Intravenous Mannitol reduces intracompartmental pressure following tibia fractures: A randomized controlled trial.

PURPOSE: Impending compartment syndrome is a common event following closed tibia fractures, which can progress to sinister compartment syndrome. Fasciotomy is the only definitive treatment available, though it has its own drawbacks and complications. Medical management at present consists of limb elevation and adequate hydration. This study aims at determining whether intravenous administration of Mannitol reduced the intracompartmental pressure in patients with closed tibial fractures. METHODS: This is a double blinded, randomized control trial done in a single tertiary care center in India. Forty-five patients were recruited between February 2012 and October 2012. Forty patients who presented to the emergency department with isolated, closed, high velocity, and proximal 2/3 tibia fractures were included in this study. Patients with contraindication to Mannitol were excluded. They were allocated into 2 groups by the investigator using computer generated randomization. The pressure in the anterior compartment of the leg was measured with a handheld Stryker pressure monitor. Then either 20% Mannitol or 0.9% normal saline as given intravenously in a blinded manner, based on the randomization. The intracompartmental pressure was measured at 0, 1 and 3 h after the infusion. The participant, investigator and statistician were masked to the group assessment. RESULTS: There was no difference in intracompartmental pressures at 1 or 3 h, between the groups. However, in patients with the baseline of compartmental pressures ≥30 mmHg, Mannitol showed a marked reduction in pressure of 8.5 mmHg at 1 h compared to almost no change in pressure in the saline group. There were no adverse events with the use of Mannitol. CONCLUSIONS: This preliminary study appears to show that Mannitol is useful in the management of the increased compartment pressure. The limitations of this study were that it only involved a small group of patients and the baseline pressures in both the groups were not comparable. More studies are required before the use of Mannitol as a standard of care in the management of compartment syndrome can be established.

A prospective multi-center study of intramedullary nailing vs casting of stable tibial shaft fractures.

BACKGROUND: The purpose of this study was to determine optimal treatment of stable tibial shaft fractures using intramedullary nailing (IMN) or casting. MATERIALS AND METHODS: We performed a multi-center prospective study cohort. Patients with stable tibia shaft fractures meeting Sarmiento's criteria (isolated closed fractures with less than 12 mm of shortening and 10° of angulation) were enrolled prospectively and treated with either a reamed IMN with static interlocking screws or closed reduction followed by long-leg casting. Both groups were weight bearing following surgery. Radiographs were taken until union, and range of motion of knee and ankle joints was assessed. Malalignment (>5°) and malunion (>10°) were determined. Functional outcome measures using short musculoskeletal assessment scores (SMFA) and a knee pain score were scheduled at 6 weeks, 3 months and 6 months. RESULTS: At 3 months, differences between the casting and IMN groups were noted in return to work (6/15 vs 3/17, P < 0.05); ankle dorsiflexion (7° vs 12°, P < 0.05); plantar flexion (28° vs 39°, P < 0.05); and SMFA domains of Dysfunction Index, Bother Index, daily activities, emotional status, and arm/hand function (P < 0.05). The SMFA mobility function demonstrated a significant trend (P = 0.065). At 6 months, malalignment was present in 3/15 in the casting group and in 1/17 in the IMN group (P = 0.02). Malunion was present in 1/15 in the cast group. One fracture in the casting group went on to nonunion and required late IMN placement at 7 months and eventually healed. There were no differences in ankle motion, SMFA scores, or return to work. There was no difference in knee pain between the groups as measured by VAS and Court-Brown pain scale at 6 months. CONCLUSIONS: Patients with stable tibia fractures treated with intramedullary nailing have improved clinical and functional outcomes at 3 months compared with those treated with casting, but there are no differences in any other outcome measure. Patients treated in a cast may have a higher incidence of malalignment or malunion. LEVEL OF EVIDENCE: Level-II prognostic.

Injury patterns and outcomes of open fractures of the proximal ulna do not differ from closed fractures.

