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

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

Aim: A prospective randomised clinical trial was performed to evaluate two forms of immobilisation in the treatment of colles fractures not requiring manipulation. Methods: Patients were randomised to either plaster cast (PC) or a removable splint: wrist splint (FWS) according to date of presentation. Patients who had associated injuries to the same upper limb, previous wrist fracture, and open fractures, below 20 years or impaired cognitive function were excluded. The hospital ethical committee approved the study and informed consent was obtained from patients. Patients were reviewed at one week, two weeks, six weeks and twelve weeks following enrolment into the trial. Radiographs were performed on the first four visits. Subjective data was obtained using a patient questionnaire. Levels of pain, comfort in cast, swelling and any modifications to the cast were documented. Was used at six and twelve weeks to assess Clinical assessment was performed by a qualified physiotherapist using the demerit score of Sarmiento which combines range of motion, grip strength and functional assessment. Results: There were thirty-seven patients in the PC group and thirty-four in the FWS group. They were well matched in terms of age and sex distribution One patient in the PC group required manipulation under anaesthesia due to loss of position at one week. There was no statistical difference between either treatment method in radiological position. Nine patients in the PC group required change of cast due to loosening or discomfort. A further eight patients in the PC group required cast trimming. Visual analogue scores for pain and cast discomfort were lower in the FS group (p< 0.05). Grip strength compared to the opposite side was higher in the FS group (55.9% Vs 47.8% at week six, 71.8% Vs 65% at week twelve). Functional assessment demonstrated a higher score in the FS group at six weeks. However the difference did not reach statistical significance at repeat examination at twelve weeks. Conclusion: In this study there was no difference in either method in maintaining fracture position. However there was greater patient satisfaction and earlier rehabilitation in those patients treated in a futura wrist splint. Patients treated in plaster cast required a greater use of plaster room resources. We feel that the use of a removable wrist splint in suitable patients with either undisplaced or minimally displaced distal radial fractures is validated by this study

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. 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

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

Objectives. The evidence base to inform the management of Achilles tendon rupture is sparse. The objectives of this research were to establish what current practice is in the United Kingdom and explore clinicians’ views on proposed further research in this area. This study was registered with the ISRCTN (ISRCTN68273773) as part of a larger programme of research. Methods. We report an online survey of current practice in the United Kingdom, approved by the British Orthopaedic Foot and Ankle Society and completed by 181 of its members. A total of ten of these respondents were invited for a subsequent one-to-one interview to explore clinician views on proposed further research in this area. Results. The survey showed wide variations in practice, with patients being managed in plaster cast alone (13%), plaster cast followed by orthoses management (68%), and orthoses alone (19%). Within these categories, further variation existed regarding the individual rehabilitation facets, such as the length of time worn, the foot position within them and weight-bearing status. The subsequent interviews reflected this clinical uncertainty and the pressing need for definitive research. Conclusions. The gap in evidence in this area has resulted in practice in the United Kingdom becoming varied and based on individual opinion. Future high-quality randomised trials on this subject are supported by the clinical community. Cite this article: Bone Joint Res 2015;4:65–9

Aim

To demonstrate the effect of location of the split of the plaster on the raised intercompartmental pressure in the volar and dorsal compartments.

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.

Introduction: We aimed to assess a simple radiological method of predicting redisplacement of paediatric forearm fractures. The Cast Index (CI) is the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site. A CI of > 0.7 was used as the standard in predicting fracture redisplacement. The cast index has previously been validated in an experimental study.

Methods: Case records and radiographs of 1001 children who underwent a manipulation under general anaesthesia for a displaced fracture of the distal forearm were studied. Redisplacement was defined as more than 15 degrees of angulation and/or more than 80 percent of translational displacement on check radiographs at 2 weeks. Angulation (in degrees) and translation displacement (in percentage) were measured on the initial and check radiographs. The CI was measured on postoperative radiographs.

Results: Fracture redisplacement was seen in 107 cases at 2 week follow up. Of the 752 patients (75%) with a CI of less than 0.7 the displacement rate was 5.58%. Of the 249 patients (25%) with a CI greater than 0.7 the redisplacement rate was 26%. The CI was significantly higher in the redisplacement group. No statistically significant difference was seen for age, sex or ethnicity. Nor were statistical differences noted in initial angular deformity, initial displacement and seniority of the surgeon. Good intra and inter observer reproducibility was observed. There was no statistical difference in patients with a cast index between 0.7 and 0.8.

Conclusion: The cast index is a simple and reliable radiographic measurement to predict the redisplacement of forearm fractures in children. Previous studies have used a CI of > 0.7 as the predictor of redisplacement although this study suggests a plaster with a CI of < 0.81 is acceptable. A high cast index is associated with redisplacement of fractures and should therefore be considered when moulding casts in distal forearm fractures.

We aimed to assess a simple radiological method of predicting redisplacement of paediatric forearm fractures. The Cast Index (CI) is the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site. CI of 0.7 was used as the benchmark in predicting fracture redisplacement. Case records and radiographs of 1001 children who underwent a manipulation under general anaesthesia for a displaced fracture of the distal forearm were studied. Redisplacement was defined as more than 15 degrees of angulation and/or more than 80 percent of translational displacement on check radiographs at 2 weeks. Angulation (in degrees) and translation displacement (in percentage) were measured on the initial and check radiographs. The Cast index was measured on the check radiographs. Good intra and inter observer reproducibility was observed for both these measurements. The cast index has been previously validated in an experimental study.

