Bone fractures are among the most common and potentially serious injuries to the skeleton, femoral shaft fractures being especially severe. Thanks to recent advances in the area of in silico analysis, several approximations of the bone healing process have been achieved. In this context, the objective of this work was to simulate the initial phase of callus formation in long bones, without a pre-meshed domain in the 3D space. A finite element approach was computationally implemented to obtain the values of the cell concentrations along the whole domain and evaluate the areas where the biological quantities reached the thresholds necessary to trigger callus growth. A voxel model was used to obtain the 3D domain of the bone fragments and callus. A mesh growth algorithm controlled the addition of new elements to the domain at each step of the iterative procedure until complete callus formation. The implemented approach is able to reproduce the generation of the primary callus, which corresponds to the initial phase of fracture healing, independently of the fracture type and complexity, even in the case of several bone fragments. The proposed approach can be applied to the most complex bone fractures such as oblique, severely comminuted or spiral-type fractures, whose simulation remains hardly possible by means of the different existing approaches available to date.

BACKGROUND:  Diaphyseal femur fractures are commonly seen in the paediatric age group as there is an increase in the incidence of road traffic accidents. Titanium elastic nailing system (TENS) and plating are the common methods used for paediatric long bone fracture fixation. The purpose of our study was to evaluate and compare functional and radiological outcomes of paediatric femur diaphyseal fractures treated with locking compression plates and with TENS.
METHODS:  Our study included 59 patients diagnosed with femur shaft fracture. Twenty-eight patients included in group one underwent open reduction and internal fixation with locking compression plates and 31 patients in group two underwent open reduction/closed reduction with intramedullary TENS. All post-operation patients were evaluated at four, eight, 10, 12, 16, 20, 24, and 36 weeks. The functional outcome was assessed based on the Flynn scoring system and radiological union based on fracture union on X-ray.
RESULTS: We analyzed our data using the Flynn scoring system. In group one, out of 28 cases treated with locking compression plates, 25 (89%) were excellent, two (7.5%) were satisfactory, and one (3.5%) was poor. In group two, out of 31 cases treated with intramedullary TENS, 26 (83.8%) were excellent and five (16.2%) were satisfactory. In our study, the average union time in group one was 11.4 weeks and in group two was 14.41 weeks. Fracture union was 100% in both groups.
CONCLUSIONS: In our study, we noted that the union of the femur shaft was early with the use of locking compression plates. In TENS, there was less intraoperative blood loss, very minimal postoperative scar, and less soft tissue damage. Also, implant removal was easier compared to locking compression plates.

Cats frequently present with diaphyseal fractures, which require treatment in order to achieve a good return to function. These fractures often occur due to significant trauma; for example, as a result of road traffic accidents, high-rise syndrome and dog bite wounds. The first priority is to ensure the patient is systemically well before embarking on any specific surgical treatment of a fracture.
Surgical management of diaphyseal fractures can be challenging due to the surgical approach for some bones being technically demanding, for example because of the presence of important neurovascular structures, and the small size of feline bones, which limits the choice of implant size and strength. Further, it may be difficult to visualise fracture alignment when using minimally invasive techniques, although the use of intraoperative fluoroscopy can aid with this, and malalignment can be common for some fracture repairs, particularly in cases where anatomical reconstruction is not possible.
This review focuses on diaphyseal long bone fractures and aims to assist decision-making, with an overview of the management and treatment options available.
Many textbooks and original articles have been published on aspects of managing fractures in small animals. The authors also provide recommendations based upon their own clinical experience.

OBJECTIVE: The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.
METHODS: From 2008 to 2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Patient demographics and injury characteristics were recorded. Details of pre-injury employment, sporting participation, and levels of return post-injury were obtained via postal questionnaire. The University of California, Los Angeles (UCLA) Activity Scale was used to quantify physical activity among active patients. Regression was used to determine factors independently associated with failure to RTW or RTS.
RESULTS: The Work Group comprised 177 patients in employment prior to injury (mean age 47 years (17 to 78); 51% female (n = 90)). Mean follow-up was 5.8 years (1.3 to 11). Overall, 85% (n = 151) returned to work at a mean of 14 weeks post-injury (0 to 104), but only 60% (n = 106) returned full-time to their previous employment. Proximal-third fractures (adjusted odds ratio (aOR) 4.0 (95% confidence interval (CI) 1.2 to 14.2); p = 0.029) were independently associated with failure to RTW. The Sport Group comprised 182 patients involved in sport prior to injury (mean age 52 years (18 to 85); 57% female (n = 104)). Mean follow-up was 5.4 years (1.3 to 11). The mean UCLA score reduced from 6.9 (95% CI 6.6 to 7.2) before injury to 6.1 (95% CI 5.8 to 6.4) post-injury (p < 0.001). There were 89% (n = 162) who returned to sport: 8% (n = 14) within three months, 34% (n = 62) within six months, and 70% (n = 127) within one year. Age ≥ 60 years was independently associated with failure to RTS (aOR 3.0 (95% CI 1.1 to 8.2); p = 0.036). No other factors were independently associated with failure to RTW or RTS.
CONCLUSIONS: Most patients successfully return to work and sport following a humeral shaft fracture, albeit at a lower level of physical activity. Patients aged ≥ 60 yrs and those with proximal-third diaphyseal fractures are at increased risk of failing to return to activity. Cite this article: Bone Jt Open 2022;3(3):236-244.

