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Fractures

Proximal humerus, humeral shaft, clavicle, and scapula fractures — epidemiology, mortality risk in elderly populations, and trauma management.

231 citationsUpdated Oct 2026

Overview¶

Fracture management is guided by the principle that treatment protocols must be based on individual clinical assessment rather than mandatory time policies or rigid guidelines [9]. The ultimate goal of any fracture classification scheme is to allow for determination of the best treatment of each individual fracture and the ability to compare efficacy of various treatment methods on a particular fracture [8]. It is too early to integrate standardized screening of fractures into treatment guidelines for patients with generalized convulsive seizures and status epilepticus until the effect of such screening is investigated [3]. For long bone fractures in the context of traumatic brain injury, treatment should be tailored to the specific clinical presentation [9].

Indications for surgical intervention remain controversial across multiple anatomical sites, with nonoperative treatment often serving as the mainstay. Nonoperative treatment remains the mainstay for most proximal humerus fractures [7], and many proximal humerus fractures can be successfully treated nonsurgically [45]. Recent evidence suggests no long-term differences in outcomes between surgical and nonsurgical cohorts for many patient populations with proximal humerus fractures [52]. Similarly, there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed scapular fractures [40], and little agreement exists on indications for surgery for scapular fractures [40]. For forearm fractures, operation is often contra-indicated if the fracture can be held without it, as non-operative management may heal faster with fewer complications [218].

Surgical options are increasingly favored for specific fracture patterns to improve union rates and functional outcomes, such as displaced midshaft clavicle fractures [55]. Surgical fixation and arthroplasty offer specific benefits for displaced proximal humerus fractures or younger patients [52]. The choice of technique for proximal humerus fractures should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations [210]. For pathological fractures of the long bones, treatment strategies depend on fracture risk and expected survival [215]. Surgery is indicated for actual pathological fractures or high-risk impending fractures of the long bones [215], while radiotherapy is indicated for small lesions without fracture risk [215]. A pathologic fracture may no longer be an absolute contraindication for limb salvage surgery in patients with osteosarcoma [27].

Anatomy & Pathophysiology¶

Scapular Architecture and Biomechanics¶

The scapula attaches to the axial skeleton via the acromioclavicular and sternoclavicular joints [70]. It is separated from the chest wall by thin gliding fibro-fatty tissue, permitting smooth excursion [70]. The scapular body is triangular in anteroposterior view, with a superior base and inferior apex [70]. The glenoid connects to the flat scapular body via the scapular neck [70]. Bony mass distribution is uneven, concentrating in the glenoid, scapular neck, and lateral border of the body [70]. Two bony pillars transmit compressive forces from the glenoid fossa: the lateral pillar connects the inferior glenoid border to the inferior angle, while the spinal pillar arises from the central glenoid and continues medially into the scapular spine base [70]. The triangle formed by these pillars and the medial border constitutes the biomechanical body, which transmits compressive forces from the glenoid [70]. The weakest bone lies primarily in the central infraspinous fossa, while the weakest area of the biomechanical body circumference is the spinomedial angle, where the spine meets the medial border [70]. In most scapular body fractures, a main fracture line passes through this spinomedial angle [70].

The scapula spans ribs two through seven and serves as an attachment for 17 muscles [86]. It is anteverted approximately 30 degrees relative to the body on the chest wall [86]. The glenoid is retroverted approximately 5 degrees relative to the scapular body [86]. The acromion possesses three ossification centers: the metacromion (base), mesoacromion (middle), and preacromion (tip) [71]. Failure of fusion among these centers results in os acromiale [71]. The coracoid process serves as the origin for the coracobrachialis muscle and the short head of the biceps tendon, while the pectoralis minor inserts onto the medial coracoid process [71]. The glenoid subchondral bone is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [71].

Evolutionary adaptations have altered scapular biomechanics. In humans, the scapula is suspended by muscles alone and has shifted caudally from the cervical position seen in lower animals [80]. Broadening of the infraspinatus fossa has redirected muscle pull vectors from the axillary border to the glenoid fossa [80]. This adaptation enhances the efficacy of the infraspinatus and teres minor as depressors and external rotators of the humeral head [80]. The acromion has enlarged compared to pronograde animals, reflecting the increasing role of the deltoid in shoulder function [80]. The coracoid process has also increased in size over time [80]. With the shoulder in 90 degrees of abduction, the coracoid extension over the glenohumeral joint mechanically limits anterior translation of the humerus relative to the glenoid [80].

Superior Shoulder Suspensory Complex¶

The superior shoulder suspensory complex (SSSC) provides a stable connection between the scapula and the axial skeleton [71]. It functions as a bone–soft-tissue ring connecting the glenoid and scapula to the clavicle [79]. The SSSC comprises the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion [71]. Specifically, it is composed of four bony landmarks—distal clavicle, acromion, coracoid process, and glenoid neck—along with the supporting ligamentous complexes of the acromioclavicular joint and coracoclavicular ligaments [79]. The superior strut of the SSSC comprises the middle clavicle, while the inferior strut comprises the lateral scapular border and spine of the scapula [71].

Proximal Humerus Anatomy and Vascular Supply¶

The proximal humerus comprises four main parts: the humeral head, greater tuberosity (GT), lesser tuberosity (LT), and humeral shaft [67]. The articular head is spherical with a diameter of 37 to 57 mm [67]. The most superior portion of the articular surface averages 8 mm above the GT [67]. The humeral version averages 29.8 degrees, ranging from 10 to 55 degrees [67]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [67]. The bicipital groove lies between the GT and LT, serving as a pathway for the long head of the biceps [67].

The anatomic neck is located at the junction of the articular surface and tuberosities [67]. The surgical neck represents an indistinct metadiaphyseal junction below the tuberosities but above the humeral shaft [67]. Fractures involving the anatomic neck carry a worse prognosis than those in other regions due to potential disruption of vascular supply to the humeral head and subsequent avascular necrosis [67]. The GT serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons, while the LT serves as the attachment site for the subscapularis tendon [67].

The proximal humerus receives blood supply from the anterior and posterior humeral circumflex branches of the third division of the axillary artery [67]. The anterior humeral circumflex artery (AHCA) provides vascular inflow to the humeral head via its terminal anterolateral branch, the artery of Laing (arcuate artery) [67]. The ascending branch of the AHCA courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and GT [67]. Injury to the arcuate artery may result in osteonecrosis of the humeral head, although additional extraosseous collateral branches can permit perfusion despite complete ligation of the arcuate artery [67].

Additional anatomical metrics include a humeral head retroversion averaging 19 degrees and an inclination (neck-shaft angle) of 41 degrees [71]. The anterolateral ascending branch of the AHCA provides the primary blood supply to the humeral head, with its terminal intraosseous portion entering at the proximal aspect of the intertubercular groove as the arcuate artery [71]. The humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [86]. The anatomic neck lies directly below the humeral head and serves as an attachment for the shoulder capsule, while the surgical neck is more distal and more often involved in fractures [86]. The transverse humeral ligament is an important stabilizer of the biceps tendon [86].

Ossification of the proximal humerus involves three centers: for the greater and lesser tuberosities and for the humeral head [75]. The humeral head center is usually present at birth, the GT center appears by 1 to 3 years of age, and the LT center appears by 5 years of age [75]. The proximal humeral ossification center fuses to the shaft by 5 to 7 years of age to form the humeral head [75]. The proximal humeral physis closes by 14 to 17 years in girls and 16 to 18 years in boys [75]. Humeral retroversion averages 65 degrees in infants and young children, gradually decreasing to adult values by 11 years of age [75]. Eighty percent of subsequent humeral growth originates from the proximal humeral physis [75]. This physis is irregularly shaped, with its apex on the posteromedial portion of the proximal humerus [75]. The periosteum is thicker and stronger in the posteromedial portion compared to the often thin anterolateral portion, explaining the tendency of proximal humeral metaphyseal fracture fragments to penetrate the anterolateral periosteum [75].

Muscular attachments include the subscapularis, which originates from the anterior scapula and inserts anteriorly onto the LT [75]. The GT provides attachment superiorly and posteriorly for the supraspinatus, infraspinatus, and teres minor [75]. The deltoid coalesces into a common tendinous insertion onto the lateral upper third of the humeral shaft [75]. The pectoralis major inserts anteriorly onto the lateral wall of the bicipital groove, forming the roof of the distal continuation of the bicipital tunnel [75]. Sixty-four percent of the humeral head blood supply arises from the posterior humeral circumflex artery [75]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [75].

Further measurements indicate a neck-shaft angle averaging 135 degrees and humeral head retroversion averaging 30 degrees [68]. Fractures of the anatomic neck have a poor prognosis due to complete disruption of blood supply to the head, whereas surgical neck fractures are common and preserve blood supply to the head [68]. The articular surface of the humeral head is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage [83]. The radius of curvature is approximately 25 mm, slightly larger in men than in women [83]. The average neck-shaft angle is 45 degrees (±5 degrees), ranging from 30 to 50 degrees [83]. The superior margin of the humeral head articular surface is normally superior to the top of the GT by 8 to 10 mm [83]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [83].

Glenohumeral Joint and Soft Tissue Structures¶

The glenoid is a convex structure of shallow depth shaped like an inverted pear [67]. The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure imparting stability to the shoulder girdle [67]. Displaced proximal humeral fractures can impede normal movement of structures passing under this arch, causing impingement and disrupting normal glenohumeral motion [67]. In proximal humeral fractures, the subdeltoid and subacromial bursae can become thickened and fibrotic, forming adhesions that limit normal glenohumeral motion [67].

The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule, inserting mainly into the GT, with the subscapularis inserted into the LT [76]. It consists of the subscapularis anteriorly, supraspinatus superiorly, and infraspinatus and teres minor posteriorly [76]. The coracoacromial arch is formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [76]. The subacromial bursa separates the tendons from the coracoacromial arch, allowing them to glide [76].

The shoulder joint comprises four articulations: sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic [84]. Bony anatomy contributes little to stability, often compared to a golf ball on a tee [84]. The glenoid is encircled by the labrum, composed of dense fibrocartilaginous tissue, which increases socket depth by 50% around the humeral head [84]. The combined glenoid articular surface and labrum create a socket approximately 9 mm deep superoinferiorly and 5 mm deep anteroposteriorly [84]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [84].

