Fracture Fixation

Surgical management of humeral, clavicular, and scapular fractures, comparing antegrade vs retrograde IMN and plate osteosynthesis.

Overview

Many proximal humerus fractures are successfully managed nonsurgically, yet indications for surgical intervention remain controversial [2]. Surgical options, including locked plating, intramedullary nailing, and arthroplasty, are reserved for specific fracture patterns and patient factors [77], though failures remain common with these fixation methods [77]. Similarly, surgical treatment for humeral shaft fractures is generally reserved for specific indications such as open fractures, polytrauma, or failure of nonoperative management [13]. For displaced distal radius fractures in patients aged 65 years and older, cast immobilization is non-inferior to volar locking plates regarding QuickDASH scores at one year [7], though operative fixation may benefit selected patients requiring rapid recovery [7].

Management of metacarpal and phalangeal shaft fractures requires that the operative method be tailored to fracture characteristics and individualized to the patient for optimal outcomes [3, 12]. In pediatric lateral condyle fractures, concepts regarding relative surgical indications, optimal pin configuration, and the use of cannulated screws or bioresorbable fixation are evolving [14]. Scapular fractures present with little agreement on surgical indications and no clear comparative evidence between surgical and nonsurgical outcomes [73]. Conversely, nonoperative treatment remains effective for most midshaft clavicular fractures in adolescents, while operative fixation is indicated for open fractures, neurovascular injury, or significant displacement [81].

The authors caution against prescribing any single method for fixing a particular fracture type [22]. An individualized management strategy must consider fracture configuration, surgeon and patient preferences, and likely patient compliance [22]. Specific techniques show promise in defined scenarios: a hybrid fixation technique using a metal plate, bioresorbable screws, and wires may be effective for Robinson type 2B clavicle fractures without complications or metal failure [19], while no advantage exists for open reduction internal fixation over percutaneous pinning for Bennett fractures [26].

Anatomy & Pathophysiology

Osseous Stability and Implant Biomechanics

Blocked threaded wire constructs for three-part humeral head fractures are biomechanically valid, allowing only micromovements insufficient to cause humeral head rotation or translation [53][54]. For four-part proximal humeral fractures treated with hemiarthroplasty, glenohumeral joint forces are significantly displaced superiorly during inferior tuberosity placement with minimal and moderate amounts of glenohumeral abduction [72]. Conversely, the modified minimally invasive reduction osteosynthesis system (MIROS) fixation for Neer 2 and 3-part proximal humeral fractures provides adequate fracture stability, permits early shoulder motion, and yields satisfactory functional and radiologic outcomes with fewer complications [85]. In complex shoulder fractures treated by reverse shoulder arthroplasty, shoulder rotational ability is improved by systematically repairing the tuberosities around the implant, provided their consolidation is anatomic [89]. The biomechanical literature regarding proximal humerus fracture implants remains diverse and heterogeneous [75].

Ligamentous and Joint Complex Injuries

Hook plate and superolateral locking plate constructs with coracoclavicular suture fixation for distal third clavicle fractures with coracoclavicular ligament disruption offer superior biomechanical stability and potentially reduce complications associated with subacromial hardware [56]. Oblique and transverse incisions for fractures of the middle and outer third of the clavicle have equivalent effects on the recovery of shoulder joint function [86]. All four generations of suspensory fixation with internal brace for Rockwood grade V acromioclavicular joint injuries demonstrate biomechanical noninferiority with no significant differences in dynamic creep, translation, displacement, or stiffness [87]. Emerging concepts regarding horizontal and rotational instability and scapular biomechanics in acromioclavicular joint injuries aim to improve treatment outcomes and patient management [67]. Current literature on acromioclavicular joint complex injuries covers anatomy, biomechanics, evaluation, and surgical outcomes to guide clinical decision-making [80].

Glenoid Reconstruction and Instability

Glenoid allografts most accurately restore articular geometry for large glenoid bone defects in anterior shoulder instability [78]. The all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation system restores glenoid bone defects and preserves normal shoulder anatomy [82]. Nonoperative treatment of displaced anterior glenoid rim fractures without dislocation in the elderly effectively avoids surgical risks and complications while preserving shoulder function [76].

Soft Tissue Repair and Kinematics

Both open and arthroscopic repair techniques for anterosuperior rotator cuff tears with subscapularis involvement significantly improve shoulder function and are relatively safe procedures [74]. Adults with lesser tuberosity fractures have acceptable outcomes, but patients with associated posterior shoulder dislocation have impaired range of shoulder movement and are more likely to develop complications [84]. Radiocapitellar prosthetic arthroplasty largely preserves elbow kinematics and stability [55]. Range of motion and strength thresholds can identify subjects with normal shoulder function in the context of proximal humerus fractures [65].

Surgical Planning and Approach

Contralateral preoperative templating for fracture reverse total shoulder arthroplasty provides an algorithmic framework for reproducible outcomes unique to each patient [70]. A minimally invasive approach combined with a novel anatomical locking plate for scapular body fractures provides a biomechanical basis to guide clinical treatment [83].

Classification

Cofield: Originally designed for periprosthetic fractures, this system may require adaptation for modern short-stem implants, as fractures can heal nonoperatively if the primary fixation point remains stable despite the fracture location [1].

Unified Classification System: This system proposes a rational approach to treatment regardless of the bone broken or joint involved, aiming to improve understanding and consistency in reporting periprosthetic fractures [29]. For peri-prosthetic fractures of the pelvis and femur, it demonstrates substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts [48].

MTM-classification: While this system covers a wide spectrum of fracture types, its precise topographic and morphological description does not deliver reproducible results [31].

3D Fracture Map: This tool provides a detailed view of fracture characteristics, enabling precise classification of lateral malleolus fractures [32].

3D Model Classifications: New classifications based on 3D models provide a useful synoptic framework for identifying complex impacted proximal humerus fracture patterns [34]. A specific variant based on morpho-volumetric evaluation of humeral head bone loss with a 3D model also provides a useful synoptic framework for identifying these complex impacted proximal humerus fracture patterns [35].

Dubberley: This classification is useful for describing coronal shear fractures of the distal humerus and selecting the surgical approach [40]. However, unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation according to Dubberley's classification [40].

Melone: This classification system is not suitable for characterizing all C3 comminuted distal radius fractures [42].

Neer: More complex fractures, including those requiring operative intervention and those with higher Neer classification scores, developed pseudosubluxation at higher rates than simpler fracture patterns [43].

Adapted AO (Hand): The adapted AO classification for hand fractures demonstrated good inter-observer agreement for bone identification [47]. It demonstrated substantial agreement for bone segment coding [47] and moderate agreement for fracture type [47].

Periprosthetic Femur (TKA): A new classification system for periprosthetic femur fractures following total knee arthroplasty considers fracture location and implant type [50]. This system is easy to use [50], shows good interobserver reliability [50], and allows conclusions to be drawn on treatment recommendations [50].

Other Considerations: Classification utility varies by fracture type; for instance, the Melone system fails for all C3 comminuted distal radius fractures [42], while the MTM-classification lacks reproducible results despite broad coverage [31]. Conversely, the Unified Classification System offers high reliability for periprosthetic pelvic and femoral fractures [48], and the adapted AO system shows varying levels of agreement for hand fractures depending on the coding element [47].

Clinical Presentation

The clinical presentation of periprosthetic and traumatic fractures varies by anatomical site and fracture stability. Nonoperative management of Cofield B total shoulder arthroplasty periprosthetic fractures may result in healing if the primary fixation point remains stable despite fracture location [1]. Many proximal humerus fractures can be successfully treated nonsurgically, though indications for surgical intervention remain controversial [2]. Routine primary nonoperative management of isolated stable radial head fractures provides a satisfactory outcome for the majority of patients, with few requiring further intervention for persisting complaints [6]. Undisplaced inferior angle of scapula fractures have a variable outcome when treated nonoperatively [16]. Minimal fracture displacement (<3 mm) of the greater tuberosity does not worsen the clinical outcome or duration of symptoms [45].

Fracture pattern, location, and patient risk factors are critical determinants of management strategy. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management of humeral shaft fractures, suggesting earlier operative intervention may be recommended [8]. Effective management of malunited fractures requires careful patient selection with detailed clinical and radiographic evaluation [9]. Providers treating patients with late presentation or late displacement of distal radius fractures have the option of surgical fixation beyond the first few weeks after injury [15]. Large, randomised trials are needed to guide management of complex proximal humeral fractures [5].