BACKGROUND: The incidence and injury patterns of open fractures of the proximal ulna are poorly elucidated and little evidence exists to guide management. QUESTIONS/PURPOSES: The purpose of this study was to compare the (1) bony injury patterns; (2) range of motion (ROM) and frequency of union; and (3) postoperative complications between open and closed fractures of the proximal ulna. METHODS: Seventy-nine consecutive open fractures of the proximal ulna were identified. After excluding fracture-dislocations, penetrating injuries, and pediatric injuries, 60 were compared in a retrospective case-control study with an age- and sex-matched group of 91 closed fractures to compare the bony injury patterns based on radiographic review. In a subset of 39 open and 39 closed fractures with sufficient followup, chart and radiographic review was performed by someone other than the operating surgeon to compare differences in final ROM, union, and postoperative complication rates at a minimum followup of 3 months (mean, 22 and 15 months; range, 3-86 months and 3-51 months for open and closed fractures, respectively). A total of 12% of the fractures were open (79 of 671) at the three study centers, and the majority of fractures were intraarticular (45 of 60 [75%]) with Gustilo-Anderson Type I and II wounds (54 of 60 [90%]). RESULTS: Overall, open fractures of the proximal ulna overall did not have more complex bony injury patterns, but there were more anterior olecranon fracture-dislocations among the open fracture group (nine of 60 [15%] versus two of 91 [2%]; p = 0.004) and more posterior olecranon fracture-dislocations in the closed fracture group (31 of 91 [34%] versus seven of 60 [12%]; p = 0.002). Final ROM was not different in both groups and all fractures healed. There was no difference in wound infection rate but a higher secondary procedure rate among open fractures of the proximal ulna (39% versus 23%, p = 0.014). CONCLUSIONS: In contrast to open fractures of the distal humerus, open fractures of the proximal ulna present with mild soft tissue injuries and do not have more complex bony injury patterns than closed fractures. Our findings suggest that open fractures of the proximal ulna are the result of tension failure of the skin secondary to the limited soft tissue envelope around the proximal ulna. Open fractures of the proximal ulna should be regarded as relatively mild injuries that are not different in severity and prognosis compared with closed fractures. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Clavicle shaft fractures: are children little adults?

Most clavicle shaft fractures in children are nondisplaced, minimally shortened or angulated, and are well treated with nonoperative management. Indications for operative fixation include open fractures and impending open fractures. Relative indications for operative fixation include fractures in multi-trauma patients, floating shoulder injuries, comminuted fractures, and shortened fractures in older adolescents. Controversies exist in preferred methods of fixation and include superior or anteroinferior plating, locked or unlocked plating, and intramedullary fixation. Retrospective studies of operative fixation in children show the feasibility and safety of fixation and are helping to define operative indications, but stronger evidence and reliable outcomes' measures for the pediatric upper extremity are still needed. Both nonoperative and operative treatment should be considered when making recommendations for treatment of significantly displaced or shortened midshaft clavicle fractures. The advantages and disadvantages of both should be clearly presented to the patient and family so that they may also participate in the decision-making process.

Flexibility in fixation: an update on femur fractures in children.

Although non-operative strategies remain a viable option for the management of some children's femur fractures, surgical management has become more popular and predictable, with potential complications better recognized and thus more easily avoided. This paper addresses the operative management of children's femur fractures highlighting the multiple techniques available to treat the spectrum of pediatric femur fractures. We present the applications of Elastic Stable Intramedullary Nailing and Locked intramedullary nailing, sub-muscular or open plating, and external fixation, and discuss the relative advantages and shortcomings of each technique. Cases are presented for illustration.

A linear-actuated torsional device to replicate clinically relevant spiral fractures in long bones.

To better understand the mechanisms underlying spiral fracture we would like to carry out biomechanical tests of long bones loaded in torsion to failure. A device was fabricated to perform torsional tests of long bones using a single-axis linear actuator. The principal operation of the device was to transform the vertical displacement of a material testing machine's linear actuator into rotational movement using a spur gear and rack system. Accuracy and precision of the device were quantified using cast-acrylic rods with known torque-rotation behavior. Cadaveric experimentation was used to replicate a clinically relevant spiral fracture in eleven human proximal tibiae; strain-gage data were recorded for a single specimen. The device had an experimental error of less than 0.2 Nm and was repeatable to within 0.3%. Strain gage data were in line with those expected from pure torsion and the cadaveric tibiae illustrated spiral fractures at ultimate torque and rotation values of 130.6 +/- 53.2 Nm and 8.3 +/- 1.5 degrees, respectively. Ultimate torque was highly correlated with DXA assessed bone mineral density (r = 0.87; p < 0.00 1). The device presented is applicable to any torsional testing of long bone when only a single-axis linear actuator is available.

