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The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.

The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual’s psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified. Non-union, defined as a fractured bone that does not heal within the expected time or is deemed unable to heal without intervention, represents a complex chronic medical condition characterized by pain and functional and psychosocial disability. In this Primer, Jupiter and colleagues discuss the epidemiology, advances in pathophysiology, diagnosis and management, and the quality of life of patients with non-union.

The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual's psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified.

While Lisfranc fracture-dislocations are the most common dislocations involving the midfoot, other isolated dislocations can occur. These injuries are far less common, especially those without significant concomitant fracture. Appropriate management is based on proper identification of the injury followed by appropriate treatment. Operative management is often required to obtain and maintain concentric, anatomic joint reduction. Fixation is required when instability persists. Soft tissue injuries must be addressed and they often impact timing of operative intervention. Knowledge of the anatomy as well at the joint function is necessary as mobile joints require temporary fixation. Fusion should be reserved for nonessential joints and salvage situations.

Objectives Quality improvement in geriatric trauma depends on timely identification of frailty, yet little is known about providers' knowledge and beliefs about frailty assessment. This study sought to understand trauma providers' understanding, beliefs, and practices for frailty assessment. Methods We developed a 20-question survey using the Health Belief Model of health behavior and surveyed physicians, advanced practice providers, and trainees on the trauma services at a single institution that does not use formal frailty screening of all injured seniors. Results were analyzed via mixed methods. Results One hundred fifty-one providers completed the survey (response rate 92%). Respondents commonly included calendar age as an integral factor in their determinations of frailty but also included a variety of other factors, highlighting limited definitional consensus. Respondents perceived frailty as important to older adult patient outcomes, but assessment techniques were varied because only 24/151 respondents (16%) were familiar with current formal frailty assessment tools. Perceived barriers to performing a formal frailty screening on all injured older adults included the burdensome nature of assessment tools, insufficient training, and lack of time. When prompted for solutions, 20% of respondents recommended automation of the screening process by trained, dedicated team members. Conclusions Providers seem to recognize the impact that a diagnosis of frailty has on outcomes, but most lack a working knowledge of how to assess for frailty syndrome. Some providers recommended screening by designated, formally trained personnel who could notify decision makers of a positive screen result.

Background. Older trauma patients often undergo computed tomography (CT) as part of the initial work-up. CT imaging can also be used opportunistically to measure bone density and assess osteoporosis. Methods. In this retrospective cohort study, osteoporosis was ascertained from admission CT scans in women aged ≥65 admitted to the ICU for traumatic injury during a 3-year period at a single, safety-net, level 1 trauma center. Osteoporosis was defined by established CT-based criteria of average L1 vertebral body Hounsfield units Results. The study cohort consisted of 215 women over a 3-year study period, of which 101 (47%) had evidence of osteoporosis by CT scan criteria. There were no differences in injury severity score, hospital length of stay, cost, or discharge disposition between groups with and without evidence of osteoporosis. Only 55 (59%) of the 94 patients with osteoporosis who survived to discharge had a documented osteoporosis diagnosis and/or corresponding evaluation/treatment plan. Conclusion. Nearly half of older women admitted with traumatic injuries had underlying osteoporosis, but 41% had neither clinical recognition of this finding nor a treatment plan for osteoporosis. Admission for traumatic injury is an opportunity to assess osteoporosis, initiate appropriate intervention, and coordinate follow-up care. Trauma and acute care teams should consider assessment of osteoporosis in women who undergo CT imaging and provide a bridge to outpatient services.