Anatomical Specifics and Outcomes: Outcomes of surgical fixation and postoperative care for metacarpal fractures are best when tailored to the fracture pattern and patient [3]. Advances in understanding fracture patterns, imaging, exposure techniques, fixation, and rehabilitation have improved patient outcomes for distal humerus fractures [11]. Treatment of tibial plateau fractures usually can yield satisfactory results, with open reduction and internal fixation remaining the mainstay of treatment [51]. Closed fracture and regular follow up were determining factors for better functional outcomes in distal femur fractures treated by open reduction and internal fixation [17]. Fracture of the femoral head is a severe injury with a relatively poor functional outcome [44].

Hand and Pediatric Fractures: Understanding the pattern of hand fractures in children and adolescents helps in making the right diagnosis and guides choosing the appropriate treatment [10]. Management of pediatric phalanx fractures is based on injury severity, with nondisplaced fractures treated via splint immobilization and unstable, displaced fractures requiring surgical management, preferably closed reduction and percutaneous pinning [21]. Early fracture fixation is often beneficial in children to avoid complications associated with prolonged immobilization, though management must be tailored to the patient's age and injury severity [37]. Dynamic external fixation for dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints provides stable fixation that allows early mobilization and yields good functional outcomes [18]. Patients with central slip fractures (volar fracture subluxations/dislocations of the proximal interphalangeal joint) should be counseled about the difficult nature of this fracture and the expected poor outcomes [20].

Acromioclavicular and Complex Dislocations: Both hook plate fixation and coracoclavicular reconstruction for acute unstable acromioclavicular dislocation yielded excellent functional outcomes [4].

Investigations

Plain radiography: Initial evaluation remains the standard for many fracture types, though limitations exist in assessing complex patterns. For periprosthetic fractures around uncemented femoral components, the addition of preoperative CT did not significantly improve accuracy in predicting fixation status compared with plain radiography [95]. In distal radius fractures treated with volar locking plates and K wires, initial fracture displacement shown radiologically was the only variable identified that influenced the persistence of a step on post-operative radiographs [107]. For posterior wall acetabular fractures, the degree of residual displacement is detected more accurately on postoperative computed tomography scans than on plain radiographs [102].

MRI: Magnetic resonance imaging is the superior diagnostic test for stress fractures of the capitate bone [101] and is useful in all symptomatic elderly patients with isolated greater trochanter fractures on plain radiographs [91]. Pretreatment MRI should be considered for tibial spine fractures to improve identification of concomitant injuries, particularly in patients managed nonoperatively or with closed reduction [94]. Early MRI facilitates expedient surgical intervention for pectoralis major avulsion in skeletally immature wrestlers, helping to prevent diagnostic delays [105]. Furthermore, all patients presenting with isolated femoral neck edema without a fracture line on initial MRI demonstrated resolution with nonoperative treatment and did not progress to surgical fixation [100].

CT: While CT is often utilized for complex planning, its utility varies by fracture type. Ultrasound imaging may be useful in cases where intra-articular and/or comminuted fractures require distal plate placement and engagement of screws in the dorsal cortex [96]. MRI data regarding biodegradable screws in osteochondritis dissecans of the knee in skeletally immature patients showed differential decomposition within and outside of bone as a possible cause of implant failure [99].

Other Considerations: The Cofield classification may require adaptation for modern short-stem implants, as fractures may heal nonoperatively if the primary fixation point remains stable despite fracture location [1]. Many proximal humerus fractures can be successfully treated nonsurgically, and indications for surgical intervention remain controversial [2]. Effective management of malunited fractures requires careful patient selection with detailed clinical and radiographic evaluation, as well as a thorough understanding of the available treatment options that continue to evolve [9]. Understanding the pattern of hand fractures in children and adolescents helps in making the right diagnosis and guides choosing the appropriate treatment [10]. Advances in understanding fracture patterns, imaging, exposure techniques, fixation, and rehabilitation have improved patient outcomes for distal humerus fractures [11].

Treatment

Non-Operative

Nonoperative management may be appropriate for Cofield B total shoulder arthroplasty periprosthetic fractures if the primary fixation point remains stable despite fracture location [1], and a substantial number of periprosthetic postoperative humeral fractures after shoulder arthroplasty can be treated nonsurgically, though those with loose implants or excessive displacement typically require surgical reconstruction [59]. Many proximal humerus fractures can be successfully treated nonsurgically, with nondisplaced or minimally displaced proximal humeral fractures managed conservatively with initial immobilization and a rehabilitation program, while displaced or unstable fractures are managed operatively [2, 24]. Routine primary nonoperative management of isolated stable radial head fractures provides a satisfactory outcome for the majority of patients with few requiring further intervention [6]. Cast immobilization is non-inferior to volar locking plates regarding QuickDASH scores after one year in patients aged 65 years and older with displaced distal radius fractures [7]. Undisplaced scapular inferior angle fractures have a variable outcome when treated nonoperatively [16], and risks and benefits of both operative and nonoperative management for scapula fractures should be discussed, noting the exceptionally low nonunion rate regardless of treatment and the commonality of persistent pain [103]. Surgical treatment for humeral shaft fractures is generally reserved for specific indications such as open fractures, polytrauma, or failure of nonoperative management [13], though fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management of humeral shaft fractures, suggesting earlier operative intervention [8]. Non-surgical treatment of 3- and 4-part proximal humerus fractures results in fewer complications and additional surgeries compared to open reduction internal fixation [36].

Operative

Indications: Operative fixation may be beneficial for selected distal radius fracture patients, especially those needing a fast recovery [7], and surgical treatment is recommended for patients with acceptably reduced intra-articular distal radial fractures [69]. Surgical intervention for humeral shaft and distal humerus fractures is indicated for specific absolute and relative indications, with plate fixation and IM nailing being the primary options, each carrying distinct complication profiles [68]. Management of pediatric phalanx fractures is based on injury severity, with nondisplaced fractures treated via splint immobilization and unstable, displaced fractures requiring surgical management, preferably closed reduction and percutaneous pinning [21]. Open reduction and internal fixation with cannulated screws for coronal fractures of the capitellum in patients older than 65 years allows stable fixation and provides satisfactory functional results with a lower complication rate [23]. If a fracture fragment of the posterior cruciate ligament from the tibia is large or medium-sized, screws or multiple pins can be used; small or comminuted fragments can be fixed with use of wire or multiple sutures [61].

Surgical Approach / Technique: The optimal surgical approach for open reduction and internal fixation of intra-articular distal humeral fractures remains controversial [28]. Arthroscopic reduction and percutaneous cannulated screw fixation might be a useful alternative for the management of capitellar fractures [33]. There is no advantage of open reduction internal fixation over percutaneous pinning for Bennett fractures according to current best evidence [26], and there is currently no high-quality evidence to guide the optimal treatment method for a Bennett's fracture [39]. Reduction of the fracture is of paramount importance in intertrochanteric fractures since poor reduction was an independent predictor for loss of fixation regardless of the implant being used [63]. Open reduction and internal fixation with screw and plate can be done to fixate fragmented fractures in shoulder reconstruction [64].

Implant Selection: Both coracoclavicular reconstruction and hook plate fixation yielded excellent functional outcomes for acute unstable acromioclavicular dislocation [4]. Anatomical bridging plate fixation assisted by suture loop reduction of fragments in high-energy comminuted midshaft clavicle fractures can lead to high rates of union and excellent clinical outcome [38]. The PHILOS plate is suitable for the majority of proximal humerus fractures provided that the correct surgical technique is used [30], though the two most common complications when using fixed-angle implants for proximal humerus fractures were nonanatomic reduction of fractures and implant perforation [49]. The method selected for metacarpal and phalangeal shaft fractures must be tailored to the characteristics of the fracture and individualized to the patient to achieve optimal outcome [12], and no single method should be prescribed for fixing a particular type of fracture; management should be individualized considering fracture configuration, surgeon and patient preferences, and likely patient compliance [22]. Management concepts for lateral condyle fractures in children are evolving regarding relative indications for surgical management, optimal pin configuration, and the use of cannulated screws and bioresorbable fixation [14].

Pain Management: A 6-day course of methylprednisolone following surgical fixation for distal radius fracture resulted in early improvement in pain and reduction in early opioid consumption [97]. Different anaesthesia methods do not affect the incidence of adverse events such as death within 30 days after surgery in oldest-old patients (aged 90 years and older) with intertrochanteric fractures [98].

Adjuncts: Treatment of fractures adjacent to humeral prostheses resulted in fracture union, prosthesis stability, and a paucity of complications [57], and care must be taken as pain improves with fracture union in acromial base fractures after reverse total shoulder arthroplasty, but functional returns are unpredictable [25]. Successful union of a non-union of the scapular body resulted in dramatic improvement in function and relief of pain [27]. Patients treated with external fixation for open tibial shaft fractures had more complications than patients treated with other methods of fixation [66].

