Fig. 1 Example of an unstable pelvic ring injury treated with percutaneous fixation of the posterior pelvic ring using S1 trans-sacral, S2 iliosacral screws, and an anterior column screw.
Courtesy of Boris A. Zelle, MD, FAAOS, FAOA


Published 5/10/2023
Andrew H. Schmidt, MD, FAAOS; Boris A. Zelle, MD, FAAOS, FAOA

What Is New in Minimally Invasive Trauma Surgery?

The subspecialty of orthopaedic trauma surgery continues to evolve, with the incorporation of minimally invasive techniques for fracture fixation and treatment of complications associated with trauma. Current approaches to minimally invasive fracture surgery represent the evolution of the philosophies of three individuals whose ideas fundamentally changed fracture surgery: Gerhard Küntscher, MD, and his foundational work and advancements in intramedullary (IM) nailing; Jeffrey Mast, MD, whose techniques of indirect fracture reduction have been widely popularized; and Gavril Ilizarov, MD, and his work on the biology and techniques of circular external fixation and bone distraction.

IM and tibial nailing
Closed reduction and closed IM nailing of long-bone fractures are the standard of care for femoral and tibial shaft fractures and are also established techniques in the humerus and forearm. Advances in the technique of nailing fractures and nail design have extended the indications for IM nailing to metaphyseal fractures and, most recently, to intra-articular long-bone fractures.

Fig. 1 Example of an unstable pelvic ring injury treated with percutaneous fixation of the posterior pelvic ring using S1 trans-sacral, S2 iliosacral screws, and an anterior column screw.
Courtesy of Boris A. Zelle, MD, FAAOS, FAOA
Fig. 2 Example of a displaced intra-articular calcaneal fracture (A) treated with limited open reduction of the posterior facet using a sinus tarsi approach with closed reduction and percutaneous screw fixation of the calcaneal tuberosity (B–D).
Courtesy of Jessica Downes, MD

Paul Tornetta III, MD, FAAOS, and Evan Collins, MD, FAAOS, first described performing tibial nailing with the knee in a semi-extended position using a small medial knee arthrotomy. This technique has been refined to what is now referred to as “suprapatellar nailing,” a technique in which an incision is made in the quadriceps tendon and the femoral trochlea is used as a guide to the proximal tibial starting point. This technique facilitates imaging, but, more importantly, it reduces deforming forces on the fracture, which contribute to malreduction and make assessment of overall limb alignment easier.

Furthermore, the latest generation of tibial nails includes more options for multiplanar interlocking screw fixation, proximally and distally, and allows for some interlocking screws to be engaged by a nail insert to increase rigidity.

The fixation of intra-articular distal femur fractures with IM nails has similarly evolved. Although IM nails were initially used primarily for extra-articular fractures, the current generation of retrograde femoral nails also includes multiplanar distal interlocking screws. Some recent designs even facilitate the use of a small lateral femoral buttress plate for improved fixation in osteopenic bone. These advances have made IM nailing a great option for the fixation of intra-articular fractures using closed or minimally invasive open techniques for fixation of the articular surface.

IM nails are also becoming more popular for fixation of proximal humeral, olecranon, and fibular fractures, and retrograde tibial-talar-calcaneal nails are now being used in cases of severe hindfoot trauma where other techniques of both internal and external fixation remain associated with high rates of complications.

Reduction and fixation
Techniques of indirect fracture reduction and fixation, as initially popularized in distal and proximal femoral fractures, have been applied to other metaphyseal fractures. One common example is the use of dorsal spanning plates to stabilize complex wrist injuries such as severe distal radial fractures. This approach restores length and alignment and often achieves an acceptable degree of fracture reduction via ligamentotaxis.

Circular external fixation has its greatest role in the correction of bone loss and deformity through distraction osteogenesis but is more often being utilized for the management of acute trauma. Hsu et al. described the technique of intentionally inducing sufficient fracture deformity using a hexapod fixator in type IIIB open tibial fractures to allow primary closure of the open wounds, followed by the gradual correction of the deformity using the hexapod frame.

Finally, there are many examples of fractures in bones with complex anatomy that traditionally require complicated ORIF (open reduction–internal fixation) with high complication rates for which minimally invasive approaches are now being utilized with less morbidity. One example is fracture of the pelvic ring, which can often be reduced and repaired with closed or limited open reduction with percutaneous fixation aided by improved intraoperative imaging (Fig. 1).

Recently, a less-invasive sinus tarsi approach to open reduction of the calcaneus has grown in popularity. This approach can be done shortly after injury and facilitates ORIF of the posterior facet of the calcaneus. The length and alignment of the calcaneal tuberosity can be easily restored with closed reduction and percutaneous fixation. Early results of the sinus tarsi approach are very encouraging and likely to revolutionize care of this common injury (Fig. 2).

In summary, minimally invasive approaches to surgery for musculoskeletal trauma continue to evolve, facilitating improved care for patients with compromised soft-tissue envelopes to achieve better outcomes with less morbidity.

Andrew H. Schmidt, MD, FAAOS, is chair of the Department of Orthopaedic Surgery at Hennepin Healthcare in Minneapolis and a professor in the Department of Orthopaedic Surgery at the University of Minnesota. Dr. Schmidt is chair of the AAOS Education Council.

Boris A. Zelle, MD, FAAOS, FAOA, is vice chair of research in the Department of Orthopaedics and chief of orthopaedic trauma at UT Health San Antonio.


  1. Vécsei V, Hajdu S, Negrin LL: Intramedullary nailing in fracture treatment: history, science and Küntscher’s revolutionary influence in Vienna, Austria. Injury. 2011;42 Suppl 4:S1-5.
  2. Gerber C, Mast J, Ganz R: Biological internal fixation of fractures. Arch Orthop Trauma Surg. 1990;109:295-303.
  3. Ilizarov GA: Clinical application of the tension-stress effect for limb lengthening. Clin Orthop. 1990;250:8-26.
  4. Tornetta P, Collins E: Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res. 1996;328:185–189.
  5. Metcalf KB, Du JY, Lapite IO, et al: Comparison of infrapatellar and suprapatellar approaches for intramedullary nail fixation of tibia fractures. J Orthop Trauma. 2021;35(2):e45-e50.
  6. Cinats DJ, Kooner S, Johal H: Acute hindfoot nailing for ankle fractures: a systematic review of indications and outcomes. J Orthop Trauma. 2021;35(11):584-590.
  7. Ruch DS, Ginn TA, Yang CC, et al: Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg Am. 2005;87-A(5):945–54.
  8. Hernández-Irizarry R, Quinnan SM, Reid JS, et al: Intentional temporary limb deformation for closure of soft-tissue defects in open tibial fractures. J Orthop Trauma. 2021;35(6):e189-e194.
  9. Lefaivre KA, Starr AJ, Barker BP, Overturf S, Reinert CM: Early experience with reduction of displaced disruption of the pelvic ring using a pelvic reduction frame. J Bone Joint Surg Br. 2009;91-B:1201-1207.
  10. Schepers T, Backes M, Dingemans SA, de Jong VM, Luitse JSK: Similar anatomical reduction and lower complication rates with the sinus tarsi approach compared with the extended lateral approach in displaced intra-articular calcaneal fractures. J Orthop Trauma. 2017;31(6):293-298.