Trauma

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Marcel Niemann Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany

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Ellen Otto Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany

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Christian Eder Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany

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Yasmin Youssef Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany

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Lutz Kaufner Charité – Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany

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Sven Märdian Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany

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  • 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.

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B Kooistra Department of Orthopaedic Surgery, Medische Kliniek Velsen, Velsen-Noord, the Netherlands

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M van den Bekerom Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands

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S Priester-Vink Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands

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R Barco Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain

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on behalf of the ESSKA Elbow and Forearm Committee

Purpose

  • 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.

Methods

  • 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.

Results

  • 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.

Conclusions

  • 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.

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Elisa Pala Department of Orthopedics and Orthopedic Oncology, University of Padova, Padova, Italy

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Alberto Procura Department of Orthopedics and Orthopedic Oncology, University of Padova, Padova, Italy

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Giulia Trovarelli Department of Orthopedics and Orthopedic Oncology, University of Padova, Padova, Italy

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Antonio Berizzi Department of Orthopedics and Orthopedic Oncology, University of Padova, Padova, Italy

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Pietro Ruggieri Department of Orthopedics and Orthopedic Oncology, University of Padova, Padova, Italy

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Purpose

  • 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.

Methods

  • 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).

Results

  • 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.

Conclusions

  • 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.

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Arjun Sivakumar Centre for Orthopaedic & Trauma Research, University of Adelaide, Adelaide, South Australia, Australia

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Suzanne Edwards Adelaide Health Technology Assessment, University of Adelaide, Adelaide, South Australia, Australia

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Stuart Millar Centre for Orthopaedic & Trauma Research, University of Adelaide, Adelaide, South Australia, Australia

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Dominic Thewlis Centre for Orthopaedic & Trauma Research, University of Adelaide, Adelaide, South Australia, Australia

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Mark Rickman Centre for Orthopaedic & Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
Department of Orthopaedics & Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia

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Purpose

  • 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.

Methods

  • 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.

Results

  • 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.

Conclusion

  • 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.

Open access
Signe Steenstrup Jensen Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark
Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark

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Niels Martin Jensen Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark

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Per Hviid Gundtoft Department of Orthopedic Surgery and Traumatology, Aarhus University Hospital, Aarhus, Denmark

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Søren Kold Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark

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Robert Zura Department of Orthopedic Surgery, Louisiana State University Medical Center, New Orleans, Louisiana, USA

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Bjarke Viberg Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark
Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark

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Background

  • 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.

Methods

  • 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.

Results

  • 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.

Conclusion

  • 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.

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Julia Riemenschneider Department of Trauma-, Hand- and Reconstructive Surgery, Goethe University, Frankfurt, Germany

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Jan Tilmann Vollrath Department of Trauma-, Hand- and Reconstructive Surgery, Goethe University, Frankfurt, Germany

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Nils Mühlenfeld Department of Trauma-, Hand- and Reconstructive Surgery, Goethe University, Frankfurt, Germany

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Johannes Frank Department of Trauma-, Hand- and Reconstructive Surgery, Goethe University, Frankfurt, Germany

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Ingo Marzi Department of Trauma-, Hand- and Reconstructive Surgery, Goethe University, Frankfurt, Germany

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Maren Janko Department of Trauma-, Hand- and Reconstructive Surgery, Goethe University, Frankfurt, Germany

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  • 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.

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Elizabeth K Tissingh The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
King’s Global Health Partnerships, School of Life Course and Population Sciences, King’s College London, London, UK

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Leonard Marais Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa

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Antonio Loro Comprehensive Rehabilitation Services for People with Disability in Uganda (CoRSU) Hospital, Kisubi, Uganda

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Deepa Bose University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

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Nilo T Paner Department of Orthopaedics, University of the Philippines, Philippine General Hospital Manila, The Phillipines

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Jamie Ferguson The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
Department of Orthopaedics, University of the Philippines, Philippine General Hospital Manila, The Phillipines

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Mario Morgensten Centre for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland

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Martin McNally The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK

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  • The global burden of fracture-related infection (FRI) is likely to be found in countries with limited healthcare resources and strategies are needed to ensure the best available practice is context appropriate. This study has two main aims: (i) to assess the applicability of recently published expert guidance from the FRI consensus groups on the diagnosis and management of FRI to low- and middle-income countries (LMICs); (ii) to summarise the available evidence on FRI, with consideration for strategies applicable to low resource settings.

  • Data related to the International Consensus Meeting Orthopaedic Trauma Work Group and the International Fracture Related Infection Consensus Group FRI guidelines were collected including panel membership, country of origin, language of publication, open access status and impact factor of the journal of publication. The recommendations and guidelines were then summarised with specific consideration for relevance and applicability to LMICs. Barriers to implementation were explored within a group of LMIC residents and experienced workers.

  • The authorship, evidence base and reach of the FRI consensus guidelines lack representation from low resource settings. The majority of authors (78.5–100%) are based in high-income countries and there are no low-income country collaborators listed in any of the papers. All papers are in English.