Other Considerations: Outcomes of surgical fixation and postoperative care for metacarpal fractures are best when tailored to the fracture pattern and patient [3]. Large, randomised trials are needed to guide management of complex proximal humeral fractures [5].

Complications

Thromboembolism: Low-molecular-weight heparin was not more effective than placebo for preventing clinically important venous thromboembolism in patients managed with leg fracture fixation [112]. Adolescents with surgically treated lower-extremity fractures have a significantly higher risk of venous thromboembolism compared to children, with risk ratios ranging from 2.4 to 4.6 depending on the specific fracture location and VTE type [119]. Venous thromboembolism was the most frequently reported complication after shoulder arthroplasty compared to open reduction and internal fixation, with reverse shoulder arthroplasty having the highest VTE rate [126]. Findings on preoperative deep venous thrombosis in young and middle-aged patients after hip fracture could be beneficial for informed prevention and optimized management [122].

Periprosthetic fracture: A decade after primary total hip replacement, periprosthetic fractures occur annually in 26 per 10,000 persons [123]. Periprosthetic fractures after primary total hip replacement are especially frequent in those with prior total knee or revision total hip replacements [123]. Fracture risk during primary total hip arthroplasty increases in patients younger than 50 and older than 80 years, in females, in patients with American Society of Anesthesiologists grade 3 to 5, and for indications other than primary osteoarthritis [149]. Operative treatment of acute peri-prosthetic femur fractures following primary total hip arthroplasty is associated with a high rate of complications (61%) and re-operation (23%) [142]. A wide range of periprosthetic acetabular fractures were observed following primary cementless total hip arthroplasty, with 71.4% being small cracks that did not necessitate revision surgery [137].

Infection: The incidence of intraoperative fractures during staged treatment of an infected total knee arthroplasty is roughly 2% [114]. There was no difference in infection rate and reoperation for infection when comparing wire, plate, and intramedullary nail fixation of open metacarpal and phalangeal fractures [138]. The rate of infection following operative treatment of Bennett's fractures is low and similar to other surgical procedures with percutaneous K-wires [143]. Patients with open hand fractures who are taken to the operating room more than 1 day from presentation did not have a higher incidence of infection [145]. The combined plating group for AO Type C distal radius fractures had a considerably higher frequency of hardware removal and postoperative infections compared to the volar locking plate group [144].

Nonunion and Malunion: Smoking status and Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle [132]. Patients with smoking status or high Disabilities of the Arm Shoulder and Hand score warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion [132]. Total hip arthroplasty after operative treatment of acetabular fractures is associated with high rates of failure due to aseptic loosening, particularly in young patients with significant bone deficiency [125]. Patient factors rather than technical factors were associated with reoperation for loosening or breakage of implants and nonunion in plate and screw fixation of bicolumnar distal humerus fractures [134]. Delayed fixation of distal radial fractures beyond three weeks after initial failed closed reduction increases the odds of reoperation, particularly in patients aged over 60 years [120].

Implant Failure and Refracture: The incidence of refracture following implant removal after bone union in midshaft clavicle fractures is underestimated [121]. Severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors for refracture after implant removal in midshaft clavicle fractures [121]. Operative fixation of paediatric hand fractures was associated with a higher risk of complications [127]. Fractures occurred in 12% of cases following prophylactic titanium elastic nailing after femoral lengthening, with a marked reduction in the rate of secondary interventions [104]. High energy fracture events and an adult aged patient group were associated with higher rates of adverse clinical outcome in open reduction internal fixation of midshaft clavicle fractures in adolescent/post-adolescent athletes [148].

Other Considerations: Large, randomised trials are needed to guide management of complex proximal humeral fractures [5]. Open reduction and internal fixation with cannulated screws for coronal fractures of the capitellum in patients older than 65 years provides stable fixation, satisfactory functional results, and a lower complication rate [23]. The S3 plate implant for proximal humerus fractures has a very low revision rate, with union seen in most fractures by 6 months [118]. Systematic review of open reduction of pediatric lateral condyle fractures demonstrates similar outcomes with union and infection rates between all fixation techniques [124]. A meta-analysis of high-quality studies on complications after volar locking plate fixation for distal radius fractures showed an overall complication rate of 30.8% [135]. Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand resulted in all fractures healing with no major complications [130]. Nonunion, malunion, and infection rates for treatment of phalangeal fractures in severely injured hands were similar to other studies [140]. There were relatively low overall mean rates of delayed union, nonunion, loss of fixation or deformity correction, and venous thromboembolism after distal femur osteotomy, regardless of an early or delayed post-operative weightbearing protocol [133]. Individualized approaches to internal fixation versus revision arthroplasty for operatively treated interprosthetic femoral fractures led to an 81% survivorship free from reoperation at two years, with 95% of patients ambulatory at two years [136]. Comparative and prospective studies are needed to more clearly define the role of magnetic compressive intramedullary nailing for humeral shaft delayed unions and nonunions and assure their safety [139]. Higher complication rates in late-treated ulnar styloid base fractures suggest surgeons should carefully select surgical candidates and modalities [146]. The systematic review on optimal surgical treatment for Neer type IIB (IIC) distal clavicle fractures showed similar major complication rates among techniques, though the hook plate technique demonstrated inferior clinical results compared to other techniques [147]. The author of a commentary on paediatric hand fractures suggests that the 6% of fractures with associated complications merit further analysis [129]. The authors of a response to a systematic review agree that more standardized reporting of complication rates and categories would be beneficial [141]. The systematic review on complications of articular distal humeral fracture fixation was limited to capturing only complications reported as such by the individual authors of the included manuscripts [141].

Recovery

Light activity (weeks): Patients with nondisplaced or minimally displaced acute proximal humeral fractures undergo initial immobilization followed by rehabilitation, while those with displaced or unstable variants require operative management [24]. For displaced distal radius fractures, cast immobilization is non-inferior to volar locking plates regarding QuickDASH scores at one year, though operative fixation may benefit selected patients needing a faster recovery [7]. Providers may opt for surgical fixation beyond the first few weeks for late presentations or late displacement of distal radius fractures [15]. In distal femur fractures treated with locking plates, closed fracture management and regular follow-up determine better functional outcomes [17]. Dynamic external fixation for dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints allows early mobilization [18]. Intramedullary nailing for unstable metacarpal fractures facilitates early range of motion and resumption of usual activities [46]. Dorsal plating for intra-articular middle phalangeal base fractures with volar instability permits early range of motion without complications [60]. Most fractures treated with closed reduction and periarticular pinning of base and shaft fractures of the proximal phalanx heal within 4 weeks [92]. Minimally invasive techniques for irreducible flexion-type supracondylar fractures of the humerus in older children offer substantial stability and excellent long-term recovery [131].

Full activity (months): Early active motion rehabilitation after locking plate fixation of proximal humerus fractures is not inferior to restrictive protocols at 24 months [58]. More aggressive rehabilitation measures should be postponed until fracture healing in minimally invasive external fixation of proximal humerus fractures [62]. Both plate fixation and intramedullary nailing return patients to pre-injury functional levels at one year for completely displaced midshaft clavicle fractures, though plate fixation provides a faster recovery period in comminuted cases compared to ESIN [79]. Successful union of scapular body fractures results in dramatic functional improvement and pain relief [27]. Athletes with surgical management of proximal interphalangeal joint repetitive stress epiphyseal fracture nonunion achieved union and returned to elite-level sport climbing within 3 months [117]. Internal fixation of combined distal radius and scaphoid fractures followed by early rehabilitation optimizes outcomes [41]. Functional return was achieved in all survivors who could walk at the time of injury with treatment of intertrochanteric and subtrochanteric hip fractures by the Ender method, with no non-unions reported [90].

Complete recovery / outcome plateau (months): Routine primary nonoperative management of isolated stable radial head fractures provides satisfactory outcomes for the majority, with few requiring further intervention [6]. Cast immobilization is non-inferior to volar locking plates in relation to QuickDASH after one year in patients aged 65 years and older with displaced distal radius fractures [7]. Pain improves with fracture union in acromial base fractures after reverse total shoulder arthroplasty, but functional returns remain unpredictable [25]. Patients with a fracture have an increased risk of failure and reoperation when using allogeneic cortical strut grafts for fibrous dysplasia of the proximal femur [93]. Older patients and those with more severe fractures are more likely to need total knee arthroplasty after repair of a tibial plateau fracture [110]. Early return to playing professional football (8 weeks or less) following fixation of 5th metatarsal stress fractures may result in delayed union in up to 24% of patients, though it does not increase the risk of long-term non-union or prevent athletes from continuing to play [111]. The best functional outcomes with clavicle hook plate fixation for displaced lateral-third clavicle fractures occur with plate removal before 6 months postoperatively, provided the fracture has healed [113]. Total knee arthroplasty after open reduction and internal fixation of a tibial plateau fracture decreases pain and improves function but is technically demanding and associated with a high failure rate (five of fifteen) [116]. Initial good results of early fracture fixation and aggressive physiotherapy in incarcerated patellar tendon in Hoffa fracture may not necessarily give subsequent good joint range of motion [52]. Patients with central slip fractures should be counseled about the difficult nature of this fracture and expected poor outcomes [20]. Severe complications requiring an unplanned return to the OR and/or permanent impairment are more likely in AO type C fractures treated with volar locked plating of distal radius fractures and require more follow-up than moderate/mild complications [88].