Ligamentous restraints include the superior glenohumeral ligament, which is the primary restraint to inferior humeral subluxation at 0 degrees of abduction [84]. The middle glenohumeral ligament limits external rotation in the lower and middle ranges of abduction but has little effect at 90 degrees of abduction [84]. The inferior glenohumeral ligament comprises an anterior band, a posterior band, and a thinner intervening axillary pouch, creating a hammock-type sling [84]. The anteroinferior glenohumeral ligament complex is the main stabilizer against anterior and posterior stresses when the shoulder is abducted 45 degrees or more [84].

Extrinsic muscles primarily control scapular movement and include the rhomboids, levator scapulae, trapezius, and serratus anterior [84]. Intrinsic muscles control the glenohumeral joint and include the rotator cuff muscles, deltoid, pectoralis major, teres major, latissimus dorsi, and biceps brachii [84]. The most important force couple involves the subscapularis and posterior rotator cuff, providing a compressive force that centers the humeral head in the glenoid cavity [84]. The tendons of the infraspinatus and supraspinatus join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [84]. The supraspinatus and subscapularis tendons join as a sheath surrounding the biceps tendon at the entrance of the bicipital groove [84]. The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the capsule surface to the tuberosities between the supraspinatus and subscapularis tendons [84].

The glenohumeral joint is a ball-and-socket joint with the greatest range of motion in the body [86]. Static restraints include articular anatomy, glenoid labrum, glenohumeral ligaments, capsule, and negative intraarticular pressure [86]. Dynamic stabilizers include the rotator cuff and biceps tendon [86]. The fibrocartilaginous glenoid labrum deepens the socket by 50% and provides a bumper to translation [86]. The sternoclavicular joint is the only true joint connecting the upper extremity with the axial skeleton, with the posterior sternoclavicular ligament serving as the strongest and primary restraint to anteroposterior instability [86]. The acromioclavicular joint is a plane/gliding joint with a fibrocartilaginous disc [86]. The coracoclavicular ligaments prevent superior displacement of the distal clavicle [86]. The trapezoid ligament is located approximately 25 mm from the acromioclavicular joint, while the conoid ligament is located approximately 45 mm from the acromioclavicular joint and is stronger than the trapezoid ligament [86].

The subscapular bursa lies between the subscapularis tendon and the neck of the scapula, communicating with the joint cavity between the superior and middle glenohumeral ligaments [72]. It often houses loose bodies in the shoulder and is a region where synovitis may be most intense [72]. The rotator interval is defined as the region between the superior border of the subscapularis and the anterior border of the supraspinatus [72]. This interval includes the region of the superior glenohumeral ligament and coracohumeral ligament, in addition to the middle glenohumeral ligament [72].

Classification¶

General Principles and Limitations¶

The ultimate goal of any fracture classification scheme is to determine the optimal treatment for each individual fracture and to enable comparison of treatment efficacy for specific fracture types [8]. However, existing systems for complex extremity fractures are often inadequate and lack therapeutic recommendations [65]. Similarly, current classifications for ballistic fractures fail to account for soft-tissue injury, anatomical location, and joint involvement [87]. For complex fractures, the primary challenge lies in interpreting the images rather than the classification system itself [11]. Anatomic classifications for distal femur fractures frequently fail to address conditions associated with supracondylar femur fractures that influence treatment or outcome [260]. The "personality" of a fracture is determined by displacement, comminution, soft-tissue injury, neurovascular status, joint involvement, osteoporosis, multiple trauma, and complex ipsilateral injuries [260]. Future studies should compare new classification systems with existing ones and evaluate the impact of reduction quality and bone quality across fracture types [12].

AO/OTA Classification System¶

AO/OTA: The fundamental principle of the comprehensive classification for long bones divides fractures into three types (A, B, C), further subdivided into groups and subgroups arranged in ascending order of severity [46]. The system uses 27 subgroups per bone segment, with colors green, orange, and red indicating increasing severity from A1 (simplest/best prognosis) to C3 (most difficult/worst prognosis) [46]. The OTA classification distinguishes between extra-articular (type A), partial articular (type B), and complete articular (type C) injuries while accounting for fracture complexity [260]. It is preferred for distal femur fractures due to its ease of use and applicability to most parts of the skeleton [260]. However, significant interobserver variation exists in coding long bone fractures using the AO system, with only 32% of individual codings agreeing with the final consensus [130].

Proximal Humerus Fractures¶

Neer: The Neer classification is a useful management tool, though accurate delineation of fracture patterns requires better imaging modalities [41]. It is based on the presence or absence of displacement of one or more of the four major segments, grouping minimally displaced fractures together regardless of the number of fracture lines [243]. Observer agreement on classifying displaced four-part fractures is low (slight to moderate), which challenges clinical approaches and complicates the interpretation of results from future randomised trials [94].

MTM: The MTM-classification covers a wide spectrum of proximal humeral fracture types, but precise topographic and morphological description does not deliver reproducible results [77].

Impacted Fractures: A new classification for impacted proximal humerus fractures based on 3D model morpho-volumetric evaluation provides a useful synoptic framework for identifying complex fracture patterns [97, 98].

Complex 4-Part Fractures: The classification of complex 4-part humeral fractures consists of 6 groups divided into 15 subgroups of calcar fracture patterns [89].

Distal Humerus: Three-dimensional reconstructions improve the reliability, but not the accuracy, of fracture classification and characterization for distal humeral fractures [88].

Open Fractures¶

Gustilo–Anderson: The classification of open fractures is important because it directs the attention of the treating surgeon to the presence and extent of injury variables [90]. The Gustilo-Anderson classification has been the mainstay of open fracture classification since 1976, describing three broad categories (I-III) based on the extent of soft-tissue injury and size of skin wounds [254]. * Type I: Clean injuries with a skin wound < 1 cm and simple fracture pattern [254]. * Type II: Skin wounds > 1 cm, with minimal soft-tissue injury and no flaps or avulsions [254]. * Type III: Revised in 1984 into subtypes III-A, B, and C, stratified according to the degree of need for local coverage and evidence of neurovascular compromise [254]. * Type III-C: Defined as an open fracture with associated vascular injury requiring repair [254].

The Gustilo classification has limited inter-observer reliability, with as little as 60% concordance between observers [254]. A new "unified" classification of open fractures based on Gustilo and OTA schemes has good validity, reliability, and acceptability, and has the potential to replace all other existing classification systems [66]. The Orthopaedic Trauma Association Board of Directors has charged the Classification Committee with designing a multi-centre study to assess reliability, validity, and ideal usage of the open fracture classification [110].

Other Anatomical Sites¶

Metacarpal Head: Intra-articular metacarpal head fractures were classified into 10 groups by anatomical involvement on roentgenographic examination [24].

Craniofacial: A comprehensive classification of craniofacial fractures divides the region into three units and distinguishes lateral and central fractures [85].

Pelvic Ring: A novel classification system for fragility fractures of the pelvic ring is based on morphological criteria and corresponds with the degree of instability [109].

Pediatric: The classification of fracture severity in children should be done in only two categories that distinguish between simple and wedge/complex fractures [103].

Multifocal Humerus: A simple classification of multifocal humeral fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment [92].

Acromial: The Levy classification is used to classify acromial fractures following reverse shoulder arthroplasty using serial radiographs and computed tomographic scans [246].

Stress Fractures: Understanding the classification and grade of stress fractures and their implications on return-to-play decisions is key to optimal care of the athlete [136].

Comminuted Humeral Head: The results of a multicenter analysis revealed fundamental differences between various types of comminuted humeral head fractures depending on the number of fragments [117].

Registry Coding: The Swedish Fracture Register is a population-based fracture register that covers fractures of all types, regardless of treatment, and collects both surgeon- and patient-reported outcome measures [119].

Clinical Presentation¶

History and General Assessment¶

A comprehensive history and physical examination are essential to evaluate the mechanism of injury and identify secondary contributing factors in patients presenting with fragility fractures [6]. Knowledge of injury mechanisms, combined with careful clinical and radiologic examinations, is required to determine the proper diagnosis of scapular fractures [2]. Scapular fractures are frequently associated with other injuries involving not only the ipsilateral extremity but also other parts of the body [2]. In cases of dog bites causing upper-limb fractures in children, a high index of suspicion from the history coupled with a careful clinical examination should alert the clinician to the possibility of an underlying fracture [31]. The diagnosis of a pathological fracture can be a trap, requiring the surgeon to be suspicious and carefully scrutinize every X-ray image [4]. When faced with a fracture in a previously abnormal bone, one should think ahead to the possible results for both the fracture and the previous abnormality [43]. A high index of suspicion will lead to an early diagnosis in primary hyperparathyroidism, an uncommon cause of pathological fractures [125].

Pathological and Metastatic Fractures¶

The management of malignant pathological fractures necessitates careful diagnostic work-up, preoperative investigation, planning, and multidisciplinary input from specialists in radiology, pathology, oncology, trauma, and orthopaedics [106]. If a definitive diagnosis cannot be made based on a thorough history, physical examination, laboratory tests, and radiographic evaluation for metastatic long bone fractures, a biopsy should be performed and a histologic diagnosis must be made before fracture fixation [118]. In patients with a history of cancer, a newly diagnosed osseous lesion cannot be assumed to be part of the same pathologic process [118]. Misdiagnosis of an osseous lesion as metastatic when it is a primary bone tumor has been attributed to incomplete patient history and radiographic evaluation as well as improper surgical biopsy techniques [118].

Trauma and Missed Fractures¶

Extremity fractures in patients with traumatic brain injury are common and often missed, but appropriate evaluation allows prompt diagnosis and optimal treatment [115]. The incidence of fractures missed on the initial examination of patients admitted to hospital as the result of trauma is at least 7.5 per cent [116]. Bone scan is an effective method of detecting missed fractures among patients with multiple severe traumas and can be used reliably as a screening test [33]. Fracture should be suspected in patients who present with pain postoperatively following reverse total shoulder arthroplasty, and workup should include plain radiographs and computed tomographic scan if indicated [23]. Scapular fractures are often associated with other injuries and can be difficult to diagnose, leading to missed or delayed diagnoses [78].

