Fixation Of Acute Fractures Research Articles

Effect of Initial Postoperative Visit Radiographs on Treatment Plans

It is a common practice among orthopaedic surgeons to make radiographs at the first outpatient postoperative visit after surgical repair of acute fractures. There is not much literature that investigates the benefits and necessity of such a practice. We hypothesized that the practice of routine postoperative radiographs is unnecessary and increases cost to the patients and the health-care system, increases radiation exposure, and provides no change in patient management. A retrospective review of patients sustaining acute fractures requiring operative fixation was done with the goal of determining how often a radiograph made at the first postoperative visit in the surgeon's office resulted in a change in patient management. Fifteen (7.5%) of 200 fractures in 171 patients had a clinical indication for a radiograph because of an abnormal physical examination finding or history of additional trauma. Three (1.5%) of these fractures had a deviation from standard postoperative care; this deviation was a change in postoperative care on the basis of the patient history and physical examination rather than radiographs. One fracture (0.5%) had a radiographic change from the immediate postoperative radiograph to the clinic radiograph, yet did not have a change in treatment. The estimated average radiation exposure per radiograph was 0.164 mSv, and the average charge to the patient per radiograph was $335.13. The majority of radiographs made at the first postoperative visit in the surgeon's office after acute fracture fixation did not result in a change in patient management and added substantial cost to the health-care system.

Open reduction and internal fixation of acute intra-articular displaced calcaneal fractures: A retrospective analysis of surgical timing and infection rates

The choice of surgical timing in open reduction for calcaneal fractures has been proposed to be associated with soft-tissue complications and infection. This study analysed the correlation between surgical timing and postoperative infection rates. We performed a retrospective single-surgeon single-facility study (Kaohsiung Medical University Hospital, KMUH) between January 2006 and January 2010. Fifty patients with 53 close intra-articular calcaneal fractures were included. They received open reduction and internal fixation via the extensile lateral L-shaped approach. We assessed the duration between heel trauma and operation from the medical records and sorted our patients into early (within 3 days), intermediate (from 3 to 10 days) and delayed (over 10 days) surgical groups. The mean follow-up period was 13 months. Only one of the 50 patients, a 74-year-old female with diabetes mellitus, developed deep infection requiring hardware removal and serial debridement. Overall, we did not find a statistical difference in postoperative infection rates in the different timing groups. Our conclusion is that in experienced hands, surgical timing may not affect postoperative infection rates in calcaneal fracture among strictly selected patients who do not have potential risk factors for wound complication. Therefore, early operation may be helpful to these patients.

Treatment of Acute Jones Fracture with Ilizarov External Minifixator: Case Series of Six Elite Athletes

No consensus has been reached about the optimal treatment of Jones fractures, especially in elite athletes. Furthermore, only limited experience with external fixation of acute Jones fractures in these patients is available. The aim of the present retrospective study was to report the clinical evaluation of a series of 6 patients—elite athletes—with unilateral acute Jones fracture, who underwent external fixation of the fracture with an Ilizarov minifixator. Treatment success and the intervals to union and the return to full athlete activity were measured for each patient. The mean follow-up duration was 48 (range 24 to 72) months. The average period from surgery to clinical healing of the fracture was 4.1 (range 4.0 to 4.2) weeks, and the interval from surgery to radiographic consolidation of the fracture was 5.8 (range 5.4 to 6.4) weeks. The patients had returned to full athletic activity by 6.7 (range 6.4 to 6.9) weeks postoperatively. No major complications developed. No cases of treatment failure (nonunion, delayed union, or refracture) were observed during the follow-up period. Our results have shown that the Ilizarov external minifixator is a reliable surgical option for the treatment of acute Jones fractures in elite athletes, allowing an early return to full competitive athletic activity. Application of this apparatus is fast and relatively simple, with a percentage of radiographic consolidation and clinical healing comparable to that with screw fixation techniques.