Rehabilitation protocol: Conservative treatment for nondisplaced or minimally displaced acute proximal humeral fractures consists of initial immobilization and a rehabilitation program [24]. Operative fixation for displaced or unstable acute proximal humeral fractures is followed by early active motion rehabilitation, which is not inferior to restrictive protocols at 24 months [58]. More aggressive rehabilitation measures should be postponed after fracture healing in minimally invasive external fixation of proximal humerus fractures [62]. Dynamic external fixation for dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints provides stable fixation allowing early mobilization [18]. Intramedullary nailing for unstable metacarpal fractures allows for stabilization, early range of motion, and reduced immobilization [46]. Dorsal plating for intra-articular middle phalangeal base fractures with volar instability allows for early range of motion without complications [60]. Internal fixation of combined distal radius and scaphoid fractures is followed by early rehabilitation to optimize outcomes [41]. Early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months [58].

Functional milestones: Routine primary nonoperative management of isolated stable radial head fractures provides a satisfactory outcome for the majority of patients [6]. Cast immobilization is non-inferior to volar locking plates in relation to QuickDASH after one year in patients aged 65 years and older with displaced distal radius fractures [7]. Operative fixation may be beneficial for selected patients with displaced distal radius fractures, especially those in need of a fast recovery [7]. Closed fracture and regular follow up are determining factors for better functional outcomes in distal femur fractures treated by open reduction and internal fixation using a distal femur locking plate [17]. Dynamic external fixation for dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints yields good functional outcomes [18]. Patients with central slip fractures should be counseled about the difficult nature of this fracture and the expected poor outcomes [20]. Successful union of a scapular body fracture results in a dramatic improvement in function and relief of pain [27]. Both plate fixation and intramedullary nailing return patients to their pre-injury functional levels at one year for completely displaced midshaft fractures of the clavicle [79]. Functional return was achieved in all survivors who could walk at the time of injury with treatment of intertrochanteric and subtrochanteric fractures of the hip by the Ender method, with no non-unions reported [90]. Most fractures treated with closed reduction and periarticular pinning of base and shaft fractures of the proximal phalanx healed within 4 weeks, and the majority of patients had excellent or good results [92]. Both athletes with surgical management of proximal interphalangeal joint repetitive stress epiphyseal fracture nonunion achieved fracture union without complications and returned to elite-level sport climbing within 3 months [117]. A Salter-Harris type III physeal fracture in the anterior inferior glenoid of a 13-year-old boy was successfully treated with arthroscopic stabilization, demonstrating return to function [115]. Minimally invasive techniques utilizing the "Joy Stick" method for managing irreducible flexion-type supracondylar fractures of the humerus in older children result in excellent long-term recovery of joint function [131].

Other Considerations: Providers treating patients with late presentation or late displacement of distal radius fractures have the option of surgical fixation beyond the first few weeks after injury [15]. Patients with a fracture have an increased risk of failure and reoperation when using allogeneic cortical strut grafts in the treatment of fibrous dysplasia of the proximal femur [93]. Older patients and those with more severe fractures are more likely to need total knee arthroplasty after repair of a tibial plateau fracture [110]. Early return to playing professional football (8 weeks or less) following fixation of 5th metatarsal stress fractures may result in delayed union in up to 24% of patients [111]. The best functional outcomes with clavicle hook plate fixation for displaced lateral-third clavicle fractures occur with plate removal before 6 months postoperatively, provided the fracture has healed [113]. Total knee arthroplasty after open reduction and internal fixation of a fracture of the tibial plateau decreases pain and improves knee function, but the procedure is technically demanding and is associated with a high failure rate (five of fifteen) [116]. Severe complications requiring an unplanned return to the OR and/or permanent impairment are more likely to occur in AO type C fractures treated with volar locked plating of distal radius fractures and require more follow-up than moderate/mild complications [88].