Importance Assessment of physical frailty in older trauma patients admitted to the intensive care unit is often not feasible using traditional frailty assessment instruments. The use of opportunistic computed tomography (CT) scans to assess sarcopenia and osteopenia as indicators of underlying frailty may provide complementary prognostic information on long-term outcomes. Objective To determine whether sarcopenia and/or osteopenia are associated with 1-year mortality in an older trauma patient population. Design, Setting, and Participants A retrospective cohort constructed from a state trauma registry was linked to the statewide death registry and Comprehensive Hospital Abstract Reporting System for readmission data analyses. Admission abdominopelvic CT scans from patients 65 years and older admitted to the intensive care unit of a single level I trauma center between January 2011 and May 2014 were analyzed to identify patients with sarcopenia and/or osteopenia. Patients with a head Injury Severity Score of 3 or greater, an out-of-state address, or inadequate CT imaging or who died within 24 hours of admission were excluded. Exposures Sarcopenia and/or osteopenia, assessed via total cross-sectional muscle area and bone density at the L3 vertebral level, compared with a group with no sarcopenia or osteopenia. Main Outcomes and Measures One-year all-cause mortality. Secondary outcomes included 30-day all-cause mortality, 30-day readmission, hospital length of stay, hospital cost, and discharge disposition. Results Of the 450 patients included in the study, 269 (59.8%) were male and 394 (87.6%) were white. The cohort was split into 4 groups: 74 were retrospectively diagnosed with both sarcopenia and osteopenia, 167 with sarcopenia only, 48 with osteopenia only, and 161 with no radiologic indicators. Among the 408 who survived to discharge, sarcopenia and osteopenia were associated with higher risks of 1-year mortality alone and in combination. After adjustment, the hazard ratio was 9.4 (95% CI, 1.2-75.4; P = .03) for sarcopenia and osteopenia, 10.3 (95% CI, 1.3-78.8; P = .03) for sarcopenia, and 11.9 (95% CI, 1.3-107.4; P = .03) for osteopenia. Conclusions and Relevance More than half of older trauma patients in this study had sarcopenia, osteopenia, or both. Each factor was independently associated with increased 1-year mortality. Given the prevalent use of abdominopelvic CT in trauma centers, opportunistic screening for radiologic indicators of frailty provides an additional tool for early identification of older trauma patients at high risk for poor outcomes, with the potential for targeted interventions.

Background: The sustentaculum tali of the calcaneus is a vital load-bearing structure. Isolated sustentacular fractures are rare and may have implications for future hindfoot function. This retrospective cohort study describes sustentacular fracture patterns and characteristics, associated foot injuries, and a method of surgical treatment via a medial approach to the calcaneus. Materials and Methods: During a 7-year period, 19 surgically-treated sustentacular fractures without calcaneal posterior facet involvement were identified from a prospectively-collected database at a single Level 1 regional trauma center. Of these, 15 underwent open reduction and internal fixation utilizing a medial approach to the calcaneus. Patient charts, plain radiographs, and CT scans were reviewed for injury characteristics/morphology and associated musculoskeletal injuries. Results: Fourteen patients had associated ipsilateral foot/ankle injuries, and nine had other musculoskeletal injuries. Seven patients had intra-articular middle facet involvement, and seven had subtalar joint subluxation or dislocation. The medial approach to the calcaneus involves distal retraction of the neurovascular bundle and toe flexors. This allowed for an accurate indirect articular reduction using the extraarticular medial calcaneal cortex, as well as reduction of any associated subluxations. No complications were related to the surgical approach. Reduction was maintained through fracture healing. Conclusion: Fractures of the sustentaculum tali are rare injuries associated with high energy mechanisms, and associated ipsilateral foot injuries are common. Open reduction and internal fixation of these fractures was reliable and possible through a medial approach involving distal retraction of the digital flexors and neurovascular bundle, allowing for an anatomical extraarticular cortical reduction.Level of Evidence: IV, Retrospective Case Series

Objective Report treatment results of periprosthetic femoral fractures adjacent or at the tip of a stable femoral stem (Vancouver Type B1) using a locked compression plate as the sole method of fracture stabilisation. Design Retrospective case series. Setting Academic Level I Trauma Centre. Patients Patients operatively treated at our institution with locked compression plating for Vancouver Type B1 periprosthetic fractures between 2002 and 2006 with at least 12 weeks of clinical follow-up were included. Patient demographics, hip arthroplasty implant characteristics, and AO/OTA fracture type were recorded. Intervention Open reduction internal fixation using a locked-plate spanning a majority of the femur through a lateral soft-tissue sparing approach. No cortical onlay allografts or cerclage devices (wires or cables) were used. Main outcome measurements Clinical union was defined at a minimum of 12 weeks as ability to walk, with or without the use of a walking aide, without pain at or around the fracture site. Radiographic union was defined by bridging bone spanning two or more cortices on orthogonal radiographs of the femur. Results Ten subjects met the inclusion criteria and were followed for a mean of 27 weeks (range 14–97 weeks). All achieved fracture union at a mean of 17 weeks (range 12–27 weeks). There were no hardware failures or changes in fracture alignment from operative radiographs. There were no major complications that necessitated reoperation. Conclusions Open reduction internal fixation of Vancouver Type B1 periprosthetic femoral fractures using a lateral locked-plate that spans the full extent of the femur as the sole method of stabilisation is a successful treatment method that minimises soft-tissue dissection and provides adequate fixation strength to maintain fracture alignment to fracture union.

