Comminuted fracture managed by Universal Mini External (UMEX) fixator: a case report of two cases and a narrative literature review

Abstract

Introduction:

Multiple protocols for care and management of closed and open fractures exist, among which the Universal Mini External (UMEX) fixator offers a versatile and cost-effective option for stabilization in complex distal limb fractures. The prognosis of fractures of the distal radius and metatarsals is evaluated under the earliest possible mobilization, rapid recovery, and desired reduction. Factors like type of injury, smoking, and type and period of intervention can have substantial effects on the successful treatment of patients.

Case presentation:

Two cases were successfully managed using the UMEX fixators. The case of a 35-year-old woman with a comminuted distal radius fracture was managed with the fixator, showing progressive restoration of her range of motion over a 7-week follow-up. The second case, a 32-year-old male smoker with a Gustilo-Anderson Type IIIA fracture of the first metatarsal, was stabilized using the fixator following thorough debridement. The patient achieved full weight-bearing by 3 months postoperatively without complications, and radiological union was confirmed.

Discussion:

Both cases positively responded to the treatment plan and care. The fixator’s modularity and reusability contributed to reduced costs, making it suitable in the limited setting. The fixators provided with functional support and immediate return of mobility with rapid healing and excellent patient satisfaction, supporting UMEX’s superiority.

Conclusion:

The UMEX fixator is effective for managing comminuted and open fractures, offering good outcomes in both upper and lower limb trauma. Its simplicity, cost-efficiency, and effectiveness make it particularly valuable in low-resource orthopedic settings.

Introduction

Limb fractures are one of the most common types of fractures, whose return to normal function and anatomy largely depends on extrinsic and intrinsic factors. Intrinsic factors include bone type, joints involved, patient age, fracture type, soft tissue injury, and distal neurovascular supply, among others. Extrinsic factors, like the timing of interventions, type of reduction used, surgical efficacy, and patients’ adherence to treatment plans, can effectively alter the course of limb fractures^[1–4^]. Among the multiple classifications and types of fractures that exist due to various reasons, such as high- to low-intensity traumas and osteopathological causes, comminuted fractures are the result of high-intensity trauma to bones and osteopathology, particularly to long bones and most commonly to extended limbs and their terminals^[5–7^]. Comminuted fractures are commonly associated with open fractures, soft tissue injuries, and compromised distal neurovascular supply, although solitary bone fractures have been infrequently reported. Comminuted fractures present the challenge of delayed healing, extensive internal fixation, and soft tissue-associated complications. These fractures are difficult to manage, bringing challenges associated with expensive treatment and complications like infections, nerve damage, compartment syndromes, stiffness, and malunion, among others[8].

HIGHLIGHTS

• Limitations preclude internal fixation.

• Ligamentotaxis via external fixation can achieve satisfactory anatomical alignment and union in complex fractures without open dissection of the fracture zone.

• In Gustilo IIIA open fractures, definitive external fixation may be appropriate when wound conditions and fracture alignment permit, avoiding the added risk of staged internal fixation.

• Functional outcome scores (DASH and AOFAS) should be recorded both preoperatively and postoperatively in future cases to allow meaningful comparison with published benchmarks.

The treatment modalities for comminuted fractures include plaster casts, open reduction and internal fixation (ORIF), and closed reduction and internal fixation (CRIF). The Universal Mini External (UMEX) fixator is a small-sized bilateral uniplanar external fixator that has shown promising results in the treatment of wrist joint intra-articular comminuted fractures ^[9,10^].

We report two cases: one of distal radius fracture (Colle’s Fracture) and another of open fracture of the first metatarsal (M1). Both were managed using the UMEX fixator with satisfactory clinical outcomes. The UMEX system used in our institution is provided by Adler Healthcare Pvt. Ltd., Mumbai, India. The system components include small-diameter Kirschner (K) wires, knurled rods, and low-profile clamps with a patented “Teardrop” design to ensure secure, three-point fixation of the wires. The specific configuration consisted of four K-wires with a diameter of 2 mm and one knurled rod of 4 mm diameter. Regular follow-up was advised for the patients, and radiographic images at subsequent follow-ups revealed fracture healing. In addition to the two cases presented, we include a narrative review of the literature to contextualize the role of UMEX in the management of comminuted and open fractures. This case report was prepared in line with the Surgical Case Report (SCARE) checklist[11].

