Aims. Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room. Methods. A randomized controlled trial was conducted. A total of 255 patients were included, aged five to 17 years, who needed plaster treatment for a fracture of the upper or lower limb. Randomization was stratified for age (five to 11 and 12 to 17 years). The intervention group was distracted with VR goggles and headphones during the plaster treatment, whereas the control group received standard care. As the primary outcome, the post-procedural level of anxiety was measured with the Child Fear Scale (CFS). Secondary outcomes included the children’s anxiety reduction (difference between CFS after and CFS before plaster procedure), numerical rating scale (NRS) pain, NRS satisfaction of the children and accompanying parents/guardians, and the children’s heart rates during the procedure. An independent-samples t-test and Mann-Whitney U test (depending on the data distribution) were used to analyze the data. Results. The post-procedural CFS was significantly lower (p < 0.001) in the intervention group (proportion of children with no anxiety = 78.6%) than in the control group (56.8%). The anxiety reduction, NRS pain and satisfaction scores, and heart rates showed no significant differences between the control group and the intervention group. Subanalyses showed an increased effect of VR on anxiety levels in young patients, females, upper limb fractures, and those who had had previous plaster treatment. Conclusion. VR effectively reduces the anxiety levels of children in the plaster room, especially in young girls. No statistically significant effects were seen regarding pain, heart rate, or satisfaction scores. Cite this article: Bone Joint J 2024;106-B(7):728–734

Introduction and objectives: The most commonly used treatment for extraarticular fractures of distal radius is closed reduction and maintenance of reduction in a cast. Two types of casts are used: plaster splint for 7–10 days and later exchanged to a circular cast and the use of circular cast immediately. The objective of this work is to compare both types of treatment in terms of ability to achieve reduction and to maintain it during healing. Methods: A prospective, randomized and blinded study was designed. To date, 21 patients enrolled the study. Informed consent was given. The inclusion criteria were: older than 35 years, extraarticular distal radius fracture sustained less than 24 hours before and not previously treated. Exclusion criteria included previous injury in the same wrist, open fracture, and not compliance with the protocol. After intrafocal anesthesia with mepivacaine 1%, fracture was reduced under traction and immobilized in a dorsal short plaster splint (splint group) or a circular short plaster cast (circular group) randomly. After 10 days of immobilization, the plaster splint was changed to a circular short plaster cast. AP and lateral X-Rays were taken before reduction, after reduction, after 10 days (before changing cast), and at 21 days. Volar inclination of lunate fossa on the lateral X-Ray was obtained. On the AP proyection, the radial inclination and radial length was measured. Complications were recorded. Data was analysed through ANOVA between groups. Results: When comparing X-rays before and after reduction, the volar inclination of the lunate fossa on lateral projection changed from −21,4° to 8,60° (30° change) after reduction in splint group and from −15,22° to 1,78° (17° change) in circular group (p< 0.05). The other comparisons were N.S. When comparing after reduction and 10 days later, the radial inclination changed from 20,20° to 18,80° (1,40° change) in the splint group and from 20,89° to 20,44 (0,44° change) in the circular group (p< 0.05). Other comparisons were N.S. No differences were found between 10 days and 21 days in any X-Ray parameter. No complications were found. Conclusions: A better reduction was achieved with the plaster splint method in the immediate X-Ray control. Nevertheless, reduction was better maintained during the first 10 days with the circular plaster cast method

