S66

Injury, Int. J. Care Injured 49S1 (2018) S66–S71

Volume 49 Supplement 1 June 2018 ISSN 0020-1383

Contents lists available at ScienceDirect

Injury
Plating of Fractures: current treatments and complications
Guest Editors: Peter Augat and Sune Larsson

j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c a t e / i n j u r y

Malalignment in plate osteosynthesis

Marie Anneberga,*, Ole Brinka
a
Aarhus University Hospital, Department of Orthopedic Surgery, Aarhus N, Denmark

K E Y W O R D S A B S T R A C T

Malalignment The aim for this review is to present general considerations in relation to malalignment after osteosynthesis
Malunion with plate fixation and its consequences after fractures in adults in each of the following anatomical locations:
Adult humerus, forearm, femur, tibia. Recommendations for accepted malalignment in humerus diaphyseal
Plating
fracture is varus <20 degrees, valgus <15 degrees, sagittal deformity <5 degrees and rotation <30 degrees.
Humerus
Antebrachium
Recommendations when treating fractures of the forearm is anatomical reduction. Varus of ulna leads
Femur to loss of pronation. Valgus of ulna leads to loss of both pronation and supination. Recommendations for
Tibia acceptable malalignment in femoral fractures is rotational deformity <15 degrees, increasing varus deformity
in intertrochanteric fractures increases load on implant. Cortical-step-sign, profile of lesser trochanter,
evaluation of ipsilateral neck anteversion are intraoperative methods to avoid rotational malalignment.
Recommendations for accepted malalignment in the tibia is shortening <10 mm, varus/valgus <5 degrees,
sagittal deformity <10 degrees. Fixation of fibula leads to less rotational and valgus malalignment, but not
enough to affect union rate of tibia, complications rate or functional score at 12 months. To avoid malalignment
in plating, pre-contoured anatomical plates are available from most manufactures. Being aware that most
such plates fit a 50-percentile Caucasian population is important in pre-surgical planning. Evaluation of the
contralateral bone and the characteristics of the plate may help in planning additional bending of pre-shaped
plates and bending tools should always be available when applying a plate, even a so-called anatomical one.
© 2018 Elsevier Ltd. All rights reserved.

Introduction pitfalls in different anatomical areas and the consequences of mal-

alignment.
The function of diaphyseal bone is to bear its joints in a fixed Considering timing, malalignment can be divided into Primary
distance and to function as punctum fixum for the muscles that Malalignment that exists as soon as the patient leaves the operating
moves them. These functions are compromised by fracture and the room and Secondary Malalignment that occurs in the postoperative
goal of treatment is to recreate the pre-trauma state with a stable, period until fracture healing occurs.
pain free bone and adjacent joints. Primary malalignment is dependent on the surgeon’s skills and
knowledge and on the complexity of the fracture.
“Restoration of length, axial alignment, and rotation is essential, Secondary malalignment is caused by a change in fracture reduc-
but anatomical reduction of every fracture fragment is not tion and alignment at some point during the postoperative period.
necessary for normal limb function.” (Piet de Boer) [1] This may be due to several factors:

To obtain this goal it is important to be aware of bone biology and • Loss of fixation in poor bone quality.
the characteristics of the implant to add the stability and alignment • Inadequate fixation in combination with an unstable fracture pattern.
necessary for the duration of bone healing. The bone biology is • Premature dynamization or non-compliance to postoperative regimen.
dependent on the patient’s physiological state, comorbidities and • Construct failure due to inadequate osteosynthesis or prolonged
the blood supply, before and after the implant has been applied. healing.
The implant can function as a surrogate cortex, but should not be
relied on as compensation for inadequate fracture reduction. A plate Malalignment can also be studied after the characteristics of the
osteosynthesis has a finite number of load cycles to failure and the deformity:
goal is to obtain uneventful healing before this occurs [2]. 1. Angulation
To obtain pre-trauma alignment of a fractured bone and hence a. Varus/valgus
optimal function of the limb the surgeon must be aware of the b. Anterior/posterior
2. Rotation
* Corresponding author at: Hoejgaardsvej 4, 8260 Viby J, Denmark a. Internal
E-mail address: [email protected] (M. Anneberg). b. External

0020-1383/© 2018 Elsevier Ltd. All rights reserved.