Percutaneous fixation of acute scaphoid fractures

BackgroundFractures of the scaphoid are common in young men. Cast immobilization usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the risk of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid.PurposeThe aim of this prospective case series study was to evaluate percutaneous scaphoid fixation for minimally displaced or undisplaced B1 or B2 fractures with respect to time to radiographic union and return to work.Patients and methodsWe report our technique and the results of a prospective study in 12 patients with acute scaphoid fractures. Patients were assessed functionally using the Mayo wrist score and by radiography. The patients were followed up until evidence of radiologic union (35-70 days), with an average of 55 days.ResultsTen patients had excellent score and two patients had good score according to the Mayo wrist score. According to patients' occupations, return to work ranged from 14 to 40 days. With respect to radiologic union, fractures were united at a mean of 55 days (35-70 days).ConclusionPercutaneous fixation for acute scaphoid fractures using Herbert screws is a satisfactory method and gives rapid functional recovery.

Return to sports after ankle fractures: a systematic review

This review aims to provide information on the time athletes will take to resume sports activity following ankle fractures. We systematically searched Medline (PubMED), EMBASE, CINHAL, Cochrane, Sports Discus and Google scholar databases using the combined keywords 'ankle fractures', 'ankle injuries', 'athletes', 'sports', 'return to sport', 'recovery', 'operative fixation', 'pinning', 'return to activity' to identify articles published in English, Spanish, French, Portuguese and Italian. Seven retrospective studies fulfilled our inclusion criteria. Of the 793 patients, 469 (59%) were males and 324 (41%) were females, and of the 356 ankle fractures we obtained information on, 338 were acute and 18 stress fractures. The general principles were to undertake open reduction and internal fixation of acute fractures, and manage stress fractures conservatively unless a thin fracture line was visible on radiographs. The best timing to return to sports after an acute ankle fracture is still undefined, given the heterogeneity of the outcome measures and results. The time to return to sports after an acute stress injury ranged from 3 to 51 weeks. When facing athletes with ankle fractures, associated injuries have to be assessed and addressed to improve current treatment lines and satisfy future expectancies. The best timing to return to sports after an ankle fracture has not been established yet. The ideas of the return to activity parameter and surgeon databases including sports-related information could induce research to progress.

Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review

The aim of this study is to better inform the sports surgeon of current evidence for the treatment of Jones fractures of the base of the 5th metatarsal. The study aimed to establish what the outcomes were for different treatments modalities. By doing this, the clinician will be better prepared to institute a logical, evidence-based approach to the treatment of their patients with this injury. A thorough literature search was performed from 1980 to present day. Studies were included based on set criteria and analysed for their validity, and their results were scrutinised. Jones fractures were segregated into acute fractures, delayed unions and non-unions. Twenty-six studies were included, of which 22 were level 4 evidence, with only 1 randomised controlled trial. Functional outcome data were limited to return to sports in most studies with few studies using established scoring systems. Return to sports following intra-medullary screw fixation for acute fractures ranged from 4 to 18 weeks. Acute fractures treated non-operatively had a union rate of 76 % (pooled), whereas in fractures treated with a screw it was 96 % (pooled). Delayed unions treated non-operatively had a union rate of 44 and 97 % treated operatively. Non-unions treated with screw fixation healed in 97 % of cases. Although supported by mostly level 4 evidence, intra-medullary screw fixation is more likely to lead to successful union of all types of Jones fractures compared to non-operative treatments. Early return to play in athletes prior to full radiological union is not advised in case of re-fracture.

Early results of a new implant: 3.0 mm headless compression screw for scaphoid fracture fixation

There has been a considerable evolution of screws used for internal fixation of scaphoid fractures. We discuss here, early results of a recently introduced implant Synthes 3.0 mm headless compression screw used for scaphoid fracture fixation. Twenty eight patients with scaphoid fractures (five acute and 23 nonunions) were treated with internal fixation by this non-variable pitch screw over a period of 18 months. All nonunions had pedicle vascularized bone grafting. All five patients with acute scaphoid fracture fixation had radiological healing at a mean of 8 weeks. Fifteen of 23 scaphoid fracture nonunions showed definite signs and a further seven showed probable signs of radiological healing at a mean of 8 months. One nonunion has failed to unite after surgery.

