Journal of Musculoskeletal Trauma

Combined acetabular and pelvic ring injuries: a reference-frame algorithm for definitive fixation sequencing: Jeong-Hyun Koh, Seungyeob Sakong; Received January 8, 2026 Accepted January 14, 2026 Published online April 9, 2026; DOI: https://doi.org/10.12671/jmt.2026.00031 [Epub ahead of print]

Abstract PDF: Combined acetabular and pelvic ring injuries are not simply “two fractures in one patient.” Reduction and fixation of one component can alter the alignment and reducibility of the other, rendering operative sequencing a primary decision variable rather than a secondary consideration. These injuries typically result from high-energy trauma, frequently occur in patients with polytrauma, and are further influenced by physiological tolerance and the feasibility of available operative corridors. The existing evidence base remains constrained by retrospective study designs, inconsistent definitions, variable classification systems, and heterogeneous outcome reporting, all of which limit the strength of comparative recommendations. This state-of-the-art review presents a surgeon-facing, algorithmic approach grounded in a reference-frame mindset. We emphasize computed tomography (CT)-based mapping and the use of consistent terminology to characterize acetabular morphology, pelvic ring instability, deformity vectors, suspicion of mechanical coupling, and feasible operative corridors. Mechanically connected acetabular and pelvic ring injuries (MCAPI) are introduced as a working framework for identifying patterns in which reduction or fixation of one injury predictably influences the other. In cases of suspected MCAPI, a posterior ring-based sequence is generally preferred, typically consisting of posterior ring reduction and fixation, definitive acetabular reconstruction, and subsequent anterior ring fixation. We propose an explicit intraoperative “GO/NO-GO” checkpoint (reference acceptable, stable, corridors feasible) to prevent acetabular reconstruction on a moving target. Acetabulum-first strategies may be appropriate only in selected anteroposterior compression- type configurations in which acetabular fixation plausibly restores sacroiliac congruency and posterior stabilization remains technically feasible. We summarize key outcome domains and complication patterns, highlighting hip dislocation as an important risk factor associated with both neurologic deficits and overall complications. Standardized CTbased definitions and outcome instruments, together with multicenter cohorts employing predefined decision pathways, are required to test sequencing strategies and to determine whether improved radiographic reduction translates into durable functional benefit.

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Percutaneous anterior leverage technique for anteromedial cortical support in intertrochanteric femur fractures: a computed tomography-based validation study: Whee Sung Son, Bum Jin Shim, Oog-jin Shon; Received September 24, 2025 Accepted December 10, 2025 Published online March 27, 2026; DOI: https://doi.org/10.12671/jmt.2025.00311 [Epub ahead of print]

Abstract PDF: Background
Anteromedial cortical support (AMCS) enhances stability in intertrochanteric femur fractures. However, reproducible, validated methods of achieving AMCS have not previously been reported. This study introduces a percutaneous anterior leverage technique and validates its AMCS effects using computed tomography (CT).
Methods
We retrospectively reviewed patients treated by a single surgeon between March 2022 and December 2024. The inclusion criteria were an AO/OTA classification of A1–A3, application of the percutaneous anterior leverage technique, available pre- and postoperative CT, and ≥6 months follow-up. Outcomes included CT-based AMCS (anterior on axial and medial on coronal images, classified as positive, neutral, or negative), time to union, union rate, changes in neck-shaft angle, and treatment failure (varus collapse, blade cut-through, or nonunion without the former two). The risk factors for failure were analyzed.
Results
Of 273 patients reviewed, 53 met the inclusion criteria. Follow-up was at least 6 months in all cases. Positive anterior support was achieved in 37 patients (69.8%) and positive medial support in 42 (79.25%). No patient demonstrated negative anterior support; one (1.9%) had negative medial support. Cortical support improved significantly after surgery. CT images demonstrated significant postoperative improvements (anterior P=0.026; medial P<0.001). Bone union was achieved in 50 patients (94.34%) at a mean of 3.93±1.48 months. The mean change in the neck-shaft angle at last follow-up was 1.75°±2.34° varus. Three patients (5.66%) experienced treatment failure. Anteromedial cortical breakage during follow-up differed between failure and non-failure groups (P=0.002), but regression identified no independent predictors. No technique-related complications were observed.
Conclusions
Our percutaneous anterior leverage technique produced favorable CT-confirmed AMCS and high union with low failure, supporting its safety and effectiveness in intertrochanteric femur fractures. Level of evidence: IV.