Occult femoral neck fracture associated with vitamin D deficiency diagnosed by MRI: case report.

Hip fractures in the young are exceedingly rare and are usually seen in instances of high energy trauma or metabolically altered bone states. In this case report, we present an occult femoral neck fracture, diagnosed by magnetic resonance imaging, in an otherwise healthy, young, active duty male patient with an isolated vitamin D deficiency treated using cannulated percutaneous screws.

Outcome of closed ipsilateral metacarpal fractures treated with mini fragment plates and screws: a prospective study.

BACKGROUND: Closed multiple metacarpal fractures are considered highly unstable and are more prone to poor functional outcome. The authors assess the functional outcome of mini fragment plate fixation in closed ipsilateral multiple metacarpal fractures. PATIENTS AND METHODS: In 21 patients with closed ipsilateral multiple metacarpal fractures treated with open reduction and internal fixation using mini fragment plate, functional outcome was assessed using the American Society for Surgery of the Hand (ASSH) Total Active Flexion (TAF) score and the Disabilities of the Arm, Shoulder, and Hand (DASH) scoring system. RESULTS: Union rate of 100% was achieved. Functional outcome was excellent in 85.71% (18 of 21) and good in 9% (2 of 21) of patients. Average DASH score was 8.47 (range 1-26). Five cases of infection (two deep, three superficial) were reported, which subsided with dressings and antibiotics. CONCLUSIONS: Plate fixation is a good option for treating closed ipsilateral multiple metacarpal fractures, providing rigid fixation for early mobilization and good functional outcome.

Experimental stimulation of bone healing with teriparatide: histomorphometric and microhardness analysis in a mouse model of closed fracture.

Fracture consolidation is a crucial goal to achieve as early as possible, but pharmacological stimulation has been neglected so far. Teriparatide has been considered for this purpose for its anabolic properties. We set up a murine model of closed tibial fracture on which different doses of teriparatide were tested. Closed fracture treatment avoids any bias introduced by surgical manipulations. Teriparatide's effect on callus formation was monitored during the first 4 weeks from fracture. Callus evolution was determined by histomorphometric and microhardness assessment. Daily administration of 40 µg/kg of teriparatide accelerated callus mineralization from day 9 onward without significant increase of sizes, and at day 15 the microhardness properties of treated callus were similar to those of bone tissue. Teriparatide considerably improved callus consolidation in the very early phases of bone healing.

Applied biomechanics in articular injuries: perspectives in the basic investigation of articular injuries and clinical application.

Joint injury is an important cause of arthritis. Although the treatment of injury, in general, has been widely studied, the contribution of injury to the development of posttraumatic arthritis is still a relatively understudied area. One of the most perplexing aspects of investigating articular injuries is the complex nature of the injury itself and the multiple facets of the injury mechanism that can potentially lead to the development of arthritis. A symposium by the Orthopaedic Research Society and the American Academy of Orthopaedic Surgeons was designed to examine the spectrum of basic science to clinical investigation in the role of biomechanics in the study of joint injury and subsequent posttraumatic arthritis. Four perspectives in the clinical aspects of managing articular injuries were investigated, including the clinical applications of basic science findings, the challenges and advancements in measuring and modeling articular fractures, the relationship of articular cartilage mechanical injuries and osteoarthritis, and the controlled creation of an intra-articular fracture to permit observations of the natural history of posttraumatic arthritis.

Fixation of displaced midshaft clavicle fractures in skeletally immature patients.