Case presentation and therapeutic intervention

Case 1

A 35-year-old right-handed woman presented to outpatient department (OPD) of Janaki Medical College and Teaching Hospital (JMCTH) with chief complaints of pain, swelling, and deformity over the right wrist, which was due to a fall while working. Upon taking a proper history, she denied any past medical or surgical history. There was no history of diabetes mellitus or hypertension, no drug or allergy history, and no family history of disease. She was a non-smoker and did not consume alcohol.

On examination of the right wrist, a dinner-fork deformity was noted, with a restricted range of motion. Distal neurovascular status (DNVS) was found to be intact. We ordered anteroposterior and lateral views of wrist X-rays, which revealed dorsal tilt, dorsal angulation, lateral translation, and impaction. No associated ulnar styloid fracture was noticed (Fig. 1).

Figure 1.

X-ray at the time of presentation (fracture denoted by arrow).

The X-ray findings were consistent with a Colle’s fracture. In the OPD, a volar slab was applied, and the patient was counseled regarding surgical management. Pre-operative investigations were sent, which were within normal limits. A pre-anesthetic checkup was done prior to surgery. Under a brachial plexus block, the patient was positioned on the operating table, and the limb was prepared with painting and draping. The fracture was reduced under C-arm guidance and stabilized with a UMEX fixator using a biplanar configuration with four 2.0 mm K-wires – two wires proximal to the fracture in the radial shaft and two wires distal in the second metacarpal – connected by a single 4 mm knurled rod on the ulnar side. Post-reduction X-ray confirmed satisfactory anatomical reduction (Fig. 2). There was no deviation from the operative plan.

Figure 2.

Post-operative X-ray.

Post-operatively, the patient was shifted to the post-operative room for observation. The patient was instructed to perform active finger flexion-extension exercises from day 1 to prevent stiffness. The patient was discharged without any post-operative complications. Dry pin site dressing was done. No pin site complication was reported by the patient during the 6 weeks.

At the 6-week follow-up, the UMEX fixator was removed, and the patient demonstrated a normal range of motion. X-ray revealed callus formation, and the fracture was united (Figs 3 and 4). Physiotherapy was advised along with patient education. After another week (7th week of follow-up) of physiotherapy, a full range of motion was achieved. The preoperative Disabilities of the Arm, Shoulder, and Hand (DASH) score was not formally recorded at the initial presentation due to the acute nature of the injury; however, a postoperative DASH score of 5/100 at 7 weeks reflects excellent functional recovery, consistent with outcomes reported by Faruque et al for UMEX-managed distal radius fractures[12]. The timeline of events is presented in Table 1.

Figure 3.

At 6-week follow-up, X-ray revealed callus formation and fracture was united (denoted by arrow).

Figure 4.

At 6-week follow-up, before UMEX removal.

Table 1.

Timeline of events for Case 1.

Timeline	Events
Day 0	Injury sustained by fall at work, presented with pain, swelling, deformity. X-ray confirmed Colle’s fracture, volar slab applied, surgical plan made
Day 1	UMEX fixator with K-wire applied under C-arm guidance
Weeks 1–6	Post-op period with regular dressing, no complications
Week 6	Fixator removed, callus formation noted, ROM assessed
Week 7	Physiotherapy completed, full range of motion achieved

Case 2

A 32-year-old man presented to the emergency department of JMCTH with complaints of pain and an open wound over the dorsum of the left foot, with active bleeding following a road traffic accident approximately half an hour before presentation (Fig. 5).

Figure 5.

Clinical photo at presentation, open fracture classified as Gustilo IIIA.

