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JHS0010.1177/1753193414548170Journal of Hand Surgery (European volume)Giddins

Review Article
The Journal of Hand Surgery

The non-operative management (European Volume)
2015, Vol. 40E(1) 33­–41
© The Author(s) 2014
of hand fractures Reprints and permissions:
DOI: 10.1177/1753193414548170
G. E. B. Giddins

Most hand fractures can be treated non-operatively. Some hand fractures, such as open injuries or markedly
displaced intra-articular fractures, are almost always treated operatively. The treatment of many fractures,
such as proximal interphalangeal joint fracture subluxations or spiral phalangeal fractures, is unclear. The
aim of this review is to establish those injuries where the outcome of non-operative treatment is unlikely to be
improved with surgery. This may help to prevent unnecessary surgery, concentrate work on finding the sub-
groups that may benefit from surgery and to establish which injuries do so well with non-operative treatment
that the only valuable clinical research in future will be large cohort studies of non-operative treatment or
randomized controlled trials comparing operative and non-operative treatments. The relevant fractures
are spiral metacarpal fractures, transverse metacarpal shaft and neck (boxer’s) fractures, base of proximal
phalanx avulsion fractures, thumb metacarpophalangeal joint ulnar and radial collateral ligament injuries and
bony mallet injuries. For the majority of these injuries, current knowledge suggests that the outcome of non-
operative treatment cannot reliably be improved upon with surgery.
Level of evidence IV

Hand fractures, metacarpal, spiral, transverse, avulsion, mallet

Date received: 30 March 2014; revised: 30 July 2014; accepted: 31 July 2014

Introduction Methods and materials
One hundred years ago hand fractures were rarely Multiple electronic and hand searches of the pub-
treated operatively. Gradually, over the last 50 years, lished literature were performed to identify fractures
there has been an increasing trend to surgical treat- that do so well with non-operative treatment that it is
ment of some hand fractures, either with K-wires or difficult for surgery to provide significant further ben-
internal fixation, led by the Arbeitsgemeinschaft für efit. Inclusion criteria aimed to include all adult frac-
OsteoDePuy Synthesefragen (AO) group (Diwaker and tures distal to the thumb and finger carpometacarpal
Stothard, 1986). Although K-wiring or open reduction joints. Even then, reports often had patients <16 year
and internal fixation (ORIF) and their variants can be old that could not be separated out. The exclusion
used for almost all fractures, it does not necessarily criteria were fractures where surgery is plainly
mean they should. It is easy for patients and clinicians needed and proven to have been beneficial: many
to be misled as to the benefits of these treatments. A open fractures; replantations; many crush injuries;
series reporting good results can be presented and displaced intra-articular fractures (excluding bony
surgeons may believe that the technique should be fol- mallet injuries and avulsion fractures); and paediat-
lowed. Most hand fractures do well with non-operative ric fractures.
treatment (Barton, 1984), so that even with relatively Online databases were sought for relevant arti-
unsuccessful surgical treatment, e.g. malunion follow- cles. Hand searches were also performed for any
ing K-wiring or ORIF, the outcome may still be good.
The aim of this review is to identify the fractures
that can still be treated reliably non-operatively. A Royal United Hospital, Bath, UK
secondary aim is to try to establish where there may Corresponding author:
be sub-groups of those fractures requiring surgery G. Giddins, Royal United Hospital, Bath BA1 3NG, UK.
that have not been defined. Email:
34 The Journal of Hand Surgery (Eur) 40(1)

Table 1.  The outcome of finger proximal phalanx avulsion fractures (the data could not be extracted from many articles).

Article Treatment No. of Mean FU Mean age Pain Function ROM Grip
patients (range) (range) (VAS DASH
(fingers) months 0–10)
Sawant et al., Early 7 (7) 57 (8–94) 39 (16–68) 0.6 (0–2) 1.3 (0–4.2) Full >90%
2007 mobilization
Mikami et al., K wiring 4 (5) 43 (30–72) 21 (11–57) NR 3.0 (0.8–10.8) 85° NR
Shewring and ORIF 33 3 26 (15–44) NR NR Full NR
Thomas 2003

DASH: disabilities of arm, shoulder, and hand; FU: follow-up; NR: not recorded; ORIF: open reduction and internal fixation; ROM: range
of movement; VAS: visual analogue scale.

