Orthopaedics & Traumatology: Surgery & Research 103 (2017) S61–S66

Available online at
ScienceDirect

Review article

Limits of internal fixation in long-bone fracture

H. Nieto , C. Baroan
Service de chirurgie orthopédique, centre hospitalier Georges-Renon, 40, avenue Charles-de-Gaulle, 79021 Niort cedex, France

a rti c l e i nf o a b s t r a c t
Article history: Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation
Received 15 December 2015 or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary
Accepted 9 November 2016 according to technique. The present study examines these limitations, based on comparative or large-
scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the
Keywords: present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open frac-
Internal fixation ture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg
Locking plate
fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking
Intramedullary nailing
plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality
External fixator
Open fracture
comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equiv-
Damage control alent when treated by intramedullary nailing or external fixation, if wound care and debridement are
effective, antibiotherapy is initiated rapidly and skin cover is restored within 7 days. Conversion from
primary external fixation to intramedullary nailing is possible if the external fixator was fitted less
than 28 days previously and skin cover was restored within 7 days. The pulmonary and systemic
impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in
multiple trauma calls for caution and what is known as “damage-control orthopedics” (DCO), a term
covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary
nailing is thus contraindicated in case of hemorrhagic shock (blood pressure < 90 mmHg), hypothermia
(< 33 ◦C), coagulation disorder (platelet count < 90,000) or peripheral lesions such as multiple long-bone
fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde
nailing with a small-diameter nail and without reaming are preferable.
© 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction
Toward the end of the 19th century, internal fixation was
described for fracture treatment, which had hitherto been exclu-
sively non-operative – and immediately ran up against its prime
limitation: infection.
Since then, limitations have been constantly pushed back,
with the introduction of asepsis rules, antibiotic prophylaxis and
ancil- laries facilitating implantation, so that internal fixation
now rivals other methods of fracture fixation and also implants.
The role of internal fixation in long-bone fractures is now
established, and treatments are ever more ambitious. The recent
increasing use of locking plates has opened up a new field of
treat- ment that remains to be assessed. Gustilo grade IIIb open
lower leg fracture is increasingly fixed by intramedullary
nailing. External fixation is no longer seen as contraindicating
conversion to inter- nal fixation. Finally, the concepts of “early
total care” (ECT) and
E-mail address: herve.nieto@ch.niort.fr (H. Nieto).
“damage-control orthopedics” open the way to considering
inter- nal fixation for the various fractures involved in multiple
trauma in certain cases.
Such are the conditions for these 4 types of internal fixation
for which we shall try to see just how far back limitations can be
pushed without exposing the patient to a risk of complications
or poor functional outcome.
2. Have locking plates pushed back the limits of long-
bone internal fixation?
2.1. Background
Fully restoring function after long-bone fracture involves well-
positioned bone healing without surrounding soft-tissue lesion.
Intramedullary nailing, screwed plates and external fixation may
be indicated, according to skin status, fracture type, location and
bone quality.
Locking plates have become widely used in the last 15 or
so years, and are now an integral part of the traumatologic

http://dx.doi.org/10.1016/j.otsr.2016.11.006
1877-0568/© 2016 Elsevier Masson SAS. All rights reserved.
S62 H. Nieto, C. Baroan / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S61–S66

armamentarium. They are alternatives to non-locking screwed

As elbow replacement is subject to loosening, the choice may be
plates and also to other types of internal fixation.
in favor of plates, for which results do not deteriorate over time.
Their primacy, based on real or supposed advantages, seems
established, but their precise role remains to be determined in
2.2.3. Displaced olecranon fracture in osteoporotic bone: plate
the light of clinical findings.
or functional treatment?
