Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation as compared to straight plates. Aims:(1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus. (2) to assess and compare their distances to adjacent anatomical structures at risk. MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated. None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1-3) in group1, 7(2-11) in group2, 14(7-25) in group3 and 6(3-8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8-28) in group1, 11(7-18) in group2, 3(2-4) in group3 and 6(3-8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18-23) in group1, 7(6-7) in group2, 4(3-5) in group3 and 7(6-7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021. MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Anterior parts of the deltoid insertion will be detached using 90°-helical and ALPS implants in MIPO-technique

Objectives. Healing in cancellous metaphyseal bone might be different from midshaft fracture healing due to different access to mesenchymal stem cells, and because metaphyseal bone often heals without a cartilaginous phase. Inflammation plays an important role in the healing of a shaft fracture, but if metaphyseal injury is different, it is important to clarify if the role of inflammation is also different. The biology of fracture healing is also influenced by the degree of mechanical stability. It is unclear if inflammation interacts with stability-related factors. Methods. We investigated the role of inflammation in three different models: a metaphyseal screw pull-out, a shaft fracture with unstable nailing (IM-nail) and a stable external fixation (ExFix) model. For each, half of the animals received dexamethasone to reduce inflammation, and half received control injections. Mechanical and morphometric evaluation was used. Results. As expected, dexamethasone had a strong inhibitory effect on the healing of unstable, but also stable, shaft fractures. In contrast, dexamethasone tended to increase the mechanical strength of metaphyseal bone regenerated under stable conditions. Conclusions. It seems that dexamethasone has different effects on metaphyseal and diaphyseal bone healing. This could be explained by the different role of inflammation at different sites of injury. Cite this article: Bone Joint Res 2015;4:170–175

The primary aim was to assess the reliability of ultrasound in the assessment of humeral shaft fracture healing. The secondary aim was to estimate the accuracy of ultrasound assessment in predicting humeral shaft nonunion.

Twelve patients (mean age 54yrs [20–81], 58% [n=7/12] female) with a non-operatively managed humeral diaphyseal fracture were prospectively recruited and underwent ultrasound scanning at six and 12wks post-injury. Scans were reviewed by seven blinded observers to evaluate the presence of sonographic callus. Intra- and inter-observer reliability were determined using the weighted kappa and intraclass correlation coefficient (ICC). Accuracy of ultrasound assessment in nonunion prediction was estimated by comparing scans for patients that united (n=10/12) with those that developed a nonunion (n=2/12).

At both six and 12wks, sonographic callus was present in 11 patients (10 united, one developed a nonunion) and sonographic bridging callus (SBC) was present in seven patients (all united). Ultrasound assessment demonstrated substantial intra- (6wk kappa 0.75, 95% CI 0.47-1.03; 12wk kappa 0.75, 95% CI 0.46-1.04) and inter-observer reliability (6wk ICC 0.60, 95% CI 0.38-0.83; 12wk ICC 0.76, 95% CI 0.58-0.91). Absence of sonographic callus demonstrated a sensitivity of 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (accuracy 92%). Absence of SBC demonstrated a sensitivity of 100%, specificity 70%, PPV 40% and NPV 100% (accuracy 75%). Of three patients at risk of nonunion based on reduced radiographic callus formation (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (and united) and the other two had non-bridging or absent sonographic callus (both developed a nonunion).

Ultrasound assessment of humeral shaft fracture healing was reliable and predictive of nonunion, and may be a useful tool in defining the risk of nonunion among patients with reduced radiographic callus formation.