Emergency management was carried out through thorough wound cleaning with normal saline (NS). Triple antibiotic therapy was initiated with intravenous cefuroxime, gentamicin, and metronidazole. After the initial stabilization of the patient in the emergency department, the wound was packed, and an orthopedic consultation was done. Clinically, the patient was assessed, and vitals were normal. Local examination was performed, revealing a skin laceration measuring approximately 10 × 5 cm². A piece of bone was exposed, and the wound was contaminated with sand and pebbles. DNVS was assessed and found to be intact. The fracture was classified as Gustilo IIIA, and the patient was advised to undergo an X-ray of the left foot with anteroposterior and oblique views (Fig. 6), which revealed a comminuted fracture of the first metatarsal. Upon taking a detailed history, it was noted that the patient did not have any previous medical or surgical history. He was a regular tobacco consumer, a smoker consuming three packs of cigarettes a day, and a frequent alcohol consumer. We counseled the patient for the surgery.

Figure 6.

Pre-operative X-ray showing comminuted fracture of the left first metatarsal with dust particles (denoted by arrows).

Under subarachnoid block, the patient was positioned in a supine position, and painting and draping were performed. Wound debridement was thoroughly carried out using NS, hydrogen peroxide, and diluted povidone-iodine. Intraoperative findings included a comminuted fracture of the shaft of the first metatarsal with loss of a piece of bone and a gap over the fracture site. The exact size of the fracture fragment was 2 × 1 cm², which was a unicortical loss with an intact posterior cortex, measured intraoperatively. Given the heavily contaminated wound (Gustilo IIIA), primary bone grafting was deferred in accordance with standard open fracture management principles[13], with secondary grafting to be considered if union failed. The fracture was reduced under C-arm guidance, and the fracture was stabilized using the UMEX fixator. The skin was approximated using stay sutures, and wound dressing was completed. Postoperative X-rays, including anteroposterior and oblique views of the left foot, were taken, revealing satisfactory reduction of the fracture (Fig. 7). The patient was shifted to the postoperative ward. Regular wound dressing was performed. Analgesics and IV antibiotics were administered for 2 weeks. Sutures were removed after 2 weeks, and the patient was discharged with education on partial weight-bearing as feasible, and every alternate day pin site dressing was advised.

Figure 7.

Postoperative X-ray: UMEX fixator in situ, fracture reduced.

At 1-month follow-up, there were no signs of pin site infections, and the wound was healthy and healed. We performed pin site dressing, and an X-ray was advised, which revealed external fixation in situ, and no callus had formed yet (Fig. 8). We advised the patient to bear full weight and perform alternate-day pin site dressing. We also advised the patient to follow up after 1 month.

Figure 8.

At 1-month follow-up: X-ray implant in situ, no callus seen.

At the 3-month follow-up, the patient presented again. Clinically, no pin-site infection was seen. The patient was walking with full weight-bearing. The patient reported no new complaints. An X-ray was advised, which revealed callus formation (Fig. 9).

Figure 9.

At 3-months follow-up: implant in situ, callus seen (denoted by arrows).

At the 4th-month follow-up, the patient was walking with full weight-bearing without any complaints of pain over the fracture site. The implant was removed, and an X-ray was advised, which revealed the fracture uniting with callus (Fig. 10). At the 5th-month follow-up, the progress of fracture healing was satisfactory, with full callus formation (Figs 11 and 12). At 9-month-follow-up, the fracture had fully united with no signs of callus or remnants of the fracture (Fig. 13). The American Orthopedic Foot and Ankle Society (AOFAS) midfoot score was 92. The timeline of events is presented in Table 2.

Figure 10.

After 4 months, the fracture uniting with callus and external fixation removed (denoted by arrows).

Figure 11.

At 5-month follow-up, the uniting fracture with callus (denoted by arrows).

Figure 12.

Clinical picture of healed fracture site with implant removal after 1 month.

Figure 13.

Fully united fracture at 9 months of follow-up (denoted by arrows).

Table 2.

Timeline of events for Case 2.

