• The aim of this systematic review and meta-analysis was to assess risk for iatrogenic radial nerve palsy (iRNP), non-union, and post-operative infection in humeral shaft fractures.

• A PubMed search including original articles comparing different treatments for humeral shaft fractures published since January 2000 was performed. Random effect models with relative risks (RR) and 95% CIs were calculated for treatment groups and outcomes.

• Of the 841 results, 43 studies were included in the meta-analysis (11 level II, 5 level III, 27 level IV). Twenty-seven compared intramedullary nailing (IM) with ORIF, nine conservative with operative treatment, four ORIF with minimally invasive plate osteosynthesis (MIPO), and three anterior/anterolateral with posterior approach. iRNP risk was higher for ORIF vs IM (18 studies; RR: 1.80; P  = 0.047), ORIF vs MIPO (4 studies; RR: 5.60; P  = 0.011), and posterior vs anterior/anterolateral approach (3 studies; RR: 2.68; P  = 0.005). Non-union risk was lower for operative vs conservative therapy (six studies; RR: 0.37; P  < 0.001), but not significantly different between ORIF and IM (21 studies; RR: 1.00; P  = 0.997), or approaches (two studies; RR: 0.36; P  = 0.369). Post-operative infection risk was higher for ORIF vs IM (14 studies; RR: 1.84; P  = 0.004) but not different between approaches (2 studies; RR: 0.95; P  = 0.960).

• Surgery appears to be the method of choice when aiming to secure bony union, albeit risk for iRNP has to be considered, particularly in case of ORIF vs IM or MIPO, and posterior approach. Due to the limited number of randomised studies, evidence on the best treatment option remains moderate, though.

• Treatment of acetabular fractures is challenging and risky, especially when surgery is performed. Yet, stability and congruity of the hip joint need to be achieved to ensure early mobilization, painlessness, and good function. Therefore, coming up with an accurate decision, whether surgical treatment is indicated or not, is the key to successful therapy.

• Data from the German pelvic Trauma Registry (n  = 4213) was evaluated retrospectively, especially regarding predictors for surgery. Furthermore, a logistic regression model with surgical treatment as the dependent variable was established.

• In total, 25.8% of all registered patients suffered from an acetabular fracture and 61.9% of them underwent surgery. The fracture classification is important for the indication of surgical therapy. Anterior wall fractures were treated surgically in 10.2%, and posterior column plus posterior wall fractures were operated on in 90.2%. Also, larger fracture gaps were treated surgically more often than fractures with smaller gaps (>3 mm 84.4%, <1 mm 20%). In total, 51.4% of women and 66.0% of men underwent surgery. Apart from the injury severity score (ISS), factors that characterize the overall picture of the injury were of no importance for the indication of a surgical therapy (isolated pelvic fracture: 62.0%, polytrauma: 58.8%). The most frequent reason for non-operative treatment was ‘minimal displacement’ in 42.2%.

• Besides fracture classification and fracture characteristics, no factors characterizing the overall injury, except for the ISS, and unexpectedly gender, are important for making a treatment decision. Further studies are needed to determine the relevance of these factors, and whether they should be used for the decision-making process, in particular surgeons with less experience in pelvic surgery, can orient themselves to.

• Fractures of the femoral head are rare injuries, which typically occur after posterior hip dislocation.

• The Pipkin classification, developed in 1957, is the most commonly used classification scheme to date.

• The injury is mostly caused by high-energy trauma, such as motor vehicle accidents or falls from a significant height.

• Emergency treatment consists of urgent closed reduction of the hip joint, followed by non-operative or operative treatment of the femoral head fracture and any associated injuries.

• There is an ongoing controversy about the suitable surgical approach (anterior vs. posterior) for addressing fractures of the femoral head. Fracture location, degree of displacement, joint congruity and the presence of loose fragments, as well as concomitant injuries are crucial factors in choosing the adequate surgical approach.

• Long-term complications such as osteonecrosis of the femoral head, posttraumatic osteoarthritis and heterotopic ossification can lead to a relatively poor functional outcome.

Cite this article: EFORT Open Rev 2021;6:1122-1131. DOI: 10.1302/2058-5241.6.210034

• Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation – all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions.

• We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients.

• A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29–0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76–2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21–2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups.

• Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually.

Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003

• A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus.

• Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons.

• In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint.

• In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care.

• This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.

Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138

• Elderly hip fracture patients are at risk of stress-related gastric mucosal damage, and upper gastrointestinal bleeding is one of the underrecognized but devastating complications.

• Proton pump inhibitors (PPIs) offer effective prophylaxis against stress-related gastric mucosal damage.

• Systematic analysis of the literature revealed numerous articles on PPIs and hip fractures, but only three articles dedicated to the analysis of prophylactic use of PPIs in patients with a hip fracture.

• There is significant reduction in upper gastrointestinal bleeding following PPI prophylaxis and reduced 90-day mortality in elderly hip fracture patients on prophylaxis.

• PPIs are generally safe, cost-effective and based on available evidence. Their prophylactic use is justifiable in elderly patients with hip fractures.

• We suggest that PPIs be prescribed routinely peri-operatively in elderly hip fracture patients. Further level-one studies on the subject will allow for firmer recommendations.

Cite this article: EFORT Open Rev 2021;6:686-691. DOI: 10.1302/2058-5241.6.200053

• The management of femoral neck fractures remains controversial. Treatment options include a wide variety of internal fixation methods, unipolar or bipolar hemiarthroplasty or total hip replacement.

• We carried out a systematic review of the available literature to detect differences between cemented and cementless fixation of bipolar prostheses in treating femoral neck fractures in patients aged 60 years or older.

• Thirteen studies involving a total of 1561 bipolar hemiarthroplasties (770 cemented and 791 uncemented) were identified. Uncemented hemiarthroplasty was associated with significantly lower blood loss (p < 0.0001), shorter operative time (p < 0.0001), less infection (p = 0.03) and lower risk of heterotopic ossification (p = 0.007). On the other hand, patients with cemented hemiarthroplasty suffered significantly less postoperative thigh pain than those with cementless implantation (p < 0.00001).

• The existing evidence indicates that uncemented bipolar hemiarthroplasty offers shorter operative time, less blood loss, lower local complications and a similar rate of systemic complications and reoperations as compared to cemented implantation.

Cite this article: EFORT Open Rev 2021;6:380-386. DOI: 10.1302/2058-5241.6.200057

• This article serves to review the existing clinical guidelines, and highlight the most recent medical and surgical recommendations, for the management of displaced femoral neck fractures (FNFs). It stresses the need for multi-disciplinary intervention to potentially improve mortality rates, limit adverse events and prevent further economic liability.

• Globally, the incidence of FNFs continues to rise as the general population ages and becomes more active. The annual number of FNFs is expected to exceed six million by 2050. The increased burden of FNFs exacerbates the demand on all services associated with treating these injuries.

• The management of FNFs may serve as an indicator of the quality of care of the geriatric population. However, despite escalating health costs, a significant 30-day and one-year mortality rate, increased rate of peri-operative adverse events and sub-optimal functional clinical outcomes, continued controversy exists over optimal patient care.

• Much debate exists over the type of surgery, implant selection and peri-operative clinical care and rehabilitation. FNF care models, systematized clinical pathways, formal geriatrics consultation and specialized wards within an established interdisciplinary care framework may improve outcomes, mitigate adverse events and limit unnecessary costs.

Cite this article: EFORT Open Rev 2021;6:139-144. DOI: 10.1302/2058-5241.6.200036

• Subtrochanteric (ST) femur fractures are proximal femur fractures, which are often difficult to manage effectively because of their deforming anatomical forces.

• Operative management of ST fractures is the mainstay of treatment, with the two primary surgical implant options being intramedullary (IM) nails and extramedullary plates.

• Of these, IM nails have a biologic and biomechanical superiority, and have become the gold standard for ST femur fractures.

• The orthopaedic surgeon should become familiar and facile with several reduction techniques to create anatomical alignment in all unique ST fracture patterns.

• This article presents a comprehensive and current review of the epidemiology, anatomy, biomechanics, clinical presentation, diagnosis, and management of subtrochanteric femur fractures.

Cite this article: EFORT Open Rev 2021;6:145-151. DOI: 10.1302/2058-5241.6.200048

• The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors.

• Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.

• Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.

• Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.

• Less invasive osteosynthesis, balanced plate–bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing.

Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050