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Cora Rebecca Schindler, Ramona Sturm, Jason Alexander Hörauf, Ingo Marzi, and Philipp Störmann

  • ‘Damage control’ is the therapeutic strategy in the treatment of polytraumatized patients and aims at securing vital functions and controlling bleeding with a favorable effect on the post-traumatic immune response.

  • The post-traumatic immune dysfunction is based on a disturbed balance between immunostimulatory and anti-inflammatory mechanisms. The extent of the immunological ‘second hit’ can be limited by delaying deferable surgical therapies until organ stabilization has been achieved by the treating surgeon.

  • Pelvic sling is easy to apply and noninvasive with effective pelvic reduction. Pelvic angiography vs pelvic packing are not antagonistic, but rather should be considered as complementary methods.

  • Operating as early as possible on unstable spinal injuries with confirmed or suspected neurological deficits by decompression and stabilization with a dorsal internal fixator.

  • Dislocations, unstable or open fracture, vascular involvement, and compartment syndrome are considered emergency indications. In extremity fracture treatment, primary definitive osteosynthesis is often dispensed with and instead, temporary stabilization with an external fixator is performed.

Vasileios P Giannoudis, Paul Rodham, Peter V Giannoudis, and Nikolaos K Kanakaris

  • Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors.

  • The spectrum of injuries and their severity is quite extensive, which dictates a clear understanding of the existing nomenclature.

  • What is defined nowadays as polytrauma or major trauma, together with other essential terms used in the orthopaedic trauma literature, is described in this instructional review.

  • Furthermore, an analysis of contemporary management strategies (early total care (ETG), damage control orthopaedics (DCO), early appropriate care (EAC), safe definitive surgery (SDS), prompt individualised safe management (PRISM) and musculoskeletal temporary surgery (MuST)) advocated over the last two decades is presented.

  • A focused description of new methods and techniques that have been introduced in clinical practice recently in all different phases of trauma management will also be presented.

  • As the understanding of trauma pathophysiology and subsequently the clinical practice continuously evolves, as the means of scientific interaction and exchange of knowledge improves dramatically, observing different standards between different healthcare systems and geographic regions remains problematic.

  • Positive impact on the survivorship rates and decrease in disability can only be achieved with teamwork training on technical and non-technical skills, as well as with efficient use of the available resources.

Luke Turley, Ian Barry, and Eoin Sheehan


  • Open tibial shaft fractures comprise almost 45% of all open fractures and are frequently the result of high-energy trauma. Due to contamination, limited soft tissue coverage of the tibial shaft and poor tibial blood supply, open tibial shaft fractures are associated with high rates of complication including malunion, non-union and infection. Intramedullary nailing (IMN) is a mainstay of treatment. This study aims to determine the frequency of the various complications in this cohort.


  • A systematic review of papers published on Embase, PubMed and Cochrane databases pertaining to the use of IMN to fix open tibial shaft fractures were included. The available evidence was collated in regard to the incidence of union, malunion, non-union and infection seen in this cohort.


  • A total of 2767 citations were reviewed, and 17 studies comprising 1850 patients were included in the analysis. There was a delayed union rate of 22.4%, malunion rate of 8.3%, non-union rate of 9.7% and infection rate of 8.1% (95% CI: 5.7%–10.8%) in this patient cohort. Subgroup analysis showed a 3-fold increase in non-union and a 2-fold increase in deep infection among Gustilo III injuries compared to Gustilo I and II.


  • IMN for open tibial shaft fractures results in high rates of union and low rates of infection, comparable to figures seen in closed injuries and superior to those seen with alternative methods of fixation. There is a substantially increased risk of complication associated with Gustilo III injuries, reinforcing the significance of the soft tissue injury in these patients.

Andrew J Harrison, Michael R Redler, David M Taylor, Ansar Mahmood, John T Jones, Yukihiro Arai, and Yoshinobu Watanabe

  • Low-intensity pulsed ultrasound (LIPUS) treatment of fractures has been available to the orthopaedic community for nearly three decades; however, it is still considered an experimental treatment by some clinicians, even though there is a wealth of clinical data.

  • Based on the evaluation of clinical trial data, we have established key criteria which can lead to LIPUS success and avoid failure. These are fracture gap size and stability, accurate transducer placement and minimum treatment number.