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Sex-specific bottlenecks and risk zones in the retrograde superior pubic ramus screw corridor: a 3D CT-based morphometric cadaver study: Ji Won Jeong, Jung Tae Ahn, Gu Hee Jung, Kun Tae Kim; Received January 22, 2026 Accepted February 7, 2026 Published online March 26, 2026; DOI: https://doi.org/10.12671/jmt.2026.00066 [Epub ahead of print]

Abstract PDF Supplementary Material: Background
Superior ramus screw fixation is commonly used to stabilize anterior pelvic ring injuries but is constrained by a narrow, irregular, and curved intraosseous corridor. Trajectory-based morphometric analysis may assist in screw diameter selection and enable identification of reproducible anatomic constriction zones.
Methods
We conducted a cross-sectional computed tomography (CT)-based morphometric study of 82 cadaveric pelvises (42 males, 40 females). Bottleneck diameter was defined as the diameter of the largest fully contained virtual cylinder along the planned trajectory, and cylinder length was recorded. Orthogonal cross-sections at 9.5-mm intervals (up to 12 segments) were generated to measure segment-wise effective diameter (defined as twice the minimum centerline-to-cortex distance) and cortical clearance, which was used as a diameter-based safety margin. Segments were realigned to the acetabular start segment to define relative segment positions (Δ seg). Feasibility was assessed for prespecified screw diameters ranging from 3.5 to 7.3 mm.
Results
Mean bottleneck diameter was larger in males than in females (7.34±1.10 vs. 5.93±0.98 mm), whereas trajectory length was similar between sexes (127.85±8.54 vs. 128.85±8.20 mm). Δ seg realignment localized corridor constriction to two discrete zones: a preacetabular zone (Δ seg −6 to −4) and a periacetabular zone (Δ seg 1 to 2), where effective diameter and cortical clearance were most limited. Feasibility rates were 100% at 3.5–4.5 mm, 95.2% vs. 82.5% at 5.0 mm, 81.0% vs. 27.5% at 6.5 mm, and 59.5% vs. 10.0% at 7.3 mm in males and females, respectively.
Conclusions
Female models demonstrated smaller trajectory-wide bottleneck diameters and segment-wise effective diameters than male models. Acetabular-referenced Δ seg realignment identified two reproducible anatomic risk zones: a preacetabular zone adjacent to the obturator neurovascular bundle and a periacetabular zone near the external iliac vessels. At diameters ≥6.5 mm, cortical proximity increased more prominently in females than in males. Level of evidence: III.

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Definitive fixation for traumatic pelvic ring injuries: a dynamically informed, posterior-referenced framework: Jeong-Hyun Koh, Seungyeob Sakong; Received January 13, 2026 Accepted January 14, 2026 Published online March 24, 2026; DOI: https://doi.org/10.12671/jmt.2026.00045 [Epub ahead of print]

Abstract PDF: Optimal definitive fixation for traumatic pelvic ring injuries remains challenging because static radiographs and computed tomography, although essential for defining morphology, do not consistently predict load-dependent behavior during early mobilization. This uncertainty contributes to substantial practice variation and continued reliance on simplified displacement thresholds, such as the 2.5 cm rule. Such rules can misclassify instability by underrepresenting posterior competence and by privileging static measurements over functional behavior. In this narrative review, we propose a dynamically informed, posterior- referenced framework composed of three linked elements: (1) decision-linked terminology that explicitly distinguishes dynamic instability, radiographic change, and clinical failure; (2) selective stress-based assessment when uncertainty is likely to alter management; and (3) escalation along a fixation continuum that weighs incremental stability against operative burden. When static imaging cannot establish posterior competence with confidence, we outline selective stress-based approaches to assess pelvic ring behavior and to translate demonstrated instability into fixation selection along a defined continuum. Across all steps, the framework emphasizes minimum necessary fixation and explicitly incorporates the cost of selection as a primary decision variable. The operative question, therefore, shifts from gap width alone to clinically relevant motion and preservation of posterior competence. In doing so, this approach aims to reduce both undertreatment and overtreatment and to improve the consistency and defensibility of definitive fixation strategies across diverse practice environments.