Open diaphyseal and meta-diaphyseal fractures of the lower extremity remain therapeutically challenging. Currently accepted treatment methods consist of a thorough irrigation and debridement of nonviable tissue combined with locked intramedullary nailing. Although exact reduction parameters remain controversial, achievement of a satisfactory reduction becomes increasingly difficult with fracture comminution and overt bone loss. We describe the simple technique of using multiple associated devitalized tibial bone fragments to obtain an accurate reduction prior to intramedullary nailing. This technique can be extended to other long bone fractures.

Objectives To describe the associated injuries, demographic distribution, and management of patients sustaining open clavicle fractures. Design Retrospective case series. Setting A single level-1 trauma center. Patients Twenty patients with open clavicle fractures were identified from a prospectively collected orthopaedic trauma registry. Intervention All patients were managed with surgical irrigation and debridement with or without internal fixation. Results Thirteen patients (65%) had a closed head injury. Fifteen patients (75%) had a significant associated pulmonary injury. In that group, there were 10 patients who had a pneumothorax (7 bilateral). Additionally, 12 patients had rib fractures and 11 had documented pulmonary contusions or effusions. Seven patients (35%) had a cervical or thoracic spine fracture or dislocation. Eight patients (40%) had concomitant scapula fractures. Six patients (30%) had additional ipsilateral upper extremity injuries remote from the shoulder girdle. One patient had a scapulothoracic dissociation. Eleven patients (55%) sustained significant facial trauma including fractures (5 patients), lacerations, and hematomas. Fourteen patients (70%) were treated with open reduction internal fixation. Fifteen patients (75%) were followed to healing (mean: 111 wk, median: 56 wk, range: 13 to 333 wk). There were no other complications related to the operative fixations. There were no known infections or nonunions. Conclusions Open clavicle fractures are a rare injury. Patients often have associated pulmonary and cranial injuries. Ipsilateral upper extremity and shoulder girdle injuries are common, whereas concomitant neurologic and vascular injuries are infrequent. The majority of patients have rapid and uneventful healing of their fractures after surgical treatment.

Objectives: The transolecranon exposure for distal humerus fractures is a suggested technique for improving articular visualization, allowing accurate reduction. Significant osteotomy complications such as nonunion and implant prominence have prompted recommendations for alternate exposures. The purposes of this study are to present the techniques and complications of the olecranon osteotomy for the management of distal humerus fractures, and to evaluate the adequacy of distal humeral and olecranon articular reductions. Design: Retrospective review. Setting: Urban level-1 University trauma center. Patients: One hundred fourteen skeletally mature AO/OTA type 13-C distal humerus fractures were identified from the orthopedic trauma database and formed the study group. Intervention: Seventy fractures (61%), including 42 open injuries, were managed using an intraarticular, chevron-shaped olecranon osteotomy. Osteotomy fixations were performed with an intramedullary screw and supplemental dorsal ulnar wiring, or plate stabilization. In the remaining 44 fractures (39%), soft-tissue mobilizing exposures were performed. Main Outcome Measure: Patient records and radiographs were reviewed to determine injury and operative characteristics, complications, and adequacy of articular reductions. Patient interviews were conducted by telephone to identify any subsequent surgical procedures. Results: The proportion of osteotomies performed increased as fracture complexity increased (P < 0.001). Sixty-seven of 70 patients had adequate follow-up to determine osteotomy union. All osteotomies united. There was 1 delayed union. Sixty-one of 70 patients had adequate follow-up to determine complications associated with ulnar fixations. Five of these patients (8%) underwent elective removal of symptomatic osteotomy fixations. An additional 13 patients had olecranon implants removed in conjunction with other surgical procedures (11 elbow contracture releases, 1 humeral nonunion repair, and 1 chronic draining sinus excision). Symptomatic ulnar fixations in this group could not be reliably ascertained, but may have been present. A total of 18 of 61 patients (29.5%), therefore, had proximal ulna fixations removed. All patients treated using an olecranon osteotomy exposure demonstrated satisfactory radiographic distal humeral articular reductions. Two osteotomies required early revision osteosynthesis secondary to loss of osteotomy reduction. Conclusions: In this study, no osteotomy nonunions were encountered in 67 patients, more than half of which were open injuries. Regardless of which type of fixation is used to secure the osteotomy, secure stabilization must be obtained. Isolated symptomatic olecranon fixation requiring removal occurred in approximately 8% of patients. Although not necessary for all fractures of the distal humerus, the olecranon osteotomy can be useful in the visualization of the complex articular injuries, allowing accurate articular reduction.