The proximal ulna should be considered apart: locking plates
2.2. The literature data
show proven benefit in fractures of osteoporotic bone, but inter-
nal fixation of a displaced olecranon fracture in over-70-year-
There have been numerous reports of the biomechanical
olds should be considered only with caution.
advan- tages of locking plates [1], but the principles of the
Gallucci demonstrated the benefit of functional treatment in a
assembly (hybrid or not) are not well established, and the
prospective study of 28 consecutive patients with displaced
clinical results need exam- ining to specify their role in
olecra- non fracture aged over 70 years. After 5 days’ cast
treatment. We therefore analyzed studies comparing results
immobilization, patients were encouraged to move their elbow
between locking plates and alternative methods. Results vary
spontaneously, without prior rehabilitation. At a mean 16
according to fracture location; some cases will not be dealt with
months’ follow-up, range
− of motion was 140 ◦–( 15◦) and pain
here, due to lack of published data.
was assessed as 1 on a 10- point scale. There were 22 cases of
non-union, none of which required surgery [6].
2.2.1. Three or 4-part fractures (on the Neer classification) of
In younger patients, tension bands are the gold-standard,
the proximal humerus in patients aged over 60 years: functional
except in comminutive olecranon fracture, metaphyseo-
treatment, implant, or locking plate? epiphyseal frac- ture and dislocation fracture of the elbow,
Fjalestad et al. [2] reported a level-2 prospective randomized where locking plates showed superiority in level-4 studies [7];
study of 50 patients aged over 60 years, with 3- or 4-part however, they presup- pose satisfactory skin status, due to the
proximal humeral fracture, comparing functional treatment (25 size of the plate which entails a risk of skin necrosis and all its
cases) ver- sus locking plate (25 cases). In the functional group, harmful consequences.
partial closed reduction was performed for the fracture of the
humeral neck, the shaft of which was displaced with respect to
2.2.4. Comminutive distal radius fracture: plate or
the head in more than half the cases. Rehabilitation was initiated
external fixator?
on D15. At 6 months’ and 1 year’s follow-up, there was no
In 2012, Jeudy et al. [8] reported a level-1 prospective
significant difference between the 2 groups in comparative
random- ized comparative study of 75 complex fractures of the
Constant score (healthy versus operated side) (P = 0.62) or
distal radius (60 AO C2 and 15 C3, characterized by joint
patient satisfaction score (American Shoulder and Elbow
comminution) man- aged by external fixator (39 cases) versus
Surgeons Score [ASESS]) (P = 0.71). These findings were con-
locking plate (36 cases). Groups were homogeneous for gender,
firmed in Launonen’s meta-analysis [3]
age, fracture type and initial displacement.
Humeral hemiarthroplasty, intended for this type of fracture, There were no significant inter-group differences in
and especially 4-part fracture, in elderly subjects, has largely
radioulnar index (P = 0.006), joint reduction quality (P = 0.34),
given way to the locking plate. Solberg et al. [4] reported a level-
reduction stabil- ity over time, onset of complex regional pain
3 retrospective study of 122 consecutive patients with 3- or 4-
syndrome (P = 0.06), recovery of wrist flexion-extension, return
part fracture; 38 managed by locking plate were compared
to previous activities (P = 0.65), or subjective result.
against 48 managed by hemiarthroplasty. Constant functional
On the other hand, locking plates provided better functional
scores were systematically better in 3-part fracture (P = 0.001) in
results at 6 months (P = 0.05) and better recovery of grip
the internal fixation group, whereas there was no significant dif-
strength (P = 0.002); therefore, despite the absence of significant
ference between treatment groups for 4-part fracture (P = 0.19).
difference in subjective result, the authors tended to favor
Osteonecrosis occurred in 6 cases, and was well-tolerated in this
internal plate fixa- tion for comminutive joint fracture in
elderly population; it should not, according to the authors, con-
younger subjects.
traindicate internal fixation [4].
Functional results in arthroplasty closely depend on
2.3. Conclusion and perspectives
tuberosity reduction and consolidation and rotator cuff
degeneration, which is frequent in this population. Reverse
Locking plates potentially broaden indications for plate fixa-
shoulder arthroplasty was developed in order to circumvent
tion, thanks to better fixation quality in complex and
these two issues, but there have been no studies with
osteoporotic fracture.
comparison against locking plates.
