The number of fractures of the distal humerus in older adults is rising due to an ageing population and an increasing incidence of fragility fractures. The management is based on the patient's preference, the pattern of the fracture, the quality of the bone and soft-tissue, the patient's comorbidities and potential for rehabilitation, as well as balancing the risk of complications such as infection, nonunion, instability, or loosening. Nonoperative treatment remains appropriate for a few low-demand or medically unfit patients. Open reduction and internal fixation (ORIF) or arthroplasty, either hemiarthroplasty (HA) of the elbow or total elbow arthroplasty (TEA), provide good outcomes when appropriately selected. An increase in the use of arthroplasty for trauma is shown in registry data, although the indications and survival remain controversial with few robust comparative and long-term data. Similar short- to mid-term functional outcomes between ORIF and TEA have been reported in recent comparative studies, with a trend towards an increased reoperation rate after ORIF, but the evidence is derived largely from small retrospective observational studies. HA of the elbow may be a viable alternative for active older patients, particularly when stable fixation is not achievable, although instability and conversion to TEA may be required. The aim of this review was to synthesize the current evidence dealing with the indications, techniques, and outcomes for nonoperative management, ORIF and arthroplasty in older patients with a distal humeral fracture.

Mandibular Condylar Fractures and Occlusal Management.

Response to the Letter to the Editor Regarding "Proton Pump Inhibitors Are Associated With Increased Risk of Site-specific Nonunion After Open Reduction Internal Fixation".

Letter to the Editor Regarding "Proton Pump Inhibitors Are Associated With Increased Risk of Site-Specific Nonunion After Open Reduction Internal Fixation".

Resident Participation in Operative Fixation of Distal Radius Fractures: A Comparison of Outcomes.

Distal humerus nonunion in adults: Management strategies and contemporary outcomes.

Classical Surgical Alternatives for the Treatment of Lesser Toe Deformities.

Femoral neck fractures constitute the predominant type of hip fracture in the elderly population and pose significant therapeutic challenges. Although internal fixation remains the standard treatment for non-displaced fractures, existing classification systems, such as the traditional anatomical categories (subcapital, transcervical, and basicervical), lack precise anatomical definitions needed to guide instrumentation therapy. Therefore, this study aims to develop a novel classification system based on the Adams' Arch to enhance fixation strategy selection. Forty-two fracture line models were created based on quantified relationships between fracture orientation, the proximity to Adams' Arch, and neck axis alignment. Each model underwent evaluation under two fixation protocols: (1) conventional triple cannulated screw fixation and (2) hybrid fixation combining cannulated screw with medial buttress plating, resulting in 84 computational models. Physiological loading conditions simulating upright human posture were applied with validated boundary constraints. First, regardless of whether the support was positive or negative, smaller angles between the fracture line and the cannulated screws were associated with increased femoral stress, with higher stress observed under positive buttress conditions. Second, as the length of Adams' Arch increased, the stress on cannulated screw 3 in both fixation groups initially rose and then declined.Notably, the cannulated screw group classified as 6-5 failed to converge. Third, increasing Adams' Arch length decreased relative displacement along the X-axis at the fracture site, corresponding with an increased angle between the fracture line and cannulated screw. Moreover, increased femoral neck distance reduced relative displacements along the X- and Y-axes as the fracture line extended further from the femoral neck. This finite element analysis identifies four critical insights: 1. The Adams' Arch-based classification provides effective biomechanical guidance for surgical management of femoral neck fractures (The classification of Subcapital, Transcervical and Basicervical was enhanced). 2.The stress on the cannulated screw peaks at intermediate lengths of the Adams' Arch.with an initial increase followed by a decline. 3. Femoral stress was higher under positive buttress support than under negative buttress conditions. 4. In elderly patients with 6-5 fracture line classification, cannulated screws alone provide insufficient fixation strength; alternative strategies such as medial plate augmentation should be considered.

Closed treatment versus open reduction and internal fixation for mandibular condylar head fractures: A systematic review and meta-analysis.

Occlusion Management in Facial Trauma: A Literature Review.