 M. Anneberg and O. Brink / Injury, Int. J. Care Injured 49S1 (2018) S66–S71 S67

3. Translation
a. Medial/lateral
b. Lengthening/shortening
c. Anterior/posterior
4. Component in one, two or three planes
a. Oblique plane deformity

When evaluating postoperative radiographs even little changes

can be signs of pending failure. Slight loss of fracture reduction, halo
around screws or slight change in screw position. Slightly change in
fracture reduction is often optimistically interpreted as “settling”.
One should wary of this consideration. Expect the appropriate
callus formation and bone healing response, direct or indirect, for
the type of osteosynthesis obtained, absolute or relative stability,
respectively.
Attention should be paid when planning lateral plating in
fractures with associated medial comminution. For example, distal
femur fractures with medial comminution or proximal humeral
fractures with medial metaphyseal comminution have a high rate
of secondary varus malalignment when failing to ensure medial
stability. Examples of means of stability are opposite site plates,
graft or both [2].
Fig. 1. Humerus fracture with varus deformity after non-operative treatment.
The aim for this review is to present general considerations and
available literature regarding malalignment and its consequences
after fractures in adults. The field is illuminated by available relevant
studies of typical and common fracture sites at the following inability to reach the pubic symphysis and at 10 degrees the sacrum
anatomical locations: humerus, antebrachium, femur, tibia. This is a could not be reached. This was the case in both models.
narrative review and fractures in children are not included. This might add new knowledge to future decision making in the
management of humeral fractures and the limits for acceptance of
Current evidence malalignment both in choosing primary treatment and when
evaluating postoperative results (Fig. 1). No recent studies have
Humerus shaft evaluated the consequences of rotational malalignment of the
humerus shaft and 30 degrees is still the generally accepted limit for
Humerus shaft fractures are common and account for approxi- operative indication [3,6].
mately 3–5% of fractures in adults [3]. The humerus has a rich blood Humerus shaft
supply with limited axial weight bearing demand, but external Recommendations
forces being predominately rotational. It is easy to immobilize.
Accepted malalignment:
As a result, fractures to the humerus shaft has historically been • Varus <20 degrees
categorized as benign with good response to conservative treatment • Valgus <15 degrees
with functional bracing and union rates of 90% and good functional • Sagittal deformity <5 degrees
• Rotation <30 degrees
and cosmetically outcome have been described [4,5].
Traditionally malalignment greater than 20 degrees in any
planes and rotation greater than 30 degrees has been the considered Forearm
indication for surgical fixation [3,6]. The limited studies available
of non-operative treatment have shown good cosmetically and Fractures of the forearm involves two bones, but they should be
functional results when angulation was limited to this degree. Most considered as one unit, as fracture and malalignment of one bone
historically studies, however, have used outcome measures like ROM affects the alignment of the other. Anatomically and according to
of elbow or shoulder as measurement for upper extremity function. the AO classification the forearm fractures are divided into proximal,
This must be taken into consideration when analyzing these results shaft and distal, and the fractures are distributed with a ratio as
as ROM in both adjacent joints must be expected to be near-normal 1:2:5 [7].
after a humeral shaft fracture, despite the malalignment of the shaft Forearm fractures involve specific problems different from
[3,4]. fractures of the diaphysis in other long bones. Failing to restore the
Crespo et al. [5] in 2016 challenged this existing paradigm. correct anatomical relationship between the two bones is strongly
In an observational study, they developed a cadaver model and a related to loss of function [8]. This is illustrated by the high rates of
3D computerized model of humeral fractures with malalignment. complications in patients who sustained a Monteggia fracture [9].
Their measured outcome was the third metacarpals ability to reach They include loosening of fixation, malunion, non-union, radioulnar
6 anatomical landmarks with the scapula immobilized. This was synostosis, ulnohumeral arthrosis, radiohumeral subluxation and
used as a surrogate for upper extremity function. They found that ulnohumeral dislocation [9].
varus malalignment was better tolerated than valgus and sagittal Snow et al. [10] conducted a cadaver study to quantify the impact
malalignment. All landmarks were reached between 5–20 degrees of varus and valgus malalignment on forearm rotation after proximal
of varus deformity. Only 2 of 6 landmarks were reached at a valgus ulna fractures. They used 8 cadaveric upper extremities and tested
deformity greater than 20 degrees and even declined drastically at pronation and supination at low, medium and high torque values
15 degrees (3/6). Valgus deformity was seen to impair the ability to in varus/valgus malalignment at 5, 10 and 15 degrees. They showed
reach posterior landmarks because of loss of internal rotation. that varus deformity resulted in decreased pronation with larger
The function was severely affected by sagittal deformity. Both deformity leading to greater loss of pronation. Supination was not
antecurvatum and recurvatum more than 5 degrees resulted in affected at 15 degrees of varus deformation.
S68 M. Anneberg and O. Brink / Injury, Int. J. Care Injured 49S1 (2018) S66–S71