However, they do not exclude failure (disassembly, non-
union, etc.) when their very strict principles (use of visors and
2.2.2. AO type-C3 comminuted supra- and inter-condylar
dynamo- metric screw-drivers) are not respected, and it is not
fracture of the distal humerus in over-65-year-olds: plate or
proven that functional outcome is improved.
implant?
The possibility of subcutaneous implantation holds out hope
McKee et al. [5] reported a level-2 prospective randomized
for better results, although it involves greater technical difficulty
study comparing conventional plate fixation versus Coonrad-
and radiation dose.
Morrey semi-constrained total elbow replacement in 42 patients
In the absence of studies with sufficient level of evidence, rec-
aged over 65 years. Internal fixation used 2 small conventional
ommendations cannot be drawn up for distal femur or proximal
compression plates, one on each column. In 5 cases, the degree
or distal tibia fracture.
of comminu- tion dictated immediate cross-over from internal
fixation to elbow replacement.
3. Limitations of intramedullary nailing in Gustilo IIIB
Elbow replacement provided significantly better Mayo Elbow
open lower leg fracture
Performance Score (MEPS) than internal fixation up to the end
of the 2-year follow-up (P = 0.015), which was not the case for
3.1. Background
DASH scores after 1 year (P = 0.1).
Only level-4 observational studies have been reported for
The Gustilo classification is the most widely used for open
lock- ing plates in this indication, with no comparative studies.
lower leg fracture. Although it fails to quantify trauma impact
McKee’s results cannot easily be extrapolated to locking plates,
on the bone
which would now be used in such cases. McKee’s follow-up
stopped at 2 years.
 H. Nieto, C. Baroan / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S61–S66
and muscle, it provides a faithful representation of trauma
severity. Grade IIIb constitutes a prognostic turning point.
Outside of extreme situations such as bone defect, elevated
contamination, possible vascular involvement or comorbidities
requiring rapid intervention of the traumatized leg,
intramedullary nailing has come to play a significant role in the
treatment of serious open lower leg fracture.
The advantage of intramedullary nailing over external fixa-
tion lies in easier wound treatment, easier mobilization of the
knee and ankle, and lower rates of non-union. The risk is of
deep intramedullary infection, which is difficult to treat and
shows unpredictable course.
3.2. Literature data
3.2.1. What are the imperatives in fixation, whether internal
or external?
In serious lower leg fracture, fixation success depends on
several factors:
• one is the quality of surgical wound care, which consists in
resecting necrotic or soon-to-be-necrotic tissue, and may
require several procedures. Wound care does not replace
debridement, which is a distinct step involving opening the
wound wide and releasing tense tissue, from the skin to the
aponeuroses, to expose dead spaces for cleansing;
• secondly, antibiotic prophylaxis needs to be of good quality, and
rapidly implemented: according to current SFAR (French Society
of Anesthesiology and Intensive Care), SoFCOT (French Society
of Orthopedic Surgery and Traumatology) and Orthorisq guide-
lines [9], antibiotic prophylaxis should be fairly wide-spectrum,
targeting Staphylococcus aureus, Staphylococcus epidermidis,
Propionibacterium, Staphylococcus spp, Escherichia coli, Kleb-
siella pneumoniae and telluric anaerobes. In the absence of allergy,
penicillin A is used, associated to beta-Lactamase inhibitors,
injected in a single dose, and repeated if necessary up to 48 hours
maximum.
3.2.2. When is the best moment to perform skin cover?
Skin cover should be performed as soon as possible when the
edges of the skin defect are viable.
Rapid conversion of open to closed fracture is fundamental. The
“fix and flap” principle has proved its efficacy in this regard.
Mathews et al. [10] reported a series of 74 consecutive Gustilo
III open lower leg fractures, including 66 grade IIIb fractures.