BACKGROUND: There is ongoing debate in the adult literature regarding fixation of displaced, closed midshaft clavicle fractures. Functional outcomes of treatment of these fractures in skeletally immature patients have not been previously investigated. METHODS: We retrospectively reviewed 14 skeletally immature patients with closed, displaced, midshaft clavicle fractures treated with open reduction internal fixation. Baseline data acquisition included demographic and radiographic indices. Follow-up data included radiographic and functional outcomes assessment using the Quick Disability of Arm, Shoulder, and Hand Questionnaire (QuickDASH), the simple shoulder test, and additional binary questions. RESULTS: Mean age for operative patients was 12.9 years. There were 12 male and 2 female cases. Twelve patients had injuries to the dominant extremity. Twelve patients had initially been treated nonoperatively, but underwent surgery due to increased displacement at 3 weeks. Minimum follow-up was 24 months. Mean postoperative total QuickDASH score was 7.0. Patients had a mean of 11 questions answered "yes" for the simple shoulder test. Four patients from the operative group underwent a second surgical procedure to remove hardware. Eight (57%) patients complained of numbness at the site of injury/surgery. Preoperative mean fracture shortening and vertical displacement were 14.4 and 19.7 mm, respectively. Follow-up radiographs at mean 3 months demonstrated healed fractures in all cases. Multiple linear regression showed no difference in QuickDASH score after adjusting for age, sex, injury to dominant extremity, shortening, and percent displacement (P = 0.220). CONCLUSIONS: In conclusion, operative treatment of displaced midshaft clavicle fractures in skeletally immature patients resulted in high scores on commonly used instruments of outcomes assessment. Operative patients may require additional surgery to remove prominent or painful hardware and may be prone to numbness at the incision site.Level IV.

Generation of Closed Transverse Fractures in Small Animals.

The most common procedure that has been developed for use in rats and mice to model fracture healing is described. The nature of the regenerative processes that may be assessed and the types of research questions that may be addressed with this model are briefly outlined. The detailed surgical protocol to generate closed simple transverse fractures is presented and general considerations when setting up an experiment using this model are described.

Repurposing denosumab for recalcitrant bone healing.

Fracture healing has four phases: haematoma formation, soft callus, hard callus and remodelling. Often, non-healing fractures have an arrest of one of these phases, which need resurgery. We have repurposed denosumab for impaired fracture healing cases to avoid surgical intervention. Here, we report a series of three cases of impaired fracture healing where denosumab was given 120 mg subcutaneous dosages for 3 months to enhance healing. All the three cases have shown complete bone union at a mean follow-up of 6.7 months (5-9 months) as assessed clinically and radiologically, and have observed no adverse effect of the therapy. Denosumab given in this dose aids fracture healing by increasing callus volume, density and bridges the fracture gap in recalcitrant fracture healing cases where the callus fails to consolidate.

Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and outcome analysis show no increase of complications in the treatment of open compared with closed fractures.

BACKGROUND: : Stable internal screw/plating systems for hand fractures have evolved during the last 20 years. The improved versatility leads to the increased use of these materials in open fractures, with the benefit of early mobilization. The aim of this retrospective study is to discern whether the broadening of the indications for these implants is accompanied by increased complication rates. METHODS: : Data from 365 patients treated during the last 10 years at our department for metacarpal or phalangeal fractures with stable internal fixation by screw or plate were gathered and analyzed. RESULTS: : Uneventful bony consolidation was observed in 91.2% (n = 333). The functional results were excellent to acceptable in 85.2%, whereas in 14.8% (n = 54), the result was unsatisfactory, the latter group presenting with concominant soft tissue injury. There was no statistically significant difference in infection and nonunion rates when comparing open and closed fractures. CONCLUSION: : These results confirm that most patients with open metacarpal and phalangeal fractures can be treated by stable internal fixation.

Treatment of Isolated Posterolateral Tibial Plateau Fracture with a Horizontal Belt Plate through the Anterolateral Supra-Fibular-Head Approach.