Stress Fractures¶

Diagnosis of stress fractures begins with a high index of suspicion, where history and physical examination can clarify the potential diagnosis [107]. The history of a typical patient with a stress fracture is usually an insidious onset of pain that begins as a dull ache noted after the exercise activity [107]. Rest from the offending activity usually relieves stress fracture pain completely, but continuation of the same activity increases the severity of the pain and causes it to begin earlier in the activity [107]. Symptoms of stress fractures generally present 4.5 weeks after a change in training regimen [107]. Physical examination for stress fractures does not always yield reproducible signs, though localized point tenderness to palpation, edema, local swelling, or palpable periosteal thickening may be present [107]. Although nearly half of first rib stress fractures in baseball players were initially missed, careful review of radiographs detected most cases with high accuracy and excellent interobserver reliability [18].

Pediatric Fractures¶

The prognosis is favourable across fracture types and circumstances of occurrence for fractures in children younger than 18 months [17]. Most pediatric fractures can be treated on an outpatient basis, with only 1 of 18 fractures requiring hospitalization or observation [39]. Fractures in children with initial angulation of <10° had no clinically significant evidence of re-angulation and should be considered stable requiring only an initial diagnostic radiograph [38]. If radiographic appearances are reassuringly benign in children with pathological fractures, biopsy can be delayed until conservative fracture management is completed [16]. Skeletal surveys are indicated for children younger than 12 months of age who have one or more fractures without a clearly identified accidental cause [120].

Specific Anatomical Presentations¶

Diagnosis of acute glenoid fractures requires plain radiographs and CT scans, while management is dictated by fracture morphology, displacement, and associated injuries [13]. Computed tomography is useful for the diagnosis of isolated avulsion fracture of the lesser tuberosity of the humerus, as this type of fracture is sometimes misdiagnosed [35]. The appropriate evaluation of greater tuberosity fracture dislocations is predicated on the ability of the treating surgeon to identify the injury in a timely fashion and have a complete and thorough understanding of the fracture pattern [123]. Aside from a focused history, physical exam and imaging remain the mainstays of diagnosis for greater tuberosity fracture dislocations [123]. Minimal fracture displacement (<3 mm) of the greater tuberosity does not worsen the clinical outcome or duration of symptoms [124]. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management of humeral shaft fractures, and earlier operative intervention may be recommended [19].

Management of proximal humerus fractures is challenging as 50% of fractures are displaced, requiring hospitalization in half the cases, yet surgery is only performed in one out of five [104]. Nonoperative treatment remains the mainstay for most proximal humerus fractures; however, operative treatment has increased over the last decade [7]. Over 90% of scapular fractures are nondisplaced or minimally displaced and can be managed conservatively [113]. Functional results are limited regardless of the fracture management for scapular spine fractures after reverse shoulder arthroplasty, and no clear preoperative risk factors were identified [131]. The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients has been assessed in a meta-analysis comparing physical examination against gold standards such as anteroposterior pelvic radiographs or CT [99]. Awareness of the double line sign may be of help in detecting clinically or radiographically missed or occult fractures of the proximal humerus [96]. Air splints are recommended for emergency treatment, pathological fractures, and situations requiring x-ray transparency, with no complications observed after twenty-four hours of use [132]. Clavicle fractures do not increase the occurrence of later subacromial pain syndrome, although the diagnosis was given 1-2 years earlier for people with a previous fracture [1].

Investigations¶

General Imaging Principles: The primary objectives of shoulder imaging are to establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and illustrate the condition to the patient [15]. Because the shoulder is a three-dimensional structure that cannot be represented by a single planar view, critical relationships such as humeral head centering change with arm position [143]. Overlying structures and metallic implants may complicate imaging of specific tissues [143]. Surgeons must adopt a judicious approach that yields necessary information while avoiding the tendency to "over-image," obtaining only scans necessary for patient care unless a specific research protocol is in place [15, 143]. Proper radiographic technique is as important as proper surgical technique for achieving desired outcomes [15]. For stiff shoulders, history and physical examination remain paramount, with ancillary studies helpful in certain circumstances [14].

Plain radiography: Radiographs remain the mainstay for fracture assessment, though interpretation is challenging with experimental studies documenting a roughly 30% error rate [249]. Clinicians and radiologists agreed on the presence or absence of fracture or dislocation in 897 of 1011 cases (89 per cent) [252]. Standardized plain films are almost always sufficient for shoulder care and provide information that cannot be obtained from CT scans [15]. The recommended series for proximal humerus fractures is the Neer trauma series, consisting of an AP view, a lateral view in the scapular plane, and a Velpeau modified axillary view [142]. At least two views are required: an anteroposterior view in the plane of the glenoid and an axillary projection with the arm in abduction [112]. The first key view is the AP view in the plane of the scapula, taken so the x-ray beam passes through the glenohumeral joint [15]. The second key view is the axillary "truth view," taken with the arm in the functional position of elevation in the plane of the scapula [15]. This view demonstrates glenohumeral relationships in functional elevation, whereas CT scans are taken with the arm adducted [15]. The standardized axillary view enables measurement of posterior subluxation or "functional decentering" not evident with the arm at the side [15].

For specific fracture patterns, fractures with initial angulation of <10° had no clinically significant evidence of re-angulation and should be considered stable, requiring only an initial diagnostic radiograph [38]. In pediatric clavicle fractures for children aged 8 years or younger, additional radiographs did not alter management or contribute positively to clinical outcomes, supporting a standardized protocol involving imaging only at the initial evaluation [293]. Conversely, repeat radiographic assessment 2-3 weeks post-injury is supported for completely displaced adolescent clavicle fractures prior to definitive treatment decisions [297]. Close follow-up with serial radiographs for the first several weeks is recommended for greater tuberosity fractures associated with anterior shoulder dislocation [283]. Appropriate views are essential for the diagnosis of facial fractures [285]. For suspected stress reactions or fractures, imaging should begin with high-resolution radiographs [244]. Although nearly half of first rib stress fractures were initially missed, careful review of radiographs detected most cases with high accuracy and excellent interobserver reliability [18]. Radiologists classified displaced comminuted midshaft clavicular fractures more reliably than surgeons, with substantial intra-observer and inter-observer agreement after viewing two-plane radiography [289]. Even under laboratory conditions, plain radiographs are insufficient to accurately predict the strength of a healing fracture [292]. Plain x-rays have poor sensitivity (20–38%) for sacral fractures [62]. If a plain radiograph does not reveal a fracture, CT may be useful for bilateral simultaneous glenoid fractures [222]. The diagnosis of a pathological fracture can be a trap; the surgeon must be suspicious and carefully scrutinize every X-ray image [4]. The problem with complex fractures is understanding the images, not the classification system [11]. Diagnosis of acute glenoid fractures requires plain radiographs and CT scans [13]. Fracture should be suspected in patients presenting with postoperative pain after reverse total shoulder arthroplasty, with workup including plain radiographs and computed tomographic scan if indicated [23]. Radiographs provide incomplete information about the fracture pattern for scapula fractures, and advanced imaging caused a change in classification into a segment more likely to be considered for surgical care [235].

CT: Computed tomography (CT) is helpful for planning fracture surgery and shoulder joint replacement [112]. CT imaging is frequently used to evaluate shoulder fractures, assess bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [151]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [154]. CT scans may offer a few degrees of increased precision in measuring glenoid version, but this precision does not improve the quality of the surgery or the clinical outcome [15]. Three-dimensional reconstructions can reveal fine details of shoulder anatomy, but this additional information rarely changes the planning or conduct of the arthroplasty [15]. Computed tomography is useful for the diagnosis of isolated avulsion fracture of the lesser tuberosity of the humerus, as this type of fracture is sometimes misdiagnosed [35]. A CT scan is essential in all patients with displaced inferior ramus fractures to examine the posterior ring in detail [281]. Dual-energy CT combines the advantages of conventional CT (good visualisation of bone matter) and MRI (medullary cavity and visualisation of occult fractures) for diagnosing fragility fractures of the pelvic ring [259]. Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics for distal humerus fractures [258].

MRI: Magnetic resonance imaging (MRI) is useful to identify osteonecrosis of the humeral head, or a bone tumour [112]. MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [151]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of the joint surfaces [151]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [151]. MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [112]. MRI accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [145]. MR arthrography (MRA) has greater diagnostic test accuracy for the detection of glenoid labral lesions compared to MRI, with MRA sensitivity of 88% and specificity of 93% versus MRI sensitivity of 76% and specificity of 87% [145]. The ABER position in MRA has significantly higher sensitivity for detecting anteroinferior labral lesions than MRA in the neutral position and is more effective in identifying Perthes lesions [145]. MRI did not appreciably change the estimation of fracture displacement compared to radiography for acute greater tuberosity proximal humeral fractures [227]. MRI is an imperative tool for operative planning in pathological fractures; however, routine use of MRI to diagnose pathological fractures in oncological patients is not recommended [229]. MRI is the golden standard for diagnosis of sacral fractures with a sensitivity of almost 100% [62]. MRI examination of the pelvis was found to be superior in detecting undislocated fractures in a cohort of patients with a high incidence of osteoporosis [303].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [112]. It is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [151]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [151]. It can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [151]. Ultrasonography can evaluate impingement in various positions and motions due to real-time imaging [151]. It can be useful in guiding injections or barbotage (aspirating calcific deposits in the rotator cuff) [112]. The most commonly performed joint examination using ultrasonography is the shoulder examination, and accuracy depends on the skill of the scanner operator and an awareness of pitfalls [95]. Dynamic ultrasonographic evaluation is important for zone II flexor tendon lacerations because of the ability to move the tendon, allowing direct visualization to pick up on partial tears that may need treatment but have normal physical examination findings [95]. Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [151].

Bone scan: Bone scintigraphy is an important adjunct to the early diagnosis of stress fracture, as it can demonstrate lesions earlier than conventional roentgenograms [298].