Key Evidence

• [L4] The Cofield classification may require adaptation for modern short-stem implants, as fractures may heal nonoperatively if the primary fixation point remains stable despite fracture location. (10.1016/j.jseint.2020.02.014)
• [L4] Outcomes of surgical fixation and postoperative care are best when tailored to the fracture pattern and patient. (10.5435/jaaos-d-25-00323)
• [L3] Both fixations yielded excellent functional outcomes. (10.1186/s12891-021-03978-3)
• [L1] There is a need for large, randomised trials to guide management of these fractures. (10.1111/j.1758-5740.2010.00075.x)
• [L4] Routine primary nonoperative management of these fractures provides a satisfactory outcome for the majority of patients, with few patients requiring further intervention for persisting complaints. (10.2106/jbjs.m.01354)
• [L1] However, operative fixation may be beneficial for selected patients, especially those in need of a fast recovery. (10.1302/0301-620x.103b2.bjj-2020-2562)
• [L5] Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. (10.1016/j.jse.2017.10.028)
• [L4] Understanding the pattern of these fractures helps making the right diagnosis and guides choosing the appropriate treatment. (10.1177/1558944719900565)
• [L5] The method selected must be tailored to the characteristics of the fracture and individualized to the patient to achieve optimal outcome. (10.5435/00124635-200003000-00005)
• [L5] Surgical treatment is generally reserved for specific indications such as open fractures, polytrauma, or failure of nonoperative management. (10.1016/j.jse.2010.11.030)
• [L5] Management concepts are evolving regarding relative indications for surgical management, optimal pin configuration, and the use of cannulated screws and bioresorbable fixation. (10.5435/jaaos-d-17-00815)
• [L3] Providers treating patients with late presentation or late displacement have the option of surgical fixation beyond the first few weeks after injury. (10.1177/1558944720930301)
• [L4] Undisplaced fractures have a variable outcome when treated nonoperatively. (10.1016/j.jse.2015.11.007)
• [L3] Closed fracture and regular follow up were determining factors for better functional outcomes. (10.1186/s13018-024-05054-7)
• [L4] It provides stable fixation that allows early mobilization and yields good functional outcomes. (10.1177/1753193416674155)
• [L4] Use of this hybrid fixation technique may be effective in treating these types of fractures with no complications or metal failure observed. (10.5397/cise.2020.00262)
• [L4] Patients should be counseled about the difficult nature of this fracture and the expected poor outcomes. (10.1016/j.jhsa.2017.03.030)
• [L5] Management is based on injury severity, with nondisplaced fractures treated via splint immobilization and unstable, displaced fractures requiring surgical management, preferably closed reduction and percutaneous pinning. (10.5435/jaaos-d-16-00199)
• [L5] The authors caution against prescribing any single method for fixing a particular type of fracture, recommending an individualised management strategy that considers fracture configuration, surgeon and patient preferences, and likely patient compliance. (10.1177/1753193411433386)
• [L4] Open reduction and internal fixation with cannulated screws allow stable fixation and provide satisfactory functional results with a lower complication rate. (10.1016/j.jse.2015.12.004)
• [L5] In case of nondisplaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen, while displaced or unstable fractures will be managed operatively. (10.1016/j.jht.2017.05.005)
• [L4] Pain improves with fracture union, but functional returns are unpredictable. (10.1016/j.jse.2011.01.029)
• [L5] According to current best evidence, there is no advantage of open reduction internal fixation over percutaneous pinning. (10.1016/j.jhsa.2015.05.017)
• [Case_report] Successful union of the fracture resulted in a dramatic improvement in function and relief of pain. (10.2106/00004623-199803000-00017)
• [L4] The optimal approach for surgical management of these fractures remains controversial. (10.1016/j.jse.2011.06.020)
• [L5] The Unified Classification System proposes a rational approach to treatment regardless of the bone broken or joint involved, aiming to improve understanding and consistency in reporting periprosthetic fractures. (10.1302/0301-620x.96b6.34040)
• [L4] It is suitable for the majority of fractures provided that the correct surgical technique is used. (10.1097/01.blo.0000194678.87258.6e)
• [L4] Although the MTM-classification covers a wide spectrum of fracture types, the precise topographic and morphological description is not delivering reproducible results. (10.1186/1471-2474-9-21)
• [L4] The 3D fracture map provides a detailed view of fracture characteristics, enabling precise classification. (10.1186/s13018-024-05424-1)
• [Case_report] This technique might be a useful alternative for the management of this type of fracture. (10.1016/j.jse.2008.07.007)
• [Abstract] The new classification provides a useful synoptic framework for identifying complex fracture patterns. (10.1016/j.jse.2022.01.040)
• [L5] The new classification provides a useful synoptic framework for identifying complex fracture patterns. (10.1016/j.jse.2020.02.022)
• [L1] Non-surgical treatment results in fewer complications and additional surgeries compared to open reduction internal fixation. (10.1177/1758573219831506)
• [L4] Anatomical bridging plate fixation assisted by suture loop reduction of the fragments, can lead to high rates of union and excellent clinical outcome. (10.1016/j.jse.2021.03.019)
• [L4] Overall there is currently no high-quality evidence to guide us to the optimal treatment method for a Bennett's fracture. (10.1177/1753193416642691)
• [L4] The study confirms the utility of the Dubberley classification in describing the fracture and selecting the surgical approach. (10.1016/j.jse.2025.05.033)
• [L4] Internal fixation of both fractures, followed by early rehabilitation, optimises outcomes. (10.1177/1753193408090099)
• [L4] The Melone classification system is not suitable for characterizing all C3 fractures. (10.1186/s13018-020-01739-x)
• [L4] More complex fractures, including those requiring operative intervention and those with higher Neer classification scores, developed pseudosubluxation at higher rates than simpler fracture patterns. (10.1016/j.jseint.2022.01.013)
• [L4] Fracture of the femoral head is a severe injury with a relatively poor functional outcome; effective management requires understanding anatomy, diagnostics, treatment options, results, and complications. (10.5435/jaaos-d-17-00901)
• [L4] Minimal fracture displacement (<3 mm) does not worsen the clinical outcome or duration of symptoms. (10.1016/j.jse.2013.01.033)
• [L4] This technique allowed for the stabilization of fractures, early ROM, resumption of usual activities, reduced immobilization, and minimal complications. (10.1177/1558944717695747)
• [L4] The adapted AO classification for hand fractures demonstrated good inter-observer agreement for bone identification, substantial agreement for bone segment coding, and moderate agreement for fracture type. (10.1177/1753193409355256)
• [L4] The Unified Classification System (UCS) for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts. (10.1302/0301-620x.96b11.34214)
• [L4] The 2 most common complications were nonanatomic reduction of fractures and implant perforation when fixed-angle implants were used. (10.1016/j.jse.2012.04.002)
• [L4] The new classification system for PPF of the femur following TKA considers fracture location and implant type, is easy to use, shows good interobserver reliability, and allows conclusions to be drawn on treatment recommendations. (10.1186/s12891-017-1855-z)
• [L4] Initial good results of early fracture fixation and aggressive physiotherapy may not necessarily give subsequent good joint range of motion. (10.1007/s00167-007-0431-8)
• [L5] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jseint.2021.06.007)
• [Abstract] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jse.2022.01.037)
• [L4] The procedure largely preserves elbow kinematics and stability. (10.1016/j.jse.2014.01.042)
• [L5] These constructs offer superior biomechanical stability in our model and potentially reduce complications associated with subacromial hardware. (10.1016/j.xrrt.2025.100645)
• [L4] Treatment resulted in fracture union, prosthesis stability, and a paucity of complications. (10.1016/j.jse.2007.05.007)
• [L2] Early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months. (10.1016/j.jse.2025.01.042)
• [L4] A substantial number of fractures can be treated nonsurgically, while those with loose implants or excessive displacement typically require surgical reconstruction. (10.5435/jaaos-d-21-01001)
• [L4] This fixation method allows for early range of motion without complications, with all fractures uniting and patients having minimal functional deficits. (10.1177/1558944718777868)
• [L4] If the fracture fragment is large or medium-sized, screws or multiple pins can be used, while small or comminuted fragments can be fixed with use of wire or multiple sutures. (10.2106/00004623-200105000-00008)
• [L5] More aggressive rehabilitation measures should be postponed after the healing of the fracture. (10.1186/s12891-024-07977-y)
• [L3] Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used. (10.1302/0301-620x.97b3.34791)
• [Case_report] Open reduction and internal fixation with screw and plate can be done to fixate fragmented fractures. (10.1177/2325967125s00053)
• [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. (10.1016/j.jse.2010.06.005)
• [L3] Patients treated with external fixation had more complications than did patients treated with other methods of fixation. (10.5435/jaaos-d-16-00127)
• [L5] By exploring emerging concepts and strategies regarding horizontal and rotational instability and scapular biomechanics, the article aims to lay the foundation for future studies aimed at improving treatment outcomes and patient management. (10.1016/j.jseint.2023.11.018)
• [L1] We therefore recommend surgical treatment for patients with these fractures. (10.2106/jbjs.20.01344)
• [L4] The information obtained from the template provides an algorithmic framework that provides reproducible outcomes for a highly functional and stable shoulder unique to each patient. (10.1016/j.xrrt.2023.05.004)
• [L5] With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly. (10.1016/j.jse.2007.06.017)
• [L5] However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. (10.5435/jaaos-20-03-130)
• [L3] Both techniques significantly improved shoulder function and are relatively safe procedures. (10.1016/j.jse.2019.09.035)
• [L4] The biomechanical literature was found to be both diverse and heterogeneous. (10.1186/s12891-015-0627-x)
• [L4] This approach effectively avoids surgical risks and complications while preserving shoulder function. (10.1186/s12891-025-08947-8)
• [L5] Overall, glenoid allografts most accurately restored articular geometry. (10.1016/j.arthro.2017.04.002)
• [L1] Both methods return patients to their pre-injury functional levels at one year, but plate fixation provides a faster recovery period in comminuted fractures compared to ESIN. (10.1302/0301-620x.99b8.bjj-2016-1318.r1)
• [L5] This article provides a current, in-depth treatise on all aspects of acromioclavicular joint complex injuries, including anatomy, biomechanics, evaluation, and surgical outcomes, to guide clinical decision-making. (10.1177/0363546506298022)
• [L5] While nonoperative treatment remains effective for most cases, operative fixation is indicated for open fractures, neurovascular injury, or significant displacement. (10.5397/cise.2025.00500)
• [L4] This technique restores glenoid bone defects and preserves the normal shoulder anatomy. (10.1016/j.arthro.2020.10.036)
• [L5] The study provided a biomechanical basis to guide the clinical treatment of scapular body fractures. (10.1186/s13018-024-04905-7)
• [L4] Adults have acceptable outcomes but patients with an associated posterior shoulder dislocation have impaired range of shoulder movement and are more likely to develop complications. (10.1016/j.jseint.2021.02.016)
• [L3] It is a minimally invasive procedure that provides adequate fracture stability and permits early shoulder motion, with satisfactory functional and radiologic outcomes and fewer complications. (10.1186/s12891-025-08600-4)
• [L2] These 2 approaches have equivalent effects on recovery of shoulder joint function. (10.1016/j.jse.2019.03.021)
• [L5] This study demonstrated biomechanical noninferiority of all four construct groups with respect to each other, with no significant differences in dynamic creep, translation, displacement, or stiffness. (10.1016/j.jse.2024.06.020)
• [L3] Severe complications requiring an unplanned return to the OR and/or permanent impairment are more likely to occur in AO type C fractures and require more follow-up than moderate/mild complications. (10.1177/1558944719828001)
• [L3] Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant, provided their consolidation is anatomic. (10.1016/j.jse.2012.03.011)
• [L4] Functional return was achieved in all survivors who could walk at the time of injury, with no non-unions reported. (10.2106/00004623-197658050-00004)
• [L4] MRI-based examination is useful in all symptomatic elderly patients whose plain radiographic findings reveal isolated GT fractures. (10.1186/s12891-018-2193-5)
• [L4] Most fractures healed within 4 weeks, and the majority of patients had excellent or good results. (10.1016/j.jhsa.2014.05.008)
• [L4] Surgeons should pay particular attention to the proximal fixation point of the allograft to decrease the risk of failure, as patients with a fracture have an increased risk of failure and reoperation. (10.1007/s11999-016-4806-3)
• [L3] Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. (10.1177/0363546520957666)
• [L3] The addition of preoperative CT did not significantly improve accuracy in predicting fixation status compared with plain radiography. (10.1302/0301-620x.107b6.bjj-2024-0829.r1)
• [L4] Ultrasound imaging may be useful in cases where intra-articular and/or comminuted fractures require distal plate placement and engagement of screws in the dorsal cortex. (10.1177/1753193410392869)
• [L2] There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. (10.1016/j.jhsa.2022.06.008)
• [L3] Different anaesthesia methods do not affect the incidence of adverse events such as death within 30 days after surgery in oldest-old patients with intertrochanteric fractures. (10.1186/s12891-023-06973-y)
• [L4] MRI data showed differential decomposition of the screw within and outside of bone as a possible cause. (10.1016/j.arthro.2014.08.032)
• [L4] All patients with isolated edema in the femoral neck without a fracture line on the initial MRI had resolution with nonoperative treatment and did not have fracture progression toward surgical fixation. (10.2106/jbjs.17.01593)
• [Case_report] Magnetic resonance imaging is the best diagnostic test, and conservative treatment with immobilization and rest is indicated. (10.1016/j.jht.2023.09.006)
• [L3] The degree of residual fracture displacement is detected more accurately on postoperative computed tomography scans than on plain radiographs. (10.2106/00004623-200303000-00018)
• [L5] Risks and benefits of both operative and nonoperative management should be discussed, noting the exceptionally low nonunion rate regardless of treatment and the commonality of persistent pain. (10.1016/j.jse.2024.05.042)
• [L3] Fractures occurred in 12% of cases, and the rate of secondary interventions was markedly reduced. (10.1186/1471-2474-14-302)
• [L4] Early orthopaedic referral and early MRI may help prevent delay in diagnosis and allow expedient surgical intervention in appropriate candidates. (10.1177/0363546509351559)
• [L4] Initial fracture displacement shown radiologically was the only variable identified that influenced the persistence of a step on post-operative radiographs. (10.1177/1753193416669502)
• [L2] Older patients and those with more severe fractures are also more likely to need total knee arthroplasty after repair of a tibial plateau fracture. (10.2106/jbjs.l.01691)
• [L4] Early return to play (8 weeks or less) may result in delayed union in up to 24% of patients, but this does not increase the risk of long-term non-union or prevent athletes from continuing to play. (10.1007/s00167-018-5104-2)
• [L1] In patients managed with leg fracture fixation, low-molecular-weight heparin was not more effective than placebo for preventing clinically important venous thromboembolism. (10.2106/jbjs.15.01442)
• [L4] The best functional outcomes occur with plate removal before 6 months postoperatively, provided the fracture has healed. (10.1016/j.jse.2011.07.020)
• [Case_report] This report describes the first case of an SH type III physeal fracture in the anterior inferior glenoid of a 13-year-old boy, outlining successful treatment and management with demonstrated return to function following arthroscopic stabilization. (10.1016/j.xrrt.2025.100596)
• [L4] Total knee arthroplasty after open reduction and internal fixation of a fracture of the tibial plateau decreases pain and improves knee function, but the procedure is technically demanding and is associated with a high failure rate (five of fifteen). (10.2106/00004623-200108000-00002)
• [L4] Both athletes achieved fracture union without complications and returned to elite-level sport climbing within 3 months. (10.1016/j.jhsa.2017.10.009)
• [L4] The implant has a very low revision rate and union was seen in most fractures by 6 months. (10.1111/j.1758-5740.2011.00144.x)
• [L3] Adolescents with surgically treated lower-extremity fractures have a significantly higher risk of venous thromboembolism compared to children, with risk ratios ranging from 2.4 to 4.6 depending on the specific fracture location and VTE type. (10.2106/jbjs.24.00810)
• [L3] Delayed fixation beyond three weeks after initial failed closed reduction increases the odds of reoperation, particularly in patients aged over 60 years. (10.1302/0301-620x.106b11.bjj-2023-1349.r1)
• [L3] The incidence of refracture following implant removal after bone union is underestimated, and severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors. (10.1186/s12891-023-06391-0)
• [L3] These findings could be beneficial in informed preventive of DVT and optimized management of hip fracture in specific group of young and mid-aged patients. (10.1186/s13018-021-02902-8)
• [L3] A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements. (10.1186/1471-2474-15-168)
• [L3] Our systematic review demonstrates similar outcomes with union and infection rates between all fixation techniques. (10.1177/17585732211010299)
• [L3] Total hip arthroplasty after operative treatment of acetabular fractures is associated with high rates of failure due to aseptic loosening, particularly in young patients with significant bone deficiency. (10.2106/00004623-199809000-00008)
• [L4] Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate. (10.1016/j.xrrt.2023.06.003)
• [L4] Operative fixation was associated with a higher risk of complications. (10.1177/1753193412475045)
• [Commentary] The author suggests that the 6% of fractures with associated complications merit further analysis and that more specific detail on fracture site, configuration, and initial treatment would be welcome. (10.1177/1753193413493725)
• [L4] All fractures healed with no major complications. (10.1177/1753193416641330)
• [L4] This technique offers substantial stability for the fracture and results in excellent long-term recovery of joint function. (10.1186/s13018-024-04922-6)
• [L3] Patients with either risk factor warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion. (10.1302/0301-620x.98b1.36260)
• [L4] There were relatively low overall mean rates of delayed union, nonunion, loss of fixation or deformity correction, and VTE after DFO, regardless of an early or delayed post-operative weightbearing protocol. (10.1002/ksa.70340)
• [L4] Patient factors rather than technical factors were associated with reoperation for loosening or breakage of implants and nonunion. (10.1016/j.jhsa.2015.07.009)
• [L1] A meta-analysis of high-quality studies that discuss the complications after VLP fixation for DRF showed an overall complication rate of 30.8%. (10.1016/j.jhsa.2023.04.022)
• [L4] Individualized approaches to internal fixation versus revision arthroplasty led to an 81% survivorship free from reoperation at two years with 95% of patients ambulatory. (10.1302/0301-620x.103b7.bjj-2020-2275.r1)
• [L3] A wide range of periprosthetic acetabular fractures were observed following primary cementless THA, with 71.4% being small cracks that did not necessitate revision surgery. (10.1016/j.arth.2025.05.075)
• [L3] There was no difference in infection rate and reoperation for infection when comparing different methods of fixation. (10.1177/17531934241277949)
• [L4] However, comparative and prospective studies looking at union rates and secondary procedures are needed to more clearly de fi ne their role in treatment and assure their safety. (10.1016/j.jseint.2021.11.022)
• [L4] Nonunion, malunion, and infection rates were similar to other studies. (10.1054/jhsb.2000.0486)
• [Letter] The authors agree that more standardized reporting of complication rates and categories would be beneficial, but note that their systematic review was limited to capturing only complications reported as such by the individual authors of the included manuscripts. (10.1016/j.jse.2022.04.012)
• [L4] Operative treatment of acute peri-prosthetic fractures is associated with a high rate of complications (61%) and re-operation (23%). (10.1016/j.arth.2012.06.003)
• [L3] The rate of infection is low and similar to other surgical procedures with percutaneous K-wires. (10.1302/0301-620x.97b7.35493)
• [L1] The combined plating group had a considerably higher frequency of hardware removal and postoperative infections. (10.1016/j.jhsa.2022.04.018)
• [L2] In addition, patients with open fractures who are taken to the operating room more than 1 day from presentation did not have a higher incidence of infection. (10.1016/j.jhsa.2018.04.032)
• [L3] Higher complication rates in late-treated fractures suggest surgeons should carefully select surgical candidates and modalities. (10.1186/s13018-018-0899-6)
• [L1] The systematic review showed similar major complication rates among techniques, but the hook plate technique demonstrated inferior clinical results. (10.1186/s13018-022-03108-2)
• [L3] High energy fracture events and an adult aged patient group were associated with higher rates of adverse clinical outcome. (10.1177/2325967119s00381)
• [L3] Fracture risk increases in patients younger than 50 and older than 80 years, females, American Society of Anesthesiologists grade 3 to 5, and indications other than primary osteoarthritis. (10.1016/j.arth.2019.06.062)