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Comparative results of the femoral neck system versus the dynamic hip screw for stable femoral neck fractures in older adults in Korea: a retrospective cohort study: Byung-Chan Choi, Byung-Woo Min, Kyung-Jae Lee, Jun-Sik Hong; J Musculoskelet Trauma 2025;38(4):203-211. Published online October 24, 2025; DOI: https://doi.org/10.12671/jmt.2025.00276

Abstract PDF: Background
This study aimed to compare the clinical and radiological outcomes of the femoral neck system (FNS) and the dynamic hip screw (DHS) for the internal fixation of stable femoral neck fractures in older adults.
Methods
This retrospective cohort study included 48 matched older adult patients based on sex, age, BMI, and osteoporosis status, who had undergone internal fixation with either FNS or DHS for stable femoral neck fractures between January 2010 and December 2022. To minimize selection bias, a 1:1 case-control matching was performed based on sex, age, body mass index (BMI), and the presence of osteoporosis. A total of 48 patients (24 in each group) were included. We compared perioperative data (operation time, hemoglobin change, transfusion rate), functional outcomes using the Koval score, and radiological outcomes, including union rate, femoral neck shortening, and complication rates.
Results
The mean operation time was significantly shorter in the FNS group than in the DHS group (60.9 minutes vs. 70.8 minutes; P=0.007). There were no statistically significant differences between the two groups in the union rate (87.5% in FNS vs. 95.8% in DHS), femoral neck shortening, final Koval score distribution, or overall complication rates (12.5% in both groups).
Conclusions
For treating stable femoral neck fractures in older adults, the FNS demonstrated comparable clinical and radiological outcomes to the DHS, with the distinct advantage of a shorter operation time. While these findings suggest that the FNS is a promising and safe alternative that may reduce the surgical burden, definitive conclusions are precluded by the small sample size, warranting further research to corroborate these results. Level of evidence: IV.

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Atypical ulnar fractures: a narrative review of current concepts and a case of bilateral surgical management: Chi-Hoon Oh, Hyun Tak Kang, Jun-Ku Lee; J Musculoskelet Trauma 2025;38(3):124-132. Published online July 24, 2025; DOI: https://doi.org/10.12671/jmt.2025.00227

Abstract PDF: Atypical ulnar fractures (AUFs) are rare complications that are often linked to long-term antiresorptive therapy. Although atypical femoral fractures are well-studied, AUFs lack standardized diagnostic and treatment protocols. This review summarizes current knowledge on AUFs, including their pathophysiology, diagnostic criteria, and management. A case of bilateral AUFs treated with two distinct osteosynthesis methods is presented, emphasizing the principles of biological healing and mechanical stabilization.

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Comparison of outcomes of reinforced tension band wiring and precontoured plate and screw fixation in the management of Mayo type IIIB olecranon fractures: Hyun Goo Kang, Tong Joo Lee, Samuel Jaeyoon Won; J Musculoskelet Trauma 2025;38(2):96-101. Published online February 28, 2025; DOI: https://doi.org/10.12671/jmt.2025.00059; Correction in: J Musculoskelet Trauma 2025;38(3):168

Abstract PDF

Background
Mayo type IIIB olecranon fractures are characterized by significant displacement and comminution, presenting a challenge in selecting the appropriate fixation technique. This study compared the clinical and radiographic outcomes, complications, and reoperation rates of reinforced tension band wiring (TBW) and precontoured plate and screw fixation (PF) in the surgical treatment of Mayo type IIIB olecranon fractures.
Methods
This retrospective review analyzed 24 patients diagnosed with Mayo type IIIB olecranon fractures, who were treated between 2005 and 2023. Of these, 11 patients underwent reinforced TBW, and 13 received precontoured PF. Clinical outcomes were assessed using Disabilities of the Arm, Shoulder, and Hand (DASH) scores and the Mayo Elbow Performance Score (MEPS). Radiographic outcomes focused on fracture union. Operative times, complication rates, and reoperation rates were compared between the groups.
Results
Both the reinforced TBW and PF groups achieved satisfactory clinical outcomes, with no significant between-group differences in DASH and MEPS scores (P>0.05). Radiographic union was achieved in all patients. The reinforced TBW group demonstrated a significantly shorter operative time than the PF group (93.6±7.4 min vs. 132.3±13.7 min; P<0.001). Complication rates were similar between the two groups (reinforced TBW, 38.4%; PF, 36.3%), but hardware-related irritation occurred more frequently in the reinforced TBW group. Reoperations were required in 15.8% of the reinforced TBW group due to hardware irritation, whereas no reoperations were necessary in the PF group.
Conclusions
Reinforced TBW and PF are both effective surgical options for managing Mayo type IIIB olecranon fractures, yielding comparable clinical and radiographic outcomes. While reinforced TBW offers shorter operative times and lower costs, PF is associated with fewer hardware-related complications. Further prospective studies are needed to optimize treatment strategies for these complex fractures. Level of Evidence: Level III.

