PRACTICAL TRAUMA TREATMENT
From The University of South Florida College of Medicine’s Orthopaedic Trauma: Concepts to Controversies
Educational Objectives
| The goal of this program is to improve the management of orthopaedic trauma. After hearing and assimilating this program,
the orthopaedic surgeon will be better able to:
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 | 1. Apply locking plates.
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| 2. Incorporate nonlocking and hybrid plating into fracture management.
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| 3. Treat periprosthetic femur fractures.
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| 4. Implement recommendations for treating open tibial shaft fractures.
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| 5. Manage compartment syndrome
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Ricci—
Synthes; Smith & Nephew; Wright (institutional/research support); Smith & Nephew; Orthovita; Wright (consultant);
Smith & Nephew (royalties). Dr. Schmidt—Smith & Nephew (consultant); Smith & Nephew; Medtronic (research support).
Dr. Zura and the planning committee reported nothing to disclose.
Acknowledgements
Drs. Ricci, Smith, and Zura were recorded at Orthopaedic Trauma: Concepts to Controversies, sponsored by the University
of South Florida College of Medicine in Snowmass, CO, February 13-16, 2008. The Audio-Digest Foundation
thanks the speakers and the sponsor for their cooperation in the production of this program.
| LOCKING PLATES: INDICATIONS, PEARLS, PITFALLS —William M. Ricci, MD, Associate Professor of Orthopaedic
Surgery, Washington University School of Medicine, and Barnes-Jewish Hospital, St Louis, MO
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| Indications for locked plating: comminuted fracture of end-segment of bone (metaphyseal; supracondylar; distal femur;
proximal tibia; proximal humerus); better fixation in osteoporotic bone
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| No significant advantages for locked plating: split depressed fracture; partial articular fracture; vertical fractures
buttress plate and lag screw; diaphyseal fracture in healthy bone
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| Hybrid locked plating: combines locked screws and traditional screws; offers advantages of locked and nonlocked
constructs
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| “Pure” locked plating: no nonlocking screws; cannot use plate as reduction aid; obtain reduction before adding locked
screws; lacks compression between plate and bone for stability
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| Simultaneous evolution: since 1990s; minimally invasive surgical techniques (preserve soft-tissue envelope); improvements
in plating technologies (locked plating)
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| Advantages of locked plating: fixed-angle construct; improved ability to withstand varus collapse; improved fixation
in osteoporotic bone
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| Screw failure: sequential with nonlocked screws—first screw loosens, transferring repetitive stress in osteoporotic bone
to next screw, etc; simultaneous with locked screws—all screws cut out of bone at once; result of additive effect; offers
better fixation in osteoporotic bone
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| Hybrid plating: use nonlocked screws first—enable plate to become reduction tool; add locked screws—for fixed-angle
support of end-segment; for improved fixation in osteoporotic bone
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| Guidelines: in any given fragment; nonlocked screws first; locked screws second
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| Risk factors for delayed healing: open fractures; obesity; diabetes
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| Tips and tricks to avoid failure: 3 areas of failure—diaphysis; distal segment; working distance of plate over fracture
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| Diaphyseal failure: screw loosening or fracture; to avoid—longer plate; screws near and far from fracture
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| Distal segment: loosening—occurs with nonlocked construct; avoid cross-threading screws; tighten screws securely; fatigue
failure—occurs distally at plate-screw interface; avoid by using multiple large locking screws; cutout—shaft
fixation good but screws cut out; occurs in proximal humerus; avoid by using more and/or bigger screws and ensuring
proper reduction
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| At plate over fracture: to avoid—use sturdy enough plate; if slow to heal, consider bone grafting or early plate exchange
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| Potential pitfalls: feel of good purchase absent—with locked screws; unicortical screws—self-drilling offers no advantage;
speaker avoids using; cross-threading—some strength lost; in response, tighten screw as much as possible and
be sure several secure screws nearby
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| Conclusion: locked plating is not—substitute for good surgery; beneficial for every fracture; synonymous with minimally
invasive technique; locked plating is—useful tool when properly applied; beneficial as fixed-angle device to prevent
varus collapse and to improve fixation in osteoporotic bone; compatible with minimally invasive technique
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| PERIPROSTHETIC FEMUR FRACTURES —Andrew H. Schmidt, MD, Associate Professor of Orthopaedic Surgery,
University of Minnesota Medical School, and Hennepin County Medical Center, Minneapolis, MN
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| Patient characteristics: cachectic; poor bone quality; many medical comorbidities; often immunocompromised; impaired
wound and bone healing; sometimes accompanying trauma from high-energy injury; implants have—osteolysis;
stress risers (from screw holes, cortical perforation, and implant itself)
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| Goals of treatment: fracture union; maintaining functioning prosthesis; avoiding succession of fractures along bone
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| Mechanical: stress risers; existing implants limiting options for further fixation; poor bone quality
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| Biologic: cytokine abnormalities; impaired cellular function
