Decision Making in Management of Intertrochanteric Femur Fractures in Adults

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Original Article | Vol 12 | Issue 1 | January-June 2026 | page: 49-55 | Sachin Kale, Wasudeo Gadegone, Sushant Srivastav, Nikhil Makhija, Ameey Abhishek, Arpan Mittal

DOI: https://doi.org/10.13107/ti.2026.v12.i01.90

Submitted: 04/03/2023; Reviewed: 27/03/2023; Accepted: 07/05/2023; Published: 10/04/2026

Authors: Sachin Kale [1], Wasudeo Gadegone [2], Sushant Srivastav [1], Nikhil Makhija [1], Ameey Abhishek [1], Arpan Mittal [1]

[1] Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India.

[2] Gadegone Hospital, Chandrapur, Maharashtra, India.

Address of Correspondence

Dr. Sachin Kale

Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India.

E-mail: sachinkale@gmail.com

Abstract

Intertrochanteric femur fractures are among the most common proximal femoral injuries, particularly in the elderly with osteoporosis. They are associated with significant morbidity, mortality, and loss of independence. Although these fractures generally have good vascularity and low nonunion rates, their inherent mechanical instability demands precise assessment of stability and individualized implant selection. This chapter provides a clinically oriented review of anatomy, biomechanics, classification, radiological evaluation, and evidence-based management strategies. Fracture stability—guided primarily by the integrity of the posteromedial cortex, lateral wall, and overall pattern—remains the cornerstone of decision-making. Stable fractures (AO/OTA 31-A1) are reliably managed with a sliding hip screw (DHS), while unstable patterns (most 31-A2 and all 31-A3) are best treated with cephalomedullary nails (e.g., PFNA or equivalent) due to their superior biomechanical stability and load-sharing properties. The integrity of the lateral wall plays a critical role in determining implant choice, as its compromise significantly increases the risk of fixation failure with extramedullary devices. Achieving proper reduction, particularly avoiding varus malalignment, is essential to prevent complications. Early surgical intervention and mobilization are key factors in reducing systemic complications such as deep vein thrombosis and pulmonary complications. In India, intertrochanteric fractures predominate among proximal femoral injuries, often with delayed presentation. Osteoporosis (Singh’s index), domestic falls, and comorbidities (hypertension, diabetes) are common. Early surgery (ideally within 48 hours when medically optimized), multidisciplinary care, and rehabilitation remain challenges but are essential for improving functional recovery and reducing mortality. Early surgical fixation and mobilization, within a multidisciplinary framework, are critical to optimizing outcomes. Individualized treatment planning, meticulous surgical technique, and early mobilization remain the cornerstones of achieving favorable functional outcomes, particularly in the elderly population.

Keywords: Intertrochanteric fracture, proximal femoral nail, dynamic hip screw, fracture stability, lateral wall, cephalomedullary nailing

References

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How to Cite this article: Kale S, Gadegone W, Srivastav S, Makhija N, AbhishekA, Mittal M. Decision Making in Management of Intertrochanteric Femur Fractures in Adults. | January-June 2026; 12(1): 49-55 | https://doi.org/10.13107/ti.2026.v12.i01.90

 

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Comparison of a Breathable Mesh Cast Versus Conventional Fiberglass Cast in Distal Radius Fractures: A Prospective Randomized Controlled Trial of 450 Patients

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Original Article | Vol 12 | Issue 1 | January-June 2026 | page: 44-48 | Shivam Mehra, Kamal Mehra, Sachin Y. Kale, Nitesh Kumar Saini, Ameey Abhishek, Nikhil Makhija, Riddhi Shah

DOI: https://doi.org/10.13107/ti.2026.v12.i01.88

Submitted: 18/02/2026; Reviewed: 13/03/2026; Accepted: 25/03/2026; Published: 10/04/2026

Authors: Shivam Mehra [1], Kamal Mehra [1], Sachin Y. Kale [2], Nitesh Kumar Saini [3], Ameey Abhishek [2], Nikhil Makhija [2], Riddhi Shah [2]

[1] Department of Orthopaedics, Mehra Hospital and Research Institute, Lucknow, Uttar Pradesh, India

[2] Department of Orthopaedics, Dr. D.Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India.

[3] Department of Orthopaedics, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Address of Correspondence Dr. Shivam Mehra Consultant Orthopaedic Surgeon, Mehra Hospital and Research Institute, Lucknow, Uttar Pradesh, India Email: drshivammehra@gmail.com

Abstract

Introduction: Clavicle Background: Distal radius fractures are among the most common fractures managed conservatively. Conventional fiberglass casts, although effective in immobilization, are frequently associated with patient discomfort, itching, sweating, and skin-related complications due to poor ventilation and moisture retention [1,2]. Breathable mesh casts have been developed to improve ventilation, hygiene, and overall patient experience.