potential missing articles. Articles were included that not then further encouragement or manipulation
had a minimum of five cases. I attempted only to under local anaesthetic would be appropriate as a
include articles with a minimum follow-up of 2 years. key aim of treatment is avoiding rotational malunion.
This proved impractical as so few had such adequate
follow-up, and so all articles with a minimum follow-
Finger transverse metacarpal
up of 6 weeks were included.
fractures – shaft and neck
Historically, patients with transverse metacarpal
Results fractures of the shaft and especially the neck (boxer’s
fracture) were left to mobilize freely and the patients
Spiral or long oblique metacarpal healed with some deformity but good function. Barton
fractures (1984) in particular showed the efficacy of plaster or
These common injuries can be treated surgically with splint support to reduce the angulation of transverse
a variety of techniques and good results have been metacarpal shaft fractures. Subsequently, the results
reported in a number of studies (Al-Qattan, 2008a, of surgical treatments have been reported with very
2008b; Al-Qattan and Lazzam, 2007). Equally good good results. A key question is: ‘What degree of mal-
results have been reported with non-operative treat- union is “acceptable”?’. The answer is unclear. For
ment (Al-Qattan, 2006). A recent study (Khan and metacarpal neck (boxer’s) fractures it has been vari-
Giddins, in press) shows that all spiral metacarpal ously suggested as: 50° to 60° flexion (Stern, 2005);
fractures, even in the presence of mal-rotation, can 30° (Ali et al., 1999; Smith and Peimer, 1977); and 20°
be treated non-operatively with very good outcomes (Bloem, 1971; Kilbourne and Paul, 1958). For little
and minimal morbidity (Table 1). In this study, all finger metacarpal shaft fractures, it has been sug-
patients were treated with early mobilization without gested as 30° (Diao and Welbourn, 2004; Stern, 2005).
a splint or plaster and encouraged to make a fist at These recommendations are only expert opinion. A
the first outpatient visit to correct any malrotation Cochrane review has shown there is no good evi-
and ensure early mobilization. Of 30 patients, 25 were dence that more marked malunion causes reduced
reviewed at a minimum follow-up of 6 months. They hand function or unacceptable deformity (Poolman
had full movement, grip strength of at least 90% of et al., 2005 (updated 2009)). It may be that more
the other hand and only minimal malrotation in one marked deformities do give functional problems. If
patient and mild discomfort in another. Previous proven, this would indicate a role for surgery, where
authors have expressed concern at the risk of dys- the deformity could not be reduced adequately
function caused by shortening of the metacarpals non-operatively.
(Low et al., 1995; Meunier et al., 2004; Strauch et al., The outcome of non-operative treatment has been
1998), but a recent biomechnical study has suggested reported widely, and apart from a mild cosmetic
that shortening up to 5 mm is not significant (Wills abnormality, there is typically an excellent functional
et al., 2013). This fits with the results of the study outcome (Poolman et al., 2005 (updated 2009)).
where shortening is accepted, and even encouraged, Although there is some limited evidence that ante-
as a means of fracture stabilization (Khan and grade intra-medullary nailing may be the best of the
Giddins, in press). reported surgical techniques (Yammine and Harvey,
Malrotation following spiral metacarpal fractures 2014), no one technique of non-operative manage-
almost always corrects with finger flexion. If it does ment has been shown to be superior in the published
Giddins 35