Deep infection rates differed significantly according to whether
defini- tive fixation and skin cover of the open fracture were
performed as a single step (P < 0.001), with a 25% rate of deep
infection (3 cases out of 12) when fracture site cover was
performed later than day 7. However, not all hospital centers are
able to ensure this strat- egy, and in that case cover by means of
an occlusive dressing with negative pressure during the first 7
days, awaiting plastic surgery,
can be equally effective.
3.2.3. What means of fixation should be chosen?
Ktistakis et al. [11], analyzing series of grade IIIb lower leg frac-
tures, showed that deep infection rates have diminished regularly
over the last 20 years, whether fractures were managed by exter-
nal fixation or intramedullary nailing; recent series converge on an
infection rate of less than 15%.
Certain studies have compared the 2 fixation techniques in
grade IIIb fracture. Tornetta et al. [12] reported a prospective
random- ized comparative series of 29 patients with grade IIIb
open fracture managed by external fixation or intramedullary
nailing without reaming; there was only 1 case of infection in
each group and no significant difference in outcome.
S63
Intramedullary nailing does not seem to be associated with
higher infection rates than external fixation.
3.3. Conclusion
In the absence of the above-mentioned factors of severity,
intramedullary nailing in Gustilo grade IIIb open lower leg frac-
ture does not seem to be associated with higher infection rates
than external fixation on condition that the following principles
are respected:
• wound care and debridement in the surgery room, repeated
until a wound with viable edges is obtained;
• prophylactic antibiotherapy initiated as of admission;
• skin cover within 7 days.
4. Limitations of secondary nailing after external
fixation of lower leg fracture
4.1. Background
Intramedullary nailing is the standard treatment for fractures of
the 2 lower leg bones. Temporary external fixation ahead of defini-
tive intramedullary nailing is occasionally used in fractures with
severe skin opening (Gustilo grade III) and/or vascular involvement.
It remains to be seen what risk of deep infection is incurred
by this sequence, and what factors may limit such risk.
Bhandari et al. reviewed all publications on the subject
between 1980 and 2003 [13]. Only 1 was level-2 [14]; all the
others were level-4. Publications since 2003 have also been level-
4; some served as a support for the present report, given their
cumulative scale and concordant findings.
4.2. Literature data
4.2.1. Why consider nailing after external fixation of the 2
lower leg fracture bones?
Secondary intramedullary nailing after external fixation in
tibial shaft fracture may be considered in the light of the high
non-union rate (10–40%) associated with isolated external
fixation [15].
The only prospective randomized study on the subject [14]
com- pared external fixation with secondary nailing versus
secondary cast immobilization. The series comprised 39 patients
with isolated Gustilo grade II, IIIa or IIIb lower leg fracture.
After ablation of the external fixator, 22 were managed by cast
immobilization and 17 by nailing. In the nailing group,
consolidation time was significantly shorter (26.3 versus 35.4
weeks; P = 0.0427) and knee and ankle ranges of motion were
better. Consolidation rates were 94% with nailing and 64% with
cast immobilization (P < 0.05). The benefit of nailing was clear.
4.2.2. When to cross over?
Bhandari et al. [13], in a meta-analysis, compared nailing per-
formed within 28 days (n = 191) or later (n = 72). The deep
infection rate was 83% lower in the first group (P < 0.001).
4.2.3. Should conversion involve 1 or 2 steps?
Reports in this controversy are contradictory. A 2-step proce-
dure, with a free interval of a few days between ablation of the
external fixator and nailing, has the theoretic advantage of
allow- ing pin orifice healing, and some authors proceed to
nailing only after the orifices have closed (after at least 9 days)
[16].
Roussignol et al. [17] reported an “all-in-one” procedure,
with- out increased risk of infection, although patients with
secretion around the fixator pins were excluded.