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| Classification: either about failed implant or at end of bone
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| Vancouver classification: widely used; based on location of fracture
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| Type A: trochanteric region
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| AG: greater trochanter
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| AL: lesser trochanter
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| Type B: most common; about or just distal to stem
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| B1: implant stable
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| B2: implant loose, and bone stock adequate for relatively standard revision
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| B3: implant loose, and bone stock inadequate; require complex revision surgery
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| Type C: distal femur
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| Beals and Tower classification: includes other features
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| Type II: metadiaphyseal fractures; occur in uncemented implants; typically with osteolysis, requiring revision surgery
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| Type IIIC: occur below long stem
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| Additional problem: fractures between implant
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| Biomechanical study: found lower area of bone with dramatic strains with loading
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| Traction: considered but usually discounted
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| External fixation: considered but usually discounted
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| Cerclage wires: now limited to fractures around trochanteric region
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| Plate fixation: standard compression plates; specialized cable plates; strut grafts; fixed-angle plates; locking plates
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| Treatment of well-fixed (type B1) implant: literature shows revision superior to plate fixation (high rate of complications);
constructs with proximal screws (alone or combined with wires) clearly most stable; take-home message—
need to apply screws to both sides of fracture
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| Dall-Miles plating: only 3 of 9 cases healed; all 6 failures had stem in varus
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| Newer fixation techniques: Ricci study of 50 consecutive patients; minimally invasive submuscular plating; locking
plates; exposure proximal and distal to fracture; no bone grafting; results—fractures healed within 12 wk; follow-up
of 41 patients found 30 returned to baseline activity
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| Tips for successful plating: whenever possible, consider fixed-angle device in distal part of femur; overlap prostheses;
obtain good fixation on both sides of fracture; apply cortical struts in manner that avoids devitalized femur
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| Fractures above total knee replacement: implant normally stable; choose between plate and retrograde nail; obtain
x-ray to determine limitations imposed on retrograde nailing by type of implant (table published in Journal of Bone and
Joint Surgery available on Internet); speaker prefers plating with minimally invasive techniques and rigid fixation
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| DISCUSSION —Drs. Ricci and Schmidt
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| How much to overlap plates: Dr. Schmidt—tries to plate whole femur; using 22- to 24-hole plate, make incision at
each end of femur and slide plate submuscularly; screws placement (greater trochanter; often behind in lesser trochanter;
sometimes in midshaft); Dr. Ricci—biomechanical engineers say 2.0 to 2.5 diameters
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| Unicortical screws and cables: Dr. Ricci—unicortical screws provide poor rotational stability; bicortical fixation required
(bicortical screw, behind or in front of prosthesis, or cables); favors 3 to 4 cables, supplementing with locked
screws if enough cortex; Dr. Schmidt—subscribes to near-near, far-far philosophy; 2 screws near fracture, 2 far from
fracture; in between, screw in cemented implant, otherwise 1 to 2 cerclage wires
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| Cerclage wiring: Dr. Ricci—efficacy of wires or cables depends on surgeon; key to avoid stripping periosteum (larger
incision in muscle helpful); Dr. Schmidt—makes big incision and inserts cables; minimally invasive at muscle; maximally
invasive at skin
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| Screws around stem: Dr. Ricci—reasonable if adequate room; long-term effect of drilling holes through cement mantle
unknown; Dr. Schmidt—uses screws fairly often; angling 2.7 screw helpful
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| B1 fracture (stable implant): Dr. Ricci—contrary to literature, B1 most common fracture today; implant rarely
loose; if loose, performs revision; Dr. Schmidt—if revision required, performs extended trochanteric osteotomy (delaying
procedure leads to destroying proximal femur while trying to avoid osteotomy)
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| 90°/90° metal plate–bone plate construct: Dr. Schmidt—medial strut graft superior to anterior-anterolateral cortical
strut graft; mechanical advantages outweigh downside of additional stripping of periosteum
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| Removing broken nail: Dr. Ricci—if no access to fracture site, uses multiple guide wires to grasp nail (not possible
with newer nails); has low threshold for opening fracture
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| OPEN TIBIAL SHAFT FRACTURES: CURRENT RECOMMENDATIONS —Robert D. Zura, MD, Assistant Professor of
Orthopaedic Surgery, Duke University School of Medicine, and Orthopaedic Trauma Service, Duke University Medical
Center, Durham, NC
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| Key questions: do I have to get out of bed in middle of night to treat open fracture? can I fix it? do I use a reamed or unreamed
nail? do I salvage or amputate mangled extremity?