See Also

• Fractures
• Internal Fixation
• Shoulder Fractures
• Reverse Shoulder Arthroplasty
• Proximal Humerus Fracture
• Shoulder Instability
• Rotator Cuff
• Total shoulder arthroplasty
• Shoulder Arthroplasty

References

[1] Nonoperative management of a Cofield B total shoulder arthroplasty periprosthetic fracture. JSES International. 2020. DOI: 10.1016/j.jseint.2020.02.014

[2] Chapter 24 Proximal Humerus Fracture. 2021.

[3] Metacarpal Fractures: An Evidence-Based Review to Guide Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00323

[4] Is coracoclavicular reconstruction necessary in hook plate fixation for acute unstable acromioclavicular dislocation?. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-03978-3

[5] Conservative versus Operative Management of Complex Proximal Humeral Fractures: A Meta-analysis. Shoulder & Elbow. 2010. DOI: 10.1111/j.1758-5740.2010.00075.x

[6] Long-Term Outcomes of Isolated Stable Radial Head Fractures. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01354

[7] Infographic: Cast immobilization is non-inferior to volar locking plates in relation to QuickDASH after one year in patients aged 65 years and older: a randomized controlled trial of displaced distal radius fractures. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b2.bjj-2020-2562

[8] Humeral shaft fractures. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.10.028

[9] Chapter 10 Malunions. 2021.

