable alignment of the radius in unstable fractures of the forearm, operation on the radius can be avoided

A randomised, prospective study was carried out on 60 patients with unstable fractures of the distal radius to compare bridging with non-bridging external fixation using pins placed in the distal fragment of the radius. The radiological results showed significant improvement in the non-bridging group at all stages of review. In particular, normal volar tilt and carpal alignment were regained and maintained. The functional results at six weeks, three months, six months and one year showed statistically better grip strength and flexion in the non-bridging group at all stages of review. Other ranges of movement showed an early advantage in the non-bridging group. Non-bridging external fixation is the treatment of choice for unstable fractures of the distal radius which have sufficient space for the placement of pins in the distal fragment

Forty comminuted or unstable fractures of the femoral shaft were treated by closed intramedullary reaming and locked nailing. Twenty-four fractures were severely comminuted, and the other 16, in the distal or proximal third of the shaft, were classified as unstable. At 12 to 30 months postoperatively all the fractures had healed. Three patients had lateral rotation deformity of 5 degrees to 10 degrees, three had shortening of 1 to 2 cm and two had lengthening of about 1 cm. There were no infections or delayed unions. Closed intramedullary locked nailing can provide stability in fractures of the femoral shaft, irrespective of the degree of comminution and the site of injury

Introduction. Unstable dorsal fracture/dislocation of PIP joint is a complex injury and difficult to treat. Different treatment methods have been described with varying results. We describe a novel technique to combine fracture fixation with volar plate repair using micro anchor suture. Material and methods. Between July and December 2005, 11 consecutive patients with unstable dorsal PIP joint dislocations underwent open reduction and volar plate repair using our technique. Nine patients had dorsal fracture dislocations and two had open dislocations. All patients were males and their average age was 26 years. All patients were reviewed with the minimum follow up of 12 months. The pain score, range of movements and grip strength were recorded and compared to the normal side. Operative Technique. Volar approach was made using a semi Brunar incision. One or two micro bioabsorbable anchors (Mitek, Ethicon Ltd, UK) were used to stabilise the joint and repair the volar plate. Additional anchor was used to repair the collateral ligament when indicated. Post-operatively the hand was rested in Edinburgh functional splint for 10 days followed by active and assisted range of movements under hand physiotherapist supervision. Results. 10 out 11 patients had excellent pain relief. The average range of movement of the PIP joint was 100 degrees. One patient with neglected PIP joint fracture dislocation for 10 weeks had mild residual pain and stiffness. The mean grip strength was 87% of that of contralateral normal side. All patients returned to their same work as before. 8 out of 9 patients returned to play their regular sports at the same level. All patients were satisfied with the functional outcome. Conclusion. Combined fracture fixation and volar plate repair through anterior approach using micro bioabsorbable anchors appears to be very effective way of treating this otherwise complex unstable fracture/dislocation of PIP joint

We describe a new technique for open reduction, bone grafting and fixation with a single Kirschner wire of unstable fractures of the distal radius. Of the 83 patients treated by this technique, most had regained volar tilt when seen at an average of 13 months after injury. Malunion was seen in 18 patients due either to poor placement of the graft and Kirschner wire or because of both volar and dorsal comminution. Assessment of hand and wrist function showed an average recovery of 63% of mass grip strength with an excellent return of specialised grip strength and range of movement. The advantages of this technique over closed methods include the ability to regain the volar tilt of the distal radius and to achieve reduction at any time before union of the fracture

The Roger Anderson external fixator was used in the treatment of unstable fractures of the distal radius in 52 patients, and the results evaluated after a follow-up averaging 58 months. The indications for its use were failure to maintain adequate closed reduction using plaster, and instability of the fracture as determined by the initial radiographs. Our radiological criteria for instability included dorsal angulation of more than 20 degrees, fractures involving the joint, radial shortening of more than 10 mm, and severe dorsal comminution. Using the Lucas modification of the Sarmiento demerit point-rating system, we found that 46 patients (89%) had good or excellent results and six (11%) were classified as fair. There were no poor results. Seven patients (14%) developed complications. None of these affected the long-term results except in one elderly woman where the pins loosened and had to be removed