S64 H. Nieto, C. Baroan / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S61–S66
4.2.4. Is it worth taking bacteriology samples during nailing?
The answer is “No”. Roussignol et al. [17], reporting 55 cases,
showed that systematic bacteriologic analysis of reaming prod-
ucts during nailing was of dubious value, with no correlation
with subsequent infection: an initial positive sample did not
predict sub- sequent infection on the nail; samples were positive
in 12 cases, without secondary infection (antibiotic therapy was
administered), and in the 4 cases of infection following nailing,
reaming product analysis had been negative.
4.2.5. What is the main risk factor for infection
following secondary nailing?
The main risk factor for infection following secondary nailing is
the degree of skin opening and time to coverage.
Yokoyama et al. [18] studied infection risk factors after sec-
ondary nailing of open lower leg-fracture with primary external
fixation, by multivariate analysis in 42 cases. Only time to skin
cov- erage, at a 1-week threshold, emerged as significantly
predictive of deep infection (P = 0.006).
Roussignol et al. reported that Gustilo skin opening grade
was the only significant factor for infection following nailing (P
= 0.045) [17].
4.2.6. What information should be given to the patient?
The advantage of converting from external fixation to
intramedullary nailing should be explained to the patient in terms
of quality of functional recovery and also consolidation and the
associated risk of infection: conversion within 28 days, in the
absence of infection on the external fixator pins, is considered opti-
mal, with an infection rate of 8.6% and non-union rate of 8% [13].
4.2.7. To sum up
The limitations of intramedullary nailing after external
fixation of lower leg fracture can presently be defined as:
• > 28 days’ external fixation;
• skin coverage later than day 7.
Secretion around external fixator pins is a relative limitation,
and should by precaution indicate 2-step conversion with a 9-
day interval.
Finally, if conditions for conversion are optimal, it should still
be born in mind that non-union and infection risks are slightly
less than 10%.
5. Limitations of primary definitive internal fixation
for femoral fracture in multiple trauma
5.1. Background
Early surgery for long-bone fracture in multiple trauma long
seemed misconceived, as patients were thought to lack the
physi- ological resources to support lengthy internal fixation
procedures.
In the 1980s, the concept of ECT emerged: definitive
treatment of each fracture in multiple trauma. Applied to all
patients regard- less of severity, the concept showed its
limitations: some patients, notably with significant pulmonary,
abdominal or cranial trauma or elevated Injury Severity Score
(ISS), did not survive this kind of treatment [19,20].
In the 1990s, the concept of DCO was therefore developed,
with early rapid temporary stabilization of fracture sites fol-
lowed by definitive treatment after the critical phase of systemic
recovery. Early fixation was mainly but not exclusively external:
some authors recommended “damage-control nailing” by small-
diameter retrograde femoral nails [21]. However, it remains to
determine the patient groups for whom definitive fixation of the
femoral fracture site alone by anterograde intramedullary nailing
after reaming can be the first-line attitude and those for whom
DCO is indicated.
5.2. Literature data
5.2.1. For which patients is DCO indicated?
DCO is indicated only for femoral shaft fracture associated
with significant pulmonary, abdominal or cranial trauma. If
there is no femoral fracture, other long-bone fractures do not
incur general postoperative complications and can therefore
benefit from pri- mary definitive treatment, even in case of
associated pulmonary, abdominal or cranial trauma.
5.2.2. What is the aim of DCO?
The aim of DCO is to enable the anesthesiologist to control
and stabilize the patient’s general health status as quickly as
possible.
The surgeon must then fix the femoral fracture site effectively
but without incurring damage [22]. The procedure should be
quick, with minimal bleeding. The aim is not to achieve
definitive fixation with perfect reduction.
DCO using plates has been attempted, but the surgical
commu- nity has not gone down this road [23]; most authors
recommend external fixation after minimal fracture site
manipulation. Retro- grade intramedullary nailing with a small-
diameter nail locked only distally may at most be acceptable
[24].
5.2.3. What is the problem with definitive anterograde
femoral intramedullary nailing?
Definitive anterograde intramedullary nailing is aggressive,
involving reaming and impaction of a nail of suitable diameter, and
may thus trigger an inflammatory response and multiple organ
dys- function syndrome (MODS) or acute respiratory distress
syndrome (ARDS).