Treatment¶

General Principles¶

Nonoperative fracture treatment remains the most common method of fracture management, although its role has changed significantly during the last 40 to 50 years [22]. Historically, nonoperative management was the only method of fracture management until about 1750 [91]. The concentration of severe injuries into specialized trauma centers has caused surgeons to overestimate the role of operative treatment in the full spectrum of fractures [91]. Treatment protocols for long bone fractures should be based on individual clinical assessment rather than mandatory time policies for fixation [9]. For patients with multiple system trauma and fractures, the decision making regarding the type and timing of treatment should be undertaken in a collaborative manner involving all members of the multidisciplinary team [165]. Life-threatening and limb-threatening injuries, including massive hemorrhage from a pelvic fracture or multiple long bone fractures, complete arterial injury in an extremity, and compartment syndromes, are addressed emergently [165]. Open fractures should be débrided in the operating room within the first 24 hours [165]. Mechanically unstable spine, pelvis, acetabulum, and proximal and diaphyseal femur fractures benefit from provisional or definitive stabilization, ideally performed within the first 36 hours after injury [165]. There are currently no clinical practice guidelines for acute pain management in musculoskeletal injury or surgery [161].

Non-Operative¶

Nonoperative management is associated with good outcomes in the majority of proximal humerus fractures in adults [200]. Nonsurgical treatment of proximal humerus fractures is not simply “benign neglect” and requires frequent follow-up examination and imaging [230]. Indications for nonsurgical treatment of proximal humerus fractures include minimal displacement, impacted displaced fractures, medical comorbidities, osteoporosis, low functional demand, and low outcome expectations [230]. One-part proximal humerus fractures are treated non-operatively with sling immobilization and enjoy almost universally good or excellent outcomes [231]. Patients with one-part proximal humerus fractures are instructed to remain in the sling for a period of 3 to 5 days depending on the level of their post-injury pain [231]. Early pendulum exercises are initiated for one-part proximal humerus fractures to improve range of motion and limit capsular retraction [231]. Strengthening exercises for one-part proximal humerus fractures are initiated after the second follow-up appointment, approximately 6 to 8 weeks post-injury, after radiographs confirm appropriate healing [231]. Non-operative treatment is advocated for the majority of non-displaced and minimally displaced isolated tuberosity fractures of the proximal humerus with generally good outcomes [213]. The results of nonoperative treatment of three- and four-part proximal humerus fractures are satisfactory even in elderly patients [206]. In case of nondisplaced or minimally displaced proximal humerus fractures, a conservative treatment consisting of initial immobilization and a rehabilitation program is chosen [209].

Non-displaced clavicle fractures are generally treated conservatively [100]. Closed, non-surgical reduction maneuvers are not effective in improving or maintaining alignment of clavicle fractures and should generally not be attempted [173]. For patients with displaced midshaft clavicle fractures assigned to nonoperative treatment, follow-up starts at the day of inclusion [163]. During the first 2 weeks of nonoperative treatment for displaced midshaft clavicle fractures, patients use a sling and are advised to perform non-weight-bearing pendulum exercises after instruction by a physiotherapist [163]. After 6 weeks of nonoperative treatment for displaced midshaft clavicle fractures, full range of motion is permitted and strengthening exercises are started [163]. Patients allocated to nonoperative care for displaced midshaft clavicle fractures received a standard sling for 6 weeks [199]. Most patients with displaced midshaft clavicle fractures in nonoperative care were advised to begin "out of sling" activities after 3 weeks [199]. At the 6-week time point, all patients with displaced midshaft clavicle fractures in nonoperative care underwent a rehabilitation schedule depending on the status of fracture healing [199]. At 3 months, patients with displaced midshaft clavicle fractures in nonoperative care were allowed pre-injury levels of activity excluding all contact sports [199]. At six months, patients with displaced midshaft clavicle fractures in nonoperative care were allowed unrestricted activities [199]. Non-operative management for adolescent displaced lateral-end clavicle fractures consisted of a broad arm sling to immobilise and support the shoulder joint for two weeks [149]. Complete avoidance of contact sport for at least 3 months is part of non-operative management for adolescent displaced lateral-end clavicle fractures [149]. Physiotherapy was not routinely used in the non-operative management of adolescent displaced lateral-end clavicle fractures [149]. This study supports the role of non-operative treatment for teenagers with completely displaced clavicle fractures, with nearly perfect outcomes reported [150].

Nonoperative treatment has been traditionally reserved for patients who were either too ill to undergo surgery or who had extremely limited functional demands for proximal humerus fractures [225]. In a review of the literature, only 5% of patients undergoing nonoperative treatment for proximal humerus fractures could expect satisfactory results [225]. When nonoperative treatment is undertaken for proximal humerus fractures, the arm is most commonly placed in a sling for a period of approximately 2 weeks [225]. After the initial 2-week sling period for nonoperative proximal humerus fractures, pendulum exercise can be begun [225]. Nonunion or malunion of the tuberosities occurs in almost all cases of nonoperative treatment for proximal humerus fractures [225]. Patients in the non-operative group for displaced proximal humerus fractures are immobilised in a sling for 2 weeks before starting self-exercises and instructed physiotherapy [189]. Patients in the nonoperative group for Neer type III and IV proximal humeral head fractures were immobilized in a sling for two weeks before beginning self-exercise and physiotherapy [226]. Conservative treatment is sufficient in non-displaced type A periprosthetic humeral fractures associated with reverse total shoulder arthroplasty [101]. Undisplaced inferior angle of scapula fractures have a variable outcome when treated nonoperatively [157]. A conservative treatment seems sufficient for other fracture types of the coracoid process [216]. Treatment for upper extremity stress fractures is predominantly nonoperative, involving relative rest and activity modification, with most fractures healing uneventfully [195]. For most long bone fractures in osteopetrosis, non-operative treatment works well [212]. The majority of pediatric proximal and diaphyseal humeral fractures were treated non-surgically [140]. Historical treatment of pediatric femur fractures has relied on non-operative approaches because fracture healing occurs relatively rapidly in children and acceptable results are generally seen [111]. Torus fractures can be safely and effectively treated with removable splints or braces [166]. Late displacement is seen in approximately one-third of complete distal radial fractures following closed reduction and cast immobilization [166]. Repeated or late reduction attempts are discouraged in displaced distal radial physeal fractures [166]. Treatment decision making for high-risk stress fractures should be based on radiographic findings with less consideration given to symptom severity [152]. The immediate goal of treatment of a high-risk stress fracture is to avoid progression and get the fracture to heal [152]. Treatment of a high-risk stress fracture typically requires either complete elimination of loading of the site or surgical stabilization [152]. If an incomplete fracture is present on plain films with evidence of fracture on MRI or CT in a high-risk location, immobilization and strict non-weight bearing is indicated [152]. Worsening symptoms or radiographic evidence of fracture progression despite nonoperative treatment is an indication for surgical fixation of high-risk stress fractures [152]. Conservative management for distal humerus fractures in patients aged 65 years and older comprised a posterior above-elbow splint for 4–6 weeks followed by routine physiotherapy [223]. As long as the effect of standardized screening of fractures is not investigated, it is too early to integrate such a screening into treatment guidelines for fractures from generalized convulsive seizures and status epilepticus [3].

Operative¶

Indications: Surgical treatment for humeral shaft fractures is generally reserved for specific indications such as open fractures, polytrauma, or failure of nonoperative management [49]. While surgical fixation and arthroplasty offer specific benefits for displaced proximal humerus fractures or younger patients, recent evidence suggests no long-term differences in outcomes between surgical and nonsurgical cohorts for many patient populations [52]. While nonsurgical management is effective for many proximal humerus fractures, surgical options including fixation and arthroplasty are utilized for complex patterns, though comparative efficacy remains variable [162]. Displaced or unstable proximal humerus fractures will be managed operatively [209]. Indications for surgical treatment of proximal humerus fractures include young, high-demand patients, elderly patients with high expectations, cooperative patients, displaced unstable nonimpacted fractures, fracture-dislocations, and adequate bone quality [230]. Closed reduction and percutaneous pinning for proximal humerus fractures is primarily reserved for the pediatric population [230]. Contraindications for closed reduction and percutaneous pinning of proximal humerus fractures include dislocations, metaphyseal comminution/diaphyseal extension, severe osteoporosis, or head-split fracture [230]. While nonsurgical management is reliable for many clavicle fractures, surgical options are increasingly favored for displaced fractures to improve union rates and functional outcomes [55]. There is a clear-cut indication for surgery in patients with overlapping of the fracture fragments (OV) ≥15% or cranio-caudal displacement (DS) ≥2.3 cm for midshaft clavicle fractures [214]. There is a clear-cut indication for surgery in patients with OV ≥13% associated with DS ≥2 cm for midshaft clavicle fractures [214]. Indications for acute fixation of adolescent displaced lateral-end clavicle fractures are open fractures, vascular injury, or skin compromise [149]. In displaced adolescent lateral-end clavicle fractures without open fracture, vascular injury, or skin compromise, operative management was selectively undertaken under patient and parental wishes at the discretion of the consultant surgeon [149]. Surgical fixation should be considered for high-risk stress fractures to expedite healing, minimize the risk of nonunion, delayed union, and refracture, and prevent catastrophic fracture progression [152]. The presence of a visible fracture line on a plain radiograph in a high-risk stress fracture should prompt serious consideration of operative management [152]. All complete fractures at high-risk sites should receive serious consideration for surgical treatment [152]. Surgical management is reasonable for long bone fractures in osteopetrosis in certain circumstances such as fracture neck and shaft of femur, Coxa Vara and failure of conservative treatment [212].

