It is difficult to predict the outcome or likely treatment that will be required for an individual child with a rigid clubfoot deformity at an early stage. 32 Dimeglio grade II, III or IV CTEV feet in 24 infants were treated with weekly serial casts according to Ponseti method. Graphical plots of the improvement obtained in Dimeglio scores during serial cast treatment of CTEV were subsequently analysed to identify characteristic features that would help predict the likely success of casting or the need and extent of surgical release. The rate of change in global Dimeglio score, hindfoot (equinus / heel varus) and midfoot (adduction / derotation) components were specifically studied. During casting the rate of change over 4 weeks and a “plateauing” of the global Dimeglio score after 4–6 weeks of casting separated those feet that responded to casting alone from those that required additional surgery. Those with “plateauing” and minimal midfoot deformity by 4 weeks (adduction /derotation score < =2) required a posterior release. Failure to correct the mid-foot deformity by 4 weeks (adduction /derotation score > = 3) predicted the need for a combined plantar medial and posterolateral release. These parameters were clearly demonstrated by graphical plots that can be easily obtained in a busy clinic setting. Graphical representation of the rate of change in Dimeglio parameters can predict the likely treatment needed for children with CTEV. A graphical algorithm has been developed that can be used during the first 6 weeks of treatment to guide Ponseti method casting and early surgical intervention

It is difficult to predict the outcome or likely treatment that will be required for an individual child with a rigid clubfoot deformity at an early stage. 32 Dimeglio grade II, III or IV CTEV feet in 24 infants were treated with weekly serial casts according to Ponseti method. Graphical plots of the improvement obtained in Dimeglio scores during serial cast treatment of CTEV were subsequently analysed to identify characteristic features that would help predict the likely success of casting or the need and extent of surgical release. The rate of change in global Dimeglio score, hindfoot (equinus/heel varus) and midfoot (adduction/derotation) components were specifically studied. During casting the rate of change over 4 weeks and a “plateauing” of the global Dimeglio score after 4–6 weeks of casting separated those feet that responded to casting alone from those that required additional surgery. Those with “plateauing” and minimal midfoot deformity by 4 weeks (adduction/derotation score < =2) required a posterior release. Failure to correct the mid-foot deformity by 4 weeks (adduction/derotation score > = 3) predicted the need for a combined plantarme-dial and posterolateral release. These parameters were clearly demonstrated by graphical plots that can be easily obtained in a busy clinic setting. Graphical representation of the rate of change in Dimeglio parameters can predict the likely treatment needed for children with CTEV. A graphical algorithm has been developed that can be used during the first 6 weeks of treatment to guide Ponseti method casting and early surgical intervention

Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery. Cite this article: Bone Joint J 2023;105-B(5):471–473

Aim. The aim of this paper is to analyse the cause of neuropathic diabetic foot ulcers and discuss their preventive measures. Methods. Review of patients with foot ulcers managed in our diabetic MDT clinics since Feb 2018 were analysed. Based on this observation and review of pertinent literature, following observations were made. Results. Forefoot. Progressive hindfoot equinus from contraction of gastroc-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus muscles and, progressive plantar flexed metatarsal heads secondary to claw toe deformity results in increased forefoot plantar pressures. In patients with insensate feet, this result in ulcer formation under the metatarsal heads from shear stress when walking. Callosity under the metatarsal heads is the earliest clinical sign. Most patients by this time have fixed tightness of the muscle groups as assessed by negative Silfverskiold test. Percutaneous tendo-Achilles lengthening (TAL) has shown to reduce the mid-forefoot plantar pressures by 32% and ulcer healing in 96% of patients within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. Proximal metatarsal osteotomies further reduce the forefoot pressures to near normality. Midfoot. Midfoot ulcers are secondary to rocker-bottom deformity a consequence of Charcot neuroarthropathy (CN). Hindfoot equinus as described and relative osteopenia from neurally mediated increased blood flow (neurovascular theory) and repeated micro-trauma (neurotraumatic theory) result in failure of medial column osseo-ligamentous structures. As the disease progress to the lateral column, the cuboid height drops resulting in a progressive rocker bottom deformity. The skin under this deformity gradually breaks down to ulceration. In the pre-ulcerative stages of midfoot CN, TAL has shown to stabilise the disease progression and in some patents’ regression of the disease process was noted. The lump can excised electively and the foot accommodated in surgical shoes. Hindfoot. These develop commonly at the pressure areas and bony exostosis in non-ambulatory patients. In ambulatory patients, the most common cause are factors that result in over lengthening of tendo-Achilles such as after TAL, spontaneous tears, or tongue-type fractures. Conclusions. Early identification of factors that result in plantar skin callosity and treating the deforming forces prevent progression to ulceration. Total contact cast without treatment of these deforming forces results in progression of these callosities to ulceration while in the cast or soon after completion of cast treatment