Introduction and Purpose. Metacarpal fractures constitute approximately one third of all hand fractures. The majority of these fractures are treated by conservative non-surgical methods. The aim of this study is to obtain the appropriate anatomical alignment of the fracture with dynamic metacarpal stabilization splint (DMSS) and to maintain the proper bone anatomy until the union is achieved. In addition, by comparing this method with short arm plaster splint (SAPS) application, it is aimed to evaluate whether patients are superior in terms of comfort, range of motion (ROM) and grip strength. Materials and Methods. In our study, SAPS or DMSS was applied to the patients with 5th metacarpal neck fracture randomly after fracture reduction and followed for 3 months. A total of 119 patients with appropriate criteria were included in the study. Radiological alignment of the fracture and amount of joint movements were evaluated during follow-up. Grip strength was evaluated with Jamar dynamometer. EQ-5D-5L and VAS scores were used for clinical evaluation. Results. 103 patients completed their follow-up. 51 patients were treated with SAPS and 52 patients were treated with DMSS. The mean age of the SAPS was 29.5 (SD ± 9.4; 16–53 years) and the mean age of the DMSS group was 27.8 (SD ± 11.6; 16–63). Pressure sores was seen in 5 patients in the DMSS group, while no pressure sore was seen in the SAPS (p = 0.008). There was no significant difference between the two groups in the VAS scores at all times. There was no significant difference between the mean dorsal cortical angulation (DCA) before the reduction, after the reduction and at the third month follow-ups. There was no statistically significant difference between the length of metacarps at first admittion before reduction, after reduction and at third month follow-ups. When the grip strength of the two groups were compared as a percentage, the grip strength of the patients in the DMSS group was found to be higher at 1st month, 2nd month and 3rd month (p <0.001). When the ROM values of the patients were evaluated, DMSS group had a higher degree of ROM in the first month compared to the SAPS group (p <0.001). No statistically significant difference was detected among groups at third month in the ROM of the IP and MP joints. However, wrist ROM was statistically higher in DMSS group at 3rd month (p <0.05). There was a statistically significant difference between EuroQol scores in favor of DMSA group (p <0.05). Discussion and Conclusion. In stable 5th metacarpal neck fractures, DMSA is as effective as SAPS to maintain bone anatomy. In addition, DMSA can be preferred for fixation plaster splint or circular plaster applications for the prevention of reduction in boxer fractures, with the advantage of having high clinical scores, which is an indication of early acquisition of grip strength, ease of use and patient comfort

Introduction: Early plaster immobilisation is important in fracture management to control pain and maintain alignment. In our institute, the initial plaster is routinely applied by junior trainees directly or is applied by Accident & Emergency (A& E) staff under the supervision of the junior trainees. In the U.K., plaster application technique has not been routinely and formally taught to the junior trainees in the hospital. Method: We aimed to review the adequacy of plaster applied or supervised by junior trainees. The criteria for an adequate of plaster immobilisation for tibial diaphyseal fractures have not been reported in the literature. We had chosen 3 simple parameters, namely, change in alignment of fracture fragments, position of the ankle and a gap index of less than 0.15, which in our view are important in terms of initial management of tibial fracture in the A& E. The gap index reflects the amount of padding applied in the plaster. These parameters were merely chosen to assess the adequacy of initial plaster immobilisation by junior trainees and should not predict the long term success or failure of the management of fracture with plaster. Sixty-five patients with tibial diaphyseal fractures were retrospectively included in the present study. The initial and post-plaster application radiographs were assessed by two senior trauma & orthopaedic specialist registrars separately. Result: Only forty-six percent (45%) of the cases had fulfilled all the three criteria. In subgroup analysis, position of the ankle is the most frequently neglected factor with 31% of the ankles held in equinus. Twenty eight percent (28%) of cases had worsening of the alignment of the fracture fragments. Fourteen percent (14%) of the cases had excessive padding applied as reflected by Gap Index of > 0.15. Conclusion: This study highlighted that the basic plastering technique by the junior trainees is inadequate. We suggest that every trainee rotating to Trauma & Orthopaedic Surgery must be taught this fast-fading away basic plaster application technique during the induction period

Background. One of the prime concerns when managing patients in plaster casts is loss of reduction. There have been studies showing that proper moulding of the plaster cast is critical in maintaining reduction. Recent studies have negated concerns that fibreglass (FG) casts do not allow swelling, when compared to plaster of Paris (POP) casts. However, their potential in maintenance of reduction has not been investigated. Materials and methods. We compared the three-point bending properties of FG casts with POP casts over the first 48 hours. The effect of splitting the casts, at one hour and 24 hours, was studied. Three identical jigs with hinged metal rods were designed to simulate a Colles fracture. The bending force was provided by 0.5 kg weight applied at one end of the jig. The resultant displacement was measured to nearest 0.01 mm over the next 48 hours. Each test was repeated 6 times (total 6 groups and 36 tests). Results. Most deformation occurred within 1 hour for FG casts and 24 hours for POP casts. The total deformation in FG cast (mean 2.4 mm) was significantly less than in POP casts (mean 4.7 mm) (p < 0.01). Splitting at 1 hour increased the final deformation of the POP cast and not of the FG cast (p < 0.05). No significant difference was noticed if the casts were split at 24 hours. Conclusion. Three-point moulding with FG casts can provide better constant loading at the fracture site than the POP casts. Early setting of FG cast allows earlier splitting. We recommend clinical trials to ascertain the safety and efficacy of split FG casts