The burden of health-care costs on society continues to grow. U.S. health-care expenditures reached $4.9 trillion in 2023, accounting for 17.6% of the U.S. gross domestic product1. In a world of limited resources, alternative treatment options need to be evaluated for their cost-effectiveness in addition to their comparative safety and effectiveness. The article by Suter et al. provides a useful cost-effectiveness analysis of the 2 alternative treatments for displaced, closed humeral shaft fractures, with practical implications for shared decision-making at the individual patient level. The practicing traumatologist must consider 2 reasonable options when treating displaced, closed humeral shaft fractures: (1) nonoperative treatment with functional bracing and (2) open reduction with internal fixation (ORIF). Nonoperative management of closed humeral shaft fractures was the established norm during the 20th century, especially after functional bracing was introduced by Sarmiento in 19772. ORIF, developed to decrease the period of immobilization and to quicken the return to function, has since become the predominant treatment modality in the U.S., with utilization increasing from 47.2% of humeral shaft fractures in 2002 to 60.3% of humeral shaft fractures in 20113. A recently published analysis found that patients who were on Medicare or Medicaid or who were self-paying were significantly less likely to undergo operative treatment for humeral shaft fractures4. Outside the U.S., functional bracing remains recommended as the first treatment of choice. Clearly, economic resource limitations continue to drive ongoing disparities in the treatment of displaced, closed humeral fractures. The prespecified economic analysis by Suter et al. compares ORIF and functional bracing in the Finnish health-care system with use of prospectively collected economic and outcome data from a pragmatic randomized clinical trial (RCT) for which 1-, 2-, and 5-year clinical results have already been published5–7. These published reports found significantly improved DASH (Disabilities of the Arm, Shoulder and Hand) and Constant-Murley shoulder function scores for the surgery group compared with the bracing group at 6 weeks and 3 months of follow-up but no significant differences at 1 year (the primary outcome measure) or at 2 and 5 years, suggesting that the ultimate trajectory of recovery was similar regardless of the allocated treatment group. In their comparison of societal versus health-care perspectives, Suter et al. identified patient-specific factors that influenced the cost-effectiveness of these 2 treatment alternatives. The base-case analysis, prespecified as the societal perspective, found that ORIF was more effective than functional bracing and yielded a cost-saving incremental net monetary benefit (INMB) of €9,423. Surgery was also clinically favored for health-related quality of life measured using the 15D utility instrument. This result was considered a cost-effectiveness win-win for society, with all bootstrapped estimates overwhelmingly found in the lower right (win-win) quadrant of the standard cost-effectiveness plane. This societal cost-saving was primarily driven by the inclusion of the indirect cost of time away from work for employed patients. Conversely, when the analysis considered only direct health-care costs, ORIF became markedly more expensive than functional bracing, with an INMB of +€4,087. Despite the solid evidence of the cost-effectiveness of ORIF from the societal perspective and the finding that 32% of patients who were randomized to functional bracing still required surgery, policy-makers might still tend to favor functional bracing because of health-care resource limitations. Simply put, humeral fracture is just 1 of many “buckets” of societal costs related to injury or degenerative conditions. Policy-makers must allocate available funds among buckets corresponding to multiple disease states and treatments. Randomized health economic trials are the gold-standard tool for guiding the allocation of funds among disease and/or treatment-specific health-care buckets at the societal level. Suter et al. also provide pragmatic evidence to inform treatment decisions for individual patients. This report should be of interest to both practicing clinicians and health economists. Cost-effectiveness was primarily calculated as an INMB in simple € terms that are easy for clinicians to understand. The incremental cost-effectiveness ratio (ICER) favored by health economists was included in the Appendix to facilitate comparison across multiple disease states and treatments. The societal cost-effectiveness of ORIF also has relevant implications for shared decision-making at the individual patient level, establishing a useful framework for patient-physician discussions. This analysis highlights the importance of taking multiple clinical and socioeconomic factors into consideration when making patient-specific decisions. Moreover, it suggests the need for patient-specific flexibility in health-care policy, rather than the typically rigid reliance on treatment guidelines imposed by payers who are forced to deal with group-level effects and resource limitations.

Computerised Hexapod-Assisted Orthopaedic Surgery (CHAOS) in the Treatment of Long Bone Malunion (Tibia and Femur) - A Comprehensive Review.