The aims of this study were to describe the type, presentation and prognostic factors of feline humeral fractures over a 10-year period and to compare three stabilisation systems for feline humeral diaphyseal fractures.
In total, 101 cats with humeral fractures presenting to seven UK referral centres between 2009 and 2020 were reviewed. Data collected included signalment, weight at the time of surgery, fracture aetiology, preoperative presentation, fixation method, surgical details, perioperative management and follow-up examinations. Of these cases, 57 cats with humeral diaphyseal fractures stabilised using three different fixation methods were compared, with outcome parameters including the time to radiographic healing, time to function and complication rate.
The majority of the fractures were diaphyseal (71%), with only 10% condylar. Of the known causes of fracture, road traffic accidents (RTAs) were the most common. Neutered males were over-represented in having a fracture caused by an RTA (P = 0.001) and diaphyseal fractures were significantly more likely to result from an RTA (P = 0.01). Body weight had a positive correlation (r = 0.398) with time to radiographic healing and time to acceptable function (r = 0.315), and was significant (P = 0.014 and P = 0.037, respectively). Of the 57 humeral diaphyseal fractures; 16 (28%) were stabilised using a plate-rod construct, 31 (54%) using external skeletal fixation and 10 (18%) using bone plating and screws only. Open diaphyseal fractures were associated with more minor complications (P = 0.048). There was a significant difference between fixation groups in terms of overall complication rate between groups (P = 0.012). There was no significant difference between fixation groups in time to radiographic union (P = 0.145) or time to acceptable function (P = 0.306).
All three fixation systems were successful in healing a wide variety of humeral diaphyseal fractures. There was a significantly higher overall complication rate with external skeletal fixators compared with bone plating; however, the clinical impact of these is likely low.

Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the \"diamond concept\", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in \"polytherapy\" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.

UNASSIGNED: Locked intramedullary nailing is the treatment of choice not only in diaphyseal fractures of long bone but also in most metaphyseal and periarticular fractures. In this study, we set out to present our experience with the Surgical Implant Generation Network (SIGN)] technique of locked intramedullary nailing in long bones that do not require the use of image intensifier, fracture table, and power reamers.
UNASSIGNED: This was a hospital-based prospective descriptive study involving 54 consecutive patients seen over a 2-year period. All closed fractures of the femur and tibia/fibula seen within the period under review were included in the study. The patients were followed up for a minimum of 12 months. Fracture union was recorded when there was absence of pain at fracture site and X-ray shows presence of bridging callus in two orthogonal views.
UNASSIGNED: Fifty seven fractures in 54 patients were managed in the period of the study. There were 46 [81%] femoral and 11 [19%] tibia/fibula fractures recorded in 47 [87%] males and 7 [13%] females with a male to female ratio of 6.7:1. Majority of the patients were within the 31--40 years age bracket (n = 25, 46%). All the fractures were as a result of motor vehicle accident. Thirty six (78%) of the femoral fractures were operated through the antegrade approach, whereas the rest (22%) were through the retrograde approach. Both proximal and distal locking were achieved in all cases. Fracture union was recorded in all but one case [98%]. Complications were observed in 8 cases, which included 5 cases of superficial infection, one case each of osteomyelitis, delayed union and nonunion.
UNASSIGNED: Locked intramedullary nailing using external jigs for screw placement as in the SIGN technique gives a good result and is recommended for use in the developing countries where image intensifiers are not readily available.