Aims. To explore individuals’ experience of a scaphoid waist fracture and its subsequent treatment. Methods. A purposive sample was created, consisting of 49 participants in the Scaphoid Waist Internal Fixation for Fractures Trial of initial surgery compared with plaster cast treatment for fractures of the scaphoid waist. The majority of participants were male (35/49) and more younger participants (28/49 aged under 30 years) were included. Participants were interviewed six weeks or 52 weeks post-recruitment to the trial, or at both timepoints. Interviews were semistructured and analyzed inductively to generate cross-cutting themes that typify experience of the injury and views upon the treatment options. Results. Data show that individual circumstances might exaggerate or mitigate the limitations associated with a scaphoid fracture, and that an individual’s sense of recovery is subjective and more closely aligned with perceived functional abilities than it is with bone union. Misconceptions that surgery promises a speedier and more secure form of recovery means that some individuals, whose circumstances prescribe a need for quick return to function, express a preference for this treatment modality. Clinical consultations need to negotiate the imperfect relationship between bone union, normal function, and an individual’s sense of recovery. Enhancing patients’ perceptions of regaining function, with removable splints and encouraging home exercise, will support satisfaction with care and discourage premature risk-taking. Conclusion. Clinical decision-making in the management of scaphoid fractures should recognize that personal circumstances will influence how functional limitations are experienced. It should also recognize that function overrides a concern for bone union, and that the consequences of fractures are poorly understood. Where possible, clinicians should reinforce in individuals a sense that they are making progress in their recovery. Cite this article: Bone Jt Open 2022;3(8):641–647

There is no agreement as to the superiority or specific indications for cast treatment, percutaneous pinning or open fracture fixation for Bennett's fractures of the thumb metacarpal. We undertook this study to compare the outcomes of treatment for patients treated for Bennett's fracture in the medium term. We reviewed 33 patients treated in our unit for a bennett's fracture to the thumb metacarpal with closed reduction and casting. Each patient was matched with a patient treated surgically. Patients were matched for sex, age, Gedda grade of injury and hand dominance. Patients were reviewed at a minimum of 5-years and 66-patients were reviewed in total. Patients were examined clinically and also asked to complete a DASH questionnaire score and the brief Michigan hand questionnaire. Follow up plain radiographs were taken of the thumb and these were reviewed and graded for degenerative change using the Eaton-Littler score. Sixty-six patients were included in the study, with 33 in the surgical and non-surgical cohorts respectively. The average age was 39 years old. In each cohort, 12/33 were female, 19/33 were right-handed with 25% of individuals injuring their dominant hand. In each coort there were 16 Grade 1 fractures, 4 Grade 2 and 13 Grade 3 fractures. There was no difference between the surgically treated and cast-treatment cohorts of patients when radiographic arthritis, pinch grip, the brief Michigan Hand Questionnaire and pain were assessed at final review. The surgical cohort had significantly lower DASH scores at final follow-up. There was no significant difference in the normalised bMHQ scores. Our study was unable to demonstrate superiority of either operative or non-operative fracture stabilization. Patients in the surgical cohort reported superior satisfaction and DASH scores but did not demonstrate any superiority in any other objectively measured domain