Surgical Approach / Technique: Although the locked plate device provides exceptional fixation stability for proximal humerus fractures, its indication must be scrutinized for each individual patient, taking the extent of trauma/fracture and age into consideration [42]. No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [171]. Percutaneous fracture treatment using the Humerusblock achieves good functional outcomes with an acceptable complication rate for displaced proximal humeral fractures in patients younger than 70 years [174]. The results of proximal humeral fractures treated with an intramedullary cage and plate demonstrate similar fracture healing, clinical improvement, and complication rates compared with conventional ORIF with screws and a side plate [196]. These techniques can result in good clinical outcomes for complex proximal humerus fractures with diaphyseal extension despite the complexity of this fracture pattern [190]. Randomized controlled trials and cost analyses are necessary to determine the optimal treatment method for complex proximal humerus fractures [182]. More RCTs are needed to definitively recommend locking plate over intramedullary nail for specific fracture patterns of proximal humerus due to observed heterogeneity [53]. Open reduction and plate fixation reduces the rate of nonunion and is associated with better functional outcomes compared with nonoperative treatment for displaced midshaft clavicle fractures, but the improved outcomes appear to result from the prevention of nonunion [194]. Conservative modality for mid-shaft clavicle fractures is associated with higher rates of non-union and delayed healing [168]. The authors advocate the use of the Tightrope device as the sole method of fixation in treating lateral end clavicle fractures [56]. Post-operatively for clavicle fractures, the arm is maintained in a sling and pendulum exercises are permitted [232]. At 2 weeks post-operatively for clavicle fractures, the sutures are removed, the sling is discontinued, and unrestricted range of motion exercises are permitted [232]. Strengthening and resisted exercises for clavicle fractures may begin when clinical and radiographic signs of healing are present, usually at 6 to 8 weeks post-operatively [232]. Return to sports for clavicle fractures may take place at 3 to 4 months post-operatively, depending on the activity involved [232]. The advantages of intramedullary fixation for clavicle fractures include a smaller incision, less soft tissue dissection, less hardware prominence, and easier surgical removal of the hardware as compared with plates and screws [232]. Intramedullary fixation for clavicle fractures has inconsistent results compared with fixation using plates and screws and is not as commonly used [232]. Contraindications to the use of intramedullary fixation for clavicle fractures include significant comminution, very small canal diameter, and lateral third clavicle fractures [232]. Treatment for acromial fractures depends on the fracture location, displacement, and patient factors and includes both non-surgical management and surgical fixation [29]. Surgical fixation for isolated acromion fractures is reported to be effective in achieving fracture union and safe to the patient [146]. As the results from the review of the literature indicate, the more medial the fracture of the base of the acromion after reverse shoulder arthroplasty, the worse the prognosis with non-operative treatment [179]. When properly stabilized, intraoperative humerus fractures during revision reverse shoulder arthroplasty do not substantially influence overall final outcomes [181]. Operative treatment for displaced scapula fractures in patients 65 years of age and older is safe and can yield good functional results and return to function [177]. Most patients with ipsilateral fractures of the scapular neck and clavicle regained normal function of the shoulder soon after the injury following open reduction and internal fixation [26]. Little agreement exists on indications for surgery for scapular fractures, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures [40]. A valid comparison between operative and nonoperative treatment cannot be made for any scapula fracture type due to low numbers, high variability, and methodological limitations [172]. While closed treatment remains the method of choice for most humeral shaft fractures, acceptable results can be achieved with internal fixation, even for difficult fractures, provided the correct principles of fixation are carefully followed [178]. The procedure of interlocking nailing should be used with caution when managing acute non-pathological humeral shaft fractures as there is a high incidence of non-union [139]. Only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for Ender nailing of acute humerus fractures [167]. In the absence of strong medical contraindications, humeral shaft fractures with any compromise to the radial nerve should be surgically explored as soon as feasible [201]. Dual plating is still indicated for certain cases of femoral shaft fractures, particularly old ununited fractures where intramedullary nailing is difficult [148]. Dual plating for femoral shaft fractures is contraindicated in severely comminuted fractures requiring extensive dissection [148]. Both minimally invasive internal fixation and symphyseal screws effectively achieved fracture union and pain relief for unstable pelvic ring fractures [183]. Both treatments for angulated fifth metacarpal fractures improved fracture angulation to about 50% of the initial angulation [185]. Surgical management may be the more conservative option for geriatric fragility fractures given the potential morbidity associated with non–weight bearing, immobilization, or casts [153]. Technical challenges at the time of surgery for geriatric fragility fractures may be overcome with the use of augments and/or dual fixation strategies, although no single technique is considered superior [153].

Complications¶

Infection and Wound Complications: Despite current treatment approaches, the rates of surgical site infection and delayed union or nonunion following treatment of open fractures remain high at 1 year and are not substantially improved from historical rates spanning several decades [291]. The risk of open fracture remained constant at 4 percent from 1937 to 1955, while the proportion of fractures amenable to and treated by operative methods increased [256]. Outcomes following open fractures were largely unaffected by serotonergic antidepressant use, likely due to the dominant biological and mechanical risks inherent to open injuries [57].

Nonunion and Delayed Union: The rate of nonunion after operatively treated long-bone fractures was 9.4% in a Medicare claims cohort [191]. The incidence of delayed union in tibial shaft fractures depends on the severity of the original injury as recognized by the presence of displacement, comminution, or open fracture [307]. In Ellis's classification (1958) of severity of injury for tibial shaft fractures, minor severity (undisplaced or angulated) was associated with a 2 per cent rate of delayed union [307]. Moderate severity (completely displaced) was associated with an 11 per cent rate of delayed union [307], while major severity (major comminution or major wound) was associated with a 60 per cent rate of delayed union [307].

Functional Outcomes and Quality of Life: Long-term outcomes of distal tibial Pilon fractures are related to the severity of the bone and soft-tissue injury and the quality of the reduction, with more severe injuries having a poorer outcome [30]. Vertebral and hip fractures have a considerably greater and more prolonged impact on health-related quality of life than forearm and humerus fractures [175]. At final follow-up, most clinical and patient-reported outcomes were significantly better in patients with 2-part proximal humerus fractures than in patients with 3- or 4-part fractures treated using an intramedullary nail designed to capture the tuberosities [48]. Overall, 55% of patients achieved the MCID at mid-term follow-up for acromial fractures following reverse shoulder arthroplasty, and worse outcomes were associated with increased fracture displacement [54].

Other Considerations: Clavicle fractures do not increase the occurrence of later subacromial pain syndrome [1], although in a registry-based study of 131,838 persons, the diagnosis of subacromial pain syndrome was given 1-2 years earlier for people with a previous clavicle fracture [1]. Shortening of the fracture had a small negative effect on the outcome in patients aged 10 to 18 years with clavicle fractures [34]. At mid-term follow-up, results for hook plate fixation of acute displaced lateral clavicle fractures are excellent and no long-term complications can be addressed to the use of the plate [160]. A pilot study of all-suture technique for fixation of unstable displaced distal clavicle fracture showed low complications and a high level of union after a follow-up of 1 year [170].

Scapular fractures that are significantly displaced can result in adverse healing and long-term functional consequences [47]. Displaced glenoid fractures are rare, and only multicenter studies extending over long periods of time will lead to accurate definition of the results and prognoses associated with operatively treated fractures [10]. The natural history of glenoid fractures in a trauma practice remains unclear and needs more research [284]. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms [50].

Percutaneous posterior fixation for unstable pelvic ring fractures leads to fracture union and excellent functional outcomes after 4 years’ follow-up [20]. Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades [267]. MRI is the golden standard for diagnosis of sacral fractures with a sensitivity of almost 100%, while plain x-rays have poor sensitivity (20–38%) [62]. No complications were noted in geriatric patients treated with 2 column screws for transcondylar distal humeral fractures, and all fractures healed at an average radiographic union time of 7.2 weeks [63]. All shoulder periprosthetic fractures united without complications at a mean time of 5.1 months (range 4–6) [159].

Atypical femoral fractures are associated with a high revision rate but good healing capacity compared to common shaft fractures [32]. Fractures occurred in 12% of cases following femoral lengthening, and the rate of secondary interventions was markedly reduced by prophylactic titanium elastic nailing [251]. Circular frame management of distal tibial fractures demonstrates favourable rates of major complications compared to those available in the existing literature [193]. NSAIDs/COX-2 inhibitors demonstrated no short-term impact on long-bone fracture-healing [169].

Open long bone fractures occur with a frequency of 11.5 per 100,000 persons per year, are more common in males, and have a bimodal age distribution [61]. Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes [21]. Age is a major factor in the aetiology and epidemiology of proximal humeral fractures, with the highest incidence occurring in women between 80 and 89 years of age [273]. More proximal humeral fractures were seen during winter months in earlier but not recent decades [59]. The incidence of osteoporosis-related fractures increased by age, regardless of the type of fracture [282].

Most pediatric fractures can be treated on an outpatient basis, with only 1 of 18 fractures requiring hospitalization or observation [39]. A high index of suspicion from the history coupled with a careful clinical examination should alert the clinician to the possibility of an underlying fracture in children with dog bites [31]. In 37 (40 per cent) of fractures in Paget's disease of bone, there was a history of pain in the affected limb for weeks or months before fracture [64]. When faced with a fracture in a previously abnormal bone, one should think ahead to the possible results, both for the fracture and for the previous abnormality [43]. The natural history of osteopenic process in osteoporosis pseudoglioma syndrome suggests it stabilizes with age, necessitating prophylaxis and diligent care of fractures and deformities [51]. Bone end fractures are traditionally said to reflect the effects of ageing [255]. It is too early to integrate standardized screening of fractures into treatment guidelines for patients with generalized convulsive seizures and status epilepticus [3]. Future studies should compare the new surgical classification for reversed oblique trochanteric femur fractures with existing classifications and evaluate the impact of reduction quality and bone quality across fracture types [12].

Recovery¶

Light activity (weeks): The evidence provided does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a typical month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): Long-term function after locking plate fixation of proximal humerus fractures is moderate and plateaus after one year [108]. Clinical outcome in tibial plateau fractures improves over time, with complex fractures potentially benefiting from tailored, long-term follow-up [5].

Rehabilitation protocol: The evidence provided does not specify a structured rehabilitation protocol, including PT phasing, immobilisation duration, weight-bearing or ROM progression, or sling/brace removal timing.

Functional milestones: At 6-month follow-up, the mean Constant score was 66.1 points and radiographically all fractures had healed in patients treated with the MultiLoc nail for proximal humerus fractures [321]. At final follow-up, most clinical and patient-reported outcomes were significantly better in patients with 2-part proximal humerus fractures than in those with 3- or 4-part fractures treated with intramedullary nails [48].

Other Considerations: The prognosis for fractures in children younger than 18 months is favourable across fracture types and circumstances of occurrence [17]. Long-term outcomes for distal tibial Pilon fractures are related to the severity of the bone and soft-tissue injury and the quality of the reduction, with more severe injuries having a poorer outcome [30]. Long-term functional deficits persist after locked plating of proximal humeral fractures [186]. Functional outcome for open pelvic fractures was usually fair to good, with the long-term outlook determined by concomitant injuries [187]. All fractures in combined femoral and tibial shaft injuries in the same limb healed within 15 months, with excellent functional end results in 89% of surviving patients [204]. Mid-term follow-up of Delta III reverse shoulder arthroplasty for complex 3- and 4-part proximal humerus fractures shows satisfying results in elderly patients [176]. The locking plate provides satisfactory functional outcomes after mid-term follow-up in patients with displaced proximal humerus fractures [202]. Long-term results of surgical management of high-energy scapula fractures highlight the importance of specialist surgical experience, structured classification, and long-term patient support [188]. Fractures that are significantly displaced can result in adverse healing and long-term functional consequences [47].

