range 9%-98%) of the surface area of medial condyle of proximal tibia. Higgins et al., confirmed the fact and showed that the fragment occupied 25% of the total tibial articular surface. Usually it is a split fracture with more than 5mm displacement rather than a depression even in osteoporotic bones. As a result there have poor outcome after conservative treatment. It is often associated with injury to anterior cruciate ligament. Open reduction and internal fixation with buttress plating is the recent recommendation for these fractures. Since the fragment is postero-medial, the direct posterior approach placed the neurovascular structures at risk. Approaching the fragment anteriorly also posed risks in the form of extensive dissection of the medial capsular structures and needed tibial tubercle osteotomy for better exposure. In a study by Hsieh et al., they used anteromedial approach and advocated it since there is no risk of neurovascular injury or flexion contracture of the knee 30 . This approach involved erasure of semi-membranosus and semi-tendinosus tendons. The medial collateral ligament was also easily injury. Since the major blood supply of knee is from the medial side there is increased risk of soft tissue devitalisation in already compromised soft tissue from high velocity injury. In 1960s, posterior approach to knee involving dissection of the neurovascular bundle was introduced by Trickey 31 . Since it was a highly demanding procedure, many had complications.
Barei et al demonstrated that distal tibial fractures with intact fibula, on the whole was considered as less severe injury than those with fractured fibula.
An intact fibula was identified as less severely injured than C type fractures 5,9 . The first principle of management by Ruedi and Allgower was restoration of fibular length which remains vital to obtaining good results. The goal of fibula fixation was restoration of limb length, to prevent varus tilt and rotation and gross mechanical alignment. Of the 30 cases, 14 cases of fracture fibula had gross displacement which required fixation with 1/3 rd tubular plate. Plating was done in fracture fibula with comminution. The rest of the cases were not fixed as most of the fractures were undisplaced stable fractures or it was fractured at different levels. All fibula fractures healed within 3 months without any gross complications 41,42,43 .
Further, the proximal row locking screws can achieve the
“raft” effect, which provides firm strength holding the ar- ticular surface. The main limitation distally is the posterior tibial neurovascular bundle. It is difficult to safely achieve exposure beyond approximately 8–10 cm distal to the lateral joint line owing to vessel trifurcation that trans- verse the interosseous membrane and muscle mass medial to the fibula. However, the length of plate is appropriate to reach the distal border, …without damaging the neuro- muscular bundle. Thus, distal tibial exposure is not neces- sarily required. According to the Rasmussen functional/
The branches of supraclavicular nerve were identified and protected when possible. The soft tissue was stripped of the subcutaneous surface of the cranial clav- icle surface in an epiperiosteal plane. The fracture ends were exposed and debrided of hematoma and interposed soft tissue. Simple or, where possible also multifragmen- tary fractures were reduced by using clamps and fixed with one or two 2.7 mm lag screws before fixing the fracture with a plate. Where reduction was not possible, fractures were reduced indirectly by bridging the frac- ture with a plate and then reducing the fragments be- tween the most lateral and most medial fragment and fixing them using an osteosuture (Fiberwire 2.0, Arthrex, Naples, FL, USA). The surgeon chose the plate type in- traoperatively depending on subjective best fit. Every surgeon had to describe the anatomical fit of the plate in the surgical report. Good anatomical fit was defined as easy positioning of the plate to the bone, small plate-to-bone distance and no need for bending to achieve this. In all patients, a superior plate was im- planted - either standard midshaft (n = 54), bridging midshaft (n = 38) or plates with lateral extension in frac- tures with large comminution zone (n = 8). The plate was fixed preliminary with clamps. Depending on bone quality, 3.5 mm polyaxial locking screws or non-locking screws were used with at least three bi-cortically placed screws on either side of the fracture. After wound irriga- tion, the wound was closed in layers using an intraarti- cular suture with an absorbable suture for skin closure.