Introduction. A subset of patients in cast awaiting fixation of ankle fractures require conversion to delayed external fixation (dEF). We aimed to evaluate the effect of delayed versus planned external fixation (pEF), then identify objective characteristics contributing to need for conversion. Method. We extracted data from our booking system to identify all ankle external fixation procedures between 2010 to 2022. Exclusions included open fractures, the skeletally immature, and pilon or talus fractures. Fractures were classified using the AO/OTA classification, then a matched cohort was identified based on fracture classification. We compared the planned, delayed and matched cohorts for demographics, posterior malleolar fragment (PMF) ratio, and degree of displacement at presentation. Results. We identified 25 pEF, 42 dEF, and 67 matched patients. Ankles with dEF had a 3.8 day longer time to ORIF from presentation than those who had pEF, and had an infection rate of 9.5%, compared to 4% in the pEF group. Two patients in the dEF group required further operative intervention. There were no infections or reoperations required in the pEF or matched groups. The dEF group were more likely to have ≥2 reductions (OR 4.13), a PMF ratio of >0.23 (OR 5.07), and have increased displacement at time of injury on lateral (32% vs 19%) and AP (62% vs 36%) radiographs. Discussion. Our retrospective study highlights the longer time to operation and increased infection rates of patients who do not get timely external fixation. We propose a series of objective parameters that predict failure of cast treatment and guide the surgeon to consider planned external fixation in some ankle

Ponseti method has become the most common and validated initial non-operative and/or minimally invasive treatment modality of idiopathic clubfoot regardless of the severity of the deformity worldwide. Despite hundreds of publications in the literature favoring Ponseti method, the data about secondary procedures performed in the follow-up period of clubfoot and their incidence remains sparse and given as small details in the articles. The objective of this study was to analyse our incidence of secondary procedures performed in the midterm followup period of idiopathic clubfoot patients treated with Ponseti method and review of the relevant literature. For this purpose 86 feet of 60 patients with idiopathic clubfoot who were treated with original Ponseti method were enrolled in this retrospective case control study. Unilateral ankle foot orthosis (AFO) was used rather than standart bar-connected foot abduction orthosis varying from 12 months to 25 months in the follow-up period and 74 of 86 (86%) feet required percutaneous achilles tenotomy. The average age of initial cast treatment was 12.64 days (range 1 to 102 days). The mean follow-up time was 71 months (range 19 to 153 months). Thirty seven feet of 24 patients recieved secondary procedures (43%) consisting of; supramalleolary derotational osteotomy (SMDO) (1 patient/2 feet), complete subtalar release (3 patients/5 feet), medial opening lateral closing osteotomy (double osteotomy) (2 patients/3 feet), double osteotomy with transfer of tibialis anterior tendon (TTAT) (2 patients/3 feet), partial subtalar release (PSTR) (3 patients/5 feet), PSTR with SDO (1 patient/1 foot), posterior release (PR) with repeated achillotomy (1 patient/2 feet), TTAT (6 patients/10 feet), TTAT with PR (2 patients/2 feet), TTAT with Vulpius procedure (1 patient/1 foot) and TTAT with SMDO (2 patients/3 feet) respectively. The amount of percutaneous achilles tenotomy (86%) in our study correlated with the literature which ranged from 80 to 90 %. The transfer of tibialis anterior tendon continued to be the most performed secondary procedure both in our study (51%) and in the literature, but the amount of total secondary procedures in our study (43%) was determined to be higher than the literature data varying from 7 to 27 percent which may be due to unilateral AFO application after Ponseti method for idiopathic clubfoot deformity in our study

Introduction: Carpal scaphoid fractures can be treated non-operatively in a cast, but the duration of treatment can take up to 12 weeks, with non-union rates of 15%. The hypothesis of this study was: percutaneous fixation of acute scaphoid fractures results in better union rates, faster time to union, and better function. Method: In a prospective study, 48 consecutive acute and subacute scaphoid fractures were treated with percutaneous Acutrak screws. These patients were compared to a case-matched control group treated non-operatively in a cast. Herbert-Fisher type A (‘crack’) and B4 (fracture-dislocations) fractures were excluded from the study. The implant is a cannulated headless titanium screw with conical design and continuous differential pitch for inter-fragmentary compression. The screw was introduced retrograde according to a technique devised by the senior author (MP). In addition to the standard postero-anterior and lateral views, prone and supine oblique views were used to achieve accurate screw placement. Results: There were 16 B1 (oblique), 15 B2 (waist), four B3 (proximal pole) and nine B5 (comminuted) fractures in each group. The average operation time was 19 minutes. The union rate was 97.7% in the operated group, and 81.8% (36/44) in the non-operated group (p< 0.05). The average time to union was significantly quicker in the operated group (seven weeks compared to 12 weeks, p< 0.05). At 12 weeks post-treatment the range of motion as well as the pinch and grip strengths were better in the operated group. After 24 weeks the two groups had comparable functional results. The mean time taken return to work was 2.5 weeks with percutaneous fixation compared to 13 weeks with cast treatment (p< 0.05). The average delay with cast group in return to work was 10.8 weeks with an average loss of income of $8815. The overall cost to the community with the screw treatment was $7640 more with cast treatment. There were no complications in the operated group and seven non-unions in the cast group. Conclusion: Primary percutaneous screw fixation of scaphoid fractures is reliable, fast, cost-efficient and reproducible. The learning curve is moderately steep. It results in improved union rates, decreased time to union, improved early function and early return to work. Prone and supine oblique views are invaluable in assessing accurate screw placement