Screw loosening is a common complication in plate fixation. However, the underlying mechanism is unclear. This study investigated screw loosening mechanisms by finite element analysis (FEA) simulation and clinical X-ray feature analysis. Two FEA models incorporated bone heterogeneity and orthotropy, representing fracture fixation using dynamic compression plate (DCP) and locking compression plate (LCP), were developed. These models were used to examine the volume of bone exceeding a certain stress value around each screw under physiologically-relevant loading conditions. These damaged bone was then separated and compared by the axial stress and radial stress of each screw. In addition, features of patients\' X-ray images showing screw loosening were analyzed to validate the loosening features simulated by the models. The FEA study showed that more damaged bone was found at the central two screws which gradually decreased toward the two end screws in all groups. More bone was damaged by the radial stress of each screw than by the axial stress. The radiological analysis of screw loosening showed that bone loss occurred at the screw closest to the fracture line first then subsequent bone loss at the screws further away from the fracture line occurred. This study found that the two screws nearest to the fracture line are more vulnerable to loosening. The radial stress of the screw plays a larger role in screw loosening than the axial stress. Bone resorption triggered by the high radial stress of screws is indicated as the mechanism of screw loosening in the diaphyseal plate fixation. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1498-1507, 2019.

UNASSIGNED: To quantify the serum albumin level and its correlation with fracture healing progression and outcomes in adult patients.
UNASSIGNED: A prospective cohort study at an institutional trauma center.
UNASSIGNED: A total of 50 adult patients with simple, fresh traumatic diaphyseal fractures of both bones of the leg managed conservatively were included in the study. Serum albumin was measured initially and at the 6th week postfracture. The clinico-radiological follow-up was done to analyze the fracture healing progression and their final outcomes, which were correlated with the quantified serum albumin level of the patients.
UNASSIGNED: Student t-test, Mann-Whitney U-test and Pearson correlation coefficient.
UNASSIGNED: As per the last clinico-radiological follow-up at the 24th week, patients were grouped into two groups: Group I (normal union n = 38) and Group II (impaired healing n = 12). The mean serum albumin levels were significantly higher in Group I when compared to Group II. The association between the serum albumin level at baseline and at the 6th week was moderate. The best cut-off measure of serum albumin level was 3.45 g/dL, both at baseline and at the 6th week after fracture to predict the healing outcome. The correlation of serum albumin levels with fracture healing outcomes was statistically significant.
UNASSIGNED: Serum albumin is moderately associated with the baseline and 6th-week values and showed a positive correlation with the bony healing progression and may provide an early predictor of the healing outcomes of simple diaphyseal tibial fractures.
ملخص البحث :هدفت هذه الدراسة المستقبلية لتحديد مستوى بروتين الألبومين في الدم وعلاقته مع شفاء الكسور لدى المرضى البالغين. تضمنت الدراسة 05 مريضاً بالغاً مصاباً بكسور بسيطة في عظمتي الساق وتمت المتابعة السريرية والشعاعية لتقييم الشفاء وعلاقته بمستوى بروتين الألبومين في الدم. قسم المرضى إلى مجموعتين وكانت مستويات الألبومين أعلى في المجموعة الأولى مقارنة مع المجموعة الثانية. وكان لارتباط مستويات الألبومين مع نتائج التئام الكسور دلالة إحصائية وقد يستخدم هذا الارتباط كمؤشر مبكر لالتئام كسور الساق.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) is currently considered the gold standard in surgical treatment of femur and tibial shaft fractures in school age paediatric patients. Although elastic intramedullary nails are available in both titanium (Ti) and stainless steel (SS) alloy, titanium nails are most commonly used. Nevertheless, there is still contrasting evidence as to whether the use of Ti nails can offer better outcomes in terms of fracture healing and stability over SS nails. The aim of this study was to compare outcomes and complications of Ti and SS ESIN for femur and tibia shaft fractures in a population of school age paediatric patients.
METHODS: All consecutive patients who underwent ESIN for femoral or tibial shaft fracture from June 2012 to May 2015 at our centre were retrospectively reviewed. Standard demographic data were collected. Pre-operative and post-operative X-rays were reviewed, complications were collected from patients charts. Patients were divided in two groups, titanium nails (Ti group) and stainless steel nails (SS group) and outcomes compared between the two.
RESULTS: A total of 34 patients were included (17 patients Ti group, 17 patients SS group) with a total of 14 femur and 21 tibia fractures. Average age at surgery was 9.4 ± 2.5 years in Ti group and 10.4 ± 2.4 years in SS group (p = 0.21). The average time to bone healing was 3 months in Ti group, and 2.8 months in SS group (p = 0.63). At final follow-up (12 months), no patient showed a coronal plane or sagittal plane deformity >10° and >15°, respectively. Complication rate was similar between the two groups (24% Ti group, 22% SS group).
CONCLUSIONS: We did not observe any significant difference in terms of bone healing, fracture mechanical stability, return to full activity, and complication rate between Ti and SS ESIN for paediatric femoral and tibial shaft fractures. While Ti nails remain a better choice for patients with metal allergy, SS nails may offer safe, effective, and cheaper alternative to Ti nails in school age femur and tibial shaft fractures.