Peter J. Stern, MD, is Norman S. & Elizabeth C.A. Hill Professor and Chairman of Orthopaedic Surgery at the University of Cincinnati College of Medicine; Stephen Albanese, MD, is Professor and Chair of Orthopedic Surgery and Medical Director of Orthopedic Surgery Clinic at SUNY Upstate Medical University; Mathias Bostrom, MD, is Residency Program Director and Academic Director of Orthopaedics at Hospital for Special Surgery and Professor of Orthopaedic Surgery, Weill Cornell Medical College, Helen Hayes Hospital; Charles S. Day, MD, MBA, is Rabkin Fellow in Medical Education, Associate Professor of Orthopedic Surgery at Harvard Medical School, and Chief/Program Director of Hand and Upper Extremity Surgery at Beth Israel Deaconess Medical Center; Steven L. Frick, MD, is Chairman of Orthopedic Surgery at Nemours Children’s Hospital and Professor of Orthopedic Surgery at the University of Central Florida College of Medicine; William Hopkinson, MD, is Professor, Vice-Chair, and Program Director of Orthopaedic Surgery & Rehabilitation at Loyola University Stritch School of Medicine; Shepard Hurwitz, MD, is Executive Director of the American Board of Orthopaedic Surgery and Professor of Orthopaedics at the University of North Carolina; Keith Kenter, MD, is Director of the Orthopaedic Surgery Residency Program, Associate Professor of Orthopaedic Surgery, and Associate Professor of Physical Medicine and Rehabilitation at the University of Cincinnati College of Medicine; John S. Kirkpatrick, MD, is Professor and Chair of Orthopaedic Surgery and Rehabilitation and Program Director of Orthopaedic Surgery Residency at the University of Florida College of Medicine; J. L. Marsh, MD, is Program Director of Residency Training Program and Professor and Carroll B. Larson Chair of Orthopaedics and Rehabilitation at the University of Iowa; Anand M. Murthi, MD, is Chief of Shoulder and Elbow Surgery and Fellowship Director at MedStar Union Memorial Hospital; Lisa A. Taitsman, MD, MPH, is Associate Professor of Orthopaedics and Sports Medicine at the University of Washington; Brian C. Toolan, MD, is Associate Professor of Surgery and Director of the Residency Program of Orthopaedic Surgery at the University of Chicago Medicine; Kristy Weber, MD, is Virginia & William Percy Professor of Orthopaedic Surgery, Division Chief of Orthopaedic Oncology, and Director of the Sarcoma Center at Johns Hopkins School of Medicine; Rick W. Wright, MD, is Dr Asa C. Dorothy W. Jones Professor of Orthopaedic Surgery, Residency Program Director, and Co-Chief of Sports Medicine at Washington University School of Medicine; Pamela L. Derstine, PhD, MHPE, is Executive Director of the Review Committees for Colon and Rectal Surgery, Neurological Surgery, Orthopaedic Surgery, and Otolaryngology at the Accreditation Council for Graduate Medical Education; and Laura Edgar, EdD, CAE, is Senior Associate Director of Outcome Assessment at the Accreditation Council for Graduate Medical Education.

Pelvic fracture and bladder rupture resulted in bladder wall entrapment in the fracture site of a patient involved in a severe motor vehicle accident. Although hematuria and bladder rupture are known to occur after fracture of the pelvis, our literature review showed no reports of this type of injury or management. Bladder extravasation was managed with catheter drainage and surgical extraction; viscus repair was performed for the bladder rupture. Fracture healing and bladder continuity resolved uneventfully.