studies (Poolman et al., 2005 (updated 2009); treat, but also stated that: ‘Avulsion fractures (of the
Yammine and Harvey, 2014). Many surgical tech- bases of the phalanges) are intraarticular according
niques have been described, including: intramedul- to their configuration and need anatomic reduction’.
lary nailing (Orbay and Touhami, 2006); K-wire Yet proximal phalanx avulsion fractures are a group
(bouquet) fixation (Downing and Davis, 2006; Faraj of injuries that attract a greater range of ‘proven’
and Davis, 1999; Foucher, 1995); intraosseous loop advice than almost any other injury. For finger proxi-
wire fixation (Al-Qattan, 2006); and external fixation mal phalanx avulsion fractures, early protected
(Margic, 2006). The results are not reliably better mobilization seems to give very reliable results
than non-operative treatment and they introduce (Sawant et al., 2007). In contrast, some authors have
complications not seen with non-operative treat- recommended that all base-of-finger avulsion frac-
ment. Non-operative treatment has complications, tures should be treated surgically because of the high
not least related to immobilization in a plaster or rate of symptomatic non- or delayed union (Bischoff
splint. As yet operative treatment has not been et al., 1994; Gee and Pho, 1982; Gross and Moneim,
shown to give better results than good non-operative 1998; Mikami et al., 2011; Schubiner and Mass, 1989;
treatment. Shewring and Thomas, 2003). Shewring and Thomas
Comparative studies offer the best way to assess (2003) reported that of eight of their patients treated
different treatments, especially randomized con- non-operatively, all had delayed union and seven
trolled trials (RCTs). As often in hand surgery, excel- were treated with ORIF and bone grafting. They report
lent RCTs are not available, but there are some useful very good results at discharge from follow-up at
comparative studies. Westbrook et al. (2008) com- 3 months with operative treatment. It appears that for
pared non-surgical and surgical treatment of meta- avulsion fractures of up to 25% of the articular sur-
carpal neck and shaft fractures in a large retrospective face on the postero-anterior radiograph, protected
study. They reported on metacarpal neck and shaft mobilization gives results that cannot easily be
fractures: 105 metacarpal neck fractures treated improved by surgery (Table 2). The available data are
non-operatively versus 18 treated operatively (13 limited, as these are either small series or contain
intramedullary K-wiring and five plating); and 113 limited follow-up. The dichotomy with the experience
metacarpal shaft fractures treated non-operatively of Shewring and Thomas (2003) who reported symp-
versus 26 treated surgically (four K-wiring and 22 tomatic delayed union in eight consecutive patients
plating). At a minimum follow-up of 2 years there and the excellent results of Sawant et al. (2007) may
were no differences in DASH score, grip strengths or be that many of these injuries may not unite with
aesthetics between the non-operative and operative bone (as for thumb metacarpophalangeal (MP) joint
groups, but a significant complication rate in the ulnar collateral ligament avulsions (Sorene and
operative groups was not present in the non- Goodwin, 2003)), but heal with sufficient stability that
operative group. Follow-up rates were low (17% for surgery is not required.
non-operative treatment and 54% for operative treat-
ment) as is typical in this patient group. A randomized
study on metacarpal neck fractures (Strub et al.,
Thumb MP joint avulsion fractures
2010) has suggested that surgery may be very slightly Ulnar collateral ligament injuries. The outcome of
better than non-operative treatment, primarily in giv- thumb MP joint avulsion fractures is also disputed. It
ing a better cosmetic result owing due to less malun- is clearly understood that the presence of a Stener
ion. This study had two groups each of 20 patients lesion, whether or not there is a bony avulsion, will
who were pseudo-randomized. The patients treated give a poor outcome with non-operative treatment
with intramedullary (bouquet) wiring required two (Giele and Martin, 2003). Some authors have reported
operations each; one to insert and one to remove the poor outcomes of avulsion fractures treated non-
wires. The only complications were in the operative operatively: Dinowitz et al. (1997) reported on nine
group, which had more dissatisfied as well as more cases with minimally displaced fractures (up to 2 mm)
very satisfied patients. Again, this study did not take treated in plaster within 6 days. They reported that all
into account the inconvenience and costs to the had persistent pain, largely resolved with surgical
patient or the healthcare system. stabilization. Kuz et al. (1999) reported on 30 patients
treated non-operatively; 30 were reviewed by ques-
tionnaire and of these 20 were seen in person. Nine-
Finger proximal phalanx collateral teen of the 30 had no pain, all reported being satisfied
ligament avulsion fractures by their treatment and none had had to change their
Bekler et al. (2006) noted that avulsion fractures of jobs. Of the 20 assessed in person, there was no sta-
the bases of the phalanges are challenging injuries to tistically significant reduction in pinch or grip strength,
36 The Journal of Hand Surgery (Eur) 40(1)

Table 2.  The outcome of finger proximal phalanx avulsion fractures (data could not be extracted from many articles).

Article Treatment No. of Mean FU Mean age Pain Function ROM Grip
patients (range) (range) (VAS DASH
(fingers) months 0–10)
Sawant et al., Early 7 (7) 57 (8–94) 39 (16–68) 0.6 (0–2) 1.3 (0–4.2) Full >90%
2007 mobilization
Mikami et al., K-wiring 4 (5) 43 (30–72) 21 (11–57) NR 3.0 (0.8–10.8) 85° NR
Shewring and ORIF 33 3 26 (15–44) NR NR Full NR
Thomas, 2003

DASH: disabilities of arm, shoulder, and hand; FU: follow-up; NR: not recorded; ORIF: open reduction and internal fixation; ROM: range
of movement; VAS: visual analogue scale.