Introduction:. Early stabilization has the potential to expedite early return to function and reduce hospital stay thus reducing cost to health care. A clinical audit was performed to test the hypothesis that early surgical stabilization lowers the rate of soft tissue complications and is not influenced by choice of distal fibular implants used for stabilization of ankle fractures. Methods:. All surgically treated adult patients with isolated unstable ankle fracture were included from April 2012 to April 2013 at a MTC in UK. Patients with poly-trauma were excluded. All patients underwent a standard surgical protocol: aim for early definitive surgical fixation (ORIF) within 24 hours however if significantly swollen than temporary stabilization with an external fixation followed by a staged definitive fixation. Results:. In total 172 consecutive unstable ankle fractures were included in one-year study period. Definitive fixation (ORIF) was achieved in 91% patients with only 9% patients required temporary stabilization with external fixation. Fibular locking plates were used in 59(38%) patients compared to conventional one-third tubular plates in 91(60%) patients. In ORIF group 42% (73) patients were operated within 24 hours of admission whilst 58% (83) under went early fixation after 24–72 hours. At one year follow up complications were recorded in 18(11%) patients including metal irritation requiring removal of implant in 6(4%) patients. Wound complications and deep infection leading to a further surgical procedure in 8(5%) patients. There was no statistical difference between complication rates (p=0.016) in early versus delayed fixation groups. Fibular locking plates were associated with higher soft tissue complications (13%) as compared with conventional plates (2%) (p=0.004). Conclusion:. Our study showed that the timing of the surgery has less influence on the complications of the ankle fracture fixation. However choice of implants requires careful consideration and we suggest caution against use of current fibular locking plates

Five consecutive unstable fractures of the distal third of the clavicle were treated by indirect open reduction and internal fixation using a temporary Bosworth-type screw. Coracoclavicular fixation provided and maintained reduction of the fracture. Healing occurred uneventfully within nine weeks in all cases. The screw was removed under local anaesthesia after healing of the fracture and there were no surgical complications. Shoulder function was restored to the pre-injury level. Temporary coracoclavicular screw fixation appears to be a valuable alternative for the treatment of type II fractures of the distal third of the clavicle

We evaluated the biomechanical properties of two different methods of fixation for unstable fractures of the proximal humerus. Biomechanical testing of the two groups, locking plate alone (LP), and locking plate with a fibular strut graft (LPSG), was performed using seven pairs of human cadaveric humeri. Cyclical loads between 10 N and 80 N at 5 Hz were applied for 1 000 000 cycles. Immediately after cycling, an increasing axial load was applied at a rate of displacement of 5 mm/min. The displacement of the construct, maximum failure load, stiffness and mode of failure were compared. The displacement was significantly less in the LPSG group than in the LP group (p = 0.031). All maximum failure loads and measures of stiffness in the LPSG group were significantly higher than those in the LP group (p = 0.024 and p = 0.035, respectively). In the LP group, varus collapse and plate bending were seen. In the LPSG group, the humeral head cut out and the fibular strut grafts fractured. No broken plates or screws were seen in either group. We conclude that strut graft augmentation significantly increases both the maximum failure load and the initial stiffness of this construct compared with a locking plate alone

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group

Aims

The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups.