Timeline	Events
Day 0	Patient met road traffic accident, open wound over dorsum of left foot. Emergency wound cleaning was done; Intravenous antibiotics were started. Surgery with thorough debridement and UMEX fixation under C-arm
Follow-up at 1 month	Wound healed, external fixation in situ, no callus yet
Follow-up at 3 months	Walking with full weight-bearing, callus formation observed
Follow-up at 4–5 months	Fracture uniting with callus formation
Follow-up at 9 months	Complete fracture union, pain-free ambulation

Discussion

UMEX as a choice of treatment

Ligamentotaxis is one of the specific closed reduction and external fixation techniques, which involves maintaining skeletal length using intact ligaments attached to bones. The external fixator attached to ligaments works as guide wires to pull displaced bone fragments to their natural location/anatomy[14]. The use of ligamentotaxis with an external fixator to treat comminuted fractures has revealed positive treatment results with fewer complications if done correctly ^[15,16^]. The use of an external fixator has the advantage of avoiding potential problems of internal fixation, such as corrosion, infection, discomfort, and ligament impingement[17]. Studies have revealed that the use of external fixators has a better chance of avoiding recurring surgeries compared to open reduction methods like plating in older adults[18]. The operative time and fracture healing time of the external fixator group were shorter than those of the internal fixator group, and the incidence of complications was lower[19]. External fixators are cheaper than conventional intramedullary nails used for internal fixation^[20–22^], making them ideal for low-income countries like Nepal, where most orthopedic patients have low income and highly traumatic injuries^[23,24^]. This cost advantage directly influenced our choice of UMEX in both cases, particularly since the fixator is reusable and locally sourced, further reducing per-case expenditure. While a formal cost analysis was not performed in this report, the cost-effectiveness of external fixation in resource-limited settings is supported by prior literature^[20,21^]. The UMEX fixator has been successfully used to treat congenital foot deformities with the added bonus of a short learning curve^[25,26^]. ORIF enhances forearm supination, anatomic volar tilt restoration, and functional results for unstable distal radius fractures, while external fixation improves wrist flexion and grip strength and remains a viable surgical alternative[27]. The UMEX has the advantage of being an easy-to-use, lightweight, cost-effective device that utilizes the principles of ligamentotaxis with promising results across simple to complex fractures, with the major advantage being its capability to maintain anatomical reduction and bone length^[9,10,12,20^]. It also provides early mobilization and a reduced risk of infection compared to open approaches[28], with a reduced possibility of metacarpal fracture as the anchoring device is a 2 mm K-wire, and no possibility of ulnar deviation as one straight rod is provided on the ulnar side[10]. With a fixation period of 4–8 weeks, complications are minimal. The UMEX offers more stable fixation as it is biplanar[12]. It has been capable of restoring partial and complete weight-bearing capability of the foot faster than surgical methods[29]. It should be noted that in low- and middle-income countries, the use of expensive surgical methods, although often yielding better results, is not feasible^[29,30^]. The use of external fixators, which provide an earlier return to function at lower expenses compared to internal fixators, highlights the need for extensive studies. Although multiple studies across the globe have shown that internal fixation offers better return of mobility and overall reduction of disability compared to external fixators, it should also be noted that these differences become irrelevant after a year of follow-up, highlighting the fact that the effects of external fixators are not inferior to internal fixators^[27,31^]. Recent studies on distal radius fractures have compared external fixation, bridging versus non-bridging frames, and the orientation of distractive forces to optimize radiographic outcomes. A randomized trial demonstrated that applying distraction perpendicular to the distal radius articular surface improves maintenance of palmar tilt and radial inclination compared with force applied parallel to the radial shaft, although functional outcomes at 12 weeks were similar between groups[32]. Another prospective randomized study compared external fixation and Kirschner wires with volar plating in intra-articular distal radius fractures and found that volar plating better maintains radiologic correction[33]. However, literature from Nepal has often focused on single anatomical regions, such as combining external and internal fixation in intra-articular distal radius fractures, with follow-ups up to 46 months[34]. In Nepal, many hospitals have limited access to high-cost implants or surgical resources, making cheaper, reusable, and simpler fixation systems potentially impactful. A study in Nepal compared closed reduction with plaster versus external fixation for unstable distal radius fractures in 40 patients and found no statistically significant difference in long-term functional or anatomical outcomes, raising cost-effectiveness as a key consideration[35].