The posterolateral tibial plateau fracture was not easy to be exposed and fixed with usual techniques. The aim of this study was to investigate the biomechanical stability and clinical outcome of the isolated posterolateral tibial plateau fracture fixed with a single horizontal belt plate through the anterolateral supra-fibular-head approach. Fracture models were created by 18 synthetic tibias and fixed with three different fixation modes. Each group was fixed and tested on the loading machine, and final vertical displacement of the fragment was detected and calculated. Clinically, a retrospective analysis of 12 cases of posterolateral tibial plateau fracture from January 2013 to December 2017 was performed. There were 8 males and 4 females, aged 33-72 years, with an average age of 49.6 years. Isolated posterolateral tibial plateau fractures were identified according to preoperative X-ray and computed tomography scan. Through the modified anterolateral supra-fibular-head approach, the fracture was reduced and fixed by a prebending T-shaped distal radius plate and rafting screws, with bone substitute grafting or autogenous iliac bone implantation. Patients were followed up to a minimum one year of time period, and the outcome was evaluated clinically and radiologically. The biomechanical study shows that horizontal belt plate fixation for the isolated PL tibial plateau fracture can provide sufficient stability, allowing early knee functional exercise and partial weight bearing. For clinical case series, the average operation time in this group was 73.3 ± 10.2 mins (range: 55-90), and the average duration of hospitalization was 9.1 ± 3.3 days (range: 5-16). Patients were followed up for 12-24 months with an average of 16.5 months, and all patients achieved radiological fracture union after an average of 13.7 weeks. At one year after operation, the average knee score of the Hospital for Special Surgery (HSS) scale was 93.2 ± 4.2 points(range: 90-98), the average score of SMFA was 21.1 ± 5.6 points (range: 14-31), and the average knee range of motion (ROM) was 121.48° ± 8.88° (range: 105°-135°). There were 8 cases that were very satisfied and 3 cases that were satisfied with the operation. For an isolated posterolateral tibial plateau fracture, the supra-fibular-head approach can fully expose the fracture site; the horizontal belt plate fixation of the fracture is stable and reliable to allow for early-stage knee rehabilitation, and the outcome of medium-term clinical follow-up was satisfactory.

Effects of Stellate Ganglion Block on Healing of Fractures Induced in Rats.

OBJECTIVE: Sympathetic blocks are used as an adjunct for pain management in the treatment of orthopedic and traumatic conditions. Stellate ganglion (ganglion stellatum) provides sympathetic innervation of the head, neck and cervicothoracic regions, and upper extremities. No study was found in the literature investigating the effects of stellate ganglion block performed in the upper extremity, on blood supply to bone, density, vascularization, and bone metabolism. Therefore, the objective of this study was to investigate the effects of stellate ganglion block on healing of closed forearm fractures that were induced in rats. Material and Methods. A total of 42 Wistar albino rats weighing between 398 and 510 g were used in this study. The rats were randomly divided into 2 groups with one group treated with stellate ganglion and the other included as the control group. In each 2 groups, a closed forearm fracture was created, confirmed with X-ray, and then stabilized by splint application. The forearm bones were examined with X-ray views on the same day and were then decalcified. RESULTS: When histological findings of the fracture region were examined, predominantly cartilage and less woven bone were found in 7 rats, equally distributed cartilage and immature bone in 14 rats, and predominantly imitation bone and less cartilage formation in 21 rats. In the control group, the agreement between the 1st and 2nd orthopedists for the radiological evaluation of bone formation was moderate. CONCLUSION: The group administered stellate ganglion block showed a more significant fracture healing.

Osteogenic protein-1 overcomes inhibition of fracture healing in the diabetic rat: a pilot study.

Type I diabetes mellitus inhibits fracture healing and leads to an increase in complications. As a pilot study, we used a closed fracture model in the diabetic rat to address the question of whether osteogenic protein-1 (OP-1) in a collagen carrier can overcome this inhibition by increasing the area of the newly mineralized callus and femoral torque to failure compared with diabetic animals with fractures treated without OP-1. Diabetes was created in 54 rats by injection of streptozotocin. After 2 weeks, a closed femur fracture was created using a drop-weight impaction device. Each fracture site was immediately opened and treated with or without 25 microg OP-1 in a collagen carrier. Animals were euthanized after 2 or 4 weeks. Fracture healing was assessed by callus area from high-resolution radiographs, callus strength from torsional failure testing, and undecalcified histologic analysis. The area of newly mineralized callus was greater in diabetic animals treated with 25 microg OP-1/carrier compared with diabetic animals with untreated fractures and with fractures treated with carrier alone. This increase in callus area did not translate into an equivalent increase in torque to failure. Osteogenic protein-1 showed some evidence of overcoming the inhibition of fracture healing in the diabetic rat.

Bone callus formation is highly disrupted by dietary restriction in growing rats sustaining a femoral fracture1.