Aims. Evaluate if treating an unstable femoral neck fracture with a locking plate and spring-loaded telescoping screw system would improve construct stability compared to gold standard treatment methods. Methods. A 31B2 Pauwels’ type III osteotomy with additional posterior wedge was cut into 30 fresh-frozen femur cadavers implanted with either: three cannulated screws in an inverted triangle configuration (CS), a sliding hip screw and anti-rotation screw (SHS), or a locking plate system with spring-loaded telescoping screws (LP). Dynamic cyclic compressive testing representative of walking with increasing weight-bearing was applied until failure was observed. Loss of fracture reduction was recorded using a high-resolution optical motion tracking system. Results. LP constructs demonstrated the highest mean values for initial stiffness and failure load. LP and SHS constructs survived on mean over 50% more cycles and to loads 450 N higher than CS. During the early stages of cyclic loading, mean varus collapse of the femoral head was 0.5° (SD 0.8°) for LP, 0.7° (SD 0.7°) for SHS, and 1.9° (SD 2.3°) for CS (p = 0.071). At 30,000 cycles (1,050 N) mean femoral neck shortening was 1.8 mm (SD 1.9) for LP, 2.0 mm (SD 0.9) for SHS, and 3.2 mm (SD 2.5) for CS (p = 0.262). Mean leg shortening at construct failure was 4.9 mm (SD 2.7) for LP, 8.9 mm (SD 3.2) for SHS, and 7.0 mm (SD 4.3) for CS (p = 0.046). Conclusion. Use of the LP system provided similar (hip screw) or better (cannulated screws) biomechanical performance as the current gold standard methods suggesting that the LP system could be a promising alternative for the treatment of unstable fractures of the femoral neck. Cite this article: Bone Joint Res 2020;9(6):314–321

Aims. There are concerns regarding nail/medullary canal mismatch and initial stability after cephalomedullary nailing in unstable pertrochanteric fractures. This study aimed to investigate the effect of an additional anteroposterior blocking screw on fixation stability in unstable pertrochanteric fracture models with a nail/medullary canal mismatch after short cephalomedullary nail (CMN) fixation. Methods. Eight finite element models (FEMs), comprising four different femoral diameters, with and without blocking screws, were constructed, and unstable intertrochanteric fractures fixed with short CMNs were reproduced in all FEMs. Micromotions of distal shaft fragment related to proximal fragment, and stress concentrations at the nail construct were measured. Results. Micromotions in FEMs without a blocking screw significantly increased as nail/medullary canal mismatch increased, but were similar between FEMs with a blocking screw regardless of mismatch. Stress concentration at the nail construct was observed at the junction of the nail body and lag screw in all FEMs, and increased as nail/medullary canal mismatch increased, regardless of blocking screws. Mean stresses over regions of interest in FEMs with a blocking screw were much lower than regions of interest in those without. Mean stresses in FEMs with a blocking screw were lower than the yield strength, yet mean stresses in FEMs without blocking screws having 8 mm and 10 mm mismatch exceeded the yield strength. All mean stresses at distal locking screws were less than the yield strength. Conclusion. Using an additional anteroposterior blocking screw may be a simple and effective method to enhance fixation stability in unstable pertrochanteric fractures with a large nail/medullary canal mismatch due to osteoporosis. Cite this article: Bone Joint Res 2022;11(3):152–161

Aims. Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care. Methods. This trial is a pragmatic, multicentre, randomized non-inferiority clinical trial with an embedded pilot, and with 12 months clinical follow-up and parallel economic analysis. A surveillance study using routinely collected data will be performed annually to five years post-treatment. Adult patients, aged 60 years and younger, with unstable ankle fractures will be identified in daily trauma meetings and fracture clinics and approached for recruitment prior to their treatment. Treatments will be performed in trauma units across the UK by a wide range of surgeons. Details of the surgical treatment, including how the operation is done, implant choice, and the recovery programme afterwards, will be at the discretion of the treating surgeon. The non-surgical treatment will be close-contact casting performed under anaesthetic, a technique which has gained in popularity since the publication of the Ankle Injury Management (AIM) trial. In all, 890 participants (445 per group) will be randomly allocated to surgical or non-surgical treatment. Data regarding ankle function, QoL, complications, and healthcare-related costs will be collected at eight weeks, four and 12 months, and then annually for five years following treatment. The primary outcome measure is patient-reported ankle function at four months from treatment. Anticipated impact. The 12-month results will be presented and published internationally. This is anticipated to be the only pragmatic trial reporting outcomes comparing surgical with non-surgical treatment in unstable ankle fractures in younger adults (aged 60 years and younger), and, as such, will inform the National Institute for Health and Care Excellence (NICE) ‘non-complex fracture’ recommendations at their scheduled update in 2024. A report of long-term outcomes at five years will be produced by January 2027. Cite this article: Bone Jt Open 2024;5(3):184–201

The purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°.

The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.