Of 14 complex proximal humeral fractures fixed using the extended deltoid-splitting approach, 13 united without complications and with comparatively minor residual functional deficits [180]. At follow-up, all arthroscopically reduced and fixed displaced intra-articular glenoid fossa fractures appeared well reduced on radiographs without evidence of post-traumatic arthritis [309]. Primary union occurred in 54 patients with simple femur shaft fractures treated with less invasive percutaneous wave plating in an average time of 13 weeks [311]. All but 1 fracture treated with the Polarus nail progressed to clinical and radiologic union [60]. All 8 patients with middle-third clavicle fractures treated with anterior plating using a dynamic compression plate went on to successful fracture union over a 2-year period [316].

Surviving patients with proximal humerus fractures frequently have persistent symptoms that can be predicted as early as after 1 year [320]. Long-term follow-up is required for physeal fractures to monitor for growth arrest and deformities [184]. Twelve months of follow-up would be preferable for surveillance of fracture-related infections in patients with open long-bone fractures [319].

The patient's age at the time of injury affected recovery from conservatively treated clavicle fractures, with 33% of those over the age of 20 years still having symptoms 3 months after sustaining the fracture [312]. Gender, age at the time of fracture, time since fracture, relative and absolute radiographic shortening, and hand dominance were not significantly correlated with subjective or objective outcomes in adolescents treated nonoperatively for displaced clavicle fractures [318]. The diagnosis of subacromial pain syndrome was given 1-2 years earlier for people with a previous clavicle fracture [1]. Worse outcomes after acromial fractures following reverse shoulder arthroplasty were associated with increased fracture displacement [54]. 55% of patients achieved the minimal clinically important difference at mid-term follow-up for acromial fractures following reverse shoulder arthroplasty [54]. Results for hemiarthroplasty for severe proximal humerus fractures are better in younger patients, while fracture severity and timing of operation do not appear to affect the outcome [315]. The natural history of osteoporosis pseudoglioma syndrome suggests the osteopenic process stabilizes with age, necessitating prophylaxis and diligent care of fractures and deformities [51]. Patients with actual pathological fractures of long bones survived an average of 4.7 months, while those with lesions stabilized prophylactically survived an average of 13.8 months postoperatively [322]. Normally healing fractures showed an increase of 3% per month on dynamic bone scanning, while delayed unions showed less than half that amount [314].