Table 3.  Thumb MP joint ulnar collateral ligament bony avulsions.

Article and Treatment No of Mean FU Mean age ROM of MP Grip Notes
year patients (range) (range) joint
(thumbs) months
Kozin and Tension band 9 26 20 (15–41) 77% 96%  
Bishop, 1994a wiring
Kuz et al., 1999 Plaster cast 30 3.1 (1–5.2) 30 The same NR No pain in 19 of 30.
or splint for Unstable in 2/20. Non-
4 weeks union 5/20
Landsman Thumb spica 12 38 (12–60) 30 (17–48) 84 (60–100) % 92 (80–100) % All healed but data on
et al., 1995 splint for ROM and strength includes
8–12 weeks tendinous injuries, which
overall did worse than the
avulsion injuries
Sorene and Plaster cast 28 30 (12–48) 34 (17–62) NR 97% No pain in 26
Goodwin, 2003  Non-union 17
aTwo were RCL injuries.

FU: follow-up; MP: metacarpophalangeal; NR: not recorded; ROM: range of movement.

but two had some instability. They reported a non- primarily a soft tissue problem, to large rotated bony
union rate of 0.25 (5 of 20). Sorene and Goodwin (2003) avulsion fragments. This is very likely to be an injury
reported on 28 cases of avulsion fractures stable at with subtypes that will benefit from surgery and oth-
original assessment who were treated with immobili- ers that will not. As yet this remains unproven. An
zation in plaster for 6 weeks and followed up for a adequately powered (probably quite large to identify
mean of 2.5 years (range 1–4). They reported that 26 of the subtypes) multicentre RCT is needed. In particu-
the 28 had no pain on movement, all patients had the lar, surgeons need to be aware that there are a range
same pinch and grip strength as the other side, yet of injuries, and as yet the best treatment for each
radiologically 60% had persistent non-union. Compa- subgroup is unclear.
rable results have been reported in many surgical
series (Bischoff et al., 1994; Kozin and Bishop, 1994). Radial collateral ligament injuries. There are fewer
At present it appears that stable bony avulsions can reports of the treatment of radial collateral ligament
probably be immobilized in plaster with the expecta- (RCL) injuries. In theory, as there is no adductor hood
tion of a good outcome (Table 3). to cause a Stener-type lesion, non-operative treat-
The treatment of unstable injuries is less clear, ment should suffice; typically immobilization in plas-
but at present surgery is probably the default posi- ter for 4–6 weeks. Nonetheless, the role of surgery
tion. As so often found, the data are inadequate. has been debated for some time (Edelstein et al.,
There is a considerable range of different types of 2008; Katz et al., 1998; Melone et al., 2000; Smith,
thumb ulnar collateral ligament avulsions injuries, 1977). There are also rare reports of radial sided
ranging from small bony avulsions, which seem to be ‘Stener’ lesions (Camp et al., 1980; Doty et al., 2010).
Giddins 37

Table 4.  The outcome of treatment of bony mallet injuries with fracture fragments more than or equal to one-third and
follow-up of a minimum of 12 months.

Article and year Treatment No. of Mean FU Mean age DIPJ ROM % of bone Crawford (or OA
patients (range) months (range) in degrees involved other) score
(fingers) years
Damron and Pull through 18 97 (24–147) 23 (17–32) 1–69 (15 51 (38–67) 10 painfree, 13 7 of 15
Engber, 1994 suture and patients) no functional
K-wire limitation
Darder-Prats K-wire 22 25 (18–48) 23 (14–34) NK >33 18E, 3G, 1F 0
et al., 1998
Fritz et al., 2005 K-wire 24 Mean unclear 31 (15–53) 1–72 >33 19 no pain  
(min. 12 months) W and N
Okafor et al., Splint for 7 11 66 (but includes NK 9–51 NR NR 10 of 11
1997 (6–12) weeks tendinous as
Hofmeister et al., Closed 23 (24) >1 year 24 4–77 40 22E/G, 2F  
2003 K-wiring
Takami et al., Open reduction 33 29 32 (19–63) 4–67 >33 NR  
2000 and K-wiring
Tetik and Closed 18 27 29 (22–47) 2–81 40 NR  
Gudemez, 2002 K-wiring

DIPJ: ; FU: follow-up; NK: ; NR: not recorded; OA: ; ROM: range of movement.