Valgus malalignment resulted in a loss of both pronation and

supination with significantly loss of supination in valgus deformity
of 15 degrees at all torque levels.
Comminuted fractures of the proximal ulna are challenging
because of the unique architecture. An anatomy study described by
Windisch et al. [11] the adult proximal ulna has a natural varus bow
at 17.7 degrees 8.5 cm distal to the olecranon tip. This leads to a risk
of unintended valgus malalignment with the use of straight plates
for comminuted proximal ulna fractures. Rickert et al. [12] studied
the forearm rotation of 752 healthy individuals and found that range
of supination is greater than that of pronation. In a population of
1504 forearms of individuals that considered themselves healthy, 42
showed to have restricted pronation but only 3 to have restricted
supination. This is supported by Kapandji [13] who stresses that
supination deficit results in greater interference with daily living
activities because it is not easily compensated for. Restricted
pronation however, can be compensated for by abduction of the
shoulder and flexion of the elbow.
It is therefore very important to keep the natural curve of the ulna
in mind when reconstructing the anatomical axes to avoid valgus
malalignment that will lead to restricted supination and impaired
function with difficulties to perform activities of daily living.
Bronstein et al. [14] tried to find out whether the frequent lack
of rotation after a distal radius fracture was due to malalignment
or contracture of the soft tissues. They used seven cadavers and
simulated different patterns of malalignment including dorsal
tilt, radioulnar translation and radial shortening. They did not test
Fig. 2. Twelve degrees of valgus malalignment of the radius in forearm fracture treated
the effect of volar tilt. They found that dorsal tilt up to 30 degrees
with plates and an insufficient cast.
and radial translation up to 10 mm led to no significant restriction
to rotation; 5-mm ulnar translation lead to a 23% reduction in
pronation. Radial shortening greater than 10 mm reduced pronation Varus collapse is also correlated with leg shortening which has a
by 47% and supination by 29%. Though based on a cadaveric study negative effect on function and quality of life [17].
with small numbers this study showed that a significant dorsal tilt Marmor et al. [18] assessed load impact in 12 cadavers with
and radial translation can be tolerated. This leads to the conclusion unstable intertrochanteric fractures, treated with sliding hip screw
that contracture of the soft tissue envelope plays an important role and plate (6), or sliding hip screw and nail (6). Load on the implants
in loss of function after a distal radius fracture. was measured at neutral, 5, 10 and 15 degrees of varus and valgus.
The architecture of the radius is also important to achieve Mean strain on the implant at 15 degrees of varus showed a 119%
anatomical restoration in a forearm fracture involving the radius. of that of neutral position for the nail and 159% for the sliding hip
Failure to restore the radial bow is related to poor functional screw. At 15 degrees of valgus strain on the implant was 60% of that
outcome with regard to pronation and supination [8] (Fig. 2). of neutral position for the nail and 42% on the sliding hip screw.
Intraoperative evaluation of pronation and supination and carefully There were no statistically difference between the two implants.
radiographic assessment of reduction is important to achieve good They concluded that regardless of implant devise greater degrees of
outcome [3]. varus increased the load on the implant whereas greater degrees of
Antebrachium valgus decreased the load.
Recommendations Rotational malalignment is more difficult to evaluate. Rotational
malalignment greater than 15 degrees after nailing have been
• Anatomical reduction should be the goal in adults.
• Avoid varus of ulna – leads to loss of pronation reported between 20% and 30% [19,20].
• Avoid valgus of ulna – leads to loss of both pronation and supination Ramanoudjame et al. [21] showed no difference in rotational
• Contracture of soft tissue plays a role in restriction of function malalignment between trochanteric nail and sliding hip screw in 40
patients. However, 40% had rotational malalignment greater than
Femur 15 degrees. Torsional external or internal malalignment greater
than 15 degrees in femoral shaft fractures is shown more likely
Femoral fractures are typically divided into proximal, shaft or to cause clinically significant problems [19]. In the late 1990s the
distal and each type has different challenges in achieving correct MIPO technique was established in attempt to reduce mal- and non-
alignment due to bone anatomy and the stress from the muscular union in fractures of the diaphyseal femur [22]. This technique also
attachments. showed problems with torsional malalignment and Collinge et al.
The most commonly used surgical technique in proximal femoral [23] described it as a problem, likely to be underreported.
fractures is closed reduction and internal fixation with plates, screws Evaluating tools to intraoperatively evaluate malreduction in
or nail [3]. The quality of reduction in the frontal and sagittal plane minimal invasive surgery include cortical-step-sign (CSS) and com-
is easily evaluated intraoperatively, but rotational malalignment is parison with the contralateral hip.
more challenging [15]. Some materials show that more than 10% Langer et al. [24] evaluated the use of CSS in evaluating intra-
of proximal femoral fractures treated with sliding hip screw and operatively malrotation of the femur by investigating 20 cadaveric
side plate or sliding hip screw and nail show intra-operatively femurs and the CSS in 10, 20 and 30 degrees of internal and external
varus malreduction defined as varus angle greater than 10 degrees rotation after osteotomy. They concluded that CSS is indicative for
compared to the contralateral side [15]. Varus malalignment rotational malreduction, but whether step of is due to external or
increase the risk of construct failure and the rate of non-union [16]. internal rotation is not possible to detect with this technique alone.
 M. Anneberg and O. Brink / Injury, Int. J. Care Injured 49S1 (2018) S66–S71 S69