Key Evidence¶

[L3] However, the diagnosis was given 1-2 years earlier for people with a previous fracture. [1] (10.1016/j.xrrt.2024.01.008)
[L4] As long as the effect of standardized screening of fractures is not investigated, it is too early to integrate such a screening into treatment guidelines. [3] (10.1111/epi.14738)
[Paper] The diagnosis of a pathological fracture can be a trap; the surgeon must be suspicious and carefully scrutinize every X-ray image. [4] (10.1016/j.otsr.2015.05.010)
[L3] Complex fractures, in particular, might benefit from tailored, long-term follow-up. [5] (10.1016/j.injury.2025.112607)
[L4] [6] (10.1007/s11914-018-0443-y)
[L5] Nonoperative treatment remains the mainstay for most fractures; however, operative treatment has increased over the last decade. [7] (10.1016/j.xrrt.2026.100809)
[L5] The ultimate goal of any classification scheme is to allow for determination of the best treatment of each individual fracture, and subsequently the ability to compare efficacy of various treatment methods on a particular fracture. [8] (10.1016/j.ocl.2008.05.002)
[L5] Treatment protocols should be based on the individual clinical assessment, rather than mandatory time policies for fixation of long bone fractures. [9] (10.1016/j.injury.2004.05.025)
[L4] Due to the rarity of displaced fractures, only multicenter studies extending over long periods of time will lead to accurate definition of the results and prognoses associated with operatively treated fractures. [10] (10.2106/00004623-199274020-00019)
[L4] The problem is understanding the images of complex fractures, not the classification system. [11] (10.1016/j.jse.2005.02.014)
[L5] Future studies should compare this new system with existing classifications and evaluate the impact of reduction quality and bone quality across fracture types. [12] (10.1016/j.injury.2026.113238)
[L5] Diagnosis requires plain radiographs and CT scans, while management is dictated by fracture morphology, displacement, and associated injuries. [13] (10.5435/jaaos-d-20-00252)
[L4] If radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. [16] (10.1016/j.injury.2006.07.040)
[L4] The prognosis is favourable across fracture types and circumstances of occurrence. [17] (10.1016/j.otsr.2012.11.004)
[L3] Although nearly half of fractures were initially missed, careful review of radiographs detected most cases with high accuracy and excellent interobserver reliability. [18] (10.1177/2325967126s00531)
[L5] Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. [19] (10.1016/j.jse.2017.10.028)
[L4] It leads to fracture union and excellent functional outcomes after 4 years’ follow-up. [20] (10.1016/j.otsr.2017.07.024)
[L3] Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes. [21] (10.1097/corr.0000000000001911)
[L4] Fracture should be suspected in patients who present with pain postoperatively, and workup should include plain radiographs and computed tomographic scan if indicated. [23] (10.1016/j.ocl.2021.03.006)
[L4] The fractures were classified into 10 groups by anatomical involvement on roentgenographic examination. [24] (10.1016/s0363-5023(83)80196-8)
[L4] Most patients regained normal function of the shoulder soon after the injury. [26] (10.2106/00004623-199407000-00024)
[L1] Therefore, a pathologic fracture may no longer be an absolute contraindication for limb salvage surgery. [27] (10.1097/corr.0000000000002687)
[L4] Treatment depends on the fracture location, displacement, and patient factors and includes both non-surgical management and surgical fixation. [29] (10.21037/aoj.2018.12.03)
[L5] A high index of suspicion from the history coupled with a careful clinical examination should alert the clinician to the possibility of an underlying fracture. [31] (10.1016/0020-1383(96)00039-3)
[L3] [32] (10.1016/j.injury.2015.09.031)
[L4] Bone scan is an effective method of detecting missed fractures among patients with multiple severe traumas and can be used reliably as a screening test. [33] (10.1016/j.otsr.2014.09.015)
[L4] However, shortening of the fracture had a small negative effect on the outcome. [34] (10.1097/bpo.0000000000000082)
[L5] Computed tomography is useful for diagnosis as this type of fracture is sometimes misdiagnosed. [35] (10.1016/1058-2746(93)90066-p)
[L4] Fractures with initial angulation of <10° had no clinically significant evidence of re-angulation and should be considered stable requiring only an initial diagnostic radiograph. [38] (10.1016/s0020-1383(98)80212-x)
[L3] Most pediatric fractures can be treated on outpatient basis, with only 1 of 18 fractures requiring hospitalization or observation. [39] (10.1097/bpo.0000000000000595)
[L5] However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. [40] (10.5435/jaaos-20-03-130)
[L4] The Neer classification is a useful management tool but accurate delineation of fracture pattern requires better imaging modalities. [41] (10.1007/s00590-008-0325-6)
[L4] Although the device provides exceptional fixation stability, its indication must be scrutinized for each individual patient, taking the extent of trauma/fracture and age into consideration and carefully weighing it against other forms of treatment. [42] (10.1097/bot.0b013e318169ef2a)
[L5] When faced with a fracture in a previously abnormal bone, one should think ahead to the possible results, both for the fracture and for the previous abnormality. [43] (10.1016/0020-1383(77)90005-5)
[Paper] Most fractures are nondisplaced and can be treated nonoperatively, following a multiphasic protocol. [44] (10.1097/bte.0000000000000089)
[L4] Fractures that are significantly displaced can result in adverse healing and long-term functional consequences and should therefore be considered for ORIF. [47] (10.5435/00124635-199501000-00004)
[L3] However, at final follow-up most clinical and patient-reported outcomes were significantly better in patients with 2-part fractures than in patients with 3- or 4-part fractures. [48] (10.1016/j.jseint.2024.03.018)
[L5] Surgical treatment is generally reserved for specific indications such as open fractures, polytrauma, or failure of nonoperative management. [49] (10.1016/j.jse.2010.11.030)
[L3] After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms. [50] (10.1007/s00590-021-03099-6)
[L5] While surgical fixation and arthroplasty offer specific benefits for displaced fractures or younger patients, recent evidence suggests no long-term differences in outcomes between surgical and nonsurgical cohorts for many patient populations. [52] (10.5435/jaaos-d-24-01073)
[L1] More RCTs are needed to definitively recommend one over the other for specific fracture patterns due to observed heterogeneity. [53] (10.1186/s13018-015-0242-4)
[L3] Overall, 55% of patients achieved the MCID at mid-term follow-up, and worse outcomes were associated with increased fracture displacement. [54] (10.1016/j.jse.2022.01.132)
[L4] While nonsurgical management is reliable for many fractures, surgical options are increasingly favored for displaced fractures to improve union rates and functional outcomes. [55] (10.5435/jaaos-d-17-00442)
[L4] The authors advocate its use for these challenging fractures. [56] (10.1177/1758573220964807)
[L3] Outcomes following open fractures were largely unaffected, likely due to the dominant biological and mechanical risks inherent to open injuries. [57] (10.1016/j.injury.2026.113127)
[L4] When indications for operative treatment are met, plate fixation is reliable and safe. [58] (10.2106/jbjs.rvw.n.00119)
[L4] More fractures were seen during winter months in earlier but not recent decades. [59] (10.1186/s12891-024-07602-y)
[L4] All but 1 fracture progressed to clinical and radiologic union. [60] (10.1067/mse.2001.109556)
[L3] Open long bone fractures occur with a frequency of 11.5 per 100000 persons per year, are more common in males, and have a bimodal age distribution. [61] (10.1016/s0020-1383(98)00125-9)
[L5] The authors emphasize that MRI is the golden standard for diagnosis with a sensitivity of almost 100%, while plain x-rays have poor sensitivity (20–38%) for sacral fractures. [62] (10.1016/j.injury.2025.112145)
[L4] No complications were noted, and all fractures healed at an average radiographic union time of 7.2 weeks. [63] (10.1097/bth.0b013e3181dfbcb1)
[L4] [64] (10.1016/0020-1383(79)90043-3)
[L5] Existing classification systems for complex extremity fractures are inadequate and lack therapeutic recommendations. [65] (10.1016/j.injury.2009.10.039)
[L4] The new “unified” classification of open fractures has good validity, reliability and acceptability, and has the potential to replace all other existing classification systems. [66] (10.1016/j.injury.2018.06.007)
[L4] Although the MTM-classification covers a wide spectrum of fracture types, the precise topographic and morphological description is not delivering reproducible results. [77] (10.1186/1471-2474-9-21)
[L4] The system divides the craniofacial region into three units and distinguishes lateral and central fractures. [85] (10.1016/s0020-1383(02)00119-5)
[Paper] Existing classification systems for ballistic fractures are inadequate because they fail to account for soft-tissue injury, anatomical location, and joint involvement. [87] (10.1016/j.injury.2004.10.023)
[L4] The classification consists of 6 groups divided into 15 subgroups of calcar fracture patterns. [89] (10.1007/s12306-012-0195-2)
[L5] The classification of open fractures is important because it directs the attention of the treating surgeon to the presence and extent of injury variables. [90] (10.5435/00124635-200305000-00008)
[Paper] A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment. [92] (10.1016/j.injury.2013.10.010)
[L4] Observer agreement on the classification of displaced four-part fractures according to the Neer system is low (slight to moderate), which challenges the clinical approach to these fractures and poses a problem for the interpretation and generalisation of results from future randomised trials. [94] (10.1007/s00264-008-0591-2)
[L3] Awareness of this sign may be of help in detecting clinically or radiographically missed or occult fractures, thus facilitating initiation of adequate therapy and obviating extra financial costs due to unnecessary additional examinations. [96] (10.1007/s00330-006-0331-1)
[L5] The new classification provides a useful synoptic framework for identifying complex fracture patterns. [97] (10.1016/j.jse.2020.02.022)
[Abstract] The new classification provides a useful synoptic framework for identifying complex fracture patterns. [98] (10.1016/j.jse.2022.01.040)
[L1] [99] (10.1007/s00402-003-0631-8)
[L4] In general, non-displaced fractures are treated conservatively. [100] (10.1007/s00068-019-01122-4)
[Paper] Conservative treatment is sufficient in non-displaced type A post-operative fracture. [101] (10.1007/s00264-015-2972-7)
[L4] Our findings suggest that the classification of fracture severity in children should be done in only two categories that distinguish between simple and wedge/complex fractures. [103] (10.1080/17453670710013753)
[L2] Management is challenging as 50% of fractures are displaced, requiring hospitalization in half the cases, yet surgery is only performed in one out of five. [104] (10.1016/j.otsr.2012.05.013)
[L5] The management of malignant pathological fractures necessitates careful diagnostic work-up, preoperative investigation, planning and multidisciplinary input from specialists in the fields of radiology, pathology, oncology, trauma and orthopaedics. [106] (10.1016/j.injury.2015.07.028)
[L5] [107] (10.1016/s0278-5919(05)70272-6)
[L4] Long-term function after locking plate fixation is moderate and plateaus after one year. [108] (10.1016/j.jseint.2026.101683)
[L4] Based on an analysis of 245 consecutive patients, the authors propose a novel classification system for fragility fractures of the pelvic ring that is based on morphological criteria and corresponds with the degree of instability. [109] (10.1016/j.injury.2013.06.023)
[L5] The Orthopaedic Trauma Association Board of Directors has charged the Classification Committee with designing a multi-centre study to collect enough data to assess reliability, validity, and ideal usage of the open fracture classification. [110] (10.1016/j.injury.2012.12.016)
[L4] The paper reviews the presentation, diagnosis, and treatment of scapular fractures, noting that over 90% are nondisplaced or minimally displaced and can be managed conservatively. [113] (10.1155/2012/903850)
[L4] Extremity fractures in patients with traumatic brain injury are common and often missed; appropriate evaluation allows prompt diagnosis and optimal treatment. [115] (10.5435/00124635-199809000-00005)
[L4] The incidence of fractures missed on the initial examination of patients admitted to hospital as the result of trauma is at least 7.5 per cent. [116] (10.1016/0020-1383(73)90005-3)
[L3] The results revealed fundamental differences between the various types of fractures depending on the number of fragments. [117] (10.1016/s1058-2746(95)80015-8)
[L5] [118] (10.5435/jaaos-22-02-90)
[L4] The Swedish Fracture Register is a well-functioning, population-based fracture register that covers fractures of all types, regardless of treatment, and collects both surgeon- and patient-reported outcome measures. [119] (10.1186/s12891-015-0795-8)
[L4] [120] (10.1016/j.injury.2025.112365)
[L5] [123] (10.1016/j.xrrt.2023.07.007)
[L4] Minimal fracture displacement (<3 mm) does not worsen the clinical outcome or duration of symptoms. [124] (10.1016/j.jse.2013.01.033)
[L5] A high index of suspicion will lead to an early diagnosis in this uncommon cause of pathological fractures. [125] (10.1016/s0020-1383(01)00134-6)
[L4] The study demonstrated significant interobserver variation in coding long bone fractures using the AO classification system, with only 32 per cent of individual codings agreeing with the final consensus. [130] (10.1016/0020-1383(93)90282-b)
[L4] Functional results are limited regardless of the fracture management, and no clear preoperative risk factors were identified. [131] (10.1016/j.jse.2018.06.007)
[L4] They are recommended for emergency treatment, pathological fractures, and situations requiring x-ray transparency, with no complications observed after twenty-four hours of use. [132] (10.2106/00004623-196446080-00013)
[Paper] Understanding the classification and grade of stress fractures and their implications on return-to-play decisions is key to optimal care of the athlete. [136] (10.1016/j.csm.2005.08.012)
[L4] The procedure should be used with caution when managing acute non-pathological fractures as there is a high incidence of non-union. [139] (10.1016/0020-1383(96)00056-3)
[L3] The majority of fractures were treated non-surgically, although surgical treatment increased with increasing age in both sexes. [140] (10.1186/s12891-022-05042-0)
[L4] This technique is reported to be effective in achieving fracture union and safe to the patient. [146] (10.1097/bot.0000000000000040)
[L4] Dual plating is still indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection. [148] (10.2106/00004623-196345020-00026)
[L4] [149] (10.1177/17585732221131922)