  • However, from a clinician’s view, the correct attitude to treatment must be observed, and this has also been discussed.

  • It is hoped, armed with this new evaluation of the clinical data, that clinicians can treat patients with LIPUS more effectively, resulting in fewer failures of treatment.

Marcel Niemann, Ellen Otto, Christian Eder, Yasmin Youssef, Lutz Kaufner, and Sven Märdian

  • The European guideline on the management of trauma-induced major bleeding and coagulopathy summarises the most relevant recommendations for trauma coagulopathy management.

  • The management of trauma-induced major bleeding should interdisciplinary follow algorithms which distinguish between life-threatening and non-life-threatening bleeding.

  • Point-of-care viscoelastic methods (VEM) assist target-controlled haemostatic treatment. Neither conventional coagulation assays nor VEM should delay treatment in life-threatening trauma-induced bleeding.

  • Adjustments may be rational due to local circumstances, including the availability of blood products, pharmaceuticals, and employees.

B Kooistra, M van den Bekerom, S Priester-Vink, and R Barco


  • The aim of this study was to systematically review clinical studies on the employed definitions of longitudinal forearm instabilities referred to as Essex-Lopresti (EL) injuries, interosseous membrane (IOM) injuries or longitudinal radioulnar dissociation.


  • A systematic literature search was performed in MEDLINE, Embase, CINAHL, Web of Science and Cochrane databases, adhering to PRISMA guidelines. All data on diagnosis and treatment were collected.


  • In total, 47 clinical studies involving 266 patients were included. Thirty-nine of 47 studies did not mention an IOM lesion as part of the EL injury. The amount of preoperative positive ulnar variance varied from >1 to >12 mm. Nine studies used some form of dynamic pre-operative or intraoperative test of longitudinal radioulnar instability.


  • There is no accepted definition of EL injury in the literature. In order to prevent underdetection of acute EL injury, a radial head fracture in a patient with wrist and/or forearm pain should raise awareness of the possibility of an EL injury. In this case, comparative radiographic studies and some form of dynamic assessment of longitudinal radioulnar stability should be performed.

Elisa Pala, Alberto Procura, Giulia Trovarelli, Antonio Berizzi, and Pietro Ruggieri


  • The aim of this study is to compare titanium vs carbon fiber intramedullary (IM) nailing in terms of response to radiotherapy, local control of the disease, time of surgery, fluoroscopy exposure, and complications.


  • From 2015 to 2021, 52 impending or pathologic fractures were treated with IM nailing in 47 patients: 18 males and 29 females with a mean age of 73. Titanium nails were used in 27 cases: femur (17 cases), humerus (8 cases), and tibia (2 cases). Carbon fiber nails were used in 25 cases: femur (17 cases), humerus (7 cases), and tibia (1 case).


  • At a mean follow-up of 8.4 months, most patients died from the disease (63.4%). Fracture healing without osteolysis progression was present in 52% of titanium nailing at a mean time of 6 months and in 53% of carbon fiber nails at a mean time of 4.6 months. No statistically significant difference has been shown in terms of healing (P = 0.5), intraoperative fluoroscopy (P = 0.7), and time of surgery in femoral nailing (P = 0.6), while a significantly lower surgical time for carbon fiber humeral nailing (P  = 0.01) was found. Two breakages of carbon fiber femoral nails were observed, and both were treated with revision with modular tumor megaprosthesis.


  • Our results suggest that surgical time and fluoroscopy exposure are not longer for carbon fiber nails compared to titanium ones. Healing seems to be faster in carbon fiber nails. Further clinical studies are needed to clarify the long-term outcomes of these implants.

Arjun Sivakumar, Suzanne Edwards, Stuart Millar, Dominic Thewlis, and Mark Rickman


  • The purpose of this study was to investigate differences in aseptic reoperation rates between single or dual lag screw femoral nails,in the treatment of intertrochanteric fractures (ITF) in elderly patients.