Tornetta et al. [25] and Bråten et al. [26] described the use of knee. Torsional deformity greater than 10 degrees was associated
image intensifier to evaluate the femoral neck anteversion and thus with more knee arthritis. Signs of knee arthritis was observed
being able to correct the malreduction. This was done by obtaining in 81% of all specimens. They showed no effect on hip arthritis.
a true lateral of the normal hip, then moving the c-arm to the knee Translational malalignment showed no correlation with arthritis of
and rotating the c-arm until alignment of the posterior condyles adjacent joints.
of the femur is obtained. The difference between the angles is the Tarr et al. [33] showed, in a study of cadaveric tibias with induced
anteversion of the normal hip. Then on the fractured side, with the malunions, that not only the degree of malalignment but also the
nail in place and locked proximally, the distal fragment is rotated level of the deformity caused significant differences in tibiotalar
until the same anteversion is obtained. Tornetta added a mean of contact areas.
15 minutes to the surgical time by this method. He showed to avoid Prasad et al. [34] set out to investigate the effect of fibular
malrotation of clinical significance with this technique. fixation in the outcome of distal third-lower limp fractures. Sixty
Jaarsma et al. [20] showed the intraoperative evaluation of the patients were divided into two groups based on whether their fibula
profile of the lesser trochanter (lesser trochanter sign) to provide was fixed or not. The tibia fracture was treated with interlocked
the same good results on avoiding malrotation as the evaluation of intramedullary nail. The fibula was fixed with a 3.5 mm Limited
the neck anteversion and this method is easier in clinical practice, Contact Dynamic Compression Plate. They draw the conclusions
as it only requires an AP image of the contralateral hip. The study that fixing the fibula resulted in less rotational malalignment and
was performed by letting five surgeons define the neutral position less valgus angulation of the tibia. However functional scores after
of ten cadaveric femora. The study also showed that using computer 12 months, union rate of the tibia and complication rates were
assistance to quantify the profile of the lesser trochanter did not add statistically similar.
to the accuracy. Collectively the following acceptable limits for malalignments
In femoral shaft fractures nailing is the gold standard [26]. Bråten have been suggested: shortening less than 10 mm [32,35]; coronal
et al. conclude that torsional deformity is very frequent and though angulation less than 5 degrees [29,36]; sagittal plane angulation less
tolerated well by most patients all efforts should be made to keep it than 10 degrees [37].
under 15 degrees. Tibia
Rotational malalignment is not only a problem in proximal and Recommendations
shaft fractures. Joon-woo Kim et al. [27] evaluated 51 patients with
Accepted malalignment
a mean age of 54.3 years who had undergone minimal invasive plate • Shortening <10 mm
osteosynthesis (MIPO) after a distal femur fracture. The postoperative • Coronal angulation <5 degrees
alignment in coronal and sagittal plane was assessed using simple • Sagittal deformity <10 degrees
• Fixation of fibula leads to less rotational and valgus malalignment, but not
radiography and rotation using computed tomography (CT).
enough to affect union rate of tibia, complications rate or functional score at
Alignment was compared to the non-fractured side and divided into 12 months
satisfactory and non-satisfactory based on four groups (excellent,
good, fair, poor) as described by Handolin et al. [28]. They showed
satisfactory result in coronal and sagittal alignment in 96.2% and Discussion