Case discussion

Distal radius fractures are among the most frequently encountered fractures of the upper limb. Comminuted or unstable fractures are a result of high-energy trauma, such as fall injuries – most commonly a fall on an outstretched hand – and direct blows or crush injuries, which are typically the cause of proximal metatarsal fractures[36]. The treatment modalities for comminuted fractures include plaster casts, ORIF, and CRIF. The mainstay of treatment for minimally displaced Colle’s fractures is closed reduction and cast immobilization, but cast immobilization is insufficient for unstable fractures with dorsal tilt and impaction[37]. On the other hand, volar plating, while offering superior radiological correction, requires more extensive soft tissue dissection and carries higher implant costs in our resource-limited setting[33]. External fixators yield good results for treating complex fractures if the bone is not osteoporotic. The role of surgery in elderly osteoporotic women presents difficulties, such as the weak hold of pins in osteoporotic bone[38]. In our case, the patient was not osteoporotic, which supported our decision to proceed with external fixation. For about 90–95 years, external fixators have been used to treat distal radial fractures. Pennig and Gausepohl suggested using an external fixator to restore the radial anatomy in cases of comminuted injury in three or more cortices and radial shortening of more than 5 mm, with or without intra-articular involvement in the inferior radioulnar joint or radiocarpal[39]. In both intra- and extra-articular fractures, reduction is achieved by manipulating the fractured fragment with ligamentotaxis, while external fixation is used to preserve the axial length[40]. Mini fixator systems, often scaled-down versions of long bone fixators, are unsuitable for hand surgery due to the intricate anatomy, risk of neurovascular injury, soft tissue entrapment by pins, and the need for pre-drilling in dense cortical bone[10]. UMEX fixators offer a versatile and minimally invasive approach to stabilize fractures.

The first metatarsal (M1) fractures occur through direct or indirect trauma. Each of the lesser metatarsals bears an equal amount of weight, and the first metatarsal supports twice the load of any of the lateral metatarsals[41]. Because of its size and thick structure, M1 fractures are uncommon, accounting for just 1.5% of metatarsal fractures[42]. Healing of metatarsal fractures typically progresses well, and complications such as symptomatic nonunion occur infrequently[43]. The M1 serves as a propulsion lever arm and is essential to gait. This short, strong bone supports a significant amount of the forefoot load and is necessary for forefoot stability and medial arch support^[44,45^]. Therefore, appropriate treatment is essential to prevent loss of function. The goal of treatment should be to restore length and alignment. Malalignment of the first metatarsal can result in abnormal loading patterns, which can have a debilitating effect on the patient. Although most nondisplaced fractures heal well with immobilization and avoiding weight-bearing, a significant number result in prolonged disability and residual dysfunction[41].

In our case, the fracture of this pivotal bone occurred in the setting of a high-energy open injury (Gustilo–Anderson IIIA), which involves extensive soft-tissue laceration or comminution, contamination, and disruption of vascularity while still allowing some periosteal coverage. An open fracture requires adequate care of the wound as well as the fracture. Gustilo IIIA foot fractures are difficult to treat because devitalized bone or tissues increase the risk of infection and non-union. Even with immediate treatment, the risk of infection is greatly increased by the damaged soft-tissue envelope and disrupted protective skin barrier; for type III open fractures, this risk has been reported to be as high as 10–50%^[13,46^]. The dorsal soft tissue over the metatarsal is restricted in open first-ray injuries, which increases the risk of infection and makes soft-tissue covering challenging following fixation. In high-grade open midfoot injuries, external fixation is frequently preferred due to these difficulties. External fixators allow stabilization of the fracture while minimizing further soft-tissue disruption^[13,46^]. Cross and Swiontkowski note that “grossly contaminated open fractures with extensive soft-tissue compromise,” such as Gustilo IIIA–C injuries, are prime indications for external fixation[13].