To evaluate the safety and efficacy of treating patients with Graf IIa developmental hip dysplasia. The management of the developmentally immature Graf Type IIa dysplastic hip is controversial. Some authors advocate early treatment with an abduction harness whilst others adopt watchful waiting. At our institution selective sonographic assessment for developmental dysplasia of the hip (DDH) was established in 1997 with prospective data collection. All infants diagnosed with Graf Type IIa hip(s) were treated with either a Pavlik harness or double nappies, with clinical and sonographic follow up until normalisation. Pelvic radiographs were routinely performed at 8 and 18 months follow up for assessment of residual dysplasia and/or complications of treatment. We evaluated the safety and efficacy of all treated patients between 2005 and 2013. Complete clinical and radiological follow up (mean 2.1 years, 0.7–6.5) was available for 103 of 118 infants. 69 were treated with a Pavlik harness and 49 with double nappies. The chosen treatment was successful in 110 hips with no documented complications, well developed ossific nuclei on follow up radiographs, and no further treatments undertaken. In the double nappy group 4 infants deteriorated sonographically so were changed to a Pavlik harness with subsequent normalisation and successful treatment. 3 patients required VDRO at age 18 months (17–20) and 1 patient required closed reduction and spica cast treatment at age 11 months. No further complications arose in this group. The 15 patients lost to follow up had successful initial treatment but failed to attend for radiographic review. Both Pavlik harness and double nappies are safe treatment modalities for Type IIa hip dysplasia. However, sonographic deterioration was observed in both groups with surgical intervention required in the minority, supporting the ongoing treatment of these immature hips

Background. Despite the suggestion by Virchow in 1856 that thrombosis was the result of venous stasis, endothelial dysfunction and hypercoagulability there are some fundamental questions which remain to be answered. The published studies fail to provide specific details such as cast type and anatomical location of the thrombosis, but instead focus on the incidence of VTE and which chemical thromboprophylaxis is most effective. Previous studies of VTE in trauma patients have involved small numbers of patients and have not look at the risk medium to long term risk. Most importantly they have not looked at the site of the VTE. This makes interpretation of the link between cast and VTE even more complex. Methodology. We analysed 1479 consecutive trauma cast applications and the incidence of symptomatic VTE in the six months following the injury. The diagonosis, cast type and site of the VTE was recorded. Results. The overall incidence of DVT was 2.5% (2.2% distal and 0.3% proximal), 50% occured inthe first 3 weeks, the rest were between 6–13 weeks. The incidence of PE was 0.7%, there was 1 death due to PE. Achilles tendon injury was a statistically significant risk factor, there were no other conditions with a specific risk. There was no difference between above and below knee cast immobilisation. However all symptomatic DVTs occured in the casted leg. Discussion. This is the first study to look at long term VTE risk and the site of thrombosis, these findings have implications for VTE prophylaxis. It would appear that the risk of developing symptomatic VTE extends beyound the currently advised treatment period. It also suggests that venous stasis and endothelial damage are more important that hypercoagulability in the development of VTE after cast treatment for trauma. We recommend a programme of exercises within the cast to reduce this risk