98% respectively. Leg length was satisfying in 92% of cases, but
rotational alignment was only satisfying in 56.9%. Of the cases with Studies on malalignment after a fracture show that obtaining
non-satisfactory rotational alignment 48.6% had a complex fracture, precise alignment is very difficult and not always necessary. It is,
but also 26.7% of simple factures ended out with non-satisfactory however, important to know the consequences of the choices you
rotational result. make in the operating room and to know that especially rotational
Femur malalignment is hard to evaluate intra-operatively.
Recommendations New techniques in plating make the control with alignment
even more challenging. With the development of minimal invasive
• Rotational deformity <15 degrees
• Avoid varus deformity in intertrochanteric fractures – increases load on techniques, it is of increasing importance that the plate is pre-
implant contoured to the bone it is used for. Bone morphology is dependent
• Cortical-step-sign, profile of lesser trochanter, evaluation of ipsilateral neck on gender, age and ethnicity. Most pre-contoured fracture plates
anteversion are methods to avoid rotational malalignment
are designed on the 50-percentile of a Caucasian population and
clinical evidence suggests that they fit poorly in an Asian population
Tibia [38]. Schmutz et al. [39] has developed a computer-based model
to quantify the fit of a locking plate design to a specific population
The existing literature is limited and the evidence low about based on CT and MR-scans instead of previous methods with the use
acceptable malalignment in tibia [29,30]. of cadavers, that are expensive and in some populations of limited
Van der Schoot et al. [31] followed patients with 88 tibia fractures availability. They defined four criteria to evaluate the fit of a locking
for 15 years. Forty-three patients (49%) had angular malalignment plates to the medial distal tibia: 1) Distance between the plate and
of more than 5 degrees. They found that patients with angular the proximal end of the tibia; 2) The angle between plate and bone
malaligned fractures had significantly more degenerative changes in the diaphyseal region as a guide for rotational alignment; 3)
in ankle and knee compared to the patients whose fractures had Distance between bone and plate in the middle of the plate at the
healed with no angular malalignment (58% vs 31%, P=0.02). Twenty level of the fracture; 4) The fit between the distal part of the plate
patients had rotational malalignment of 5 degrees or more. They did and the distal bone fragment. An overall anatomical fit was only
not show statistically greater incidence of osteoarthritis in ankle obtained in 4/21 (19%) of the models. This shows that anatomical fit
or knee compared to the patients whose fractures healed without plates are customized to fit an average bone, meaning perfect fit to
rotational deformity. They concluded that angular deformity was the individual bone is rarely obtained.
associated with worse functional outcomes. Weinberg et al. [32] Ahmad et al. [40] made an experimental biomechanical in vitro
studied 37 pair of cadaveric tibias, one side containing a healed study of the mechanical stability of locking compression plate
tibia fracture. They showed that the specimens with coronal plane on humeral sawbone when applied flush to the bone and 2 and
deformity greater than 5 degrees had more arthritis, whereas 5 mm from the bone. They showed no difference in stability of the
sagittal deformity over 10 degrees had no impact on arthritis of the construct between the 0- and 2-mm group, but when applied 5 mm
S70 M. Anneberg and O. Brink / Injury, Int. J. Care Injured 49S1 (2018) S66–S71