Aims. Describe a statistical and economic analysis plan for the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) randomized controlled trial. Methods. DRAFFT2 is a multicentre, parallel, two-arm randomized controlled trial. It compares surgical fixation with K-wires versus plaster cast in adult patients who have sustained a dorsally displaced fracture of the distal radius. The primary outcome measure is the Patient-Rated Wrist Evaluation (PRWE, a validated assessment of wrist function and pain) at 12 months post-randomization. Secondary outcomes are measured at three, six, and 12 months after randomization and include the PWRE, EuroQoL EQ-5D-5L index and EQ-VAS (visual analogue scale), complication rate, and cost-effectiveness of the treatment. Results. This paper describes the full details of the planned methods of analysis and descriptive statistics. The DRAFFT2 study protocol has been published previously. Conclusion. The planned analysis strategy described records our intent to conduct statistical and within-trial cost-utility analyses. Cite this article: Bone Joint Open 2020;1-6:245–252

BACKGROUND: One of the prime concerns when managing patients in plaster casts is loss of reduction. There have been studies showing that proper moulding of plaster cast is critical in maintaining reduction. Recent studies have negated concerns that fibreglass (FG) casts do not allow swelling, when compared to plaster of Paris (POP) casts. However, their potential in maintenance of reduction has not been investigated. MATERIALS AND METHODS: We compared the three-point bending properties of FG casts with POP casts over the first 48 hours. The effect of splitting the casts, at one hour and 24 hours, was studied. Also, the tolerance to handling was assessed by moving the hinge joint while the casts were setting. Three identical jigs with hinged metal rods were designed to simulate Colle’s fracture. The bending force was provided by 0.5 kg weight applied at one end of the jig. The resultant displacement was measured to nearest 0.01 mm over the next 48 hours. Each test was repeated 6 times (total 8 groups and 42 tests). RESULTS: Most deformation occurred within 1 hour for FG casts and 24 hours for POP casts. The total deformation in FG cast (mean 3.4 mm) was significantly less than in POP casts (mean 6.2 mm) (p > 0.05). Splitting at 1 hour increased the final deformation of the POP cast and not of the FG cast (p > 0.05). No significant difference was noticed if the casts were split at 24 hours. CONCLUSION: Three-point moulding with FG casts can provide better constant loading at the fracture site than the POP casts. Early setting of FG cast allows earlier splitting. We recommend clinical trials to ascertain the safety and efficacy of split FG casts

Introduction. Venous thromboembolism (VTE) is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. This incidence should in theory reduce if the patients are ambulatory early in the treatment phase. The aim of this study was, therefore, to identify a difference in the incidence of symptomatic VTE by treating acute Achilles tendon rupture patients with conventional non-weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were retrospectively reviewed and prospectively followed. The patients' demographics, treatment modality (non-weight bearing plaster versus weight bearing boot), and the type of plaster immobilisation was compared to assess whether they affect the incidence of clinical VTE. The predisposing risk factors were also analysed between the treatment groups. Out of 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a conventional non-weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. On the other hand, 41 patients were treated with functional weight bearing mobilisation (Vacupad). Patients who did have a symptomatic thromboembolic event also had an ultrasound scan to confirm a deep vein thrombosis of the lower limb or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients had a thromboembolic event (19.1%). On the other hand, out of the 41 patients who were treated with functional weight bearing mobilisation, only 2 patients had a symptomatic thromboembolic event (4.2%). This was statistically significant (p=0.012). This shows that patients who are treated in a non-weight bearing plaster have about five times increased risk of developing a sypmptomatic VTE compared to those treated by functional weight bearing mobilisation. There was however no difference in the predisposing factors in patients who developed VTE compared to those who did not. Conclusion. The incidence of symptomatic VTE after acute Achilles tendon rupture is high and under-recognised. Asymptomatic VTE after this injury is probably even higher. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non-weight bearing cast. There is a need for further research to define the possible benefit of thromboprophylaxis in patients treated by non-weight bearing plasters