Objective The purpose of this study was to examine the efficacy of a fluoroscopically guided hip capsulotomy. Methods Ten fresh-frozen paired cadaveric hips were injected under fluoroscopic guidance with saline sufficient to generate an intra-articular pressure greater than 58 mmHg. The pressure was monitored continuously using a percutaneous transducer. A limited lateral approach to the proximal femur was performed by one of two senior orthopaedic trauma surgeons. Using a scalpel under fluoroscopic guidance, each surgeon made one attempt at an anterior capsulotomy. Changes in intra-articular pressure were recorded throughout the procedure. The specimens were then dissected to measure the extent of each capsulotomy as well as the distance from the capsulotomy to nearby neurovascular structures. Results A rapid and substantial decrease in intra-articular pressure was seen in all hips. The mean intra-articular pressure postcapsulotomy was 8.4 mmHg. The capsulotomies averaged 15.1 mm in length. None of the attempts at capsulotomy lasted longer than 90 seconds. The average distance between capsulotomy and the lateral-most branch of the femoral nerve was 19.5 mm. The femoral artery was on average 40.3 mm from the capsulotomy. There was no correlation between the side on which capsulotomy was performed and its extent or proximity to neurovascular structures. Conclusions Fluoroscopically guided hip capsulotomy through a small lateral incision appears to be a safe, effective, and expedient method, which may substantially reduce intra-articular pressure after minimally displaced femoral neck fractures.

To evaluate the validity of using lateral intraoperative fluoroscopic imaging to assess the reduction of the tibial plafond articular surface, two hypotheses were tested: 1) the distal tibial subchondral shadow on the lateral ankle radiograph is created equally by the medial, central, and lateral portions of the distal tibia; and (2) displacement of a 5-mm width osteochondral fragment is consistently recognizable on lateral fluoroscopic imaging.Six human fresh-frozen tibial plafond cadaveric specimens were sagitally sectioned in 5-mm increments after removal of the anterior soft tissue and stabilization of the position of the ankle through external fixation. To test the first hypothesis, a perfect lateral radiograph was taken after sectioning the specimens. The sagittal sections were then removed sequentially from medial to lateral. A perfect lateral radiograph was taken after each change. The sagittal sections were then removed beginning laterally and moving medially. A perfect lateral radiograph was taken after each change. The images were then compared with specific evaluation of the change in the subchondral shadow density. To test the second hypothesis, three malreductions were created by displacing a 5-mm osteochondral segment. After each malreduction, a perfect lateral radiograph was saved. These saved fluoroscopic images were placed in random order with lateral images of normal specimens. Four experienced ankle surgeons were then asked to determine whether the radiographs revealed displacement. Inter- and intraobserver reliability was then evaluated.First, the subchondral shadow of the distal tibia appears to be created by an equal confluence of the subchondral bone of the medial, central, and lateral aspects of the tibial plafond. Second, fellowship-trained observers experienced in pilon fracture treatment correctly identified malreduction only 45% of the time. Intraclass correlation coefficient revealed very poor interobserver reliability with an alpha reliability statistic of 0.183. Intraobserver reliability across all four observers yielded an alpha statistic of 0.474, indicating inconsistencies in observers' evaluation of identical images at separate viewings.It is difficult to discern rotational or translational displacement of a 5-mm osteochondral fragment on a perfect lateral fluoroscopic view of the ankle. Even with what appears to be a perfect lateral fluoroscopic view intraoperatively, displacement may still be present. When small osteochondral fragments are present, direct visualization of the articular surface is necessary to confidently establish that an anatomic reduction has been achieved.

The purpose of this study was to evaluate risk factors for nonunion after femoral nailing of femoral shaft fractures. A case-control study with two to one matching was conducted. Forty-five patients with 46 femoral nonunions (cases) and 92 patients with healed femoral shaft fractures (controls) were identified from our orthopedic trauma registry. All cases and controls were initially managed with reamed, statically locked femoral nails. The characteristics that were significantly different between the two groups were open fracture, delay to weight bearing, and tobacco use. Fracture classification, gender, direction of nail insertion (antegrade vs. retrograde), and Injury Severity Score were not predictive of nonunion. We conclude that open fracture, tobacco use, and delayed weight bearing are risk factors for femoral nonunion after intramedullary nailing for diaphyseal femur fractures.