from the bone, the construct showed increased plasticity during [6] Zagorski JB, Latta LL, Zych GA, Finnieston AR. Diaphyseal fractures of the humerus.
cyclic compression and failed at a lower load. This illustrates the Treatment with prefabricated braces. J Bone Joint Surg Am 1988;70:607–10.
[7] Zhang Y. Clinical epidemiology of orthopedic trauma. vol. 2012. Thieme; n.d.
importance of a good fit between plate and bone.
[8] Schemitsch EH, Richards RR. The effect of malunion on functional outcome after
Jin-Ho Hwang et al. [38] studied the mismatch of anatomical pre- plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg
contoured locking plates in the Asian population and demonstrated Am 1992;74:1068–78.
the resulting malalignment in using a minimal invasive technique [9] Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM. The posterior Monteggia lesion. J
Orthop Trauma 1991;5:395–402.
and failing to realize that there is a mismatch between the plate and
[10] Snow BJ, Javidan P, Itamura JM, Lee TQ. The effects of varus or valgus malalignment
the femur. In their cadaver study, they found a consistent pattern of of proximal ulnar fractures on forearm rotation. J Orthop Trauma 2014;28:143–7.
mismatch in the proximal end of an 11-hole Locking compression [11] Windisch G, Clement H, Grechenig W, Tesch NP, Pichler W. The anatomy of the
plate-distal femur applied on the lateral surface of the distal femur. proximal ulna. J Shoulder Elb Surg 2007;16:661–6.
The average distance at the proximal tip of the plate was 11.36 mm. [12] Rickert M, Bürger A, Günther CM, Schulz CU. Forearm rotation in healthy adults of
all ages and both sexes. J Shoulder Elb Surg 2008;17:271–5.
Locking the plate in this position will increase the risk of tissue [13] Kapandji A. Biomechanics of pronation and supination of the forearm. Hand Clin
irritation though contained in a large muscle envelope. Forcing the 2001;17:111–22, vii.
plate closer to the bone will result in significant valgus malalignment [14] Bronstein A, Heaton D, Tencer A, Trumble T. Distal radius malunion and forearm
at the fracture site. This pitfall is especially important to take into rotation: a cadaveric study. J Wrist Surg 2014;03:007–11.
[15] Simmermacher RKJ, Ljungqvist J, Bail H, Hockertz T, Vochteloo AJH, Ochs U, et al.
consideration in comminuted fractures.
The new proximal femoral nail antirotation (PFNA) in daily practice: results of a
Being aware that most pre-contoured anatomical plates fits a multicentre clinical study. Injury 2008;39:932–9.
50-percentile Caucasian population is important in pre-surgical [16] Laros GS. Intertrochanteric fractures. The role of complications of fixation. Arch
planning. Evaluation of the contralateral bone and the characteristics Surg Chic Ill 1960 1975;110:37–40.
[17] Zlowodzki M, Brink O, Switzer J, Wingerter S, Woodall J, Petrisor BA, et al. The
of the plate may help in planning additional bending of pre-shaped
effect of shortening and varus collapse of the femoral neck on function after fixa-
plates and bending tools should always be available when applying tion of intracapsular fracture of the hip: a multi-centre cohort study. J Bone Joint
a plate, even a so-called anatomical one. Surg Br 2008;90:1487–94.
In the future, we will experience better anatomical designs, when [18] Marmor M, Liddle K, Buckley J, Matityahu A. Effect of varus and valgus align-