In practice, external fixation devices allow the wounded segment to be spanned without the fracture zone being dissected, maintaining the blood flow and enabling repeated wound covering or debridement treatments. External fixation helps lessen further periosteal stripping and prevents inserting implants directly in the area of damage, as opposed to internal fixation.

Sen emphasizes that conventional internal implants in the foot may be “fraught with complications related to wound healing and infection” because of the limited soft-tissue envelope[47]. Internal plates or screws on the first metatarsal risk tendon or skin irritation and preclude easy wound surveillance. By contrast, a small-profile external construct (such as a mini fixator) can be applied with percutaneous pins in safe zones and provides rigid support without extensive dissection^[47,48^].

In previous reports of severe first-ray fractures, external fixation has been successfully used as either a temporizing or definitive treatment. For example, Miller and Shever described an open, comminuted first metatarsal fracture treated with a uniplanar mini-external fixator and bone grafting (demineralized bone matrix)[49]. Similarly, Kataoka et al used an Ilizarov mini external fixator on a patient with a first metatarsal fracture and severe swelling^[48^]. Pablo et al mentioned that by avoiding further soft-tissue injury, the patient could start weight-bearing at 7 weeks and had excellent function at 1 year with no pain[50]. These reports suggest that external fixation can serve as the sole definitive fixation in cases of first-ray injuries with compromised soft tissues[29]. In our case, we chose the UMEX to achieve stable fixation while accommodating the contaminated wound. Like the devices used by Kataoka et al and Miller et al, the UMEX is low-profile and modular, permitting primary closure and future wound care^[48,49^]. Our experience with UMEX is consistent with the fact that the fixator-maintained alignment until union, and the patient ultimately achieved pain-free ambulation. Even in larger tarsal injuries, mini-external devices have enabled early rehabilitation. Such data underscore that external frames can permit earlier mobilization and functional recovery compared to prolonged non-weight-bearing. In our patient, although the first metatarsal bears significant load, the external construct allowed protected progression of weight-bearing as tolerated.

The first metatarsal’s role in weight-bearing and propulsion makes its injury clinically significant, and high-energy open fractures compound the difficulty of fixation. Gustilo IIIA first-ray fractures require thorough debridement and soft-tissue management. External fixation is a valuable strategy in this context because it stabilizes the fracture while preserving blood supply and facilitating wound care^[13,46^]. The UMEX mini-external fixator provided sufficient stability to achieve union without further soft-tissue compromise, consistent with other reports of mini-external fixator use in forefoot trauma^[29,49^]. Ultimately, our case supports the clinical relevance of external fixation in managing severe first-ray open fractures, with outcomes comparable to those in the foot and ankle literature.

In the above-mentioned two cases, the use of a UMEX external fixator for both distal radius and first metatarsal (M1) fractures resulted in satisfactory radiological union, anatomical alignment restoration, and early mobilization. The patient achieved satisfactory functional outcomes with no significant complications. However, adequate callus formation for the first metatarsal fracture treated with UMEX (Case 2) was observed later than typically expected. Chang et al demonstrated that cigarette smoke inhalation significantly impairs angiogenesis during early bone healing and delays fracture union[51]. Serial radiographs in our patient (months 1–9) were consistent with delayed but progressive union, achieving complete consolidation by 9 months.

For case 2, two main management strategies were considered: staged management (temporary damage-control external fixation followed by delayed internal fixation once the wound was clean) versus immediate definitive external fixation. Given the degree of contamination, segmental bone loss, and limited dorsal soft tissue, immediate internal fixation was contraindicated^[13,46^]. Staged conversion to internal fixation was considered, but given the progression of wound healing and maintained fracture alignment in minimal time, definitive management with the UMEX was elected, consistent with reports by Miller and Shever[49] and Kataoka et al[48]

Considering the positive results in this instance, UMEX external fixation seems to be a useful instrument in orthopedic surgery. While the UMEX may not replace internal fixation, in cases of soft tissue compromise, where early mobilization is desired, UMEX can be used as discussed above. In order to restore alignment, maintain function, and produce positive clinical results, orthopedic surgeons must ultimately combine in-depth anatomical knowledge with cutting-edge fixation techniques, like the UMEX system, when managing complex comminuted fractures.