Aims. The Ponseti method is an effective evidence-based treatment for clubfoot. It uses gentle manipulation to adjust the position of the foot in serial treatments towards a more physiological position. Casting is used to hold the newly achieved position. At first, the foot resists the new position imposed by the plaster cast, pressing against the cast, but over time the tissues are expected to adapt to the new position and the force decreases. The aim of this study was to test this hypothesis by measuring the forces between a clubfoot and the cast during treatment with the Ponseti method. Patients and Methods. Force measurements were made during the treatment of ten idiopathic clubfeet. The mean age of the patients was seven days (2 to 30); there were nine boys and one girl. Force data were collected for several weeks at the location of the first metatarsal and the talar neck to determine the adaptation rate of the clubfoot. Results. In all measurements, the force decreased over time. The median (interquartile range) half-life time was determined to be at 26 minutes (20 to 53) for the first metatarsal and 22 minutes (9 to 56) for the talar neck, suggesting that the tissues of the clubfoot adapt to the new position within several hours. Conclusion. This is the first study to provide objective force data that support the hypothesis of adaptation of the idiopathic clubfoot to the new position imposed by the cast. We showed that the expected decrease in corrective force over time does indeed exist and adaptation occurs after a relatively short period of time. The rapid reduction in the forces acting on the foot during treatment with the Ponseti method may allow significant reductions in the interval between treatments compared with the generally accepted period of one week

Purpose. The treatment of children with contractures involving the lower limbs is challenging. Many are confined to wheelchairs for several years till their potential to ambulate is discovered. The aim is to review the treatment and outcome of eight children treated for contractures and deformities of the lower limbs following confinement to wheelchairs. Methods. Eight children aged 4–14 years were treated for contractures of the hips, knees and feet between 2005 and 2011. The initial diagnosis was not made in 5 children. All children had never walked previously. Four patients were labelled “cerebral palsy”. All children were seen with a physiotherapist to assess their walking potential. Genetic and paediatric medical assessment was also made. Final diagnosis revealed arthrogryposis (n = 3) pterygium syndrome (n = 1) calcinosis cutis (n = 1) viral neuropathy (n = 1) and cerebral palsy (n = 2). Clinically all children were assessed to have good upper limb function for use of crutches. Surgical correction of the feet was required in 6 patients. Extension osteotomies of the knees were done in 8 patients following serial plaster cast treatment and hamstring release. Hip releases were done in 4 patients. Results. The osteotomies healed well following above knee cast immobilisation. All patients are ambulant with above knee calipers, anterior knee straps and boots. Two children required repeat extension osteotomies. Follow up ranges between 8 months to 5 years. Conclusion. Patients with contractures of the lower limb should have careful clinical assessment. If upper limb function is suitable for holding crutches and the patients have the potential to kneel with the body erect, careful preoperative planning should be undertaken to improve the foot for weight bearing and the knees with extension osteotomies and ambulation. Accurate diagnosis is essential

Aims

The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome.

Introduction and Aims: Union of femoral shaft fractures in a shortened position is a recognised complication of spica cast treatment. Such shortening can only be assessed radiographically until the spica has been removed. The constraints of a spica cast complicate the imaging of the femur and may lead to error in assessing shortening. This study aims to quantify the magnitude of such error for application to clinical practice. Method: A model for a spiral femoral fracture in a spica cast was devised. Shortening of the femoral segment through telescoping and angulation was controlled with a Wagner lengthening device external to the spica. Shortening from angulation and telescoping were varied and radiographic measurements compared with real measurements. The correlation between true and radiographic shortening of > 2cm was measured with the kappa value. Results: There was good agreement between radiological and real shortening of > 2cm. Where shortening was present without angulation, the radiological measurement over-estimated the degree of shortening. The error increased with the amount of shortening. Angulation of more than 30 degrees caused the radiological measurement to under-estimate the true amount of segmental shortening. Conclusion: This study suggests that radiological measurement of femoral shortening in a spica should reliably predict clinically significant shortening when there is less than 30 degrees of fracture angulation

Aim: The aim of this study was to evaluate management of non-articular distal tibial fractures. Materials & Methods: Between January 2000–December 2004, we treated 25 children with a non-articular distal tibia fracture. All fractures were isolated high velocity injuries (11-Road traffic accidents; 14-Sports injuries) without neurovascular compromise. Only 2 out of 25 were open (grade I) fractures. There were 19 males and 6 females aged 7–16 years (average 11.4 years). On radiography, the fracture patternsvaried from transverse-7 patients, spiral-8 patients, short oblique-7 patients, and communited-3 patients.16 patients had an associated fibula fracture. 20 of the 25 fractures were primarily treated in a cast while the remaining 5 were primarily treated by external fixator (3-Orthofix; 2-Ilizarov) as closed reduction was unstable. The average period in cast/external fixator was 8.4 weeks and the average follow-up 6.2 months. Results: On early follow-up, 8 of the 20 fractures (40%) that were initially treated in a cast needed intervention (plaster wedging-5; external fixator-3) because of displacement/angulation of the fracture. 7 (28%) of the 8 fractures needing intervention were short oblique fractures. There was no correlation between open injury/associated fibula fracture and displacement/angulation. Conclusion: Short oblique fractures had a high failure rate with cast treatment. We recommend close monitoring with weekly radiographs for cast treated fractures or alternately primary external fixation of unstable, short oblique fractures