Tibial shaft fractures require surgical stabilization preferably by intramedullary nailing. However, patients often report functional limitations even years after the injury. This study investigates the influence of the surgical approach (transpatellar vs. parapatellar) on gait performance and patient reported outcome six months after surgery. Twenty-two patients with tibial shaft fractures treated by intramedullary nailing through a transpatellar approach (TP: n=15, age 41±15, BMI 24±3) or a parapatellar approach (PP: n=7, age 34±15, BMI 23±2) and healthy, matched controls (n=22, age 39±13, BMI 24±2) were assessed by instrumented motion analysis six months after intramedullary nailing. Short musculoskeletal function assessment questionnaire (SMFA) as well as kinematic and kinetic gait data were collected during level walking. Comparisons among approach methods and control group were performed by analysis of variance and Mann-Whitney test. Six months after surgery, knee kinetics in both groups differed significantly compared to controls (p <.04). The approach method affected gait speed (TP: p = .002; PP: p = .08) and knee kinematics in the early stance phase (TP: p = .011; PP: p = .082), with the parapatellar approach showing a more favorable outcome. However, the difference between patient groups was not significant for any of the assessed gait parameters (p > .2). Also, no differences could be found in the bother index (BI) or function index (FI) of SMFA between surgical approach methods (BI: TP: Mdn = 7.2, PP: Mdn = 9.4; FI: TP: Mdn = 10.3, PP: Mdn = 9.2, p > .7). Our study demonstrates, that six months after surgery for tibial shaft fractures functional limitations remain. These limitations appear not to be different for either a trans- or a parapatellar approach for the insertion of the intramedullary nail. The findings of this study are limited by the relatively short follow up time period and small number of patients. Future studies should investigate the source of the functional limitation after intramedullary nailing of tibial shaft fractures

Proximal humeral shaft fractures are commonly treated with long straight locking plates endangering the radial nerve distally. The aim of this study was to investigate the biomechanical competence in a human cadaveric bone model of 90°-helical PHILOS plates versus conventional straight PHILOS plates in proximal third comminuted humeral shaft fractures. Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (group1) or a straight long PHILOS plate (group2). An unstable proximal humeral shaft fracture was simulated by means of an osteotomy maintaining a gap of 5cm. All specimens were tested under quasi-static loading in axial compression, internal and external rotation as well as bending in 4 directions. Subsequently, progressively increasing internal rotational loading until failure was applied and interfragmentary movements were monitored by means of optical motion tracking. Flexion/extension deformation (°) in group1 was (2.00±1.77) and (0.88±1.12) in group2, p=0.003. Varus/valgus deformation (°) was (6.14±1.58) in group1 and (6.16±0.73) in group2, p=0.976. Shear (mm) and displacement (°) under torsional load were (1.40±0.63 and 8.96±0.46) in group1 and (1.12±0.61 and 9.02±0.48) in group2, p≥0.390. However, during cyclic testing shear and torsional displacements and torsion were both significantly higher in group 1, p≤0.038. Cycles to catastrophic failure were (9960±1967) in group1 and (9234±1566) in group2, p=0.24. Although 90°-helical plating was associated with improved resistance against varus/valgus deformation, it demonstrated lower resistance to flexion/extension and internal rotation as well as higher flexion/extension, torsional and shear movements compared to straight plates. From a biomechanical perspective, 90°-helical plates performed inferior compared to straight plates and alternative helical plate designs with lower twist should be investigated in future paired cadaveric studies

Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures. The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation. 42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes. All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group. The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008). When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment. Trial registration number: ClinicalTrials.gov NCT03067454