DORSAL PERCUTANEOUS CANNULATED MINI-SCREW FIXATION FOR FRACTURES OF THE HAMATE HOOK

Open fixation of acute fractures, delayed union and non-union of the hamate hook through a palmar approach has been reported. Minimal invasive fixation using a dorsal percutaneous approach and a headless cannulated mini-screw is another option not commonly considered. The authors present their case series of patients who underwent dorsal percutaneous fixation of acute fractures and delayed union of the hamate hook. This study retrospectively reviewed six consecutive patients (five male patients and one female patient) with non-displaced acute fractures (< 8 weeks) and delayed union (8 to 12 weeks) of the hamate hook treated with dorsal percutaneous cannulated mini-screw fixation. The indications for surgery included wrist pain, patient refusal of conservative treatment, and prevention of non-union and hook excision. Exclusion criteria included displacement or inadequate size of the hamate hook, previous surgery, associated carpal injury, flexor tendon rupture, and median or ulnar nerve lesion in the carpal tunnel and Guyon's canal respectively. Each fracture was visualized by radiography and computed tomography before and after the intervention. Anatomically correct fixation of the hamate hook with central screw positioning was achieved in all patients. No displacement or disruption of the cortical shell of the hook was observed. The union rate was 100% with all patients being able to resume their pre-injury activities after an average of seven weeks from surgery. This pilot study demonstrates that non-displaced acute fractures and delayed union of the hamate hook can be treated successfully by dorsal percutaneous cannulated mini-screw fixation with minimal morbidity and complications.

Comparison of dorsal and volar percutaneous screw fixation methods in acute Type B scaphoid fractures

In this study, we aimed to compare the clinical and functional results of patients treated with dorsal or volar percutaneous screw fixation for acute scaphoid fractures. We retrospectively evaluated 27 wrists of 26 patients (24 males, 2 females; mean age: 33.1 years) who underwent dorsal or volar percutaneous screw fixation for acute scaphoid fractures between 2000 and 2009. The dorsal approach group contained 13 wrists and the volar approach group 14 wrists. Splint was removed and wrist exercises initiated on the 10th postoperative day. Pinch power, grip power and range of motion were evaluated using the contralateral wrist as controls. Functional evaluation was performed using the patient-rated wrist evaluation score (PRWE) and Mayo wrist scoring system. According to the Herbert and Fisher's classification system there were 9 B2, 3 B3 and 1 B1 fractures in the dorsal approach group, and 12 B2 and 2 B1 fractures in the volar approach group. Fracture union was achieved in all patients. There was no significant difference between the two groups according to functional and clinical results (p>0.05). All patients returned to their jobs in an average of 4.2 weeks and there was no significant difference between the groups (p=0.437). Wrist flexion was significantly better in the control wrists in both groups (p=0.009). In one patient, the screw was removed due to ongoing pain and asymptomatic screw head displacement in the scaphotrapezoid joint was detected in another. The surgical approach does not affect the clinical and functional outcomes in percutaneous screw fixation of Type B scaphoid fractures. Percutaneous fixation is a valuable treatment method for Type B scaphoid fractures as it enables early wrist motion and high patient satisfaction.

Incidence of Scaphotrapezial Arthritis Following Volar Percutaneous Fixation of Nondisplaced Scaphoid Waist Fractures Using a Transtrapezial Approach

To investigate whether volar percutaneous screw fixation of scaphoid waist fractures via a transtrapezial approach causes degenerative changes at the scaphotrapezial (ST) joint at short- to medium-term follow-up. A total of 34 patients were available for follow-up at a mean of 6.1 years (minimum follow-up, 3.7 y) after volar percutaneous fixation of acute scaphoid waist fractures via a transtrapezial approach. The clinical follow-up examination included assessment of pain using a visual analog scale, range of motion, grip strength, and key pinch strength. We obtained radiographs of both hands in 3 views. We staged degenerative changes at the ST joint according to the modified Eaton and Glickel classification. The modified Mayo wrist score showed excellent clinical results using the described technique. One patient showed asymptomatic unilateral stage 2 osteoarthritic changes at the ST joint. We noted 6 screw protrusions, which required screw removal in 2 patients, in the early stages of use of the transtrapezial technique. One patient was treated surgically for a bone cyst. Volar percutaneous screw fixation of nondisplaced scaphoid waist fractures using a transtrapezial approach does not lead to symptomatic scaphotrapezial osteoarthritis at short- to medium-term follow-up. Therapeutic IV.