PURPOSE: To evaluate the effects of food restriction on fracture healing in growing rats. METHODS: Sixty-eight male Wistar rats were assigned to two groups: (1) Control and (2) Dietary restriction. After weaning the dietary restricted animals were fed ad libitum for 42 days with 50% of the standard chow ingested by the control group. Subsequently, the animals underwent bone fracture at the diaphysis of the right femur, followed by surgical stabilization of bone fragments. On days 14 and 28 post-fracture, the rats were euthanized, and the fractured femurs were dissected, the callus was analyzed by dual-energy X-ray absorptiometry, micro-computed tomography, histomorphometry, mechanical tests, and gene expression. RESULTS: Dietary restriction decreased body mass gain and resulted in several phenotypic changes at the bone callus (a delay in cell proliferation and differentiation, lower rate of newly formed bone and collagen deposition, reductions in bone callus density and size, decrease in tridimensional callus volume, deterioration in microstructure, and reduction in bone callus strength), together with the downregulated expression of osteoblast-related genes. CONCLUSION: Dietary restriction had detrimental effects on osseous healing, with a healing delay and a lower quality of bone callus formation.

Medial malleolus: Operative Or Non-operative (MOON) trial protocol - a prospective randomised controlled trial of operative versus non-operative management of associated medial malleolus fractures in unstable fractures of the ankle.

BACKGROUND: There are limited data reporting the outcome of patients with non-operatively managed medial malleolus fractures compared to those treated surgically in the presence of fibular stabilisation for unstable fractures of the ankle. Conservative management could result in fewer complications, reduced surgical time and lower cost. The purpose of this study is to determine if any difference exists in patient reported and surgical outcomes 1 year after surgery between operative and non-operative treatment of medial malleolar fractures in combination with stabilisation of the lateral malleolus. METHODS/DESIGN: This is a single-centre, prospective, randomised controlled trial that aims to randomise 154 participants with an unstable ankle fracture to 'non-fixation' (n = 77) or 'fixation' (n = 77) of an associated well-reduced medial malleolus fracture following fibular stabilisation. The study will include patients ≥ 16 years of age with a closed bimalleolar or trimalleolar ankle fracture who are able to consent, complete questionnaires in the English language, and complete follow-up over a 1-year period. Randomisation will occur intra-operatively when the medial malleolus fracture is deemed 'well-reduced', with 2 mm or less of fluoroscopic displacement. The technique for fixation of both the medial and lateral malleoli is at the discretion of the operating surgeon. Patient-reported, observer-rated, and radiographic assessments will be collected at baseline and then at the following post-operative assessment points: 2 weeks, 6 weeks and 1 year. Postal questionnaire outcome data will be collected at 3 and 6 months. The primary outcome measure will be the Olerud Molander Ankle Score (OMAS) at 1 year following surgery. Secondary outcome measures will include the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5D (EQ-5D), pain, treatment satisfaction, time to return to activity, operative tourniquet time, and complications. DISCUSSION: There is only one previous randomised trial comparing non-fixation with fixation of associated medial malleolus fractures but that was limited by the lack of baseline patient-reported outcome data and an inferior sample size. This current prospective trial aims to provide high-quality evidence regarding the requirement for medial malleolar fixation in unstable ankle fractures. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03362229 . Registered retrospectively on 5 December 2017.

Fifth Metatarsal Jones Fractures in the Athlete.

Fifth metatarsal fractures, otherwise known as "Jones" fractures, occur commonly in athletes and nonathletes alike. While recent occurrence in the popular elite athlete has increased public knowledge and interest in the fracture, this injury is common at all levels of sport. This review will focus on all three types of Jones fractures. The current standard for treatment is operative intervention with intramedullary screw fixation. Athletes typically report an acute episode of lateral foot pain, described as an ache. Radiographic imaging with multiple views of the weightbearing injured foot are needed to confirm diagnosis. If these images are inconclusive, further magnetic resonance imaging (MRI) or computed tomography (CT) is used. Nonoperative treatment is not commonly used as the sole treatment, except when following reinjury of a stable screw fixation. While screw selection is still controversial, operative treatment with intramedullary screw fixation is the standard approach. Technical tips on screw displacement are provided for Torg (types I, II, III) fractures, cavovarus foot fractures, recurrent fractures, revision surgery, occult fractures/high-grade stress reactions, and Jones' variants. Excellent clinical outcomes can be expected in 80% to 100% of patients when using the intramedullary screw fixation to "fit and fill" the medullary canal with threads across the fracture site. Most studies show the timing for return to sports with optimal healing to be seven to twelve weeks after fixation. LEVEL OF EVIDENCE: Level V, expert opinion.