However, we are not quite sure why intramedullary nailing
is so damaging; studies are contradictory, and it is not clear
whether the reaming, the intramedullary impaction or the
associated bleeding should be incriminated.
Pape et al. [20] reported a prospective randomized compar-
ative study of 165 stable multiple trauma patients managed by first-
line definitive intramedullary nailing or external fixation and
conversion to intramedullary nailing after a few days. Biologi-
cal inflammation parameters were more elevated in the primary
intramedullary nailing group than in secondary intramedullary
nailing, and did not increase after external fixation alone.
The Canadian Orthopaedic Trauma Society [25] conducted a
multicenter prospective randomized comparative clinical study
in level-1 trauma centers, with 315 multiple trauma patients pre-
senting 322 femoral shaft fractures, divided into 2 groups
according to ISS greater or less than 18. There was no significant
difference in ARDS rate according to whether nailing involved
reaming or not [25]. Reaming seemed not to be implicated.
There are no randomized studies comparing external fixation
versus definitive anterograde intramedullary nailing for DCO in
unstable multiple trauma.
5.2.4. What is the role of biological markers?
Numerous biological markers (C-reactive protein [CRP],
tumor necrosis factor [TNF ], interleukin [IL 6-8-10-18],
procalcitonin [PCT], etc.) have been assayed to study plasma
levels in multiple trauma [26].
Only IL 6 reliably correlates with trauma severity and post-
traumatic complications [26].
 H. Nieto, C. Baroan / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S61–S66
5.2.5. What, finally, are the contraindications to definitive
femoral anterograde intramedullary nailing in multiple
trauma?
The risks associated with definitive femoral anterograde
intramedullary nailing depend on baseline clinical status, pro-
gression in intensive care, and certain intraoperative parameters.
The classical “trauma triad of death”, comprising varying degrees
of hypovolemic shock, hypothermia and coagulopathy, somewhat
underestimates severity, especially in case of pulmonary trauma.
The triad needs supplementing with soft-tissue trauma
param- eters: the severity of soft-tissue trauma can have
pulmonary consequences that are especially serious in case of
initial thoracic trauma [27].
The initial clinical and paraclinical parameters to be taken
into account are [27]:
• hemorrhagic shock: systolic blood pressure < 90 mmHg;
• hypothermia < 33 ◦C;
• coagulopathy: platelet count < 90,000;
• soft-tissue trauma:
◦ long-bone fracture(s) associated with femoral fracture,
◦ crushing trauma,
◦ pelvic fracture,
◦ pulmonary contusion with AIS (Abbreviated Injury Scale) score
> 2.
If 3 of these 4 criteria obtain, DCO is indicated and
anterograde femoral intramedullary nailing thus
contraindicated.
Two other parameters, considered negative, also counsel cau-
tion:
• mean pulmonary blood pressure (PBP) > 24 mmHg;
• increase in PBP exceeding 6 mmHg during anterograde femoral
intramedullary nailing, if attempted, in which case the internal
fixation technique has to be changed.
5.2.6. When is the best time to perform the second procedure
in DCO?
Whatever the primary fixation technique, an interval must be
left between the first procedure and the “consolidation procedure”.
Pape et al. [27] studied onset of ARDS or MODS after pri- mary
external fixation of femoral fracture in 4314 patients. Organ
dysfunction was associated with second procedures last- ing more
than 3 hours or conducted between the 2nd and 4th day post-
trauma. Multiple trauma patients without organ dys- function had
been reoperated between the 6th and 8th days
(P < 0.0001).
Pape et al. [20] also reported normalized IL 6 levels between the
6th and 8th days, confirming the above clinical findings.
5.2.7. To sum up
The pulmonary and visceral consequences of the periph-
eral component of multiple trauma and treatment by definitive
anterograde femoral intramedullary nailing are increasingly
well understood.