Introduction. Peri prosthetic fracture is a recognised complication following Total ankle arthroplasty (TAA). There is limited literature on post operative management following TAA and controversies exist based on surgeon preferences. This project reports the incidence of peri- prosthetic fractures in patients managed with 2 different post-operative protocols. Materials and Methods. Patients undergoing primary TAA with a diagnosis of Osteoarthritis (OA) or Post-traumatic Osteoarthritis (PTOA) were recruited into a randomized controlled trial. These patients did not require any additional procedures. Patients were consented for the trial and randomized to one of two treatment groups (Early mobilisation after surgery vs. immobilisation in a plaster cast for 6 weeks post operatively). Plaster group patients underwent a graduated physiotherapy program from 6-12 weeks and early mobilisation group patients from 1-12 weeks. Complications any were recorded at 2, 4, 6 and 12 weeks post-operatively. Results. A total of 16 ankle replacements were done for a diagnosis of OA (10) and PTOA (6). Mean age was 58 years (±11.75) for the plaster group and 64 years (± 9.32) for the early mobilisation group. 7 patients were randomized to the plaster group and 9 patients were randomized to the early mobilisation group. Of the plaster group 1 patient sustained an intra-operative fracture tibia and 2 patients reported with a fractured medial malleolus. Of the early mobilisation group, 1 patient reported with a peri prosthetic fracture tibia at 6 weeks and 3 patients reported a fractured medial malleolus at 3 months follow up. The percentage of fracture incidence between plaster versus early immobilisation group was 42.8% and 44.4 % respectively. Conclusions. These early results demonstrate no significant differences in the incidence of fracture rates between groups. Further studies of post-operative management are needed to study the correlation with peri-prosthetic fracture rates after TAA

Aim. To assess if Osteoset (CaSO4) improves graft incorporation after shelf procedure and whether spica immobilisation is necessary. Methods/results. 49 patients with acetabular dysplasia treated by shelf procedure were reviewed retrospectively. Group 1 (19 children) and group 2 (12 adults) had shelf acetabuloplasty using autogenous bone graft and CaSO4. Group 3 (18 children) underwent shelf acetabuloplasty using autogenous bone graft alone. Group 2 was assessed separately to avoid age bias. Within group 3 we compared 10 patients managed in plaster for six weeks with 8 mobilized on crutches post operatively. Total shelf and graft area, total shelf length, extra-osseous shelf length and speed of graft incorporation were measured radiologically. There was no difference in shelf indices between patients treated in plaster and those mobilized on crutches. Use of CaSO4 significantly enlarged shelf volume by 3 months post-operative with less resorption, which was maintained throughout follow-up. In contrast the non-CaSO4 group showed a steady decrease in shelf volume. The extra-osseous shelf length was initially similar in groups 1 & 3. By 6 weeks the group 1 extra-osseous shelf was significantly greater than for group 3 and was maintained throughout follow-up. Graft incorporation was faster in group 1. Shelf area and extra-osseous shelf length improved significantly in group 2. However total shelf length decreased slightly by 6 months. Conclusions. The ‘shelf procedure’ is used to contain the femoral head in acetabular dysplasia. The technique described by Staheli recommended plaster spica immobilization for 6 weeks to prevent graft resorption. Our results suggest this is unnecessary. CaSO4 improves graft volume, graft incorporation and reduces resorption in children compared to controls, with similar results in adults using CaSO4

Objectives: To show that the treatment of buckle fracture in children in a soft bandage, rather than a plaster cast, is an effective and safe method of treatment, with an earlier return to normal function. Methods: In order to determine the difference between the two groups it was decided to compare the range of movement at three weeks. Power calculations were performed using the minimum difference for a two-sample t-test method and assuming a non-central distribution. The calculation was performed on Minitab release version 12.1 Assuming a required difference of 5 degrees and a standard deviation of 5 degrees also with a required power of 0.9(90%) this gave a required sample size of 23 for each group i.e a total of 46 patients. Guidelines for the parents, consent forms, doctor and nurse protocols, a guidance poster for the A& E, treatment profiles for each patient and a questionnaire for parents were written. The project was submitted for ethical approval in July 1999 and granted at the end of that month. Patients enter the trial after parents agree and sign the consent form. Allocation to either plaster or bandage is random and parents draw previously sealed envelopes themselves. Those allocated to bandage are seen each week and measurements taken of their range of movement. Results: Thirty seven patients have completed the study. 17 have been allocated to bandage the rest to cast. Those in bandage show an excellent range of movement at the first week with no reported problems on their questionnaires. One patient has transferred from bandage to plaster at the request of the parents. Problems encountered have been compliance of those in bandage to return for follow up after two weeks and, ensuring all patients enter the trial and attend the right clinic. Conclusion: Results suggest a positive result for treatment in bandage with no reported adverse effects and, a highly desirable result for the patient. We would hope to suggest a change in treatment policy for such fractures