Standing fracture repair has become established as an acceptable technique with a good long-term prognosis. However, no study has compared racing outcomes with case-matched controls. To compare racing outcomes between a large dataset of horses undergoing standing fracture repair against case-matched controls. Retrospective case-matched controlled comparative study. Thoroughbred racehorses undergoing standing repair of distal limb fracture(s) over 10 years (2012-2022) at five hospital centres across North America and Europe were included. Data retrieved included age, sex, fracture type, pre- and post-operative racing status, days elapsed between repair and first start, and number of starts and places (1-3), which were used to generate a performance index (PI) and a performance index per start (PI/S). Two case-matched controls were assigned and used for post-operative comparison of racing performance. 185/265; 69.8% (confidence interval (CI): 63.9%-75.4%) of horses raced post-surgery. No significant difference in the proportion of cases and case-matched controls (260/342; 76% (CI: 71.3%-80.4%)) that returned to racing was observed. No significant difference in post-operative performance indicators (N starts, PI, PI/S) between cases ((9, inter-quartile-range (IQR): 14) (7, IQR: 14) (0.64, IQR: 1)) respectively, and case-matched controls ((9, IQR: 17) (5, IQR: 14.8) (0.6, IQR: 0.66)) respectively, was observed. Fracture type, limb, sex, or pre-operative racing experience did not affect the proportion of horses returning to racing. The retrospective nature of this study may lead to the omission of data for analysis. Horses undergoing standing internal fixation of select proximal phalanx and third metacarpal/tarsal condylar fractures have a good prognosis for return to racing and comparable performance with case-matched controls. Horses that undergo standing fracture repair have good longevity, outweighing surgical costs and loss of training.

BackgroundThe role of arthroscopy in the management of ankle fractures is controversial. This study aims to evaluate the prevalence of intra-articular pathologies detected during arthroscopically assisted reduction and internal fixation (ARIF) of ankle fractures, stratified by fracture classification, for indirect comparison to current literature. We also present short- to mid-term patient-reported outcomes (PROs) for a subset of the participant cohort.MethodsWe retrospectively analyzed the intra-articular findings of 134 patients who underwent ARIF of ankle fractures. A statistical analysis was performed to assess for significant differences in the proportions of affected patients across fracture types for each intra-articular pathology. PROs included Visual Analog Scale (VAS) ratings and Foot and Ankle Ability Measure scores for Activities of Daily Living (FAAM ADL).ResultsIntra-articular pathologies were noted in 92.5% of patients including sources of anterior impingement such as synovitis (52.2%), soft tissue (29.9%), and loose bodies (33.6%), as well as syndesmotic injury (47.0%), deltoid injury (26.1%), and osteochondral defects (29.1%) (Figure 1). Deltoid injury was more frequently detected in Weber C fractures than in any other fracture type. Syndesmotic injury occurred significantly more frequently in Weber C fractures than in Weber A (P < .01) and Weber B fractures (P < .001) (Table 1, Figure 2). PROs obtained for a subset of patients at the final follow-up reflected low VAS scores (mean = 1.78, n = 49) and high FAAM ADL scores (mean = 71.1, n = 14).ConclusionArthroscopy during ankle fracture surgery is valuable in the detection of intra-articular pathologies that may require treatment to ensure positive patient outcomes. Furthermore, fracture type may be correlated with higher incidence of certain intra-articular pathologies. While future direct comparison is necessary between open reduction and internal fixation (ORIF) and ARIF, our study proposes that ARIF detects issues that may otherwise remain undetected during ORIF and suggests that concomitant arthroscopy is beneficial for ankle fracture fixation.Level of Evidence:Level IV-Case series.

IntroductionOpen reduction and internal fixation with plating is the most common surgical method of treatment for displaced intra-articular calcaneal fractures, but it has a high infection rate, which leads to chronic osteomyelitis, causing permanent disability; also, the postoperative complications are higher than those of percutaneous techniques. Thus, percutaneous fixation techniques using various indirect reduction methods provide an alternative to addressing these issues. Our study aimed to compare the functional outcomes of displaced intra-articular calcaneal fractures treated with percutaneous fixation using the Essex-Lopresti technique and 3-point distraction technique described by Forgon and Zadravecz.Materials and methodsA prospective randomized superiority study of displaced intra-articular calcaneal fractures was conducted between July 2015 and June 2020. Patients were randomized into 2 groups; group A was operated using the Essex-Lopresti technique, and in group B, a 3-point distracter was used to aid reduction. Functional assessment was done using calcaneal fracture scoring system of Kerr et al and Maryland foot scoring system.ResultsThere were 43 patients with 46 displaced intra-articular calcaneal fractures, with 27 males and 11 females. The mean duration of follow-up was 28 months. There were 20 patients with 23 calcaneal fractures in group A and 18 patients with 18 calcaneal fractures in group B. No statistically significant difference was found in functional outcomes of both techniques, but the operating time was significantly longer in group B patients.ConclusionBoth the Essex-Lopresti technique and use of a 3-point distractor coupled with percutaneous cancellous screw fixation of displaced intra-articular calcaneal fractures provide good functional outcomes with minimal complications. There is no statistically significant difference in the functional outcomes, but outcome scores were better in the 3-point distractor group.