Implant manufacturers develop new products to improve existing fracture fixation methods or to approach new fracture challenges. New implants are commonly tested and approved with respect to their corresponding predecessor products, because the knowledge about the internal forces and moments acting on implants in the human body is unclear. The aim of this study was to evaluate and validate implant internal forces and moments of a complex physiological loading case and translate this to a standard medical device approval test. A finite elements model for a transverse femur shaft fracture (AO/OTA type 32-B2) treated with a locked plate system (AxSOS 3 Ti Waisted Compression Plate Broad, Stryker, Kalamazoo, USA) was developed and experimentally validated. The fractured construct was physiologically loaded by resulting forces on the hip joint from previously measured in-vivo loading experiments (Bergmann et. al). The forces were reduced to a level where the material response in the construct remained linear elastic. Resulting forces, moments and stresses in the implant of the fractured model were analysed and compared to the manufacturers’ approval data. The FE-model accurately predicted the behaviour of the whole construct and the micro motion of the working length of the osteosynthesis. The resulting moment reaction in the working length was 24 Nm at a load of 400 N on the hip. The maximum principle strains on the locking plate were predicted well and did not exceed 1 %. In this study we presented a protocol by the example of locked plated femur shaft fracture to calculate and validate implant internal loading using finite element analysis of a complex loading. This might be a first step to move the basis of development of new implants from experience from previous products to calculation of mechanical behaviour of the implants and therefore, promote further optimization of the implants’ design

Proximal humeral shaft fractures are commonly treated with long straight plates or intramedullary nails. Helical plates might overcome the downsides of these techniques as they are able to avoid the radial nerve distally. The aim of this study was to investigate in an artificial bone model: (1) the biomechanical competence of different plate designs and (2) to compare them against the alternative treatment option of intramedullary nails. Twenty-four artificial humeri were assigned in 4 groups and instrumented as follows: group1 (straight 10-hole-PHILOS), group2 (MULTILOCK-nail), group3 (45°-helical-PHILOS) and group4 (90°-helical-PHILOS). An unstable proximal humeral shaft fracture was simulated. Specimens were tested under quasi-static loading in axial compression, internal/external rotation and bending in 4 directions monitored by optical motion tracking. Axial displacement (mm) was significantly lower in group2 (0.1±0.1) compared to all other groups (1: 3.7±0.6; 3: 3.8±0.8; 4: 3.5±0.4), p<0.001. Varus stiffness in group2 (0.8±0.1) was significantly higher compared to groups1+3, p≤0.013 (1: 0.7±0.1; 3: 0.7±0.1; 4: 0.8±0.1). Varus bending (°) was significantly lower in group2 compared to all other groups (p<0.001) and group4 to group1, p=0.022. Flexion stiffness in group1 was significantly higher compared to groups2+4 (p≤0,03) and group4 to group1, p≤0,029 (1: 0.8±0.1; 2: 0.7±0.1; 3: 0.7±0.1; 4: 0.6±0.1). Flexion bending (°) in group4 was higher compared to all other groups (p≤0.024) and lower in group2 compared to groups1+4, p≤0.024. Torsional stiffness remained non significantly different, p≥0.086. Torsional deformation in group2 was significantly higher compared to all other groups, p≤0.017. Shear displacement remained non significantly different, p≥0.112. From a biomechanical perspective, helical plating with 45° and 90° may be considered as a valid alternative fixation technique to standard straight plating of proximal third humeral fractures. Intramedullary nails demonstrated higher axial and bending stiffness as well as lower fracture gap movements during axial loading compared to all plate designs. However, despite similar torsional stiffness they were associated with higher torsional movements during internal/external rotation as compared to all investigated plate designs

The aim of this study was to perform a systematic review of the literature on Gustilo-Anderson (GA) type IIIB open tibial shaft (AO-42) injuries to determine the consistency of reporting in the literature. A search of PubMed, EMBASE and Cochrane Central Register of Controlled Trials was performed to identify relevant studies published from January 2000 to January 2021 using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The study was registered using the PROSPERO International prospective register of systematic reviews. Patient/injury demographics, management and outcome reporting were recorded. There were 32 studies that met the inclusion criteria with a total of 1,947 patients (70.3% male, 29.7% female). There were 6 studies (18.8%) studies that reported on comorbidities and smoking, with mechanism of injury reported in 22 (68.8%). No studies reported on all operative criteria included, with only three studies (9.4%) reporting for time to antibiotics, 14 studies (43.8%) for time from injury to debridement and nine studies (28.1%) for time to definitive fixation. All studies reported on the rate of deep infection, with a high proportion documenting union rate (26/32, 81.3%). However, only two studies reported on mortality or on other post-operative complications (2/32, 6.3%). Only 12 studies (37.5%) provided any patient reported outcomes. This study has demonstrated a deficiency and a lack of standardized variable and outcome reporting in the orthopaedic literature for Gustilo-Anderson type IIIB open tibial shaft fractures. We propose a future international collaborative Delphi process is needed to standardize