Introduction. To investigate if the gap index measured in the follow-up X-rays predicts the reduction of swelling in the plaster cast thereby increasing the risk of re-displacement of fracture treated by manipulation alone. Materials/Methods. We selected for this study a cohort of children who presented with a traumatic displaced fracture of distal radius at the junction of metaphysis and diaphysis who were treated with manipulation alone. This cohort was chosen because of the high risk of re-displacement following closed manipulation of this unstable fracture and to maintain uniformity of the fracture type. Cast index and Gap index was measured in the intra-operative radiograph and at two-weeks to note the change in these indices. Gap index which is measured by summing radial and ulnar translation/inner diameter of cast in the AP X-ray and similar translation on the lateral x-ray/inner diameter of cast, with a measure of <0.15 considered to be a satisfactory cast. Results. Forty-one children with a mean age of 9 years (mode-8, range 4–15 yrs) admitted between Jan 2008 and Feb 2010 with the above described fracture and were treated with manipulation alone were included in this study. Serial radiographs show a gradual loss of reduction in 34 (83%) children and 17 (41%) of these children required re-manipulation. As the plaster cast was not changed the cast index remained same while the gap index increased in the follow-up x-rays as the swelling subsided. In those children whose reduction remained satisfactory, the initial gap index was 0.14 which changed to 0.18 (n=7, p>0.05) while in children in whom the fracture lost reduction, the initial gap index was 0.18 and changed to 0.25 (n=34, p=0.0092) at two weeks. Conclusion. Gap index can easily be calculated on follow-up radiographs and can be used to assess the adequacy of plaster cast. From this study we can conclude that it is effective in assessing the adequacy of plaster cast as the swelling subsides

Background. Patients presenting to fracture clinic who have had initial management of a fracture performed by Accident and Emergency (A+E) often require further intervention to correct unacceptable position. This usually takes the form of booking a patient for a general anaesthetic to have manipulation under anaesthesia (MUA) or open surgery. Methods. Prospective data collection over a 6-month period. Included subjects were those that had initial management of a fracture performed by A+E, who went on to require re-manipulation in fracture-clinic. Manipulations were performed by trained plaster technicians using entonox analgesia followed by application of moulded cast. Radiographs were reviewed immediately post-manipulation by treating surgeon and patient managed accordingly. A retrospective review of radiograph images was performed by two doctors independently to grade the outcomes following manipulation. Results. 38 patients with 39 fractures included in study. Sites of fracture included 32 distal radius, 2 ankle, 1 spiral distal tibia and fibula, 3 metacarpal and 1 proximal phalanx of finger. 22 patients had anatomical/near-to anatomical reduction at post fracture-clinic manipulation of fracture and was the as well as definitive management (satisfactory outcome). 13 patients had a outcome 2 (minimally displaced but and satisfactory reduction of the fracture) at post fracture-clinic reduction. 12 of these were deemed acceptable went onto outcome 1 for definitive management with 1 going to outcome 2 (requiringed further manipulation). 4 patients had unsatisfactory reduction of fracture outcome 3 at post fracture-clinic reduction and all of these patients went onto outcome 3 (required surgery). Conclusions. This study supports the practice of possible primary reduction and if required, re-manipulation and cast moulding using only entonox analgesia, of selected patient cases fractures by trained plaster technicians. Without this intervention, almost all of these cases will have required an MUA or additionally Kirscher wire or open fixation. There is potential to utilise a plaster technician in A+E, reducing the need for further fracture clinic appointments, being more acceptable to patients and having a resultant cost-saving implication. Level of Evidence. Level 3

Introduction and aims. Cast immobilisation of paediatric forearm fractures has traditionally used plaster of Paris. Recently, synthetic casting materials have been used. There have been no studies comparing the efficacy of these two materials. The aim of this study is to investigate whether one material is superior for paediatric forearm fracture management. Methods. A single-centre prospective randomised trial of patients presenting to the Women's and Children's Hospital with acute fractures of the radius and/or ulna was undertaken. Patients were enrolled into the study on presentation to the Emergency Department and randomised by sealed envelope into either a fiberglass or plaster of Paris group. Patients then proceeded to a standardised method of closed reduction and cast immobilisation. Clinical follow-up occurred at one and six weeks post-immobilisation. A patient satisfaction questionnaire was completed following cast removal at six weeks. All clinical complications were recorded and cast indexes were calculated. Results. Initially 50 patients were recruited to the study, with equal randomisation. There were no significant differences between the patient demographics of the two groups. The results from this sample indicated an increase in clinical complications involving the plaster of Paris casting group. These complications included soft areas of plaster requiring revision, loss of reduction with some requiring re-manipulation and a high rate of cast spliting due to material swelling. The fractures that loss reduction had increased cast indices. Fibreglass casts were also preferred by patient and their families, with many observational comments regarding the light-weight and durable nature of the material. Conclusions. Cast immobilisation of paediatric forearm fractures is a common orthopaedic treatment. There is currently no evidence regarding the best material for casting. This study suggests that both clinical outcomes and patient satisfaction are superior with fiberglass casts, we are continuing this study to enable greater power with our results