  • Electronic databases were searched for RCTs and prospective cohort studies treating elderly ITF patients with a single or dual screw femoral nails. Data for aseptic reoperation rates between single screw, dual separated screw and dual integrated screw devices were pooled using a random-effects meta-analysis with 95% CIs. Pooled proportions were compared using a N-1 chi-squared test. Complications contributing to aseptic reoperation rates were extracted, and the contribution of cut-out and periprosthetic fracture as a proportion of reoperations was analysed using a negative binomial regression model.


  • Forty-two (n  = 42) studies were evaluated, including 2795 patients treated with a single screw device, 1309 patients treated with a dual separated screw device and 303 patients treated with a dual integrated screw device. There was no significant difference in aseptic reoperation rates between single and dual lag screw femoral nails of both separated and integrated lag screw designs. Moreover, complications of cut-out and periprosthetic fracture as a proportion of reoperations did not differ significantly between devices.


  • The current evidence showed that aseptic reoperation rates were not significantly different between single and dual screw nails of a separated lag screw design. For dual integrated screw devices, due to insufficient evidence available, further high quality RCTs are required to allow for decisive comparisons with these newer devices.

Signe Steenstrup Jensen, Niels Martin Jensen, Per Hviid Gundtoft, Søren Kold, Robert Zura, and Bjarke Viberg


  • There are several studies on nonunion, but there are no systematic overviews of the current evidence of risk factors for nonunion. The aim of this study was to systematically review risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures.


  • Medline, Embase, Scopus, and Cochrane were searched using a search string developed with aid from a scientific librarian. The studies were screened independently by two authors using Covidence. We solely included studies with at least ten nonunions. Eligible study data were extracted, and the studies were critically appraised. We performed random-effects meta-analyses for those risk factors included in five or more studies. PROSPERO registration number: CRD42021235213.


  • Of 11,738 records screened, 30 were eligible, and these included 38,465 patients. Twenty-five studies were eligible for meta-analyses. Nonunion was associated with smoking (odds ratio (OR): 1.7, 95% CI: 1.2–2.4), open fractures (OR: 2.6, 95% CI: 1.8–3.9), diabetes (OR: 1.6, 95% CI: 1.3–2.0), infection (OR: 7.0, 95% CI: 3.2–15.0), obesity (OR: 1.5, 95% CI: 1.1–1.9), increasing Gustilo classification (OR: 2.2, 95% CI: 1.4–3.7), and AO classification (OR: 2.4, 95% CI: 1.5–3.7). The studies were generally assessed to be of poor quality, mainly because of the possible risk of bias due to confounding, unclear outcome measurements, and missing data.


  • Establishing compelling evidence is challenging because the current studies are observational and at risk of bias. We conclude that several risk factors are associated with nonunion following surgically managed, traumatic, diaphyseal fractures and should be included as confounders in future studies.

Julia Riemenschneider, Jan Tilmann Vollrath, Nils Mühlenfeld, Johannes Frank, Ingo Marzi, and Maren Janko

  • Different treatment options for acetabular fractures in the elderly and nonagenarians exist; a consistent guideline has not been established, yet. The purpose of this study is to give an overview of how those fractures can be handled and compares two different surgical treatment methods.

  • A total of 89 patients ≥ 18 years between 2016 and 2021 with acetabular fractures in our department received a surgical intervention with plate fixation via the Stoppa approach or a total hip arthroplasty with a Burch–Schneider ring and integrated cup. 60 patients ≥ 65 were compared in two groups, 29 patients between 65 and 79 and 31 patients ≥ 80. For comparison, data on operation times, hospitalization, complications during operation and hospital stay, blood loss and postoperative mobilization were collected.

  • Characteristics could be found for indications for operative osteosynthesis or endoprosthetics based on the X-ray analysis. There was a tendency to treat simple fractures with osteosynthesis. Patients between 65 and 79 with an osteosynthesis had benefits in almost every comparison. Patients ≥ 80 with a plate fixation had advantages in the categories of postoperative complications, blood loss and transfusion of erythrocyte concentrates. Statistical significant differences were noticed in both groups regarding the operation time. Patients between 65 and 79 with osteosynthesis had significant benefits for postoperative complications, hospitalization, number of blood transfusions and postoperative mobilization.

  • Finding the best supportive treatment option is difficult, and decision-making must respect fracture patterns and individual risk factors. This study shows that plate fixation via the Stoppa approach has some benefits.