Methods: A total of 450 adult patients with closed distal radius fractures were enrolled in this prospective randomized controlled trial and equally allocated into two groups: breathable mesh cast (n = 225) and conventional fiberglass cast (n = 225). The primary outcome was patient comfort assessed using the Visual Analog Scale (VAS) for itching. Secondary outcomes included skin complications, patient compliance, and radiological fracture union. Statistical analysis was performed using independent t-tests and chi-square tests, with p < 0.05 considered significant.

Results: Mean VAS itching scores were significantly lower in the breathable cast group at all time points (p < 0.001). Skin complications occurred in 8.4% of patients in the mesh cast group compared with 25.3% in the fiberglass group (p = 0.001). Compliance was significantly higher in the mesh cast group (95.1% vs 84.0%, p = 0.006). Fracture union rates were comparable between the groups (97.3% vs 95.6%, p = 0.48).

Conclusion: Breathable mesh casts significantly improve patient comfort and reduce skin complications without compromising fracture healing, making them a superior alternative to conventional fiberglass casts.

Keywords: Breathable mesh, Cast, Distal radius fractures, VAS

References

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How to Cite this article: Mehra S, Mehra K, Kale SY, Saini NK, Abhishek A, Makhija N, Shah R | Comparison of a Breathable Mesh Cast Versus Conventional Fiberglass Cast in Distal Radius Fractures: A Prospective Randomized Controlled Trial of 450 Patients | January-June 2026; 12(1): 44-48 | https://doi.org/10.13107/ti.2026.v12.i01.88

 

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A Prospective Study to Assess Radiological and Functional Outcomes in the Surgical Management of Displaced Middle Third Clavicle Fractures Fixed with TENS Titanium Elastic Intra-Medullary Nail

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Original Article | Vol 12 | Issue 1 | January-June 2026 | page: 36-43 | Sanjay Chhawra, Rahul Aggarwal, Raman Jain, Amit Gupta, Amit Nagar, Rishav Anand, Rajat Mudgal, Hritik Swarnkar

DOI: https://doi.org/10.13107/ti.2026.v12.i01.86

Submitted: 21/02/2026; Reviewed: 29/03/2026; Accepted: 02/04/2026; Published: 10/04/2026

Authors: Sanjay Chhawra [1], Rahul Aggarwal [1], Raman Jain [1], Amit Gupta [1], Amit Nagar [1], Rishav Anand [1], Rajat Mudgal [1], Hritik Swarnkar [1]

[1] Department of Orthopaedics, Jaipur Golden Hospital, Sector 3 Rohini, New Delhi, India.

Address of Correspondence

Dr. Sanjay Chhawra,

Department of Orthopaedics, Jaipur Golden Hospital, Sector 3 Rohini, New Delhi, India.

E-mail: sanjaychhawra@yahoo.com

Abstract

Introduction: Clavicle fractures are common injuries, accounting for 5%-10% of total fractures. The middle third of the clavicle is fractured in 69% of cases, the distal third is fractured in 28% of cases, and the proximal third is fractured in 3% of cases. Early displaced midshaft clavicle fractures were treated conservatively after studies it has being defined that there is nonunion with decreased functional outcome. Surgery is indicated in the event of substantial fracture displacement and accompanying neurovascular damage. Plate osteosynthesis is the conventional approach for treating fractures requiring internal fixation with various complications. Intramedullary fixation using the titanium elastic nailing system (TENS) is becoming a more preferred method for internal fixation of displaced mid-clavicular fractures with minimal incision and better functional outcomes.

Methodology: A prospective study was undertaken with a sample size of 30 patients over two years, with all cases followed up for 12 months. A complete clinical examination of the patient was conducted to evaluate associated injury radiological assessment of the intramedullary diameter of the clavicle was also done. Following approval and clearance from the institutional ethics committee, patients who met the inclusion criteria were enrolled in the study after providing informed consent. The functional outcomes of the study included ASES, CONSTANT, and VAS.

Result: The mean operation time was 40 min, 3 days after surgery the VAS score was 2-3, Union in weeks mean was 10 weeks and functional score after 12 months ASES Score 3 cases of 51-70 22 cases of 71-90 5 cases of 91-100 and at last CONSTANT Score- 12th month 1 cases 56-70 15 cases of 71-85 14 cases of 86-100

Conclusion: TENS is a safe, stable, minimally invasive surgical technique in indicated cases with reduced duration of the surgery, decrease the surgical site morbidity, early mobilization, faster return to daily activities, excellent cosmetic results with a lower complication rate.