Objective: The Ponseti method for the treatment of club foot has been shown to be effective in children up to one year of age. However, it is not known whether it is successful in older children. In this prospective study, we used Ponseti method in club foot after walking age; that are neglected or undergone an insufficient previous treatment. Materials and Methods: From 2003 to 2005 we treated and followed-up 37 feet of 30 patients. All the club foot deformities corrected by the method described by Ponseti, with minor modifications. The mean age at presentation was 21 months (12–72 months) and the mean follow-up was 26 months (16–32 months). 21 feet had previous conservative and surgical treatments. The mean applied cast count that used for this method was 5.4 (4 – 8 cast). After cast treatment we performed achilotomyfor 15 feet, achiloplasty for 20 feet and achiloplasty and posterior capsulotomy for 2 feet. All the patients evaluated before and after treatment by the Dimeglio classification. Results: Before treatment 35 feet were grade 3 and 2 feet were grade 4, and after the treatment 11 feet were grade 0, 26 feet were grade 1. All the patients deformities were corrected and the treatment results were statically significant (p=0.0001). Patients distincted in two groups according to their age at the beginning of the treatment. 20 feet were younger than 20 months and 17 feet were older than 20 months. All the patients younger than 20 months had grade 3 deformity before treatment and 19 feet improved grade 1 and 1 foot improved to grade 2 after this method. In patients older than 20 months 15 feet were grade 3 and 2 feet were grade 4. and after this treatment method in this group 13 feet were improved to grade 1 and 4 feet were improved to grade 2. Patients older than 20 months had worse results for the components of varus, medial rotation of calcanopedal block and adductus thant the other group. And difference in these groups were significant. (p> 0.005). Conclusion: We conclude that the Ponseti method is a safe, effective and low-cost treatment for idiopathic club foot presenting after walking age

We undertook a prospective, single blinded, randomized, controlled trial of one hundred children treated with either an above or below elbow cast for treatment of closed, distal third forearm fractures requiring reduction. The re-manipulation rate in the below elbow group was 2% (95%CI: 0–11%) compared to 6% (95%CI: 2–15%) in the above elbow group, p=0.62. Above elbow casts do not appear to improve fracture immobilization nor reduce the requirement for re-manipulation in pediatric distal third forearm fractures. Debate exists regarding the benefits of using below elbow casts instead of above elbow casts for maintaining reduction in pediatric distal third forearm fractures. The literature indicates a loss of reduction rate of 14.6% of children treated in an above elbow cast and 2.5% in those treated with a below elbow cast. We undertook a prospective, single blinded, randomized, controlled trial of one hundred children treated with either an above or below elbow cast for treatment of closed, distal third forearm fractures requiring reduction. Outcome measures included re-manipulation rate, fracture displacement during cast wear, and cast complications. One hundred patients were suitably enrolled; fifty-four received an above elbow cast, forty-six received a below elbow cast. The two groups were similar in terms of age and gender. The above elbow group contained a higher proportion of both bone fractures (41/54) than the below elbow group (27/46). There were no significant differences between the two cast groups in initial, post-reduction or cast-off fracture angulation; nor any difference in the amount of fracture displacement during cast wear. The number of cast complications was similar between the two groups. The re-manipulation rate in the below elbow group was 2% (95%CI: 0–11%) compared to 6% (95%CI: 2–15%) in the above elbow group, p=0.62. Above elbow casts do not appear to improve fracture immobilization nor reduce the requirement for re-manipulation in pediatric distal third forearm fractures. Funding Hip Hip Hooray, Saskatoon