Diaphyseal fractures of the tibia are occasionally associated with compartmental syndrome of the leg. Current treatment includes surgical decompression of all involved compartments, debridement of nonviable muscle tissue, and skeletal stabilization. Numerous methods of fasciotomy have been described in the literature, with most surgeons favoring the two-incision method. The single-incision, 4-compartment fasciotomy is an alternative method but has received little attention in the orthopaedic literature. We detail the surgical technique for the single-incision, 4-compartment fasciotomy of the leg without fibulectomy and report its usage in the management of diaphyseal tibial fractures with compartmental syndrome.

The incidence of nonunion after humeral shaft fractures is low with both operative and nonoperative interventions. However, when a delayed union or nonunion occurs, it can be a very debilitating, leading to limited function and pain. Several methods have been described for the management of humeral diaphyseal nonunions. We present 11 cases managed with a transverse, shortening osteotomy and compression plating with or without bone grafting. Of the 11 cases, 10 had prior surgical treatment of open reduction and internal fixation. Union was achieved in all 11 humeri.

Halo-vest orthoses have been associated with complications. Previous reports have suggested increased complications in elderly patients; however, data are limited. This study reviewed 75 patients ≥65 years with cervical spine fractures treated with halo-vest orthoses. Forty-one patients (55%) experienced at least 1 complication. Pin-site problems were the most frequent adverse outcome. Seventeen patients (23%) had significant pulmonary compromise. Pulmonary complications were associated with high morbidity. We found an 8% early mortality rate. Halo-vest orthoses are useful devises. However, adverse events experienced by elderly patients are common and may lead to significant morbidity and mortality.

Bicondylar tibial plateau fracture management remains therapeutically challenging, partly because of multiplanar articular comminution. This study was performed to evaluate the frequency and morphologic characteristics of the posteromedial fragment in this injury pattern.Retrospective chart and radiographic review.Urban Level 1 university trauma center.Fifty-seven patients sustaining 57 Orthopedic Trauma Association (OTA) C-Type bicondylar tibial plateau fractures formed the study group.Between May 2000 and March 2003, 170 OTA C-Type bicondylar tibial plateau fractures were identified using an orthopaedic database. One hundred and forty-six fractures had computed tomographic (CT) scans performed prior to definitive fixation and were reviewed using the Picture Archiving and Communication System (PACS). Sixty-six (45.2%) injuries had fractures that involved the medial articular surface. Nine with suboptimal CTs were excluded, leaving 57 injuries for review. Forty-two patients demonstrated coronal plane posteromedial fragments. Morphologic evaluation of the posteromedial fragment included articular surface area, maximum posterior cortical height (PCH), and sagittal fracture angle (SFA).Forty-two of 57 injuries (74%) demonstrated a posteromedial fragment that comprised a mean of 58% of the articular surface of the medial tibial plateau (range, 19%-98%) and a mean of 23% of the entire tibial plateau articular surface (range, 8%-47%). Mean posteromedial fragment height was 42 mm (range, 16-59 mm), and mean sagittal fracture angle was 81 degrees (range, 33 degrees to 112 degrees). Six patients demonstrated fracture patterns not accurately identified by the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fracture classification system.A posteromedial fragment was observed in nearly one third of the bicondylar plateau fractures evaluated. The morphologic features of this fragment may have clinical implications when using currently available laterally applied fixed-angle screw/plate implants to stabilize these injuries. Alternate or supplementary fixation methods may be required when managing this injury pattern.

Despite advances in surgical technique, fracture fixation alternatives, and adjuncts to healing, femoral nonunion continues to be a significant clinical problem. Femoral fractures may fail to unite because of the severity of the injury, damage to the surrounding soft tissues, inadequate initial fixation, and demographic characteristics of the patient, including nicotine use, advanced age, and medical comorbidities. Femoral nonunion is a functional and economical challenge for the patient, as well as a treatment dilemma for the surgeon. Surgeons should understand the various treatment alternatives and their role in achieving the goals of deformity correction, infection management, and optimization of muscle strength and rehabilitation. Used appropriately, nail dynamization, exchange nailing, and plate osteosynthesis can help minimize pain and disability by promoting osseous union. A review of the potential risk factors and treatment alternatives should provide insight into the etiology and required treatment of femoral nonunion.

Osteochondral fractures of the lateral femoral condyle are uncommon injuries. These fractures often are misdiagnosed, and the majority of the cases reported have been managed with surgical excision. We present 2 cases of osteochondral fractures of the lateral femoral condyle. Both patients were treated with open reduction internal fixation of their fractures. A lateral approach to the posterolateral aspect of the distal femur is described.