Functional and radiographical outcomes
Follow-up evaluation was performed during the routine follow-up examinations at the outpatient clinic by asses- sing the Constant Score. The original Constant Score values were converted according to Gerber et al.  to receive a normative age- and sex-specific relative Con- stant Score. At a mean follow-up of 27 months the mean relative Constant Score significantly improved by 21 points in the presented patient collective (p < 0.05; see Table 1). The functional results are comparable to other authors who operatively treated non- or malunions of the clavicle. Jubel et al.  reported a relative Constant Score of about 95% at a follow-up of 18 months after intramedullary nailing of clavicular non-unions. The au- thors state that performing surgery without using an iliac crest bone graft constitutes a relevant advantage of intramedullary nailing. However, the requirement of a bone graft is not depending on the used implant but ra- ther on the local bone defect size. In addition intrame- dullary nailing leads to inferior biomechanical rotational stability in comparison to plate fixation . McKee et al.  published the results of non-lockingplate fix- ation in 15 patients suffering from malunions of the clavicle after initial conservative treatment. The authors found a significant improvement of pre- to postoperative self-assessed DASH scores. Nevertheless, in their study loss of plate fixation was seen in one patient and another patient developed a non-union. Hence we consider intramedullary nailing or single non-lockingplate fix- ation in non- or malunions of the clavicle with a signifi- cant clavicle shortening in comparison to the healthy contralateral side as an insufficient approach due to the remaining instability allowing for movement with an in- creased risk of loss of fixation or persisting non-union.
The results are evidence that locked plates are good implant in the treatment of intra-articular unstable fractures of distal radius. It allows effective anatomic realignment and early wrist mobilization. It is biomechanically superior due to closer joint interface placement and better screwing capability in different orders. A successful anatomic alignment was made possible regardless of the direction of fracture angulation with volar lockingplate. 90% the patients went back to their daily activities with good recovery.
HTO fixation plates are similar to those used for fracture fixation and can generally be categorized as non-locking and locking. The mechanical principles are quite different for non-locking and locking plates, providing distinct mechanical environments for bone healing. Non-locking plates rely on bone-platecompression and high friction at the bone- plate interface to provide fracture site stability 31 . At higher loads, however, non-locking screws that are drilled into the bone can begin to loosen. This reduces bone-plate friction, may render the plate unstable and increases the risk of complications such as hardware failure, delayed union, non-union and loss of correction 32 . Lockingplate designs address mechanical issues with threaded fixed-angle screws or interference washers that control the axial rotation between the screw and the plate, and eliminate screw-plate-bone motion 33 . The mechanism does not rely on high friction at the bone-plate interface, but rather maintains stability at the angular-stable screw-plate interface 31 . Locking plates also convert shear stresses to compressive stresses, improving fixation since bone has a stronger resistance to compressive stress compared to shear. The mechanical advantages of locking plates provide stronger implant stability and resistance to higher load-bearing, and are therefore suggested to be advantageous for healing after medial opening wedge HTO 23,34 .
OPEN REDUCTION AND INTERNAL FIXATION WITH LOCKINGCOMPRESSION PLATES:
Lockingcompression plates are advanced generation implant which has the special bio-mechanics. Lockingcompressionplate contains property of both internal and external fixation, . Lockingcompression devices provides rigid and stable anatomical construct due to threaded locking head screw. Locking head screw technology generates greater holding power because threaded head can be fix as a fixed angular stable construct. This fixed angular stable construct is independent from friction fitting. Surgical fixation with medial anatomical lockingcompression plating for lower third tibial fracture by open and MIPO technique yields fixed and stable anatomical limb alignment and superior functional outcome than other implants. . High rates of fracture union with early union, low reoperation rates and early return to routine activities are the main advantages.