Comparative analysis of the two cases

Despite involving anatomically distinct sites – the distal radius (upper limb) and the first metatarsal (lower limb) – both cases share common principles that guided UMEX application. In both instances, ligamentotaxis was the primary mechanism of reduction, utilizing intact soft tissue attachments to guide displaced fragments into alignment without direct surgical dissection of the fracture zone. This minimized soft tissue trauma, consistent with the biological rationale for external fixation in comminuted injuries^[14,40^]. Key differences existed in postoperative management. Case 1 allowed early active mobilization of the fingers from day 1, with the fixator removed at 6 weeks and physiotherapy commenced immediately thereafter, reflecting the upper limb’s capacity for earlier functional rehabilitation. In contrast, case 2 required a more gradual progression from partial to full weight-bearing over 3 months, owing to the load-bearing demands of the first metatarsal and the more severe soft tissue injury (Gustilo IIIA). The fixator was retained for 4 months to ensure adequate skeletal stability. Both cases demonstrate that UMEX provides sufficient stability for fracture union without internal hardware, making it appropriate in settings where soft tissue compromise, wound contamination, or limited resources preclude conventional fixation.

Strengths and limitations

This report only examines two cases, which inherently limits the generalizability of the findings. Nevertheless, the capability of UMEX to address injuries in both upper and lower limbs is illustrated by the selection of two different anatomical locations, specifically the distal radius and the first metatarsal. This case report highlights its versatility, cost-effectiveness, and value in resource-limited settings. The aim of this report is not to draw conclusive results but to share hands-on clinical experiences from a setting with limited resources. These results add to the existing literature and emphasize the potential benefits of UMEX, all while recognizing that further, larger studies and comparative research are needed to confirm these insights.

Conclusion

The successful outcomes in these two cases highlight the versatility and effectiveness of the UMEX fixator in managing complex comminuted fractures, including open injuries. Its minimally invasive nature, adjustable construct, and favorable cost profile make it an ideal choice, particularly in low-resource environments. These cases support the UMEX fixator as a valuable tool in trauma care, promoting early mobilization and satisfactory functional outcomes with minimal complications.

Ethical approval

Ethical review and approval were not required for the case report, as the university waives ethical approval. The case report does not contain any personal information about the patient. Name of the University: Tribhuvan University. Name of College: Janaki Medical College and Teaching Hospital.

Consent

A written informed consent was obtained from the patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal upon request.

Sources of funding

The author(s) received no financial support for the research, authorship, or publication of this article.

The study did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

D.K.P.: treating physician, supervision, writing, and review. H.S.Y.: conceptualization, resources, literature review, manuscript preparation, and the corresponding author who submitted the paper for publication. K.S.: writing – literature review and editing, conclusion, and image. N.K.Y.: writing – review and editing, conclusion, and image.

Conflicts of interest disclosure

The authors declare no conflict of interest.

Research registration unique identifying number (UIN)

None.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Not applicable.

Guarantor

Hem Shankar Yadav.

Declaration of AI use

During the preparation of this work, the author(s) used Grammarly in order to enhance language, grammar, and clarity. After using this tool/service, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the publication.

Patient’s perspective

Case 1: “I was worried when I was unable to move my wrist, but after surgery with the UMEX fixator, I was relieved that I could start moving my hand early. I had no major problems with the device, and once it was removed, my wrist felt normal again. I am satisfied with the outcome and grateful for the care I received.”

Case 2: “At first, I was very concerned because of the open wound and the amount of bleeding. The doctors explained the need for thorough cleaning and using the external fixator. Though it took several months, I was able to walk normally again. The fixator looked unusual at first, but it worked well and I am happy that my foot healed without further surgery.”