Keywords: TENS, Clavicle, Union

References

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2. Wiesel B, Nagda S, Mehta S, Churchill R. Management of Midshaft Clavicle Fractures in Adults. J Am Acad Orthop Surg. 2018 Nov 15;26(22):e468-e476. [PubMed]

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4. Ban I, Troelsen A. Risk profile of patients developing nonunion of the clavicle and outcome of treatment–analysis of fifty five nonunions in seven hundred and twenty nine consecutive fractures. Int Orthop. 2016 Mar;40(3):587-93. [PubMed]

5. Roberto Postacchini & Stefano Gumina Long-term results of conservative management of midshaft clavicle fracture International Orthopaedics (SICOT) (2010) 34:731–736 DOI 10.1007/s00264-009-0850-x

6. Andreas Papaleontiou Conservative vs surgical treatment of midshaft clavicular fractures: a systematic review EFORT Open Reviews (2026) 11 349–358 https://doi.org/10.1530/EOR-2025-0005

7. Kadakia AP, Rambani R, Qamar F, McCoy S, Koch L, Venkateswaran B. Titanium elastic stable intramedullary nailing of displaced midshaft clavicle fractures: A review of 38 cases. Int J Shoulder Surg 2012;6:82 5.

8. Fu B. Minimally invasive intramedullary nailing of clavicular fractures by a new titanium elastic nail. Acta Orthop Traumatol Turc 2016;50:494 500.

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21. WEINA JU1 Comparison of plate fixation vs. intramedullary fixation for the management of mid shaft clavicle fractures: A systematic review and meta analysis of randomised controlled trials Experimental and Therapeutic Medicine 20: 2783-2793, 2020 DOI: 10.3892/etm.2020.9002

22. Jun Sung Park, Sang Hyun Ko Plate fixation versus titanium elastic nailing in midshaft clavicle fractures based on fracture classifications Journal of Orthopaedic Surgery 28(3) 1–11 DOI: 10.1177/2309499020972204

23. Hrushikesh Saraf a, Sarang Kasture bClosed vs open nailing for displaced middle third fracture of the clavicle. Does it matter? Journal of Clinical Orthopaedics and Trauma Volume 7, Supplement 2, October–December 2016, Pages 161-165 https://doi.org/10.1016/j.jcot.2016.08.005Get rights and content

24. Partha Saha Plate versus titanium elastic nail in treatment of displaced midshaft clavicle fractures A comparative study Indian Journal of Orthopaedics | November 2014 | Vol. 48 | Issue 6 DOI: 10.4103/0019-5413.144227

How to Cite this article: Chhawra S, Aggarwal R, Jain R, Gupta A, Nagar N, Anand R, Mudgal R, Swarnkar H | A Prospective Study to Assess Radiological and Functional Outcomes in the Surgical Management of Displaced Middle Third Clavicle Fractures Fixed with TENS Titanium Elastic Intra-Medullary Nail | January-June 2026; 12(1): 36-43 |

https://doi.org/10.13107/ti.2026.v12.i01.86

 

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Comprehensive Management of Proximal Humerus Fractures in Adults: A Practical Clinical Review and Decision-Making Framework

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Review Article | Vol 12 | Issue 1 | January-June 2026 | page: 31-35 | Sachin Kale, Nilesh Kamat, Shailesh Pai, Ashok Shyam, Gaurav Sharma, Nikhil Makhija , Riddhi Shah

DOI: https://doi.org/10.13107/ti.2026.v12.i01.84

Submitted: 04/03/2023; Reviewed: 27/03/2023; Accepted: 07/05/2023; Published: 10/04/2026

Authors: Sachin Kale [1], Nilesh Kamat [1], Shailesh Pai [1], Ashok Shyam [1], Gaurav Sharma [1], Nikhil Makhija [1], Riddhi Shah [1]

[1] Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India. Address of Correspondence Dr. Sachin Kale Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India. E-mail: sachinkale@gmail.com

Abstract

Background: Proximal humerus fractures accounts for 5-6% of all adult fractures, treatment of which still remains controversial. The present review highlights the clinical review and propose a decision making framework for the treatment of proximal humerus fractures.

Methods: This narrative review focuses on key principles that directly influence day-to-day clinical decision-making. The review has been subdivided into sections covering anatomy and biomechanics, Clinical evaluation and imaging, various classification systems, decision-making and complications.