[10] Frequency, Pattern, and Treatment of Hand Fractures in Children and Adolescents: A 27-Year Review of 4356 Pediatric Hand Fractures. HAND. 2020. DOI: 10.1177/1558944719900565

[11] Chapter 26 Distal Humerus Fracture. 2021.

[12] Operative Treatment of Metacarpal and Phalangeal Shaft Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200003000-00005

[13] Humeral shaft fractures: a review. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.11.030

[14] Current Concepts in the Treatment of Lateral Condyle Fractures in Children. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-17-00815

[15] Radiographic Outcomes and Complications of Delayed Fixation of Distal Radius Fractures. HAND. 2020. DOI: 10.1177/1558944720930301

[16] Inferior angle of scapula fractures: a review of literature and evidence-based treatment guidelines. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.11.007

[17] Prospective study on functional outcome of distal femur fracture treated by open reduction and internal fixation using distal femur locking plate in Tibebe Ghion Specialized Hospital, Bahirdar, North West Ethiopia. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05054-7

[18] The use of dynamic external fixation in the treatment of dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416674155

[19] Additional fixation using a metal plate with bioresorbable screws and wires for robinson type 2B clavicle fracture. Clinics in Shoulder and Elbow. 2020. DOI: 10.5397/cise.2020.00262

[20] The Central Slip Fracture: Results of Operative Treatment of Volar Fracture Subluxations/Dislocations of the Proximal Interphalangeal Joint. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.03.030

[21] Pediatric Phalanx Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-16-00199

[22] Re: Al-Qattan MM. Displaced unstable transverse fractures of the shaft of the proximal phalanx of the fingers in industrial workers: reduction and K-wire fixation leaving the metacarpophalangeal and proximal interphalangeal joints free. J Hand Surg Eur. 2011, 36: 577–583. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193411433386

[23] Open reduction and internal fixation of coronal fractures of the capitellum in patients older than 65 years. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.12.004

[24] Acute proximal humeral fractures in adults. Journal of Hand Therapy. 2017. DOI: 10.1016/j.jht.2017.05.005

[25] Acromial base fractures after reverse total shoulder arthroplasty: report of five cases. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.01.029

[26] Bennett Fracture. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.05.017

[27] Non-Union of the Scapular Body. A Case Report. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199803000-00017

[28] Effects of surgical approach on functional outcomes of open reduction and internal fixation of intra-articular distal humeral fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.06.020

[29] The Unified Classification System (UCS): improving our understanding of periprosthetic fractures. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b6.34040

[30] Fixation of Proximal Humerus Fractures Using the PHILOS Plate. Clinical Orthopaedics & Related Research. 2006. DOI: 10.1097/01.blo.0000194678.87258.6e

[31] Inter- and intraobserver reliability of the MTM-classification for proximal humeral fractures: A prospective study. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-21

[32] Morphological and clinical study of lateral malleolus fractures based on fracture mapping: a retrospective study. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05424-1

[33] Arthroscopic reduction and percutaneous cannulated screw fixation of a capitellar fracture of the humerus: A case report. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.07.007

[34] A New Classification Of Impacted Proximal Humerus Fractures Based On 3D Model. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.040

[35] A new classification of impacted proximal humerus fractures based on the morpho-volumetric evaluation of humeral head bone loss with a 3D model. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.02.022

[36] Comparison of surgical and non-surgical treatments for 3- and 4-part proximal humerus fractures: A network meta-analysis. Shoulder & Elbow. 2019. DOI: 10.1177/1758573219831506

[37] Chapter 38 High-Energy Injury and Polytrauma. 2020.

[38] High-Energy Comminuted Midshaft Clavicle Fractures: Midterm Clinical and Radiological Results of Operative Treatment Using Assisted Suture Loop Reduction and Internal Fixation with Anatomical Locking Plates. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.019

[39] Management of Bennett’s fractures: a review of treatment outcomes. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416642691

[40] Unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation: a long-term retrospective study according to Dubberley's classification. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.05.033

[41] Combined Fractures of the Distal Radius and Scaphoid. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408090099

[42] Melone’s concept revisited in comminuted distal radius fractures: the three-dimensional CT mapping. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01739-x

[43] Incidence and risk factors for pseudosubluxation of the humeral head following proximal humerus fracture. JSES International. 2022. DOI: 10.1016/j.jseint.2022.01.013

[44] Assessing the Value of Routine Pathologic Examination of Resected Femoral Head Specimens After Femoral Neck Fracture. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00901

[45] Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.033

[46] Radiographic and Clinical Assessment of Intramedullary Nail Fixation for the Treatment of Unstable Metacarpal Fractures. HAND. 2017. DOI: 10.1177/1558944717695747

[47] Reliability of a Classification of Fractures of the Hand Based On the AO Comprehensive Classification System. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409355256

[48] Field testing the Unified Classification System for peri-prosthetic fractures of the pelvis and femur around a total hip replacement. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b11.34214

[49] Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.04.002

[50] A new classification of TKA periprosthetic femur fractures considering the implant type. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1855-z

[51] Chapter 41 Fractures of the Tibial Plateau. 2021.

[52] Incarcerated patellar tendon in Hoffa fracture: an unusual cause of irreducible knee dislocation. Knee Surgery, Sports Traumatology, Arthroscopy. 2007. DOI: 10.1007/s00167-007-0431-8

[53] Three-part humeral head fractures treated with a definite construct of blocked threaded wires: finite element and parametric optimization analysis. JSES International. 2021. DOI: 10.1016/j.jseint.2021.06.007

[54] Three-Part Humeral Head Fractures Treated With A Definite Construct Of Blocked Threaded Wires: Finite Element And Parametric Optimization Analysis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.037

[55] Radiocapitellar prosthetic arthroplasty: a report of 6 cases and review of the literature. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.01.042

[56] A biomechanical comparison of hook plate vs. superolateral locking plate with coracoclavicular suture fixation for distal third clavicle fractures with coracoclavicular ligament disruption. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.100645

[57] Treatment of fractures adjacent to humeral prostheses. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.05.007

[58] Postoperative treatment of proximal humerus fractures with an early active motion protocol: a prospective randomized controlled trail. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.042

[59] Periprosthetic Postoperative Humeral Fractures After Shoulder Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-01001

[60] Dorsal Plating for Intra-articular Middle Phalangeal Base Fractures With Volar Instability. HAND. 2018. DOI: 10.1177/1558944718777868

[61] Arthroscopically Assisted Treatment of Avulsion Fractures of the Posterior Cruciate Ligament from the Tibia. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200105000-00008

[62] Does minimally invasive external fixation of proximal humerus fractures provide adequate stability? A biomechanical in vitro study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07977-y

[63] Sliding hip screw versus sliding helical blade for intertrochanteric fractures. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b3.34791

[64] Fibular Strut Graft Insertion in Shoulder Reconstruction with Internal Fixation using Plate and Screw: A Case Report and Technical Note. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00053

[65] Does objective shoulder impairment explain patient-reported functional outcome? A study of proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.06.005

[66] Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00127

[67] Current trends in surgical treatment of the acromioclavicular joint injuries in 2023: a review of the literature. JSES International. 2024. DOI: 10.1016/j.jseint.2023.11.018

[68] Chapter 91 Fractures of the Humeral Shaft and the Distal Humerus. 2019.

[69] Volar Plate Fixation Versus Cast Immobilization in Acceptably Reduced Intra-Articular Distal Radial Fractures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01344

[70] Contralateral preoperative templating for fracture reverse total shoulder arthroplasty: technique article and case series. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.05.004

[71] Chapter 51 Periprosthetic Fractures. 2021.

[72] Neer Award 2006: Biomechanical assessment of inferior tuberosity placement during hemiarthroplasty for four-part proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.06.017

[73] Management of Scapular Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-03-130

[74] Retrospective review of open and arthroscopic repair of anterosuperior rotator cuff tears with subscapularis involvement: a single surgeon's experience. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.09.035

[75] A scoping review of biomechanical testing for proximal humerus fracture implants. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0627-x

[76] Outcomes of nonoperative treatment of displaced anterior glenoid rim fractures without dislocation in the elderly: should instability be a concern?. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08947-8

[77] Chapter 90 Proximal Humeral Fractures. 2019.