Virtual mechanical testing is a method for measuring bone healing using finite element models built from computed tomography (CT) scans. Previously, we validated a dual-zone material model for ovine fracture callus that differentiates between mineralized woven bone and soft tissue based on radiodensity. 1. The objective of this study was to translate the dual-zone material model from sheep to two important clinical scenarios: human tibial fractures in early-stage healing and late-stage nonunions. CT scans for N = 19 tibial shaft fractures were obtained prospectively at 12 weeks post-op. A second group of N = 33 tibial nonunions with CT scans were retrospectively identified. The modeling techniques were based on our published method. 2. The dual-zone material model was implemented for humans by performing a cutoff sweep for both the 12-week and nonunion groups. Virtual torsional rigidity (VTR) was calculated as VTR = ML/φ [N-m. 2. /°], where M is the moment reaction, L is the diaphyseal segment length, and φ is the angle of twist. As the soft tissue cutoff was increased, the rigidity of the clinical fractures decreased and soft tissue located within the fracture gaps produced higher strains that are not predicted without the dual zone approach. The structural integrity of the nonunions varied, ranging from very low rigidities in atrophic cases to very high rigidities in highly calcified hypertrophic cases, even with dual-zone material modeling. Human fracture calluses are heterogeneous, comprising of woven bone and interstitial soft tissue. Use of a dual-zone callus material model may be instrumental in identifying delayed unions during early healing when callus formation is minimal and/or predominantly fibrous with little mineralization. ACKNOWLEDGEMENTS:. This work was supported by the National Science Foundation (NSF) grant CMMI-1943287

Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and optimized plate-to-bone fit design. On the other hand, mini-fragment plates used in dual plating mode have demonstrated promising clinical results. However, these two bone-implant constructs have not been investigated biomechanically in a human cadaveric model. Therefore, the aim of the current study was to compare the biomechanical competence of single superior plating using the new generation plate versus dual plating with low-profile mini-fragment plates. Sixteen paired human cadaveric clavicles were assigned pairwise to two groups for instrumentation with either a 2.7 mm Variable Angle Locking Compression Plate placed superiorly (Group 1), or with one 2.5 mm anterior plate combined with one 2.0 mm superior matrix mandible plate (Group 2). An unstable clavicle shaft fracture AO/OTA15.2C was simulated by means of a 5 mm osteotomy gap. All specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis and monitored via motion tracking. Initial stiffness was significantly higher in Group 2 (9.28±4.40 N/mm) compared to Group 1 (3.68±1.08 N/mm), p=0.003. The amplitudes of interfragmentary motions in terms of craniocaudal and shear displacement, fracture gap opening and torsion were significantly bigger over the course of 12500 cycles in Group 1 compared to Group 2; p≤0.038. Cycles to 2 mm shear displacement were significantly lower in Group 1 (22792±4346) compared to Group 2 (27437±1877), p=0.047. From a biomechanical perspective, low-profile 2.5/2.0 dual plates demonstrated significantly higher initial stiffness, less interfragmentary movements, and higher resistance to failure compared to 2.7 single superior variable-angle locking plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation especially in unstable fracture configurations