We conclude that the use of one or two lag screws along with a single posteriorly placed 4.5-mm contouredlockingcompressionplate having at least two locking screws in the distal fragment provides sufficient rigid fixation in distal metaphyseal fractures of the humerus. The dissection does not extend beyond the apex of the olecranon fossa. The implant stops well short of the olecranon fossa. Excellent results can be achieved in these fractures without the use of dual plating and without the need for expensive customized implants or elaborately modified implants. Careful patient selection is important for this technique and indiscriminate use of single-plate fixation should be avoided. Physiolog- ically, young patients with good bone quality and good motivation for post-operative physiotherapy are suitable for this technique. Patients with open fractures, highly comminuted fractures, fractures with intercondylar exten- sions and pathological fractures are not suitable for this type of fixation.
humerus shaft fractures. Some surgeons often used the ex- ternal fixator for temporary fracture reduction in the MIPO fixation. Anatomical bending is also a problem that needs to overcome, especially in humerus shaft fractures with proximal or distal farcture extension when using 4.5 mm narrow lockingcompressionplate (NLCP, AO, Switzerland, Davos). In simple transverse fracture, it is enough to use a intramedullary nailing. However, in spiral humerus shaft fractures with proximal metaphyseal fracture extension, anatomically contoured bending of rigid NLCP plate to the proximal humerus is hard to make adequate
Several new locked plate- screw devices have been developed over the past few years. Research suggests that plate with locked screws may provide improved fracture stability and healing. When a screw is locked to the plate, a fixed point of contact is created, which may be advantageous in the cancellous bone of the distal tibia. Anatomically precontoured locking plates specifically designed for the distal tibia fractures have favourable shapes of screw configuration, which may enhance the maintenance of the reduction and reduce hardware complications. The screw configuration of the locking screws in the distal tibial head is multidirectional.
the upper limb, anatomic reduction and rigid fixation are mandatory.
This is achieved by open reduction and internal fixation with DCP and screws . Fracture management is a dynamic procedure advancing since the first introduction of internal fixation in 1886 by Hansmann in Hamburg. Improvements were sought to achieve stable internal fixation and stable bone-implant connection; early functional mobilization led to the use of bridging plates. The use of bridging plates is thought to be associated with undisturbed fracture zone, providing relative stability and secondary healing with callous formation meeting the treatment objectives. In addition, this procedure is not associated with devascularization of fracture fragments. Surgical adaptations are required for the application of LCP.
and inadequate fixation technique is used for the treatment of such fractures.
Similarly, these fractures are also associated with higher incidence of infections, joint stiffness, melanin and early onset of osteoarthritis. So these fractures have to be appropriately managed to overcome these factors [11-15]. This led to the concept of indirect reduction and biological fixation of fractures with preservation of vascularises and soft tissue integrity to the bone fragments [16- 21]. Principle’s of management includes anatomic restoration, axial alignment and rotational stability of particular surface. The management of distal femur fracture with anatomical distal lockingcompressionplate (LCP) has multiple benefits. It provides multiple points of fixed plate to screw contact, generating greater stability than is provided by a single lateral construct, which potentially reduces the tendency for varus collapse. The locking screws also provide stronger fixation of the plate in the proximal fragment by eliminating any potential for toggle and sequential screw loosening.
But associated split and displaced fragments or larger articular depression usually heals with a valgus alignment and hence have a great risk of osteoarthritis due to uneven joint loading. Isolated medial condyle fractures, even with minimal displacement, have greater chances of healing in varus malalignment because of the peculiarity of the fracture pattern, tending to have more obliquity in the coronal plane. Hence anatomical reduction is recommended for all medial condyle fractures. Non operative management for schatzker type V & VI fractures in young and active adults usually gives substandard results.
The present study comprehensively evaluated the bio- mechanical characteristics of specimens in LCP group
(i.e., with a medial distal tibial LCP), EF-tibia group (i.e., with medial distal tibial LCP with 30-mm plate-bone distances), and EF-femur group (i.e., with medial distal femur LCP with 30-mm plate-bone distances). The flex- ible construct compression stiffness of both distal femur LCP and distal tibial LCP, as revealed in the test, sug- gested that potential risks of delayed union or nonunion existed in both techniques; distal femur LCP would be a better one due to its higher axial compression stiffness and torsional rigidity. Given all advantages and risks, distal femur LCP was recommended as an external fixa- tor in treating distal tibial fractures, but should be used cautiously.