[L2] This study further supports the role of non-operative treatment for teenagers, with nearly perfect outcomes reported bringing into question the role of acute operative management of these fractures given its associated risks and costs. [150] (10.1177/2325967123s00041)
[L5] Large-scale randomized studies are needed to assess indications and results for the various possible internal fixation techniques. [156] (10.1016/j.otsr.2016.11.007)
[L4] Undisplaced fractures have a variable outcome when treated nonoperatively. [157] (10.1016/j.jse.2015.11.007)
[L4] All fractures united without complications at a mean time of 5.1 months (range 4–6). [159] (10.1016/s0020-1383(13)70018-4)
[L4] At mid term the results are excellent and no long term complications can be addressed to the use of the plate. [160] (10.1186/1749-799x-7-2)
[L4] While nonsurgical management is effective for many fractures, surgical options including fixation and arthroplasty are utilized for complex patterns, though comparative efficacy remains variable. [162] (10.5435/jaaos-d-15-00240)
[L1] [163] (10.2106/jbjs.15.01394)
[L3] However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment. [167] (10.2106/00004623-198769040-00013)
[L2] Conservative modality is associated with higher rates of non-union and delayed healing. [168] (10.1016/j.injury.2018.04.012)
[L3] Our study demonstrated no short-term impact of NSAIDs/COX-2 inhibitors on long-bone fracture-healing. [169] (10.2106/jbjs.20.01663)
[L4] This pilot study showed low complications and a high level of union after a follow-up of 1 year. [170] (10.1016/j.xrrt.2022.01.005)
[L4] No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. [171] (10.1016/j.injury.2010.10.016)
[L4] A valid comparison between operative and nonoperative treatment cannot be made for any fracture type due to low numbers, high variability, and methodological limitations. [172] (10.1097/00005131-200603000-00013)
[L4] Percutaneous fracture treatment using the HB achieves good functional outcomes with an acceptable complication rate. [174] (10.1016/j.injury.2015.05.017)
[L3] Vertebral and hip fractures have a considerably greater and more prolonged impact on HRQOL than forearm and humerus fractures. [175] (10.1007/s00198-004-1622-5)
[L3] Mid-term follow-up shows satisfying results in terms of the treatment of severe displaced fractures in elderly patients with RSA. [176] (10.1186/1471-2474-14-231)
[L4] Operative treatment for displaced fractures in patients 65 years of age and older is safe and can yield good functional results and return to function. [177] (10.1097/bot.0000000000000710)
[L4] While closed treatment remains the method of choice for most fractures, acceptable results can be achieved with internal fixation, even for difficult fractures, provided the correct principles of fixation are carefully followed. [178] (10.2106/00004623-198668030-00018)
[L5] As the results from the review of the literature indicate, the more medial the fracture, the worse the prognosis with non-operative treatment. [179] (10.4103/0973-6042.123531)
[L3] Of the 14 fractures, 13 united without complications and with comparatively minor residual functional deficits. [180] (10.1016/j.injury.2008.05.031)
[L3] When properly stabilized, these fractures do not substantially influence overall final outcomes. [181] (10.1007/s11999-015-4448-x)
[L3] Randomized controlled trials and cost analyses are necessary to determine the optimal treatment method for such fractures. [182] (10.1097/bot.0000000000000229)
[L3] Both fixation techniques effectively achieved fracture union and pain relief. [183] (10.1007/s00264-026-07026-4)
[L3] Both treatments improved fracture angulation to about 50% of the initial angulation. [185] (10.1016/s0363-5023(96)80132-8)
[L4] Long-term functional deficits persist. [186] (10.1007/s11999-011-1935-6)
[L4] Functional outcome was usually fair to good with long-term outlook determined by concomitant injuries. [187] (10.1016/s0020-1383(98)00246-0)
[L4] This study provides the longest reported follow-up of scapula fracture surgery to date and highlights the importance of specialist surgical experience, structured classification, and long-term patient support. [188] (10.1016/j.jseint.2026.101682)
[L2] [189] (10.1136/bmjopen-2018-024916)
[L4] These techniques can result in good clinical outcomes despite the complexity of this fracture pattern. [190] (10.1097/bot.0b013e31829a346d)
[L3] The rate of nonunion after operatively treated long-bone fractures was 9.4%. [191] (10.2106/jbjs.22.01127)
[L4] Proper selection of fractures and good surgical technique are necessary to avoid complications. [192] (10.1016/s0363-5023(05)80091-7)
[L4] This study describes the mid-to-long term outcomes of patients who underwent CFF of a distal tibia fracture, representing the largest available series, and demonstrating favourable rates of major complications compared to those available in the existing literature. [193] (10.1016/j.injury.2025.112808)
[L1] Open reduction and plate fixation reduces the rate of nonunion and is associated with better functional outcomes compared with nonoperative treatment, but the improved outcomes appear to result from the prevention of nonunion. [194] (10.2106/jbjs.l.00307)
[L5] Treatment is predominantly nonoperative, involving relative rest and activity modification, with most fractures healing uneventfully. [195] (10.1016/j.csm.2005.08.008)
[L4] The results demonstrate similar fracture healing, clinical improvement, and complication rates compared with conventional ORIF with screws and a side plate. [196] (10.1016/j.jse.2021.05.001)
[L3] [199] (10.1097/bot.0b013e3181d8290e)
[L4] Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults. [200] (10.5312/wjo.v5.i5.685)
[L5] In the absence of strong medical contraindications, humeral shaft fractures with any compromise to the radial nerve should be surgically explored as soon as feasible. [201] (10.1097/00132589-200001020-00003)
[L4] The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. [202] (10.1007/s00590-010-0655-z)
[L4] All fractures healed within 15 months, and functional end results have been excellent in the majority of the surviving patients (89 per cent). [204] (10.1016/0020-1383(77)90133-4)
[L4] The results of the nonoperative treatment of these fractures are satisfactory even in elderly patients. [206] (10.1097/bot.0b013e318210ea56)
[L4] Therefore, we believe this modality should be utilized if fracture deformity warrants surgical consideration and to adequately compare data across studies. [208] (10.1007/s11999-011-1820-3)
[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. [209] (10.1016/j.jht.2017.05.005)
[L5] The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. [210] (10.1016/j.xrrt.2024.01.001)
[L1] These findings suggest that open fractures should be excluded as an entry criterion in future clinical trials. [211] (10.1016/0020-1383(94)90159-7)
[L4] For most long bone fractures non-operative treatment works well, but surgical management is reasonable in certain circumstances such as fracture neck and shaft of femur, Coxa Vara and failure of conservative treatment. [212] (10.1016/j.injury.2009.02.009)
[L4] Non-operative treatment is advocated for the majority of non-displaced and minimally displaced fractures with generally good outcomes, while displaced fractures may require arthroscopically assisted fixation or open/percutaneous reduction and internal fixation depending on fracture type and patient factors. [213] (10.1016/j.injury.2007.09.022)
[L4] There is a clear-cut indication for surgery in patients with overlapping of the fracture fragments (OV) ≥15% or cranio-caudal displacement (DS) ≥2.3 cm, as well as in those with OV ≥13% associated with DS ≥2 cm. [214] (10.1007/s00264-009-0850-x)
[L5] Treatment strategies for pathological fractures of the long bones depend on fracture risk and expected survival, with surgery indicated for actual fractures or high-risk impending fractures and radiotherapy for small lesions without fracture risk. [215] (10.1302/2058-5241.1.000008)
[L4] A conservative treatment seems sufficient in other fracture types. [216] (10.1007/s00402-020-03496-2)
[L5] If a plain radiograph does not reveal a fracture CT may be useful. [222] (10.1016/0020-1383(94)90166-x)
[L3] [223] (10.1007/s00402-026-06514-x)
[L5] [225] (10.1016/j.hcl.2007.08.002)
[L1] [226] (10.1016/j.jseint.2026.101617)
[L4] MRI did not appreciably change the estimation of fracture displacement compared to radiography. [227] (10.1177/2325967119851472)
[L3] MRI is an imperative tool for operative planning in pathological fractures; however, we recommend against the routine use of MRI to diagnose pathological fractures in oncological patients. [229] (10.1007/s00402-018-3012-z)
[L4] Radiographs were shown to provide incomplete information about the fracture pattern, and advanced imaging caused a change in classification into a segment more likely to be considered for surgical care. [235] (10.1097/bot.0b013e3182382625)
[L4] [243] (10.2106/00004623-197052060-00001)
[L5] The imaging evaluation of a patient in whom a stress reaction or fracture is clinically suspected should begin with high-resolution radiographs of the area in question. [244] (10.1016/j.csm.2005.08.009)
[L3] [246] (10.1016/j.jse.2021.12.024)
[L4] Radiographs remain the mainstay for fracture assessment, but their interpretation is challenging with experimental studies documenting a roughly 30% error rate. [249] (10.1016/j.rcl.2015.02.013)
[L3] Fractures occurred in 12% of cases, and the rate of secondary interventions was markedly reduced. [251] (10.1186/1471-2474-14-302)
[L4] Clinicians and radiologists agreed on the presence or absence of fracture or dislocation in 897 of 1011 cases (89 per cent). [252] (10.1016/s0020-1383(80)80048-9)
[L5] [254] (10.1302/2058-5241.3.170072)
[L3] Bone end fractures are traditionally said to reflect the effects of ageing. [255] (10.1016/0020-1383(95)90032-2)
[L4] The risk of open fracture remained constant at 4 percent from 1937 to 1955, while the proportion of fractures amenable to and treated by operative methods increased. [256] (10.2106/00004623-195840050-00025)
[L1] Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics. [258] (10.1016/j.jse.2012.01.009)
[L4] DECT thus combines the advantages of conventional CT (good visualisation of bone matter) and MRI (medullary cavity and visualisation of occult fractures). [259] (10.1007/s00402-019-03283-8)
[Paper] Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. [267] (10.1016/j.injury.2020.02.096)
[L4] Age is a major factor in the aetiology and epidemiology of these fractures, with the highest incidence occurring in women between 80 and 89 years of age. [273] (10.1080/000164701753542023)
[Paper] A CT scan is essential in all patients with displaced inferior ramus fractures to examine the posterior ring in detail. [281] (10.1007/s00402-014-1993-9)
[L4] The incidence of fractures increased by age, regardless of the type of fracture. [282] (10.1007/s00198-007-0453-6)
[L4] Therefore, we recommend close follow-up with serial radiographs for the first several weeks to allow for optimal treatment. [283] (10.1097/bot.0000000000000343)
[L5] The natural history of glenoid fractures in a trauma practice remains unclear and needs more research. [284] (10.1016/j.injury.2024.111880)
[L4] Appropriate views on radiographs are essential. [285] (10.1016/0020-1383(94)90184-8)
[L4] Radiologists were found to classify these fractures more reliably than surgeons, with substantial intra-observer and inter-observer agreement after viewing the fractures on two-plane radiography. [289] (10.1016/j.clinimag.2014.07.012)
[L3] Despite current treatment approaches, the rates of surgical site infection and delayed union/nonunion following treatment of open fractures remain high at 1 year and are not substantially improved from historical rates spanning several decades. [291] (10.2106/jbjs.24.01055)
[L5] Even under laboratory conditions, the information gained from plain radiographs is not sufficient to accurately predict the strength of a healing fracture. [292] (10.1002/jor.1100030211)
[L4] These additional radiographs did not alter management or contribute positively to clinical outcomes, supporting a standardized protocol involving imaging only at the initial radiographic evaluation for children aged 8 years or younger. [293] (10.5435/jaaosglobal-d-26-00031)
[L3] The findings of this study support repeat radiographic assessment 2-3 weeks post-injury prior to making definitive treatment decisions. [297] (10.1177/2325967121s00455)
[L4] Bone scintigraphy is an important adjunct to the early diagnosis of stress fracture, as it can demonstrate lesions earlier than conventional roentgenograms. [298] (10.2106/00004623-197759070-00006)
[L2] MRI examination of the pelvis was found to be superior in detecting undislocated fractures in a cohort of patients with a high incidence of osteoporosis. [303] (10.1016/j.injury.2014.10.050)
[L4] [307] (10.1016/0020-1383(72)90022-8)
[L4] At the time of follow-up all fractures appeared well reduced on radiographs without evidence of post-traumatic arthritis. [309] (10.1016/s1058-2746(96)80252-7)
[L4] Primary union occurred in 54 patients in an average time of 13 weeks. [311] (10.1016/j.injury.2010.01.101)
[L4] The patient's age at the time of injury affected recovery, with 33 per cent of those over the age of 20 years still having symptoms 3 months after sustaining the fracture. [312] (10.1016/0020-1383(88)90006-x)
[L4] Normally healing fractures had an increase of 3 per cent per month and delayed unions less than half that amount. [314] (10.1016/0020-1383(81)90162-5)
[L4] Results are better in younger patients, while fracture severity and timing of operation do not appear to affect the outcome. [315] (10.1067/mse.2002.126615)
[L4] We have a case series of 8 patients over a 2-year period, who were followed up and all went on to successful fracture union. [316] (10.1097/bth.0b013e318273f102)
[L4] Gender, age at the time of fracture, time since fracture, relative and absolute radiographic shortening, and hand dominance were all not significantly correlated with subjective or objective outcomes. [318] (10.1016/j.injury.2015.04.019)
[L5] The author concludes that 90 days of follow-up is inadequate for surveillance of fracture-related infections in patients with open long-bone fractures, especially for research purposes, and that 12 months of follow-up would be preferable. [319] (10.1097/corr.0000000000001964)
[L3] Our results suggest that there is a substantial mortality in patients with a proximal humerus fracture, as we have previously reported, and that surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year. [320] (10.1080/17453670510041295)
[L4] At 6-month follow-up in 17 patients, the mean Constant score was 66.1 points, and radiographically all fractures had healed. [321] (10.1007/s00064-011-0085-z)
[L4] The patients with actual fractures survived an average of 4.7 months, while those with lesions stabilized prophylactically survived an average of 13.8 months postoperatively. [322] (10.2106/00004623-197658080-00002)

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