Implant removal after clavicle plating is common. Low-profile dual mini-fragment plate constructs are considered safe for fixation of diaphyseal clavicle fractures. The aim of this study was to investigate: (1) the biomechanical competence of different dual plate designs from stiffness and cycles to failure, and (2) to compare them against 3.5mm single superoanterior plating. Twelve artificial clavicles were assigned to 2 groups and instrumented with titanium matrix mandible plates as follows: group 1 (G1) (2.5mm anterior+2.0mm superior) and group 2 (G2) (2.0mm anterior+2.0mm superior). An unstable clavicle shaft fracture (AO/OTA15.2C) was simulated. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with torsion around the shaft axis and compared to previous published data of 6 locked superoanterior plates tested under the same conditions (G3). Displacement (mm) after 5000 cycles was highest in G3 (10.7±0.8) followed by G2 (8.5±1.0) and G1 (7.5±1.0), respectively. Both outcomes were significantly higher in G3 as compared to both G1 and G2 (p≤0.027). Cycles to failure were highest in G3 (19536±3586) followed by G1 (15834±3492) and G2 (11104±3177), being significantly higher in G3 compared to G2 (p=0.004). Failure was breakage of one or two plates at the level of the osteotomy in all specimens. One G1 specimen demonstrated failure of the anterior plate. Both plates in other G1 specimens. Majority of G2 had fractures in both plates. No screw pullout or additional clavicle fractures were observed among specimens. Low-profile 2.0/2.0 dual plates demonstrated similar initial stiffness compared to 3.5mm single plates, however, had significantly lower failure endurance. Low-profile 2.5/2.0 dual plates showed significant higher initial stiffness and similar resistance to failure compared to 3.5mm single locked plates and can be considered as a useful alternative for diaphyseal clavicle fracture fixation. These results complement the promising results of several clinical studies

Abstract. Objectives. The need to accurately forecast the injury burden has never been higher. With an aging, ever expanding trauma population and less than half of the beds available compared to 1990, the National Health Service (NHS) is stretched to breaking point1,2. Resultantly, we aimed to determine whether it is possible to predict the proportionality of injuries treated operatively within orthopaedic departments based on their number of Neck of Femur fracture (NOF) patients reported both in our study and the National Hip Fracture Database (NHFD). Methods. We utilised the ORthopaedic trauma hospital outcomes - Patient operative delays (ORTHOPOD) dataset of 22,585 trauma patients across the four countries of the United Kingdom (UK) admitted to 83 hospitals between 22/08/22 – 16/10/22. This dataset had two arms: arm one was assessing the caseload and theatre capacity, arm two assessed the patient, injury and management demographics. Results. Our results complied with the data reported to the NHFD in over 80% of cases for both the 2022 and five-year average reported numbers. More operations were performed for elderly hip fractures alone than for the combined totals of the next four most common fractures: ankle, distal radius, tibial shaft and forearm (6387 vs 5922). Conversely, 10 out of the 13 fracture types were not encountered by at least one hospital and 93% of hospitals encountered less than 2 fractures of a certain type.60% of trauma is treated within Trauma Units (TUs) however, per unit, Major Trauma Centres (MTCs) treat approximately 43% more patients. Similarly, 11 out of the 14 fracture types examined presented more frequently to a MTC however 3 of the most common fractures had a preponderance for TUs (elderly hip, distal radius and forearm fractures). After excluding NOF, lower limb fractures accounted for approximately 57% of fractures in all countries and ankle and distal radius fracture combined comprised more than 50% in 74% of regions. There were few outliers across the study regarding number of fractures treated by a hospital with tibial shaft fractures demonstrating the highest number of outliers with 4. Conclusions. The number of hip fractures seen on average by an individual unit remains relatively consistent as does the regional variation of any given fracture; resultantly, it is possible to predict injury proportionality based off a unit's hip fracture numbers. This powerful tool could transform both resource allocation and recruitment. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Femoral shaft fractures are potentially devastating injuries. Despite this, clinical studies of the biomechanics of this injury are lacking. We aimed to clinically evaluate bone behaviour under high and low energy trauma in paediatric, adult and older patients. Single-centre retrospective study identifying all diaphyseal femoral fractures between Feb 2015-Feb 2017. Peri-prosthetic and pathological fractures were excluded. Patients were subdivided into groups 1 (paediatric, <16yo), 2 (adult, 17–55yo) and 3 (older, >55yo) to reflect immature, peak bone age and osteoporotic bone respectively. Chi-Squared analysis assessed significance of bone age to degree of comminution and fracture pattern. A p-value <0.05 was significant. A total 4130 radiographs were analysed with 206 femoral shaft fractures identified. Forty-three patients were excluded with 163 remaining. Group 1, 2 and 3 included 38, 37 and 88 patients respectively. Mean age 50.8 (SD 32.8) with male-to-female ratio of 1:1.2. Groups 1 and 3 included majority simple fractures (35/38 and 62/88 respectively). Group 2 included more comminuted injuries (33/37). Bone age to degree of comminution proved significant (p<0.05) with a bimodal distribution of simple fractures noted in groups 1 and 3. Energy to fracture was significant in group 2, where a high energy injury was associated with comminution (p<0.05). This study is the first to demonstrate an association between fracture comminution and age. Simple femoral shaft fractures showed a bimodal age distribution in paediatric and older patients regardless of mechanism energy. High energy mechanism trauma was directly related to fracture comminution at peak bone age