Clinical Outcomes of Single-Stage Surgical Intervention for Open Pronation-External Rotation Ankle Fracture-Dislocation.

To evaluate 1 year mortality, complication rates, and functional outcomes after internal fixation of femoral periprosthetic knee fractures following total knee arthroplasty, and to identify predictors of adverse outcomes and increased healthcare resource utilization. This retrospective cohort study included 102 consecutive patients with femoral periprosthetic knee fractures classified as UCPF VB3 and VC3 treated with internal fixation at a single tertiary center between 2010 and 2023. Interprosthetic fractures and combined fixation techniques were excluded. Primary outcomes were 1 year mortality and postoperative complications. Secondary outcomes included length of stay, discharge destination, and ambulatory status at follow up. Patients were markedly frail, with a mean age of 82.4 ± 10.8 years and mean Charlson Comorbidity Index of 5.6. One year mortality was 16.7% and was associated with older age, higher ASA class, higher Charlson index, impaired pre fracture ambulation, and fracture related infection. Overall complication rate was 29.4%, including 15.7% infections and 13.7% mechanical failures. Open reduction was more frequent in plate fixation and resulted in longer operative times, without increasing complication rates. Median hospital stay was 18 days, 66.3% required discharge to nursing facilities, and only 7.8% regained independent ambulation. Outcomes were worse in patients who developed complications. Outcomes after internal fixation of femoral periprosthetic knee fractures are driven primarily by patient frailty rather than fixation technique. Functional recovery is limited and resource utilization is substantial, underscoring the need for improved risk stratification and perioperative care pathways.

This study comparatively analyzed the biomechanical performance of different vertebral level osteotomies in patients with severe kyphosis secondary to ankylosing spondylitis (ASK) using finite element analysis. The hilus pulmonis-hip axis (HP-HA) method was employed to determine osteotomy angles. Posterior vertebral column resection (PVCR) was simulated at four distinct vertebral levels (T12, L1, L2, and L3), followed by pedicle screw-rod fixation combined with interbody fusion cages. Total displacement, von Mises stress distribution in the pedicle screw-rod construct, titanium cage, and cage-vertebral interface were evaluated and compared across models. Four finite element models (A-D, corresponding to T12, L1, L2, and L3 osteotomies) were successfully established and validated. Total displacement decreased progressively from model A to model D, measuring 6.88mm, 5.44mm, 3.90mm, and 2.26mm, respectively. Peak von Mises stresses in the pedicle screw-rod systems were 115.58MPa, 139.53MPa, 191.35MPa, and 184.14MPa, respectively. Model D (L3 osteotomy) demonstrated the smallest displacement and well-dispersed stress distribution, while model A (T12 osteotomy) exhibited the largest displacement despite having the lowest screw-rod stress. All stresses remained below the yield strength of the internal fixation devices. This finite element study demonstrates that L3 osteotomy yields superior stability compared to T12 osteotomy, though the conclusion is based on a single-case model and requires further validation through multicase studies. These findings underscore the importance of considering segment-specific biomechanical factors in surgical planning for ASK patients.