Midshaft clavicular fractures: comparison of intramedullary pin and plate fixation

Intramedullary pin and plate fixation for midshaft clavicular fractures both have their proponents, but little comparative data are available. We performed a retrospective comparison of these 2 techniques. A retrospective review was performed on 40 consecutive patients with closed, simple, or wedge-type midshaft clavicular fractures that were identified from a prospectively collected orthopedic trauma database. Eight patients were excluded due to incomplete follow-up. Intramedullary pins were used in 18 patients and plates in 14; of these, 7 plates were placed superiorly, 6 anteriorly, and 1 inferiorly. Treatment method was determined by preference of the treating surgeon. Among the patients treated with intramedullary pin fixation, all 18 fractures healed, and each underwent a planned procedure for pin removal. Complications included 1 intraoperative pin breakage, 1 superficial wound infection, 2 prominent symptomatic pins, and 1 transient brachial plexopathy. Among the patients treated with plating, delayed union occurred in 1, and refractures occurred in 2 (1 required a second procedure). Three patients underwent plate removal for symptomatic hardware. No patients in either group had significant loss of shoulder motion. Intramedullary pin fixation for acute, simple, or wedge-type midshaft clavicular fractures provides a safe and predictable alternative to plate and screw fixation.

Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults

Surgical fixation of fractures of the shaft of the humerus generally involves plating or nailing. It is unclear whether one method is more effective than the other. To compare compression plating and locked intramedullary nailing for primary surgical fixation (surgical fixation of an acute fracture or early fixation following failure of conservative treatment) of humeral shaft fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2011), The Cochrane Library 2011, Issue 1, MEDLINE and EMBASE (both to February 2011) and trial registries for ongoing trials. Randomised and quasi-randomised controlled trials comparing compression plates and locked intramedullary nail fixation for humeral shaft fractures in adults. Two authors independently assessed trial methodology and extracted data. Disagreement was resolved by discussion, or third party adjudication. Treatment effects were assessed using risk ratios for dichotomous data and mean differences for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using a fixed-effect model. Five small trials comparing dynamic compression plates with locked intramedullary nailing were included in this review. These involved a total of 260 participants undergoing surgery for either acute fractures or after early failure of conservative treatment. All five trials had methodological flaws, such as the lack of assessor blinding, that could have influenced their findings. There was no significant difference in fracture union between plating and nailing (five trials, RR 1.05; 95% CI 0.97 to 1.13). There was a statistically significant increase in shoulder impingement following nailing when compared with plating (five trials, RR 0.12; 95% CI 0.04 to 0.38). Intramedullary nails were removed significantly more frequently than plates (three trials, RR 0.17; 95% CI 0.04 to 0.76). There was no statistically significant difference between plating and nailing in operating time, blood loss during surgery, iatrogenic radial nerve injury, return to pre-injury occupation by six months or American Shoulder and Elbow Surgeons (ASES) scores.Two further small trials are awaiting classification. The available evidence shows that intramedullary nailing is associated with an increased risk of shoulder impingement, with a related increase in restriction of shoulder movement and need for removal of metalwork. There was insufficient evidence to determine if there were any other important differences, including in functional outcome, between dynamic compression plating and locked intramedullary nailing for humeral shaft fractures.

Operative versus Nonoperative Management of Displaced Midshaft Clavicle Fractures: A Prospective Cohort Study

To compare results of primary internal fixation of acute displaced midshaft clavicle fractures with those managed nonoperatively in terms of fracture union and functional outcome. Prospective cohort study. Level II military trauma center. Seventy-three patients (civilian and military) between 20 and 50 years of age with displaced midshaft clavicle fractures were allocated either to the operative (n = 45) or nonoperative (n = 28) group. Patients in the nonoperative group were managed by simple sling immobilization, whereas in the operative group, fractures were reduced and fixed with a contoured reconstruction plate. The patients were actively followed up during an 18-month period. Primary outcome measures were the rates of nonunion and symptomatic malunion; secondary outcomes included the assessment of the Constant score and the overall local complication rate. The 18-month follow-up rate was 90%. All fractures in the operative group united compared with eight nonunions (29%) in the nonoperative group (P = 0.002). Ten symptomatic malunions (36%) occurred in the nonoperative group, whereas only two (4%) were reported for the operative group (P = 0.0008). Constant shoulder scores were significantly better for the operative group at all follow-ups (P < 0.0001). All six operative complications were implant-related. In this prospective cohort study, primary open reduction and internal plate fixation of acute displaced midshaft clavicular fractures resulted in improved outcomes and a decreased rate of nonunion and symptomatic malunion compared with nonoperative treatment.