It is well recognized that mildly displaced RCL avul- et al., 2001; Kronlage and Faust, 2004; Pegoli et al.,
sion fractures treated non-operatively usually achieve 2003; Rocchi et al., 2006; Teoh and Lee, 2007). This
a very good outcome (Köttstorfer et al., 2013). The is an operation with an acknowledged high risk of
role of surgery for more widely displaced or unstable complications (Bischoff et al., 1994; Stern and
injuries is unclear. Many authors believe that surgery Kastrup, 1988; Webhe and Schneider, 1984). Authors
is required on the basis that ‘considerable displace- of more recent techniques report a lower risk of
ment of torn ends can prevent the RCL from healing’ complications, particularly the risks of skin break-
(Köttstorfer et al., 2013). These authors have shown down (Auchingloss, 1982; Badia and Riano, 2004;
good results with surgery for more unstable injuries, Bauze and Bain, 1999; Cheon et al., 2011; Damron
but the original premise that the ligament will not and Engber, 1994; Darder-Prats et al., 1998; Fritz
heal with marked displacement or instability is et al., 2005; Hiwatari et al., 2014; Ishiguro et al.,
unproven. Again RCL injuries cannot be assumed to 1997; King et al., 2001; Kronlage and Faust, 2004;
be a single problem requiring one type of treatment. Pegoli et al., 2003; Rocchi et al., 2006; Teoh and Lee,
The optimal treatment for each subgroup is not yet 2007). In general, reasonably consistent good
established. One particular problem may be the long results are reported for various surgical treatments
time to recover fully from thumb MP joint collateral of bony mallet injuries with a dorsal fracture frag-
ligament avulsion injuries, which skews the clinical ment of oone-third or more (Table 4). The recom-
impression of treatment outcome in short-term mendation to treat fractures of one-third or more
reviews. has come from a number of authors, most particu-
larly Stark et al. (1987). There are concerns about
needing anatomical reduction of the fracture and
Bony mallet injuries preventing subluxation of the main distal phalanx
There has been a plethora of articles reporting tech- fracture fragment (Bauze and Bain, 1999; Cheon
niques for reducing and holding the dorsal avulsion et al., 2011; Damron and Engber, 1994; Darder-
fracture fragment in bony mallet injuries Prats et al., 1998; Fritz et al., 2005; Hiwatari et al.,
(Auchingloss, 1982; Badia and Riano, 2004; Bauze 2014; Ishiguro et al., 1997; King et al., 2001; Kronlage
and Bain, 1999; Cheon et al., 2011; Damron and and Faust, 2004; Pegoli et al., 2003; Rocchi et al.,
Engber, 1994; Darder-Prats et al., 1998; Fritz et al., 2006; Teoh and Lee, 2007). When subluxation needs
2005; Hiwatari et al., 2014; Ishiguro et al., 1997; King to be treated is unproven, although some cases do
38 The Journal of Hand Surgery (Eur) 40(1)

Figure 1.  ‘Stable’ bony mallet injury as shown by gliding on the extension lateral radiograph.