DCO should provide sufficient stability to allow definitive
treat- ment of the femoral fracture. This must imperatively
include cautious manipulation of the fracture site by minimal
external fixa- tion or retrograde “damage-control nailing” with a
small-diameter nail.
First-line definitive anterograde femoral intramedullary nail-
ing should be considered in stable multiple trauma. In unstable
multiple trauma, on the other hand, definitive intramedullary
nailing can only be considered after assessment based on clin-
ical and biological criteria, requiring close team-work with the
anesthesiologist.
S65
Disclosure of interest
The authors declare that they have no competing interest.
References
[1] Stoffel K, Dieter U, Stachowiak G, Gächter A, Kuster MS. Biomechanical
testing of the LCP - how can stability in locked internal fixators be
controlled? Injury 2003;34(Suppl. 2):11–9,
http://dx.doi.org/10.1016/j.injury.2003.09.021.
[2] Fjalestad T, Hole M, Hovden IAH, Blücher K, Stromsoe K. Surgical treatment
with an angular stable plate for complex displaced proximal humeral frac-
tures in elderly patients: a randomized controlled trial. J Orthop Trauma
2012;26:98–106.
[3] Launonen AP, Lepola V, Flinkkilä T, Laitinen M, Paavola M, Malmi-
vaara A. Treatment of proximal humerus fractures in the elderly:
a systemic review of 409 patients. Acta Orthop 2015;86(3):280–5,
http://dx.doi.org/10.3109/17453674.2014.999299.
[4] Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three
and four-part proximal humeral fractures. J Bone J Surg Am 2009;91:1689–97,
http://dx.doi.org/10.2106/JBJS.H.00133.
[5] McKee MD, Veillette CJH, Hall JA, et al. A multicenter, prospective,
randomized, controlled trial of open reduction internal fixation ver-
sus total elbow arthroplasty for displaced intra-articular distal humeral
fractures in elderly patients. J Shoulder Elbow Surg 2009;18(1):3–12,
http://dx.doi.org/10.1016/j.jse.2008.06.005.
[6] Gallucci GL, Puizzi NS, Slullitel PA, Boretto JG, Alfie VA, Donndorff
A, et al. Non-surgical functional treatment for displaced olecra-
non fractures in the elderly. J Bone Joint Surg Br 2014;96:530–4,
http://dx.doi.org/10.1302/0301-620X.96B4.33339.
[7] Navarro RA, Hsu A, Wu J, Mellano CR. Complications in olecranon fracture
surgery: a comparison of tension band vs locked plate osteosynthesis. J Shoul-
der Elbow Surg 2013;22(10):e34.
[8] Jeudy J, Steiger V, Boyer P, Cronier P, Bizot P, Massin P. Treatment of
complex fractures of the distal radius: a prospective randomised compari-
son of external fixation versus locked volar plating. Injury 2012;43:174–9,
http://dx.doi.org/10.1016/j.injury.2011.05.021.
[9] SFAR, SOFCOT, ORTHORISQ: Recommandations Antibioprophylaxie en
Orthopédie et Traumatologie V012011. http://www.sfar.org/article/669/
antibioprophylaxie-en-chirurgie-et-medecineinterventionnelle-patients-
adultes-cc-2010.
[10] Mathews JA, Ward J, Chapman TW, Khan UM, Kelly MB. Single-stage
orthoplastic reconstruction of Gustilo-Anderson Grade III open tib-
ial fractures greatly reduces infection rates. Injury 2015;46:2263–6,
http://dx.doi.org/10.1016/j.injury.2015.08.027.
[11] Ktistakis I, Giannoudi M, Giannoudis PV. Infection rates after
open tibial fractures: are they decreasing? Injury 2014;45:1025–7,
http://dx.doi.org/10.1016/j.injury.2014.03.022.
[12] Tornetta III P, Bergman M, Watnik N, Berkowitz G, Steuer J. Treatment of grade III B
open tibial fractures: a prospective randomised comparison of exter- nal
fixation and non-reamed locked nailing. J Bone Joint Surg (Br) 1993;75: 13–9.