[78] Restoration of Articular Geometry Using Current Graft Options for Large Glenoid Bone Defects in Anterior Shoulder Instability. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.04.002

[79] Plate fixationversusintramedullary nailing of completely displaced midshaft fractures of the clavicle. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b8.bjj-2016-1318.r1

[80] Evaluation and Treatment of Acromioclavicular Joint Injuries. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506298022

[81] Midshaft clavicular fractures in adolescents: a comprehensive review of diagnosis and management. Clinics in Shoulder and Elbow. 2025. DOI: 10.5397/cise.2025.00500

[82] Excellent Clinical and Radiological Midterm Outcomes for the Management of Recurrent Anterior Shoulder Instability by All-Arthroscopic Modified Eden-Hybinette Procedure Using Iliac Crest Autograft and Double-Pair Button Fixation System: 3-Year Clinical Case Series With No Loss to Follow-Up. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2020.10.036

[83] Finite element analysis of the treatment of a minimally invasive approach combined with a novel anatomical locking plate for scapular body fractures. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04905-7

[84] What are the patient-reported outcomes, functional limitations, and complications after lesser tuberosity fractures? a systematic review of 172 patients. JSES International. 2021. DOI: 10.1016/j.jseint.2021.02.016

[85] Assessment of fracture stability following modified minimally invasive reduction osteosynthesis system (MIROS) fixation for Neer 2 and 3-Part proximal humeral fractures. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08600-4

[86] Comparison of the effectiveness of oblique and transverse incisions in the treatment of fractures of the middle and outer third of the clavicle. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.03.021

[87] The TightRope study: a cadaveric, biomechanical comparison of generations of suspensory fixation with internal brace for Rockwood grade V acromioclavicular joint injuries. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.06.020

[88] Complications of Volar Locked Plating of Distal Radius Fractures: A Prospective Investigation of Modern Techniques. HAND. 2019. DOI: 10.1177/1558944719828001

[89] Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.03.011

[90] Treatment of intertrochanteric and subtrochanteric fractures of the hip by the Ender method. The Journal of Bone & Joint Surgery. 1976. DOI: 10.2106/00004623-197658050-00004

[91] Diagnostic strategy for elderly patients with isolated greater trochanter fractures on plain radiographs. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2193-5

[92] Outcomes of Closed Reduction and Periarticular Pinning of Base and Shaft Fractures of the Proximal Phalanx. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.008

[93] What Is the Role of Allogeneic Cortical Strut Grafts in the Treatment of Fibrous Dysplasia of the Proximal Femur?. Clinical Orthopaedics & Related Research. 2017. DOI: 10.1007/s11999-016-4806-3

[94] Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520957666

[95] Does CT improve the accuracy of predicting implant fixation status for periprosthetic fractures around uncemented femoral components?. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b6.bjj-2024-0829.r1

[96] Screw prominences related to palmar locking plating of distal radius. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193410392869

[97] A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.06.008

[98] Effects of neuraxial or general anaesthesia on postoperative adverse events in oldest-old patients (aged 90 years and older) with intertrochanteric fractures: a retrospective study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06973-y

[99] Implant Failure After Biodegradable Screw Fixation in Osteochondritis Dissecans of the Knee in Skeletally Immature Patients. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.08.032

[100] Femoral Neck Stress Fractures: MRI Risk Factors for Progression. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.01593

[101] Stress fracture of capitate bone—A case report of an unusual fracture. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.09.006

[102] COMPUTED TOMOGRAPHIC ASSESSMENT OF FRACTURES OF THE POSTERIOR WALL OF THE ACETABULUM AFTER OPERATIVE TREATMENT. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200303000-00018

[103] Sling and forget it? A systematic review of operative versus nonoperative outcomes for scapula fractures. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.05.042

[104] Prophylactic titanium elastic nailing (TEN) following femoral lengthening (Lengthening then rodding) with one or two nails reduces the risk for secondary interventions after regenerate fractures: a cohort study in monolateral vs. bilateral lengthening procedures. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-302

[105] Pectoralis Major Avulsion in a Skeletally Immature Wrestler. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509351559

[107] Comparison of distal radius fracture intra-articular step reduction with volar locking plates and K wires: a retrospective review of quality and maintenance of fracture reduction. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416669502

[110] Risk of Total Knee Arthroplasty After Operatively Treated Tibial Plateau Fracture. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.l.01691

[111] Early return to playing professional football following fixation of 5th metatarsal stress fractures may lead to delayed union but does not increase the risk of long-term non-union. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5104-2

[112] Low-Molecular-Weight Heparin Did Not Differ from Placebo in Preventing Clinically Important Deep Venous Thrombosis After Surgical Repair of Leg Fracture. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.01442

[113] Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.07.020

[114] Intraoperative_Fracture_During_Staged_Total_Knee_Reimplantation_in_the_Treatment_S0883540314000631. n.d..

[115] Salter-Harris type III fracture-dislocation of the glenoid: a case report. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.100596

[116] Total Knee Arthroplasty After Open Reduction and Internal Fixation of Fractures of the Tibial Plateau. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200108000-00002

[117] Surgical Management of Proximal Interphalangeal Joint Repetitive Stress Epiphyseal Fracture Nonunion in Elite Sport Climbers. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.10.009

[118] Early Experience of Managing Proximal Humerus Fractures with the S3 Plate. Shoulder & Elbow. 2011. DOI: 10.1111/j.1758-5740.2011.00144.x

[119] Risk of Venous Thromboembolism in Pediatric Patients with Surgically Treated Lower-Extremity Fractures. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00810

[120] Delayed fixation of distal radial fractures beyond three weeks after initial failed closed reduction increases the odds of reoperation. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2023-1349.r1

[121] Refracture after plate removal of midshaft clavicle fractures after bone union—incidence, risk factors, management and outcomes. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06391-0

[122] Incidence and risk factors associated with preoperative deep venous thrombosis in the young and middle-aged patients after hip fracture. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-021-02902-8

[123] Prevalence and risk factors for periprosthetic fracture in older recipients of total hip replacement: a cohort study. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-168

[124] Open reduction of pediatric lateral condyle fractures: a systematic review. Shoulder & Elbow. 2021. DOI: 10.1177/17585732211010299

[125] Total Hip Arthroplasty after Operative Treatment of an Acetabular Fracture. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199809000-00008

[126] Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.06.003

[127] Paediatric hand fractures. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193412475045

[129] Commentary on Young et al. Paediatric hand fractures. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413493725

[130] Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand: a review of 31 consecutive fractures. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416641330

[131] Minimally invasive techniques utilizing the “Joy Stick” method for managing irreducible flexion-type supracondylar fractures of the humerus in older children. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04922-6

[132] Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b1.36260

[133] Postoperative weightbearing timing after distal femur osteotomy is not associated with rates of union or complications: a systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70340

[134] Plate and Screw Fixation of Bicolumnar Distal Humerus Fractures: Factors Associated With Loosening or Breakage of Implants or Nonunion. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.07.009

[135] Complications Following Volar Locking Plate Fixation of Distal Radius Fractures in Adults: A Systematic Review of Randomized Control Trials. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.04.022

[136] Outcomes of operatively treated interprosthetic femoral fractures. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b7.bjj-2020-2275.r1

[137] Rate- and Patient-Specific Risk Factors for Periprosthetic Acetabular Fractures During Primary Total Hip Arthroplasty Using a Press-Fit Cup. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.05.075

[138] Comparing infection rates with wire, plate and intramedullary nail fixation of open metacarpal and phalangeal fractures. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934241277949

[139] Technical considerations and early results of magnetic compressive intramedullary nailing for humeral shaft delayed unions and nonunions. JSES International. 2022. DOI: 10.1016/j.jseint.2021.11.022

[140] Treatment of Phalangeal Fractures in Severely Injured Hands. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2000.0486

[141] Response to Dirckx et al regarding: “Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis”. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.04.012

[142] Operative Treatment of Early Peri-Prosthetic Femur Fractures Following Primary Total Hip Arthroplasty. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.06.003

[143] Long-term patient-reported outcomes following Bennett’s fractures. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b7.35493

[144] Volar Locking Plate Compared With Combined Plating of AO Type C Distal Radius Fractures: A Randomized Controlled Study of 150 Cases. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.04.018

[145] Comparison of Open and Closed Hand Fractures and the Effect of Urgent Operative Intervention. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.04.032

[146] Early and late fixation of ulnar styloid base fractures yields different outcomes. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0899-6

[147] What is the optimal surgical treatment for Neer type IIB (IIC) distal clavicle fractures? A systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03108-2

[148] Clinical Outcomes For Open Reduction Internal Fixation Of Midshaft Clavicle Fractures In Adolescent/post-adolescent Athletes Utilizing A Two Month Return To Play Protocol. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00381

[149] Risk Factors for Intraoperative Periprosthetic Femoral Fractures During Primary Total Hip Arthroplasty. An Analysis From the National Joint Registry for England and Wales and the Isle of Man. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.06.062