Conclusion: The management of proximal humerus fractures should always be individualized, integrating fracture-specific factors such as pattern, displacement, and vascular compromise with patient-related considerations including age, bone quality, and functional expectations. A thorough understanding of anatomy, biomechanics, and available treatment modalities is essential for optimal outcomes. Advances in fixation techniques and the increasing role of shoulder arthroplasty—especially reverse shoulder arthroplasty—have significantly improved functional results, particularly in the elderly population. Careful patient selection and adherence to sound surgical principles remain the cornerstone of successful management.

Keywords: Proximal Humerus fracture, Clinical decision making, Neer classification

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How to Cite this article: Kale S, NKamat N, Pai S, Shyam A, Sharma G, Makhija N, Shah R | Comprehensive Management of Proximal Humerus Fractures in Adults: A Practical Clinical Review and Decision-Making Framework | January-June 2026; 12(1): 31-35 |

https://doi.org/10.13107/ti.2026.v12.i01.84

 

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Comprehensive Management of Distal End Radius Fractures in Adults: A Clinical Review and Decision-Making Approach

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Review Article | Vol 12 | Issue 1 | January-June 2026 | page: 25-30 | Sachin Kale, Altaf Warid, Gaurav Sharma, Ashok Shyam, Ashok Ghodke, Nikhil Makhija

DOI: https://doi.org/10.13107/ti.2026.v12.i01.82

Submitted: 07/01/2026; Reviewed: 02/02/2026; Accepted: 06/03/2026; Published: 10/04/2026

Authors: Sachin Kale [1], Altaf Warid [1], Gaurav Sharma [1], Ashok Shyam [1], Ashok Ghodke [1], Nikhil Makhija [1]

[1] Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Sachin Kale,

Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India.

E-mail: sachinkale@gmail.com

Abstract

Background: Distal radius fractures represent one of the most frequently encountered injuries in orthopaedic practice worldwide, accounting for a significant proportion of upper limb fractures across all age groups. These fractures demonstrate a bimodal distribution, occurring commonly in young individuals following high-energy trauma and in elderly osteoporotic patients after low-energy falls. Over the past few decades, the management of distal radius fractures has undergone substantial evolution, driven by advancements in imaging modalities such as computed tomography, a deeper understanding of wrist biomechanics, and the development of improved fixation techniques. These advances have enabled more precise fracture characterization and have contributed to better functional restoration.

Objectives: This review aims to provide a comprehensive yet practical overview of distal radius fractures, with particular emphasis on systematic clinical evaluation, commonly used classification systems, and contemporary evidence-based management strategies. The goal is to aid clinicians in making informed decisions tailored to individual patient and fracture characteristics.

Methods: A narrative review was conducted using standard orthopaedic textbooks, peer-reviewed journal articles, and widely accepted clinical guidelines. Relevant literature focusing on epidemiology, fracture classification (including commonly used systems such as Frykman, Fernandez, and AO/OTA), imaging modalities, and both conservative and surgical management approaches was analyzed to synthesize current best practices.

Results: The management approach to distal radius fractures largely depends on fracture stability, displacement, intra-articular involvement, and patient-related factors such as age, bone quality, functional demands, and comorbidities. Stable, extra-articular fractures with acceptable alignment generally respond well to conservative treatment, including immobilization with casting. However, unstable fractures—characterized by dorsal comminution, significant displacement, loss of radial height or inclination, and intra-articular extension—are associated with a higher risk of malunion and functional impairment when treated non-operatively. Surgical intervention in such cases has been shown to provide superior anatomical reduction and improved functional outcomes. Among surgical options, volar locking plate fixation has gained widespread acceptance due to its biomechanical stability, ability to maintain reduction in osteoporotic bone, and facilitation of early mobilization. Other modalities, including external fixation, percutaneous pinning, and dorsal plating, remain relevant in selected scenarios.

Conclusion: The management of distal radius fractures should be individualized, considering both fracture-specific characteristics and patient-related factors. A thorough clinical and radiological assessment is essential for optimal decision-making. Modern fixation techniques, particularly volar locking plates, have significantly enhanced the ability to achieve stable fixation and early functional recovery. Nevertheless, careful patient selection and adherence to sound surgical principles remain critical to achieving favorable outcomes.