ment on implant loading after proximal femur fracture fixation. Eur J Orthop Surg
designs are based on large databases with CT bone images from
Traumatol 2016;26:379–83.
several representative populations [41]. [19] Bråten M, Terjesen T, Rossvoll I. Torsional deformity after intramedullary nailing
More technology such as computer based preoperative planning of femoral shaft fractures. Measurement of anteversion angles in 110 patients. J
tools will help us to choose the right implant, and 3D printers that Bone Joint Surg Br 1993;75:799–803.
produce and customize plates that fits the geometry of any bone [20] Jaarsma RL, Verdonschot N, van der Venne R, van Kampen A. Avoiding rotational
malalignment after fractures of the femur by using the profile of the lesser tro-
could perhaps revolutionize plate osteosynthesis. chanter: an in vitro study. Arch Orthop Trauma Surg 2005;125:184–7.
This review focuses on common relevant fracture sites and [21] Ramanoudjame M, Guillon P, Dauzac C, Meunier C, Carcopino JM. CT evalua-
the included locations are used to illuminate general pitfalls and tion of torsional malalignment after intertrochanteric fracture fixation. Orthop
problems when treating fractures of the long bones in adults. The Traumatol Surg Res 2010;96:844–8.
[22] Krettek C, Müller M, Miclau T. Evolution of minimally invasive plate osteosynthe-
evidence shows that especially rotation is hard to control and focus
sis (MIPO) in the femur. Injury 2001;32 Suppl 3:SC14–23.
on the problem and knowledge on the best ways to handle rotation [23] Collinge CA, Gardner MJ, Crist BD. Pitfalls in the application of distal femur plates
is important tools to bring to the operation room. for fractures. J Orthop Trauma 2011;25:695–706.
The goal to restore the pre-trauma state with a stable, pain free [24] Langer JS, Gardner MJ, Ricci WM. The cortical step sign as a tool for assessing
and correcting rotational deformity in femoral shaft fractures. J Orthop Trauma
bone and adjacent joints after a fracture in an adult long bone is not
2010;24:82–8.
always possible. Knowledge of the consequences of malalignment is [25] Tornetta P, Ritz G, Kantor A. Femoral torsion after interlocked nailing of unstable
key to offer the patient the best individual care. Cost, immobilization, femoral fractures. J Trauma 1995;38:213–9.
pre-trauma function, co-morbidities and future demands are [26] Bråten M, Tveit K, Junk S, Aamodt A, Anda S, Terjesen T. The role of fluoroscopy
in avoiding rotational deformity of treated femoral shaft fractures: an anatomical
important parameters to take into consideration when choosing
and clinical study. Injury 2000;31:311–5.
the right treatment strategy, this often being variations of bracing, [27] Kim J-W, Oh C-W, Oh J-K, Park I-H, Kyung H-S, Park K-H, et al. Malalignment
plating or nailing. after minimally invasive plate osteosynthesis in distal femoral fractures. Injury
2017;48:751–7.
Disclosure [28] Handolin L, Pajarinen J, Lindahl J, Hirvensalo E. Retrograde intramedullary nailing
in distal femoral fractures--results in a series of 46 consecutive operations. Injury
2004;35:517–22.
The authors of this manuscript hold no conflict of interest. No [29] Schmidt AH, Finkemeier CG, Tornetta P. Treatment of closed tibial fractures. Instr