[13] Bhandari M, Zlowodzki M, Tornetta P, Schmidt A, Templeman DC.
Intramedullary nailing following external fixation in femoral and tibial shaft
fractures. J Orthop Trauma 2005;19:140–4.
[14] Antich-Adrover P, Marti-Garin D, Murias-alvarez J, Puente-Alonso CW. Exter-
nal fixation and secondary intramedullary nailing of open tibial fractures. A
randomised, prospective trial. J Bone Joint Surg Br 1997;79:433–7.
[15] Giotakis N, Panchani SK, Narayan B. Segmental fractures of the tibia
treated by circular external fixation. J Bone Joint Surg Br 2010;92:687–92,
http://dx.doi.org/10.1302/0301-620X.92B5.22514.
[16] Blachut PA, Meek RN, O’Brien PJ. External fixation and delayed intramedullary nailing
of open fractures of the tibial shaft. A sequential protocol. J Bone Joint Surg
Am 1990;72:729–35.
[17] Roussignol X, Sigonney G, Potage D, Etienne M, Duparc F, Dujardin F. Sec-
ondary nailing after external fixation for tibial shaft fracture: risk factors for
union and infection. A 55 case series. Orthop Traumatol Surg Res 2015;101(1):
89–92.
[18] Yokoyama K, Uchino M, Nakamura K, Ohtsuka H. Risk factors for deep
infection in secondary intramedullary nailing after external fixation for open
tibial frac- tures. Injury 2006;37:554–60,
http://dx.doi.org/10.1016/j.injury.2005.08.026.
[19] Wenda K, Runkel M, Degreif J, Ritter G. Pathogenesis and clinical rel-
evance of bone marrow embolism in medullary nailing–demonstrated
by intraoperative echocardiography. Injury 1993;24(Suppl. 3):S73–81,
http://dx.doi.org/10.1016/0020-1383(93)90011-T.
[20] Pape H-C, Grimme K, Van Griensven M, Sott AH, Giannoudis P, Morley
J, et al. Impact of intramedullary instrumentation versus damage control
for femoral fractures on immunoinflammatory parameters: prospective ran-
domized analysis by the EPOFF Study Group. J Trauma 2003;55(1):7–13,
http://dx.doi.org/10.1097/01.TA.0000075787.69695.4E.
[21] Higgins TF, Horwitz DS. Damage control nailing. J Orthop Trauma
2007;21(7):477–81.
S66 H. Nieto, C. Baroan / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S61–S66
[22] Hauser CJ, Zhou X, Joshi P, Cuchens MA, Kregor P, Devidas M, et al. The immune
microenvironment of human fracture/soft-tissue hematomas and its relation-
ship to systemic immunity. J Trauma 1997;42:895–903.
[23] Bosse MJ, MacKenzie EJ, Riemer BL, et al. Adult respiratory distress syndrome,
pneumonia, and mortality following thoracic injury and a femoral fracture
treated either with intramedullary nailing with reaming or with a plate. A
comparative study. J Bone Joint Surg Am 1997;79(6):799–809.
[24] Duwelius PJ, Huckfeldt R, Mullins RJ, Shiota T, Woll TS, Lindsey KH, et al. The
effects of femoral intramedullary reaming on pulmonary function in a sheep
lung model. J Bone Joint Surg Am 1997;79(2):194–202.
[25] The Canadian Orthopaedic Trauma Society. Reamed versus unreamed
intramedullary nailing of the femur: comparison of the rate of
ARDS in multiple injured patients. J Orthop Trauma 2006;20:384–7,
http://dx.doi.org/10.1055/s-0030-1267128.
[26] Hildebrand F, Giannoudis P, Kretteck C, Pape HC. Damage control:
extremities. Injury 2004;35:678–89,
http://dx.doi.org/10.1016/j.injury.2004.03.004.
[27] Pape HC, Giannoudis P, Krettek C, Trentz O. Timing of fixation of major fractures in blunt
polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma
2005;19:551–62.