Keywords: AO Classification, Distal End Radius Fractures, Volar Plating, Decision Making

References

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How to Cite this article: Kale S, Warid A, Sharma G, Shyam A, Ghodke A, Makhija N | Comprehensive Management of Distal End Radius Fractures in Adults: A Clinical Review and Decision-Making Approach | January-June 2026; 12(1): 25-30 | https://doi.org/10.13107/ti.2026.v12.i01.82

 

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Fixation Modalities for Medial Void in Distal Femur Fractures: A Narrative Review

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Review Article | Vol 12 | Issue 1 | January-June 2026 | page: 21-24 | Sachin Kale, Ashok Ghodke, Tejaswini Milind Patankar, Gaurav Kanade, Abhilash Srivastava, Sagar Deshpande

DOI: https://doi.org/10.13107/ti.2026.v12.i01.80

Submitted: 09/02/2026; Reviewed: 04/03/2026; Accepted: 21/03/2026; Published: 10/04/2026

Authors: Sachin Kale [1], Ashok Ghodke [2], Tejaswini Milind Patankar [2], Gaurav Kanade [1], Abhilash Srivastava [1], Sagar Deshpande [3]

[1] Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India.

[2] Department of Orthopaedics, M G M Medical College Kamote Navi Mumbai, Maharashtra, India

[3] Department of Physiotherapy, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Sachin Kale;

Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India.

E-mail: sachinkale@gmail.com

Abstract

Medial void in distal femur fractures—resulting from metaphyseal comminution, cortical bone loss, or segmental defects—predisposes constructs to varus collapse, non-union, and hardware failure if left unsupported. This narrative review synthesises current fixation strategies to address the medial defect, including: (1) lateral locked plating with augmentation (subchondral rafting, kickstand/medial column screws, bone graft and substitutes, and cement augmentation), (2) dual plating with a medial buttress, (3) nail–plate combination constructs, and (4) emerging concepts such as far cortical locking and linked constructs. Across biomechanical and clinical studies, strategies that restore a medial buttress or create a stable load-sharing environment reduce varus collapse, improve radiographic parameters, and may shorten time to union in comminuted, osteoporotic, or peri‑articular patterns. Technique selection should be individualised by patient factors (bone quality, soft tissue, comorbidities), fracture morphology (AO/OTA 33‑A3/C3, periprosthetic, non‑union), and intra‑operative reduction behaviour. We propose a pragmatic, reduction‑first algorithm prioritising medial column support, balanced construct flexibility, adequate working length, and biological preservation. Future work should include comparative trials of dual plating versus nail–plate constructs with standardised indications and patient‑reported outcomes.

Keywords: Distal femur fracture, Medial void, Dual plating, Nail–plate construct, Cement augmentation, Far cortical locking, Kickstand screw

References

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3. Ricci WM, Streubel PN, Morshed S, Collinge CA, Nork SE, Gardner MJ. Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases. J Orthop Trauma. 2014;28(2):83–89.

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13. Baumann AN, et al. Nail‑plate combination constructs versus single traditional constructs for distal femur fractures: comparative outcomes. Injury. 2024.

14. Xu W, et al. Comparison of retrograde nail plus lateral plate versus dual plating in AO/OTA 33C distal femur fractures: a retrospective cohort. Sci Rep. 2025;15.

15. Bäumlein M, et al. Cement augmentation of angular stable plate fixation in distal femur: biomechanical effects of fenestrated condylar screws. BMC Musculoskelet Disord. 2020;21:282.

16. Wähnert D, et al. Implant augmentation in the treatment of distal femoral fractures: a biomechanical investigation. Injury. 2013;44(6):785–789.

17. DeBaun MR, et al. Calcium phosphate cement and locked plate augmentation of large distal femoral defects: comparative study. Knee. 2019;26(5):1040–1048.

18. Bottlang M, Doornink J, Fitzpatrick DC, et al. Far cortical locking enables flexible fixation with periarticular locking plates. Clin Orthop Relat Res. 2011;469:1757–1765.

19. Bottlang M, et al. Dynamic fixation of distal femur fractures using far cortical locking screws: prospective observational study. J Orthop Trauma. 2014;28(12):e276–e283.

20. Stockton DJ. Distal Femur Fractures—OTA Core Curriculum; selected readings and references (includes Ricci et al.). 2021.

How to Cite this article: Kale S, Srivastava A, Deore S, Yadav A, Kushdeep, Datta S | The Three-Stitch Technique for Antegrade Humerus Nailing: A Minimally Invasive Approach to Improved Functional Outcomes and Reduced Complications in Humerus Shaft Fractures Narrative review | January-June 2026; 12(1): 15-20 | https://doi.org/10.13107/ti.2026.v12.i01.78

 

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