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| Initial treatment: evaluation in emergency department; sterile dressing; reduce and splint; begin antibiotics; timing of
debridement—performing in <6 hr found to have no effect on outcome; treatment—meticulous debridement; explore
and extend wound; deliver bone ends for full exposure; excise foreign matter, necrotic muscle, and unattached bone fragments;
fasciotomy as indicated; high-pressure pulsatile lavage—97% effective in reducing bacterial count; promoted
bacterial count in to canal ≤4 cm; damaged bone; low-pressure lavage—equally effective within 3 hr of contamination;
less bone damage; not as effective after >6 hr; soap-solution lavage—found to reduce infection rates; new standard of
care
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| Wound closure: type I and type II wounds (“clean, simple”) can be closed initially; if in doubt, redebride in 24 to 72 hr;
high-grade wound—bead pouches; vacuum-assisted closure; redebride in 24 to 72 hr
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| External fixator: can be applied quickly; allows easy monitoring of soft tissues and compartments; malunion rate 20%;
pin-track infection risk; reserve for damage-control orthopaedics
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| Intramedullary (IM) nail: gold standard; less malunion and shortening; earlier weight-bearing; early ankle and knee motion;
reduced time to union
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| Arguments for reamed nail: larger diameter; reaming provides autograft; better fracture healing
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| Arguments for unreamed nail: small diameter; preserves endosteal blood supply; better fracture healing; negative
finding—more hardware failure than with reamed nail
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| Recent studies: in 161 open fractures, unreamed nails had less hardware failure than previously reported; Study to Prospectively
evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT)—unpublished results suggest less
pronounced difference between reamed and unreamed nails
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| Plating: increased deep infection risk ≤13%
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| When methods compared: external fixators better than plates; reamed and unreamed nails better than external fixators;
reamed nails may be better than unreamed nails
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| Bone grafting: may be indication for bone morphogenic protein (BMP); BMP proved safer, with fewer infections and
faster fracture healing; cost effectiveness unknown
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| Limb salvage vs amputation: saving patient always more important than limb; analysis of 527 patients (119 amputations;
54 immediate; 64 delayed); no difference at 2 and 7 yr; salvage less expensive (for young patient, lifetime cost of
prosthesis almost $0.5 million)
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| Predictors of poor outcome: major complication; poor education; nonwhite; low income or no insurance; smoker; low
self efficacy; involvement with legal system
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| Plantar sensation: absence not absolute indication for amputation; 80% of 29 limbs admitted to hospital without sensation
regained sensation by 24 mo
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| COMPARTMENT SYNDROME —Dr. Schmidt
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| Clinical findings: pain over affected compartment; stretch pain; patient feels cast or splint too tight; neurologic—
numbness early sign; each compartment has sensory nerve that can be tested; for anterior compartment, document sensation
in first web space for deep peroneal nerve
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| Making diagnosis: can reliably rule out compartment syndrome in absence of clinical findings; presence of findings not
clear indication compartment syndrome present
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| Diagnostic problem: regional or intravenous anesthesia may mask symptoms
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| Intramuscular (IM) pressure measurement: adjunct to clinical examination; may be only means in unconscious
patients; normal muscle compartment pressure 0 to 8 mm Hg; elevated pressure itself not indication of degree of tissue