Citations

Citations to this article as recorded by

Suture tension band fixation of olecranon fractures: description and early outcomes of a novel technique
Joseph G. Monir, Frank L. Vazquez, Musab Gulzar, Kevin Cuneo, Thomas McQuillan, Michael B. Gottschalk, Eric R. Wagner
JSES Reviews, Reports, and Techniques.2026; 6(2): 100707. CrossRef
Are posterior olecranon locking plates a problem for patients after fracture healing because of prominence?
Reva Qiu, Mallika Makkar, Richard Buckley
Injury.2025; 56(11): 112769. CrossRef

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Outcomes of open reduction and internal fixation using 2.0/2.4 mm locking compression plate in isolated greater tuberosity fractures of humerus: Sung Choi, Dongju Shin, Sangwoo Kim, Byung Hoon Kwack; J Musculoskelet Trauma 2025;38(1):32-39. Published online January 24, 2025; DOI: https://doi.org/10.12671/jmt.2025.00005

Abstract PDF: Background
The purpose of this study was to retrospectively evaluate the radiographic and clinical results of a small single or double low-profile plate fixation of 2.0/2.4 mm locking compression plate (LCP) in treating isolated greater tuberosity (GT) fractures of the humerus. Methods: From June 2015 to October 2022, patients who underwent LCP in treating isolated GT fractures of the humerus were included in this study. The radiological and clinical results were analyzed in 15 patients who underwent open reduction and internal fixation used 2.0/2.4 mm LCP. Results: Bone union was achieved in 14 patients (93.3%) and one failed case was treated with a 2.4 mm single LCP fixation. Radiological union was achieved within 10–20 weeks. Complications occurred in two patients (13.3%), including the reduction failure and shoulder stiffness. At the final follow-up, the average clinical scores were as follows: a visual analog scale for pain of 2.1 (range, 0–5) and a University of California, Los Angeles score of 27.2 (range, 18–31). Regarding range of motion (ROM), the average active ROMs were 142° for forward flexion (range, 120°–150°), 147.1° for abduction (range, 120°– 180°), and 59.3° for external rotation (range, 45°–80°). For internal rotation, the average was observed to reach the 10th thoracic vertebra (range, 1st lumbar vertebra–7th thoracic vertebra). Conclusions: The clinical and radiologic outcomes of treating isolated GT fracture using 2.0/2.4 mm LCP were favorable, and double low-profile plate fixation may be beneficial for sufficient fracture stability if possible. Level of evidence: Level IV, case series.

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Risk Factors of Fixation Failure in Femoral Neck Fractures: Sung Hyun Yoon, Kyu Beom Kim, Hyung Jun Lee, Kyung Wook Kim; J Korean Fract Soc 2023;36(4):118-124. Published online October 31, 2023; DOI: https://doi.org/10.12671/jkfs.2023.36.4.118

Abstract PDF: Purpose
Internal fixation after a femoral neck fracture (FNF) is one of the conventional treatment options for the young and active elderly patients. However, fixation failure of internal fixation is a probable complication. The treatment of fixation failure after a primary internal fixation of the FNF remains a challenge.
Materials and Methods
Between July 2002 and March 2017, 83 patients who underwent internal fixation after FNF were retrospectively analyzed. Radiological assessments, including Pauwels’ angle, fracture level, reduction quality, and bone union, were measured, preoperatively and postoperatively. Moreover, intraoperative variables such as time to surgery, surgical time, and estimated blood loss were also evaluated.
Results
The patients were divided into the fixation failure and the non-failure groups. Among the 83 patients, 17 cases (20.5%) of fixation failure after the primary internal fixation of the FNF were identi-fied. When comparing the two groups according to the radiographic data, Pauwels’ angle and the reduction quality based on Garden’s angle showed significant differences (p<0.001). Moreover, when comparing the intraoperative variables, unlike the surgical time and estimated blood loss, significant differences were noted in the time interval from injury to surgery and specifically in whether the surgery was performed within 12 hours after injury (p<0.001).
Conclusion
Pauwels’ angle, reduction quality, and time to surgery are the major factors that can predict the possibility of internal fixation failure of the FNF. Early and accurate anatomical reduction is needed to decrease complications after the internal fixation of the FNF.