Purpose. To elucidate whether there is an advantage in external fixation supplementation of K-wires in comparison to K-wires and plaster, in the treatment of distal radius fractures without metaphyseal comminution. Indications. Distal intraarticular radius fractures, Frykman VIII or VIII without metaphyseal comminution. Contraindications. Metaphyseal comminution, general medical contraindications for surgical intervention. Study design. Fifty-one patients were prospectively randomised in two groups: 24 patients were treated with K-wire and spanning external fixation supplementation, and 27 were treated with K-wires and plaster. Results. Patients were monitored following the operation with a minimum follow up of 1 year, and checked independently of surgeon for pain, satisfaction and range of motion. There was a statistically significant difference in favour of the external fixation patient group for pain (Visual Analogue Score, Ex-Fix group: mean 14.9, plaster group: mean 28.1, p<0.001) and satisfaction (Ex-Fix group: mean 89.7, plaster group: mean 76.3, p<0.001,). Although one would expect that range of motion would be reduced in the external fixation group, there were no statistically significant differences found in favour of plaster; on the contrary supination results were surprisingly in favour of the external fixation group (Ex-Fix group: mean 54.4, plaster group: mean 45.2, p<0.05). Conclusion. In this study, external fixation supplementation of K-wiring had statistically significant superior results in patient satisfaction score, pain score, and wrist supination in comparison to plaster augmentation of K-wiring

The aim of this study was to assess the usefulness of Cast index and an indigenously developed Gap index as measures of poor moulding of plaster. 20 cases of re-manipulation of distal third forearm fractures excluding growth plate injuries were compared with a control of 80 patients. 5 patients in the control group had an axial deviation of more than 10 degrees but were not remanipulated and therefore were included in the failure group. The gap index and the cast index of the two groups was compared as predictors of failure of conservative treatment. The groups were similar in terms of demography and post reduction alignment. There was a significant difference (< 0.001) in the Cast index and the Gap index of both the groups. The sensitivity of the Cast index (> 0.8) in predicting failure of plaster was 48% while that of the sum of Gap index (> 0.15) in AP & Lat view was 88%. Gap index was found to be more accurate (84%) than Cast index (78%) in predicting failure. The gap index is a better predictor of failure than the cast index. A quick assessment of these indices, especially by the less experienced surgeons, is a good practice before accepting any plaster following a manipulation of distal radial fractures. It would not only save the patient a second anaesthesia but also complications of a more extensive second procedure and of course hospital resources

The aims of this study were i) to see if there is an association between poorly applied plasters and redisplacement of paediatric forearm fractures, and ii) to define reliable radiographic measurements to predict redisplacement of these fractures. The two radiographic measurements which were assessed were Cast Index and Padding Index which are a guide to plaster moulding and padding respectively. The sum of these was termed as the Canterbury Index. Case records and radiographs of 142 children who underwent a manipulation for a displaced fracture of forearm were studied. Angulation, translation displacement, Cast index and Padding index were measured on radiographs. Redisplacement was seen in 44 cases (32.3%). The means and 95 % Confidence intervals for cast index and padding index were 0.87 (0.84, 0.90) and 0.42 (0.39, 0.62) in the redisplacement group whereas were 0.71 (0.69, 0.72) and 0.11 (0.09, 0.12) in the group with no redisplacement respectively. Initial displacement, Cast index, Padding index and Canterbury Index were significantly greater in the redisplacement group (p< 0.005). No statistically significant difference was seen for age, fracture location, initial angular deformity and seniority of the surgeon. We suggest that Cast Index > 0.8, Padding Index > 0.3 and Canterbury Index > 1.1 are significant risk factors for redisplacement of conservatively treated paediatric forearm fractures

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non- weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients' demographics, treatment modality (non- weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non- weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non- weight bearing cast

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient. This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism. Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study. Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported. Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non-weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients demographics, treatment modality (non-weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non-weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non-weight bearing cast