Abstract. Objectives. Three-dimensional visualisation of sonographic callus has the potential to improve the accuracy and accessibility of ultrasound evaluation of fracture healing. The aim of this study was to establish a reliable method for producing three-dimensional reconstruction of sonographic callus. Methods. A prospective cohort of ten patients with a closed tibial shaft fracture managed with intramedullary nailing were recruited and underwent ultrasound scanning at 2-, 6- and 12-weeks post-surgery. Ultrasound B-mode capture was performed using infrared tracking technology to map each image to a three-dimensional lattice. Using echo intensity, semi-automated mapping was performed by two independent reviewers to produce an anatomic three-dimensional representation of the fracture. Agreement on the presence of sonographic bridging callus on three-dimensional reconstructions was assessed using the kappa coefficient. Results. Nine of the ten patients achieved union at six months. At six weeks, seven patients had bridging callus at ≥1 cortex on the three-dimensional reconstruction; when present all united. Compared to radiographs, no bridging callus was present in any patient. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8%-sensitive and 100%-specific to predict union). At twelve weeks, nine patients had bridging callus at ≥1 cortex on three-dimensional reconstruction and all united (100%-sensitive and 100%-specific to predict union). Compared to radiographs, seven of the nine patients that united had bridging callus. Three-dimensional reconstruction of the anteromedial and anterolateral tibial surface was achieved in all patients, and detection of sonographic bridging callus on the three-dimensional reconstruction demonstrated substantial inter-observer agreement (kappa=0.78, 95% confidence interval 0.29–1.0, p=0.011). Conclusions. Three-dimensional fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to identify impaired healing at an early stage in fracture management. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. 1. To describe the epidemiology of metacarpal shaft fractures (MSF) in adults. 2. To evaluate the variation in practice and document complications following usual care. 3. To explore factors associated with treatment modality. 4. To document hospital resource use following MSF. Methods. A multi-centre, retrospective, cross-sectional study of MSF at six centres. The healthcare records, operative notes and imaging of adults presenting within 10 days of a MSF, affecting the second to fifth metacarpal between 1st August 2016 to 31st July 2017, were reviewed. Total number of Emergency Department (ED) attendances were used to calculate prevalence. Data analyses are primarily descriptive with 95% confidence intervals to quantify uncertainty in estimates. Results. Of 837, 212 ED attendances, 793 patients (75% male, 25% female), with 897 MSF were eligible, a prevalence of 0.1%. The median age was 27 years (16–97); the highest incidence was in males aged between 16 and 24 years. The most common fracture pattern was transverse. While 83% were treated non-surgically overall, this varied across centres. Twelve different types of non-surgical and six different types of surgical treatment were used. Multi-fragmentary fracture patterns were most likely to be treated surgically and long oblique least likely. Fracture pattern, complexity, displacement and age were associated with treatment modality. Patients treated surgically required more radiographs, longer radiographic and outpatient follow-up and were more likely to be referred for therapy. 5% (39/793) experienced a complication. 20% (160/783) failed to attend at least one or more clinic appointments. Conclusions. MSF are a common injuries, predominantly affecting young males of working age. There is variation in mode and type of treatment, with the majority treated non-surgically in the selected centres. Despite a low complication rate, they require considerable secondary care resources. Further research into the optimal treatment modality for these injuries is needed. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. Polytrauma patients are at high risk of systematic inflammatory response syndrome (SIRS) due to an exaggerated unbalanced immune response that can lead to multiple organ failure and increased mortality. This response is often heightened following acute surgical management as a result, damage-control orthopaedics (DCO) was born. This allows the patient to be stabilised using external fixation allowing physiology to improve. This systematic review aims to compare DCO against early total care (ETC) (<24hrs intramedullary nailing) in polytraumatised patients with femoral shaft fractures using a diagnosis of acute lung injury (ALI) as the primary outcome measure. Method. A systematic review of MEDLINE, EMBASE, CENTRAL and AMED was carried out to identify all English language studies comparing ETC versus DCO using ALI as the primary outcome measure. Two authors independently screened the studies and performed data extraction. Risk of bias was assessed using the Cochrane risk of bias tool and the Risk-of-Bias Assessment Tool for Non-randomised Studies. Results. Three studies were selected for final inclusion. One multicentre RCT demonstrated a significantly higher odds ratio (6.69) of ALI in the subgroup receiving ETC compared to DCO. The two other studies were retrospective case series with one reporting no significant difference and the second study reporting a significant reduction in ARDS when a DCO approach was used (7.8% vs 15.1%). Meta-analysis was not possible due to heterogeneity. Conclusions. This review supports evidence that in the more unstable patients (Injury Severity Score≥30) treated surgically for femoral shaft fractures in the first 24 hours, DCO may have a protective effect over ETC for ALI. However further studies with large sample sizes are needed to provide clarity on the subject area. Level of Evidence. 1. Ethics. No approval required given the nature of this study (systematic review)