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Does the Use of a Silicone Ring Tourniquet Help Reduce Bleeding in the Minimally Invasive Internal Fixation with Locking Plate for Distal Femoral Fractures?: Ki-Bong Park, Hong-Ki Jin, Il-Yeong Hwang, Sung-Who Chang, Sung-Cheon Na; J Korean Fract Soc 2020;33(3):148-153. Published online July 31, 2020; DOI: https://doi.org/10.12671/jkfs.2020.33.3.148

Abstract PDF

Purpose
This study evaluated the usefulness of a silicone ring tourniquet by analyzing the changes in the perioperative hemoglobin (Hb) levels or amount of perioperative bleeding compared to those of a pneumatic tourniquet or no usage during minimally invasive plate fixation for distal femoral fractures.
Materials and Methods
From January 2017 to December 2019, 30 patients who underwent minimally invasive plate fixation using a locking compression plate for distal femoral fractures were evaluated and classified as a silicone ring tourniquet (Group 1), a pneumatic tourniquet (Group 2), and no usage (Group 3). The variables for analysis were age, sex, preoperative Hb (preHb), postoperative 72-hour Hb (postHb), differences between preHb and postHb (preHb-postHb), amount of intraoperative and overall transfusion, estimated unit of transfusion corrected by preHb-postHb and total transfusion (Hb-lost), amount of intraoperative and postoperative and total bleeding. One-way ANOVA was used to identify the differences between the groups.
Results
The age, sex, operation time, preHb, preHb-postHb, amount of intraoperative and overall transfusion and Hb-lost were similar in the two groups. The amount of intraoperative bleeding was significantly lower in Group 1 than Group 3 (p=0.004), but there was no difference in the amount of postoperative and total bleeding between the two groups.
Conclusion
The use of a silicone ring tourniquet in the minimally invasive plate fixation for distal femoral fractures decreased the amount of intraoperative bleeding compared to no use of a tourniquet.

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Silicone ring tourniquet could be a substitute for a conventional tourniquet in total knee arthroplasty with a longer surgical field: a prospective comparative study in simultaneous total knee arthroplasty
Tae sung Lee, Kwan Kyu Park, Byung Woo Cho, Woo-Suk Lee, Hyuck Min Kwon
BMC Musculoskeletal Disorders.2023;[Epub] CrossRef

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A Retrospective Comparative Study of Internal Fixation with Reconstruction Plate Versus Anatomical Locking Compression Plate in Displaced Intercondylar Fractures of Humerus: Tong Joo Lee, Young Tae Kim, Dae Gyu Kwon, Ju Yong Park; J Korean Fract Soc 2014;27(4):294-300. Published online October 31, 2014; DOI: https://doi.org/10.12671/jkfs.2014.27.4.294

Abstract PDF: PURPOSE
To analyze the clinical result of a conventional reconstruction plate (CRP) fixation and locking compressive plate (LCP) fixation on the surgical treatment of an adult's displaced intercondylar fracture of humerus.
MATERIALS AND METHODS
A total of 40 patients enrolled in the study were treated between August 2002 and May 2012. Fixation with a CRP was performed in 20 patients (group A) and anatomical locking compression plate fixation was performed in 20 patients (group B). The clinical and functional evaluation was performed according to the Mayo elbow performance score and Cassebaum classification of elbow range of motion (ROM), disabilities of the arm, shoulder and hand score.
RESULTS
The Mayo elbow functional evaluation scores, eight cases were excellent, 10 cases were good, and two cases were fair in group A, and 12 cases were excellent, seven cases good, and one case fair in group B; both groups showed satisfactory results. The durations of attaining 90 to 120 degrees of the ROM of joints postoperatively were 8.3 days on average (6 to 15 days) in group A and 5.5 days on average (5 to 9 days) in group B, demonstrating a significant difference between the two groups (p=0.04). Although the correlations of clinical results according to the difference of bone mineral densities (BMDs) were not statistically significant between the two groups (p=0.35), loss of fixation occurred due to loosening of screws in two patients with low BMDs in whose operations reconstruction plates were used.
CONCLUSION
The use of locking compressive plate on the surgical treatment of an diaplaced intercondylar fracture of humerus have a good clinical results because that permits early rehabilitation through good fixation and reduces the complications such as loosening of screws.

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