Proximal humeral fractures (PHFs) are a significant healthcare burden, representing the third most common osteoporotic fracture in older adults. Although open reduction and internal fixation (ORIF) with the Proximal Humeral Internal Locking System (PHILOS) provides a reliable rate of osseous union, postoperative complications such as shoulder stiffness and residual pain remain prevalent. Current rehabilitation protocols are predominantly glenohumeral-centric and often overlook fracture-associated scapular dyskinesis. This randomized controlled trial (RCT) aims to evaluate whether incorporating a systematic scapular control and stabilization program into standard postoperative rehabilitation yields superior outcomes after PHILOS fixation. A single-centre, prospective RCT was conducted from June 1, 2023, to December 31, 2024. Sixty eligible patients (aged 18 to 80years) with severely displaced two- or three-part PHFs were randomized (1:1) to a scapular-focused rehabilitation (SFR) group (n = 30) or a standard rehabilitation (SR) group (n = 30). Both groups attended supervised physiotherapy twice weekly for 12weeks, with the SFR group receiving additional systematic scapular stabilization exercises. The primary outcome was the Constant-Murley score (CMS) at 12months. Secondary outcomes included the Disabilities of the Shoulder, Arm, and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Shoulder Pain and Disability Index (SPADI), and visual analog scale (VAS) pain scores assessed at one, three, six and 12months, along with EuroQol (EQ) scores, patient-reported satisfaction and radiographic evaluations (neck-shaft angle [NSA] and humeral head height [HHH]). Baseline characteristics were well balanced between the two cohorts. The SFR group had significantly higher adjusted mean CMS at 1month (46.1 ± 7.5 vs. 41.5 ± 8.4; P = 0.039) and threemonths (63.4 ± 9.6 vs. 57.2 ± 9.1; P = 0.018) postoperatively than the SR group. Similarly, the SFR cohort had significantly superior DASH, ASES, SPADI pain, and VAS pain scores at one and threemonths (all P < 0.05). Furthermore, health-related quality of life, comprehensively evaluated via EQ-5D and EQ-VAS indices (P < 0.05), as well as patient-reported satisfaction metrics (P < 0.001), were markedly higher in the experimental cohort during the initial threemonths of intensive rehabilitation. However, these functional differences attenuated over time, with no statistically significant differences in CMS (P = 0.325) or secondary clinical outcomes at the 12-month final follow-up. Radiographic analysis revealed no significant intergroup differences in NSA or HHH at any time point (P = 0.600 and P = 0.462 at 3months, respectively), indicating that the targeted intervention did not compromise construct stability. Incorporating systematic scapular-focused exercises into standard postoperative rehabilitation after PHILOS fixation for PHFs serves as a beneficial adjunct that significantly accelerates early functional recovery, reduces early postoperative pain, and improves patients' overall health utility and satisfaction in the early stages. These early gains are achieved without compromising fracture reduction or implant stability. Although long-term functional outcomes converge by 12months, this accelerated recovery trajectory provides substantial clinical value by effectively reducing the burden of early postoperative disability in a vulnerable demographic.

Management of unstable anterior pelvic ring fractures has shifted toward minimally invasive fixation techniques. This prospective randomized cohort study compares anterior subcutaneous internal fixator with percutaneous retrograde pubic ramus screw fixation, evaluating radiological outcomes, functional scores, complications, and peri-operative parameters. Fifty adult patients with unstable anterior pelvic ring injuries (Tile B & C; Young-Burgess lateral compression and vertical shear mechanisms) were enrolled between 2023 and 2025 and randomized into two equal groups: group 1 (internal fixator) and group 2 (retrograde pubic screw). Both groups underwent individualized posterior ring fixation as required. Outcomes assessed included operative time, blood loss, fluoroscopy time, union rate, Matta radiological score at 6 months, Majeed and Pelvic Outcome Scores at 12 months, and post-operative complications. Management of anterior pelvic injury showed that retrograde screw fixation demonstrated significantly shorter operative time (32.0 ± 9.2 vs. 50.3 ± 8.4min, p < 0.001) and less intraoperative blood loss (68.3 ± 16.2 vs. 122.3 ± 31.8ml, p < 0.001). Radiological outcomes were comparable: excellent Matta score in 68% vs. 64% (p = 0.834). Union time showed no significant difference (14.1 ± 2.4 vs. 15.1 ± 1.5 weeks, p = 0.076). Functional outcomes at 12 months showed no significant difference in Majeed score (p = 0.517), while Pelvic Outcome Score favored the retrograde screw group (32.3 ± 3.5 vs. 30.0 ± 3.3, p = 0.023). Internal fixator had a higher rate of lateral femoral cutaneous nerve injury (28%), while retrograde screw fixation showed fewer reoperations and lower implant removal rate. Upon reviewing study cases and relevant literature, both minimally invasive techniques can provide reliable fixation and comparable radiological and functional outcomes for unstable anterior pelvic ring fractures. Retrograde pubic ramus screw fixation offers advantages of reduced blood loss and lower neurovascular complications. Internal fixator offers slightly reduced fluoroscopy exposure but carries a higher risk of lateral femoral cutaneous nerve irritation. Level 4.