Background. Intramedullary nailing is a widely accepted treatment method for femoral fractures. Failure of locking screws is often a threatening complication, particularly on comminuted fractures. For comminuted fractures, the locking nails are load-bearing devices. The load transfer between fractured fragments is made through especially the locking screws for these load bearing situations. Nonunion, malunion, delayed union, shortening, and nail migration are the expected results if early failure of locking screws is present with comminuted fractures. In this study our aim was to compare the bending resistance of titanium and stainless steel locking screws. Methods. We tested 60 locking screws in six groups (titanium, stainless steel, unthreaded, low threaded and high threaded) in a steel tube that has 30 mm inner diameter, which imitates the lesser trochanter level. We determined the yield points at three-point bending tests that permanent deformation started in the locking screws using an axial compression testing machine. Results. The three-point bending resistance of 5 mm low threaded titanium locking screws (bending at 1413 N loading) was 46.5 % less than the three-point bending resistance of 5 mm low threaded stainless steel locking screws (bending at 2171 N loading) (p < 0.001). Five mm stainless steel locking screws are 29–57 % more resistant to three-point bending deformation than titanium ones. Conclusions. Therefore, stainless steel locking screws instead of titanium ones must be preferred in comminuted femur shaft fractures. In intramedullary nailing of comminuted or long oblique femur fractures, a locking screw should be 5 mm low threaded or unthreaded stainless steel or 5 mm unthreadedtitanium. Five mm high threaded titanium or stainless steel screws must not ever be used as a locking screw. Level of Evidence. 5. Disclosure. Authors declare that there is no conflict of interest related to the present study