injury
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| Perfusion (differential) pressure: based on relation between IM pressure and blood pressure (BP); if diastolic BP >30 mm
Hg above IM pressure, fasciotomy not indicated; intraoperative measurement—rely on preoperative pressure (anesthesia
lowers intraoperative pressure)
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| Continuous pressure monitoring (CPM): associated with earlier diagnosis of compartment syndrome; early fasciotomy
decreased rate of nonunion and improved outcome
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| Clinical examination: if benign, syndrome absent; if not benign or not possible, consider measuring IM pressure
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| If IM pressure <30 mm Hg, syndrome absent; if >30 mm Hg, calculate perfusion pressure
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| If perfusion pressure >30 mm Hg, fasciotomy not indicated; if <30 mm Hg, follow patient (fasciotomy may be necessary)
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| Treatment: reduce pressure as fast as possible; irreversible changes occur in 6 to 8 hr; perform fasciotomy, extending entire
length of compartment and skin; complications—prominent scars; skin grafting often necessary; some patients develop
chronic venous insufficiency
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| Avoiding fasciotomy: need to improve diagnostic criteria; avoid circumferential bandages and splints; elevate limb
above heart (dependent limb increases venous stasis); improve tissue oxygenation—increase tolerance of muscle to ischemia;
decrease IM pressure; hyperbaric oxygen not feasible; pharmacologic means (free radical scavengers; small-volume
resuscitation with hypertonic saline) not currently available; reducing tissue pressure—foot pumps; diuretics (eg,
mannitol); tissue ultrafiltration under investigation by speaker
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| Summary: remain vigilant; consider CPM; document findings frequently and thoroughly; less invasive therapies expected
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Suggested Reading
Clausen JD et al: Biomechanical evaluation of Caspar Cervical Spine Locking Plate systems in a cadaveric model. J
Neurosurg 84:1039, 1996; Do Koh Y et al: A biomechanical comparison of modern anterior and posterior plate fixation
of the cervical spine. Spine 26:15, 2001; Duggal N et al: Unilateral cervical facet dislocation: biomechanics of fixation.
Spine 30:E164, 2005; Egol KA et al: Biomechanics of locked plates and screws. J Orthop Trauma 18:488, 2004; Gardner
MJ et al: Hybrid locked plating of osteoporotic fractures of the humerus. J Bone Joint Surg Am 88:1962, 2006;
Gardner MJ et al: Second-generation concepts for locked plating of proximal humerus fractures. Am J Orthop 36:460,
2007; Halpern AA et al: Anterior compartment pressures in patients with tibial fractures. J Trauma 20:786, 1980;
Harris IA et al: Continuous compartment pressure monitoring for tibia fractures: does it influence outcome?... J Trauma
60:1330, 2006; Kakar S et al: Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for
the diagnosis of compartment syndrome. J Orthop Trauma 21:99, 2007; Kumar V et al: Less invasive stabilization system
for the management of periprosthetic femoral fractures around hip arthroplasty. J Arthroplasty 23:446, 2008; Lin J et
al: Locked nailing of severely comminuted or segmental humeral fractures. Clin Orthop Relat Res:195, 2003; Markolf
KL et al: Variables affecting pedicle screw plate fixation of an unstable L3-L4 defect. Clin Orthop Relat Res:283, 1996;
Nassif JM et al: Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating
closed tibial shaft fractures: a randomized prospective study. J Orthop Trauma 14:554, 2000; Roberts JW et al: Biomechanical
evaluation of locking plate radial shaft fixation: unicortical locking fixation versus mixed bicortical and unicortical
fixation in a sawbone model. J Hand Surg [Am] 32:971, 2007; Spivak JM et al: The effect of locking fixation screws on
the stability of anterior cervical plating. Spine 24:334, 1999; Vallier HA et al: Failure of LCP condylar plate fixation in
the distal part of the femur. A report of six cases. J Bone Joint Surg Am 88:846, 2006; Wu CC: Reaming bone grafting to
treat tibial shaft aseptic nonunion after plating. J Orthop Surg (Hong Kong) 11:16, 2003.
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