Background. Avulsion fractures of the base of the fifth metatarsal are some of the commonest foot injuries. The robust scientific evidence on the optimal non-operative treatment of these fractures is scant. We designed and conducted a prospective randomised non-inferiority controlled trial of symptomatic treatment versus cast immobilisation with the null hypothesis that cast immobilisation gave substantial benefit over the symptomatic treatment in terms of patient reported outcome measures(PROMs). The alternative hypothesis was that symptomatic treatment was not inferior. Methods. The primary outcome was the validated Visual Analogue Scale Foot and Ankle (VAS FA) score ranging from 0 to 100. The non-inferiority boundary was set at −10 points. Power sizing determined a minimum of 12 patients per group. Anticipating a significant loss to follow up, 60 patients of 16 years of age or older were randomised to receive either below knee walking cast immobilisation (n = 24) or symptomatic double- elasticated bandage (n = 36) for 4 weeks. Secondary outcome measures were EuroQol-5D, and American Orthopaedic Foot and Ankle Society scores. Data was analysed at the baseline, 4 weeks, 3 months and 6 months post injury by a clinician blinded to a treatment arm. Results. Symptomatic treatment proved to be non-inferior to cast immobilisation treatment in terms of VAS FA at baseline, 4 weeks and 6 months. Secondary outcomes showed similar comparative values between two treatment groups. Loss to follow up reached 43% at 6 months. The imputation of missing data was done and confirmed the non-inferiority of symptomatic treatment. Conclusions. Cast immobilisation does not appear to give benefits over symptomatic treatment of these injuries in terms of validated PROMs in adults. A significant loss to follow up should be expected with these fractures in medium term. Level of Evidence. II. Approval. NRES Yorkshire and the Humber reference: 11/YH/0297. Disclosure. This study was supported with a small research grant from a British Orthopaedic Foot and Ankle Society

Purpose: The aim of this study was to evaluate the clinical and radiological results and hospital stay of incorporated hip spica cast treatment in peadiatric diaphyseal femoral fractures. Material and methods: 49 femoral diaphyseal fractures of 48 children who were admitted to our institution between March 1998 and November 2001 were included in this study. Mean age was 4.5 years. Mean follow up was 30.5 months.The mechanisms of the fractures were: 45.7% road traffic accident, 8.3% falling and 6.2% sports injuries. Immediate supracondylar skeletal traction with a 3 mm. K-wire was applied to all patients under general anesthesia. This wire was incorporated with a hip spica cast after the reduction of the fracture under fluoroscopic control. All patients discharged from the clinic after 24 hours. Reduction and evidence of callus formation have been carefully checked with two plane X-rays taken on the follow-ups. We have removed the cast and K-wire in the evidence of callus formation on both AP and lateral X-ray views. After two weeks of careful rehabilitation program the patients were encouraged to walk with full weight bearing. The patients were followed in every three months in the first year and in every six months in the second year. Radiological assessment of roentgenograms and scoring of the final radiological result after fracture consolidation were evaulated as shown in Table 1. Findings: The average hospital stay was 24 hours. We have noticed pin tract infection only in 2 cases. We had only one re-fracture. Mean duration of cast removal was 6.9 weeks and mean consolidation time of the fracture was 13.3 weeks. On the final follow-up X-rays, mean overriding was 6mm(range 0–20 mm.). Mean shortening of the affected limb was 2mm. The mean deformity noted at the cast removal was as follows: Varus angulation 3.8 degrees, Valgus angulation 5.6 degrees, Anterior angulation 13.3 degrees. At the final examination we have noted the mean deformity angles as follows: Varus angulation 1.7 degrees, Valgus angulation 3.6 degrees, Anterior angulation 2.27 degrees. We have evaluated the results as excellent in 35 cases(72%), good in 9 cases(19%), moderate in 4 cases(9%). Conclusion: The treatment of femur fractures in children is controversial and highly variable. Each method of treatment has practical and theoretical advantages and disadvantages. The literature provides few comparative studies. Malunion is the most frequently used endpoint of treatment but every treatment is prone to different types of malunion. Any evaluation of treatment must consider all aspects of malunion including displacement, angulation, rotation, and length. Our study suggests that the clinical results of immediate incorporated hip spica cast application is a very reliable method compared with other choice of treatments. Safe and easy application, short hospital stay and low cost, are the major advantages of this method