The medullary canal was opened via Kirschner wire perfor- ation. A steel ruler was used to measure the gap size. If the defect size was within 2 cm, the fragments were aligned and immobilized with a pointed reduction clamp and fixed with a LCP (Synthes, Switzerland). The LCP was placed on the anterosuperior side of the clavicle. The anatomic reduc- tion and screw lengths were confirmed by fluoroscopy. If the defect was greater than 2 cm, bone grafting was used, and the patient was excluded from these analyses. The wounds were closed in a routine manner, and sterile com- pression dressings were applied.
One of the new ways to repair the ST fracture is to use the PFLCP (16). The success of using PFLCP depends on the correct selection of the patient, the application of a suit- able length of the plate, the presence of medial buttress at the fracture site, and the use of the kickstand screw (17). In Barquet et al. study of 3500 cases of proximal femoral fractures, the results of using extra and intra-medullary implants were compared. They reported that the mortal- ity rate, infection, union, bleeding, and surgical duration were not significantly different between the two groups (18).
In our study, the major complication was secondary loss of reduction following a varus collapse of the fracture. This also resulted in subacromial impingement due to a reduced acromio-humeral distance. In these three patients, there was loss of medial hinge integrity due to impaction and osteoporosis, causing the fractures to be unstable. Recent studies have demonstrated a direct association between medial support and subsequent reduction loss [30,38]. In the MIPO group in this study, wound healing occurred faster and there was minimal scaring following surgery. Thus, patients might have engaged in early full weight bearing activities and functional exercises, leading to delayed healing.
plate to a distal femur lockingplate for treating distal femur fractures.
At present, the surgical treatment of distal femoral fractures is mainly through the lateral approach and anterolateral approach. However, the internal condyle and articular surface of femur cannot be fully exposed in the lateral approach, so it is difficult to reset the articular cartilage surface accurately. At the same time, the unevenness or fixed infirmness of the residual articular cartilage can lead to traumatic arthritis or dysfunction of the knee joint. The lateral approach may also damage the iliotibial band, resulting in lateral instability of the knee after operation [14–16]. Sher et al.  reported that the injury of the tibial tunnel in the lateral approach is likely to result in the instability of the knee joint. In the anterolateral approach, the femoral rectus was sepa- rated from the vastus lateralis to reveal the vastus inter- medius muscle. The vastus intermedius, periosteum, and the joint capsule were cut longitudinally. To reveal the distal femoral fractures, the rectus femoris, vastus intermedius muscle, and patella were pulled to the medial side. However, it dissected the musculi vastus intermedius, which may result in severe postoperative scar healing and thus greatly affect the contraction of the quadriceps femoris . In the posterolateral approach, the vastus lateralis and the biceps femoris were bluntly separated, and the fracture ends were fully exposed by tractioning the vastus lateralis forward. This operation is simple and time-saving, and the integrity of the vastus lateralis is well protected. This technique avoids the destruction of the local blood flow of the fracture ends caused by the incision of the vastus lateralis muscle. At the same time, this technique can avoid the swelling of the postoperative limb caused by the severe destruction of the local soft tissue. The postoperative pain is lighter, which is conducive to early functional exercise. In this study, the posterolateral approach was used to treat the Table 1 General information of the patients
The surfaces of the condyles that articulate with the tibia are rounded posteriorly and become flatter inferiorly. On each condyle, a shallow oblique groove separates the surface that articulates with the tibia from the more anterior surface that articulates with the patella. The surfaces of the medial and lateral condyles that articulate with the patella together form a V-shaped trench, which faces anteriorly. The lateral surface of the trench is larger and steeper than the medial surface. Lateral view of the distal femur shows that the anterior half of the condyles is aligned with the shaft of the femur. Axial view shows the condyles are wider posteriorly, thus giving a trapezoidal shape to the distal femur.