  • The FRI consensus guidelines give a clear set of principles for the optimum management of FRI. Many of these – including the approach to diagnosis, multidisciplinary team working and some elements of surgical management – are achievable in low resource settings. Current evidence suggests that it is important that a core set of principles is prioritised but robust evidence for this is lacking. There are major organisational and infrastructure obstacles in LMICs that will make any standardisation of FRI diagnosis or management challenging. The detail of how FRI consensus principles should be applied in low resource settings requires further work.

  • The important work presented in the current FRI consensus guidelines is relevant to low resource settings. However, leadership, collaboration, creativity and innovation will be needed to implement these strategies for communities who need it the most.

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Mario Herrera-Pérez Foot and Ankle Unit, Orthopaedic Department, Hospital Universitario de Canarias, Tenerife, Spain
School of Medicine, Universidad de La Laguna, Tenerife, Spain

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Pablo Martín-Vélez Foot and Ankle Unit, Orthopaedic Department, Hospital Universitario de Canarias, Tenerife, Spain

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David González-Martín Foot and Ankle Unit, Orthopaedic Department, Hospital Universitario de Canarias, Tenerife, Spain
School of Medicine, Universidad de La Laguna, Tenerife, Spain

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Miguel Domínguez-Meléndez Foot and Ankle Unit, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain

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Ahmed E Galhoum Specialty Doctor Trauma and Orthopaedics, George Eliot Hospital NHS Trust, Nuneaton, UK

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Victor Valderrabano Schmerzklinik, Basel, Switzerland
University of Basel, Basel, Switzerland

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Sergio Tejero Foot and Ankle Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain
School of Medicine, Universidad de Sevilla, Sevilla, Spain

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  • Osteoporotic ankle fractures result from mechanical forces that would not ordinarily result in fracture, known as ‘low-energy’ trauma, such as those equivalent to a fall from a standing height or less.

  • Osteoporotic ankle fractures in frail patients are becoming more and more frequent in daily practice and represent a therapeutic challenge for orthopaedic surgeons.

  • The main problems with frail patients are the poor condition of the soft tissues around the ankle, dependence for activities of daily living and high comorbidity.

  • The decision to operate on these patients is complex because conservative treatment is poorly tolerated in unstable fractures and conventional open reduction and internal fixation is associated with a high rate of complications.

  • The authors conducted a narrative review of the literature on primary tibiotalocalcaneal nailing of ankle fractures in frail patients and categorized the different factors to consider when treatment is indicated for this conditon. Difficulty of ambulation, age over 65 years old, deteriorated baseline state and instability of the fracture were the most frequently considered factors.

  • Finally, the authors propose an easy and quick clinical scoring system to help in the decision-making process, although further comparative studies are required to explore its validity.

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Karl Stoffel Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland

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Christoph Sommer Department of Surgery, Kantonsspital Graubuenden, Chur, Switzerland

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Mark Lee Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California, USA

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Tracy Y Zhu AO Innovation Translation Center, AO Foundation, Davos, Switzerland

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Karsten Schwieger AO Innovation Translation Center, AO Foundation, Davos, Switzerland

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Christopher Finkemeier Sutter Roseville Medical Center, Roseville, California, USA

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  • For complex distal femoral fractures, a single lateral locking compression plate or retrograde intramedullary nail may not achieve a stable environment for fracture healing.

  • Various types of double fixation constructs have been featured in the current literature. Double-plate construct and nail-and-plate construct are two common double fixation constructs for distal femoral fractures.

  • Double fixation constructs have been featured in studies on comminuted distal femoral fractures, distal femoral fracture with medial bone defects, periprosthetic fractures, and distal femoral non-union.

  • A number of case series reported a generally high union rate and satisfactory functional outcomes for double fixation of distal femoral fractures.

  • In this review, we present the state of the art of double fixation constructs for distal femoral fractures with a focus on double-plate and plate-and-nail constructs.

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Rui Zhang Department of Orthopedics, Shanghai Jiao Tong University affiliated Sixth People’s Hospital, Shanghai, China

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Xiaoyu Wang Department of Orthopedics, Shanghai Jiao Tong University affiliated Sixth People’s Hospital, Shanghai, China

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Jia Xu Department of Orthopedics, Shanghai Jiao Tong University affiliated Sixth People’s Hospital, Shanghai, China

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Qinglin Kang Department of Orthopedics, Shanghai Jiao Tong University affiliated Sixth People’s Hospital, Shanghai, China

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Reggie C Hamdy Department of Pediatric Surgery, Montreal General Hospital, Montreal, Quebec, Canada

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  • Monteggia fracture is characterized by radial head dislocation combined with proximal ulnar fracture.

  • If not diagnosed at an early stage, these lesions can gradually lead to forearm deformities and dysfunction, finally resulting in neglected Monteggia fracture. When the radial head is not reduced, several deformities develop at the humeroradial joint, including cubitus valgus and osteoarthritis.

  • Adequate radiographs are crucial when the surgeons deal with forearm injuries.

  • At present, proximal ulnar osteotomy and open reduction of chronic radial head dislocation provides satisfactory functional outcomes because of anatomic alignment reconstruction.

  • Supplementary procedures, including transcapitellar pinning and repair or reconstruction of the annular ligament, which are performed in order to enhance stability of the humeroradial joint, should be thoroughly assessed based on joint rotational stability after reduction and on potential complications.

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