progress to symptomatic dislocation. In one of the surgery was better than non-operative (typically
most widely cited articles (Webhe and Schneider, splint) treatment for all types of mallet injury (Handoll
1984) the authors reported that among patients with and Vaghela, 2004 (updated in 2008)). They did, how-
dorsal fracture fragments of over one-third fol- ever, acknowledge that there may be a subgroup of
lowed-up for a mean of 3.25 years the 15 patients these injuries that would benefit from surgery.
treated non-operatively did as well as the six treated The main area of concern is when there is a large
operatively. They concluded that operative treat- fracture fragment >33% of the articular surface on the
ment gave no better results than non-operative lateral radiograph, which may lead to volar subluxa-
treatment. Similarly, a series with a 5 year follow-up tion of the main distal fracture fragment of the distal
has shown that both tendinous and bony mallet inju- phalanx. Recent work (Giddins, unpublished data) has
ries treated non-operatively achieve good objective shown that the risk of subluxation can be assessed by
and very good subjective outcomes (Okafor et al., a lateral hyperextension radiograph performed within
1997). Among the bony mallet injuries were some 1–2 weeks of injury. If there is gliding of the joint
with fracture fragments >1/3, but they are (Figure 1), i.e. it remains congruent as it goes into
not reported separately. They also reported some extension, then this is a stable joint. The presumption
evidence of degeneration at the distal interphalan- is that there has not been so much collateral ligament
geal (DIP) joint in 10 of 11 patients with large frac- injury that subluxation will occur. If there is pivoting
ture fragments within 5 years. Other authors have (Figure 2), then subluxation will usually occur,
reported on degeneration. Webhe and Schneider although this may only be mild. Exactly what level of
(1984) noted no difference between operative and subluxation requires treatment is unclear. The data, if
non-operative treatment in rates of radiographic established, will help narrow down further the indica-
osteoarthritis (OA). Other authors have reported tions for surgery in these patients. As with the above
rates of up to 50%, yet some of only 0% (Table 4). examples, surgery has not been shown reliably to
Almost certainly their criteria (which are reported improve the outcome for most patients with bony mal-
rarely) differ, making comparison difficult. The risk let injuries over non-operative treatment. But in this
of radiographic OA would be a potential concern, but group of patients, there is clearly a subgroup of
for the fact that long-term symptomatic degenera- patients who do badly suffer DIP joint stiffness and
tive arthritis in the DIP joints is not widely reported pain following significant volar subluxation and even
in patients who have had bony mallet injuries, i.e. as dislocation of the main distal phalanx fracture frag-
hand surgeons we rarely see patients requiring ment. This subgroup will almost certainly benefit from
treatment for symptomatic DIP joint arthritis who different treatment possibly surgery.
had bony mallet injuries decades earlier. It would
appear that the majority of patients with bony mallet
injuries do not require surgical treatment.
A Cochrane review reported that there was a pau- There are many problems with the existing literature,
city of good studies and there was no evidence that not least the paucity of RCTs. There is bias in many of
Giddins 39

Figure 2.  ‘Unstable’ bony mallet injury as shown by pivoting on the extension lateral radiograph.

the studies, and often incomplete data or outdated As a speciality, we should try to focus our research
outcome reporting. In addition, while the operative efforts on areas where we might make a significant
treatments are typically well described (although the difference ahead of tackling those with marginal gains.
post-operative care often less so) the non-operative Different patterns of displaced phalangeal fractures,
treatment is often described in little detail. There is a and proximal inter-phalangeal joint fracture subluxa-
considerable difference between uninhibited mobili- tions or pilon fractures, are two topics where the opti-
zation, supervised mobilization with regular follow- mal treatments are very unclear and where research
up and immobilization in a plaster or splint. The could make a considerable difference.
quality of the follow-up almost certainly varies This is not a diatribe against surgical treatment of
greatly. The outcome of, and indications for, non- these fractures. Rather, I believe, the review high-
operative treatment also depend upon other factors, lights the need to identify the subgroups that do
such as clinic availability, patient availability (some badly with non-operative treatment (if they exist),
have to travel long distances making regular follow- such as through large cohort studies of non-opera-
up difficult) and therapy. tive treatment or to identify new insights, for exam-
The available data suggest that for the above frac- ple the role of gliding or pivoting in bony mallet
tures surgery does not reliably confer benefit over injuries. In addition, any future studies of these inju-
‘good’ non-operative treatment. As surgery typically ries that report an improvement in outcome with
costs more, both in terms of patient risk and health- surgery, should ideally be run as RCTs in compari-
care costs, it suggests that for these fractures non- son with vigilant and clearly described non-operative
operative treatment should be the default position, treatment, as the established non-operative out-
accepting the need for clinical judgement for indi- comes are so good that a cohort or case series of
vidual cases. In time, there may be newer techniques operative treatment is very unlikely to improve on
allowing much earlier return to function, with lower the published data.
risks that may supersede non-operative treatment.
The dichotomies of different authors recommend- Conflict of interests
ing such radically different treatments may have None declared.
occurred for a number of reasons: surgeon prefer-
ence/bias; a misunderstanding of the anatomy and
pathology of the injury; an over-emphasis on biome-
chanical or cadaveric studies that may not apply in This research received no specific grant from any funding
clinical practice; an over emphasis on bone union that agency in the public, commercial, or not-for-profit sectors.
may not affect outcome in many cases; and possibly
most of all, the variability of the injuries such that a References
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