funding was received for this work. Course Lect 2003;52:607–22.
[30] Sarmiento A. On the behavior of closed tibial fractures: clinical/radiological cor-
relations. J Orthop Trauma 2000;14:199–205.
Acknowledgment
[31] van der Schoot DK, Den Outer AJ, Bode PJ, Obermann WR, van Vugt AB.
Degenerative changes at the knee and ankle related to malunion of tibial frac-
The authors of this manuscript express their thanks to the tures. 15-year follow-up of 88 patients. J Bone Joint Surg Br 1996;78:722–5.
Osteosynthesis and Trauma Care Foundation for the sponsorship of [32] Weinberg DS, Park PJ, Liu RW. Association between tibial malunion deform-
ity parameters and degenerative hip and knee disease. J Orthop Trauma
the publication of this Supplement in Injury.
2016;30:510–5.
[33] Tarr RR, Resnick CT, Wagner KS, Sarmiento A. Changes in tibiotalar joint contact
References areas following experimentally induced tibial angular deformities. Clin Orthop
1985:72–80.
[1] Richard Buckley, Moran CG, Buckley R, editors. AO principles of fracture manage- [34] Prasad M, Yadav S, Sud A, Arora NC, Kumar N, Singh S. Assessment of the role
ment. vol. 2007. Thieme; n.d. of fibular fixation in distal-third tibia–fibula fractures and its significance in
[2] Gardner MJ, Evans JM, Dunbar RP. Failure of fracture plate fixation. J Am Acad decreasing malrotation and malalignment. Injury 2013;44:1885–91.
Orthop Surg 2009;17:647–57. [35] Hasenboehler E, Rikli D, Babst R. Locking compression plate with minimally inva-
[3] Rockwood CA, Court-Brown CM, Heckman JD, Mcqueen, Ricci W, Tornetta P, et al. sive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective
Rockwood and Green’s fractures in adults. Eighth edition. Wolters Kluwer; 2015. study of 32 patients. Injury 2007;38:365–70.
[4] Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of [36] Kettelkamp DB, Hillberry BM, Murrish DE, Heck DA. Degenerative arthritis of the
fractures of the shaft of the humerus. J Bone Joint Surg Am 1977;59:596–601. knee secondary to fracture malunion. Clin Orthop 1988:159–69.
[5] Crespo AM, Konda SR, De Paolis A, Cardoso L, Egol KA. Posttraumatic malalign- [37] Merchant TC, Dietz FR. Long-term follow-up after fractures of the tibial and fibu-
ment of the humeral shaft: challenging the existing paradigm. J Orthop Trauma lar shafts. J Bone Joint Surg Am 1989;71:599–606.
2016;30:e48–52. [38] Hwang J-H, Oh J-K, Oh C-W, Yoon Y-C, Choi HW. Mismatch of anatomically
 M. Anneberg and O. Brink / Injury, Int. J. Care Injured 49S1 (2018) S66–S71 S71

pre-shaped locking plate on asian femurs could lead to malalignment in the mini- [40] Ahmad M, Nanda R, Bajwa AS, Candal-Couto J, Green S, Hui AC. Biomechanical
mally invasive plating of distal femoral fractures: a cadaveric study. Arch Orthop testing of the locking compression plate: when does the distance between bone
Trauma Surg 2012;132:51–6. and implant significantly reduce construct stability? Injury 2007;38:358–64.
[39] Schmutz B, Wullschleger ME, Kim H, Noser H, Schütz MA. Fit assessment of ana- [41] Banerjee S, Faizan A, Nevelos J, Kreuzer S, Burgkart R, Harwin SF, et al. Innovations
tomic plates for the distal medial tibia. J Orthop Trauma 2008;22:258–63. in hip arthroplasty three-dimensional modeling and analytical technology
(SOMA). Surg Technol Int 2014;24:288–94.