Optimal Fixation of Acute Scaphoid Fractures: Finite Element Analysis

The hypothesis of this study was that more stable fixation of acute scaphoid fractures may be achieved by a screw placed perpendicular to the fracture plane than along the long axis of the scaphoid, as previously suggested. We examined this assumption on different fracture patterns using a finite element analysis model. A computed tomography scan of an intact scaphoid of a young man provided the data set for all fracture models. We used semiautomatic segmentation to create 3-dimensional computer models of the 3 simple fracture configurations: oblique, transverse waist, and proximal fractures, according to the Herbert classification. Each fracture type was analyzed, using finite elements, for its biomechanical response to 2 types of virtual fixation: a screw placed either perpendicular to the fracture plane or centrally along the long axis of the scaphoid. We measured motion at the fracture plane (in millimeters) and strain in the screw threads (in millipascals). Considerably less motion was measured at the fracture plane with the perpendicular screw compared with the long axis screw, especially in the oblique-type fractures: (1) Herbert-type B1 oblique fracture mean motion of 0.05 mm (+/-0.03) for the perpendicular screw versus 0.28 mm (+/-0.05) for the long axis screw; (2) B2 transverse waist fracture mean motion of 0.06 mm (+/-0.03) for the perpendicular screw versus 0.18 mm (+/-0.06) for the long axis screw; and (3) B3 proximal fracture mean motion of 0.07 mm (+/-0.01) for the perpendicular screw versus 0.28 mm (+/-0.011) for the long axis screw. Higher strains were measured on the screw placed perpendicular to the fracture. According to this model, higher fixation stability is achieved when the scaphoid is fixated perpendicular to the fracture. In transverse waist fractures, a centrally placed screw will also be perpendicular to the fracture, which explains the results of previous models.

Treatment of Acute Scaphoid Fractures: A Systematic Review and Meta-Analysis

The purpose of this review was to assess the current evidence supporting operative fixation versus casting for acute scaphoid fractures through a systematic review and meta-analysis of the literature. Our search yielded 59 articles that met our inclusion criteria with five studies achieving high, 22 moderate, and 32 low Structured Effectiveness Quality Evaluation Scale scores. Pooled results of the four Sackett level 1 evidence studies showed no significant difference between the operative (114/115, 99%) versus non-operative group (106/112, 95%) (p = 0.07) when the definition of nonunion was based on more definitive criterion versus plain radiographs that may be insufficient to assess bony union. Similar results were found for the Sackett level 2 and 4 articles. This systematic review reveals that significant weaknesses exist in the literature with respect to the level of evidence and quality of published studies on this topic. Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures.

The Factors Associated with Prolonged Inpatient Stay after Surgical Fixation of Acute Ankle Fractures

In order to identify specific factors associated with prolonged inpatient stay following surgical correction of acute ankle fracture, we conducted a retrospective cohort study of patients who underwent acute ankle fracture repair, comparing length of hospital stay to the reason for delay of surgery (logistical versus clinical), type of fracture, and age. Our findings showed that delay in surgical repair beyond 24 hours following presentation to the emergency department was associated with a statistically significant overall longer length of stay, in comparison to patients who underwent surgery within the first 24 hours ( P = .022). Delay due to clinical reasons statistically significantly increased the length of stay ( P = .004), whereas those due to purely logistical reasons also prolonged the stay, although this association was not statistically significant in our study ( P = .086). We also observed a statistically significant positive correlation between age and length of stay ( P ≤ .001, Spearman's rho = 0.55). Interestingly, patients with a trimalleolar fracture showed a shorter length of stay if the repair was delayed, although this could not be shown to be statistically significant. The results of this investigation indicate that length of hospital stay following ankle fracture is increased by delaying surgical repair of the ankle greater than 24 hours from the time that the patient presents to the emergency department, as well as increased patient age.

Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation

The development of a deep wound infection in the presence of hardware after open reduction and internal fixation presents a clinical dilemma, and there is scant literature to aid in decision-making. The purpose of the present study was to determine the prevalence of osseous union with maintenance of hardware after the development of postoperative infection within six weeks after internal fixation of a fracture. The present study included 121 patients from three level-I trauma centers, retrospectively identified from billing and trauma registries, in whom 123 postoperative wound infections with positive intraoperative cultures had developed within six weeks after internal fixation of acute fractures. The incidence of fracture union without hardware removal was calculated, and the parameters that predicted success or failure were evaluated. Eighty-six patients (eighty-seven fractures; 71%) had fracture union with operative débridement, retention of hardware, and culture-specific antibiotic treatment and suppression. Predictors of treatment failure were open fracture (p = 0.03) and the presence of an intramedullary nail (p = 0.01). Several variables were not significant but trended toward an association with failure, including smoking, infection with Pseudomonas species, and involvement of the femur, tibia, ankle, or foot. Deep infection after internal fixation of a fracture can be treated successfully with operative débridement, antibiotic suppression, and retention of hardware until fracture union occurs. These results may be improved by patient selection based on certain risk factors and the specific bacteria and implants involved.

Percutaneous retrograde screw fixation of non-displaced fractures of the scaphoid waist: an antirotation wire may not be necessary

Some authors recommend using an antirotation wire when performing percutaneous screw fixation of acute non-displaced scaphoid waist fractures. The aim of this study of 21 cadaveric wrists was to assess the usefulness of such a wire in Herbert's B2-type fractures. A B2-type fracture was created experimentally on each scaphoid. An antirotation wire was inserted in eight wrists. Retrograde percutaneous fixation using a double-threaded headless cannulated screw was performed on all wrists. Computed tomography was used to measure interfragmentary rotation. No interfragmentary rotation was noted in either group. Our study suggests that using an antirotation wire may be unnecessary when performing retrograde percutaneous screw fixation of isolated B2-type scaphoid fractures.

Volar Percutaneous Screw Fixation for Scaphoid Waist Delayed Union

Volar percutaneous cannulated screw fixation of acute scaphoid waist fractures reportedly produces high rates of healing and early return to work, but the method has not been reported for treating scaphoid waist delayed unions. We therefore report the surgical results of percutaneous screw fixation in scaphoid waist delayed union in 12 patients. All patients were male with an average age of 31.1 years. Duration of injury was 12 weeks (range, 6-20 weeks). However, no patient had carpal instability, scaphoid deformity, or avascular necrosis of the proximal fracture fragment. The minimal followup was 12 months (mean, 20 months; range, 12-24 months). Preoperative radiographs showed slight bone resorption at the fracture site in five patients and cyst formation in three patients. A cannulated screw was introduced volarly under image intensifier guidance in all patients. All fractures united uneventfully. At 12 month followups, the flexion and extension arcs of the injured wrist were 94% and 93% of the uninjured wrist. Grip strength averaged 34 +/- 3 kg, which was 92% of the grip strength of the uninjured hand. The Mayo Modified Wrist Score was 94 +/- 6 points and the Disabilities of the Arm, Shoulder, and Hand score was 9 +/- 6 points. Our experience suggests volar percutaneous screw fixation is a reliable method to treat scaphoid waist delayed union. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Intraoperative Distraction in the Upper Extremity

Intraoperative distraction aids in the restoration of length, facilitates reduction, assists in maintaining rotational alignment, and provides a temporary stable platform for definitive fixation of acute fractures, malunions, and nonunions. This technique has been described at length in the lower extremity; however, there is a paucity of literature regarding its use in the upper extremity. Distraction is the application of tension across a fracture site. Proximal and distal fixation may be achieved in several ways, with common instrumentation including the use of an external fixator set. Intraoperative distraction may be invaluable in the treatment of displaced fractures of the upper extremity. The objective of this paper was to detail the technique of intraoperative distraction in the surgical treatment of fractures of the clavicle, humerus, radius, and ulna.