Background. Bothlimited-contact dynamic compression plate (LC-DCP) and locking compression plate (LCP) systems were designed to provide enhanced bone healing and to improve stability at fracture site. However, implant failure, delayed union, nonunion and instability are still frequently encountered complications. The purpose of this study was to determine the biomechanical characteristics of a novel persistent compression dynamic plate (PCDP) which provides a persistent compression to fracture edges, and to compare the biomechanical properties of such a novel plate with the commonly used LCP. Methods. The novel persistent compression dynamic plate (PCDP) system is composed of a body, an inner compression spring and a distal mobile component. The body (proximal part) contains an adjustable screw and the distal part of the dynamic system can slide inside the body through a special tube. 12 (saw bone) artificial femoral bones were used. Transverse distal shaft fracture was created in all the saw bones at the same level, 6 femurs were fixed using the novel PCDP, whereas the other 6 femurs were fixed using the well-known LCP. All samples had undergone a nondestructive repetitive different forces (axial compression, bending and torsion), to evaluate the biomechanical differences between the two plating systems. Results. Under axial load the mean stiffness value was 439,0 N/mm for the PCDP and 158,9 N/mm for the LCP. There was nosignificant difference in A-P (anteroposterior) ve P-A (posteroanterior) bending stiffness values between PCDP and LCP, P=0.37 and P=0.80 respectively. However LCP provided significantly stiffer fixation in medial and lateral bending tests than PCDP (P=0.037) and (P=0.016), respectively. But no significant difference was detected between the two plating system in the torsional stiffness P=0.15. Conclusion. These results do not show any significant biomechanical difference in the applied torsional and bending stresses between LCP and PCDP. However the remarkably increased persistent compression effect of the PCDP created a considerable stress on fracture edges which may accelerate bone healing. Level of Evidence. Level 5

There has been evidence of association between femoral shaft fractures and prolonged bisphosphonate therapy. We present a case series of bisphosphonate-associated fractures and invaluable lessons we have learnt. Over the last three years at our unit we have collected a case series of eight patients who have had atypical femoral fractures whilst on bisphosphonate therapy. We present illustrative cases, a summary of key findings, and invaluable lessons we have learnt. There was a long period of prodromal pain for two years before incomplete fractures developed. We speculate this is a warning sign of impending fracture. This may have been prevented with screening. Between incomplete fracture and complete fracture there was a short window of one month. Five patients presented with complete fracture, and three with thigh pain +/- evidence of incomplete fracture. Of the latter group all but one went on to develop complete fractures. The one patient who did not progress died six years after diagnosis. Of those five patients who presented with initial complete fracture, three patients recall thigh pain before fracture on further questioning. Despite being diaphyseal femoral fractures, there is a higher risk of neck of femur fractures in this patient cohort (both patients with initial interlocked nails subsequently developed neck of femur fractures soon after and were revised to cephalomedullary nails). Excluding one death from unrelated cause, only one patient has signs of complete fracture healing. All other patients are still receiving follow-up (mean 490 days). Three patients reported bilateral symptoms (pain). Two had had bilateral symptoms for one year. Both had visible incomplete fractures on further radiographic scrutiny; one underwent prophylactic cephalomedullary nailing, one was managed with active surveillance. We suggest that improved pain and radiographic changes of cortical healing may be misleading and should not be relied upon. Cephalomedullary nailing is the treatment of choice in these fractures due to higher risk of neck of femur fractures in this cohort. We suggest prompt prophylactic cephalomedullary nailing when radiographic incomplete fractures are identified due to a short window before progression to complete fracture, and the need to consider contralateral prophylactic nailing in patients describing bilateral symptoms. We speculate that thigh pain is a warning sign of impending fracture and fracture-progression can be prevented with appropriate screening