The adequacy of reduction after manipulation was estimated by the postreduction translation and angulation of the radius and ulna in anteroposterior and lateral plain film radiographs. The 1001 patients who qualified for the study, fracture redisplacement was seen in 107 cases at the all important two week follow up. Seven hundred and fifty-two patients had cast indices of 0.8 or less whilst 249 had casting indices of 0.81 or more. In patients with cast indices of 0.8 or less, the displacement rate was only 5.58%. However, in patients with cast indices of 0.81 or more, the displacement rate was 26%. Initial displacement, angulation and the post manipulation cast index were the three factors which were significantly higher in the redisplacement group.

No statistically significant difference was seen for age, sex or ethnicity. Nor were statistical differences noted in initial angular deformity, initial displacement and seniority of the surgeon. There was no statistical difference in patients with cast indices between 0.7 and 0.8.

Cast index is a simple reliable radiographic measurement to predict the redisplacement of forearm fractures in children. A plaster with a CI of > 0.81 is prone to redisplacement. A high cast index is associated with redisplacement of fractures and should therefore be considered when moulding casts is distal forearm fractures.

Only 10–15% of those thought clinically to have a fractured scaphoid are confirmed as having fractures on initial radiographs. A further 1–20% of those who had initially negative radiographs go on to have fractures confirmed on subsequent radiographs taken 10–14 days later.

Fifty patients initially considered clinically to have scaphoid fractures were identified: 32 females and 18 males, with a mean age of 32 years, range 10–88 years, 68% were noted to have injured their dominant hand. Four patients, (8%), had scaphoid fractures identified on initial radiographs and only 1 patient, (2%), was found to have an occult scaphoid later. Three patients were found to have other bony injuries leaving 42 patients, (84%), having no fracture identified. Thirty-eight of this final group could be contacted and completed telephone questionnaires. The remaining 4 were lost to follow up. Patients were asked questions about employment, time off work, interference with other activities and general satisfaction with treatment.

The mean time in plaster was 16 days, range 9–42 days. Eighteen of those in work, (47% of the total, 66.7% of the workers), had time off work. The mean length of time off work was 18.4 days, range 14–42 days. Sixteen of these received full “sick pay” for their time off. Personal hygiene was affected in 84%, housework in 37.5%, sports/hobbies for 55%, driving in 76% and social activities in 11.8%. Only 2 patients overall, suffered personal financial loss which amounted to less than one hundred pounds each.

Only 3 people, (8%), expressed dissatisfaction with their management when directly questioned. All patients would have preferred an immediate diagnosis had this been possible. Alternative to this treatment including bone scanning and MRI are discussed.

Aims. The aim of this study was to compare the longer-term outcomes of operatively and nonoperatively managed patients treated with a removable brace (fixed-angle removable orthosis) or a plaster cast immobilization for an acute ankle fracture. Methods. This is a secondary analysis of a multicentre randomized controlled trial comparing adults with an acute ankle fracture, initially managed either by operative or nonoperative care. Patients were randomly allocated to receive either a cast immobilization or a fixed-angle removable orthosis (removable brace). Data were collected on baseline characteristics, ankle function, quality of life, and complications. The Olerud-Molander Ankle Score (OMAS) was the primary outcome which was used to measure the participant’s ankle function. The primary endpoint was at 16 weeks, with longer-term follow-up at 24 weeks and two years. Results. Overall, 436 patients (65%) completed the final two-year follow-up. The mean difference in OMAS at two years was -0.3 points favouring the plaster cast (95% confidence interval -3.9 to 3.4), indicating no statistically significant difference between the interventions. There was no evidence of differences in patient quality of life (measured using the EuroQol five-dimension five-level questionnaire) or Disability Rating Index. Conclusion. This study demonstrated that patients treated with a removable brace had similar outcomes to those treated with a plaster cast in the first two years after injury. A removable brace is an effective alternative to traditional immobilization in a plaster cast for patients with an ankle fracture. Cite this article: Bone Joint J 2023;105-B(4):382–388

Aims. The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury. Methods. Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient’s initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed. Results. Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury. Conclusion. For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function. Cite this article: Bone Jt Open 2024;5(2):132–138

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

Aim. The purpose of this study was to investigate the effects of plaster/splint immobilisation of the knee/ankle on driving performance in healthy individuals. Methods & Materials. Twenty-three healthy drivers performed a series of emergency brake tests in a driving simulator having applied above knee plaster casts, below knee plaster casts, or a knee brace with increasing restriction. Results. Our study showed that compared to braking normally, total brake reaction time was significantly longer when wearing an above knee plaster cast, below knee plaster cast or a knee brace with zero degrees of freedom (p<0.001). Increases in movement time from accelerator to brake accounted for some of the increase in the total brake reaction time. However, unexpectedly thinking time also increased with the level of restriction (p<0.001). Conclusion. These results suggest that all patients wearing a plaster cast or knee brace are significantly impaired in their ability to perform an emergency stop. We suggest changes to the legislation that prevents patients driving with lower limb plaster casts or knee braces

Aims. Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type. Methods. Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. Results. In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65. Conclusion. Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338–343

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. Scaphoid fractures with displacement have a higher incidence of nonunion and unite in a humpback position that can cause pain and reduced movement, strength and function. The aim of this study is to review the evidence available and establish the risk of nonunion associated with management of displaced scaphoid fractures in a plaster cast. Methods. Electronic databases were searched using the MeSH (Medical Subject Headings) controlled vocabulary (scaphoid fractures, AND'd with explode displaced, or explode nonunion, or explode non-healing or explode cast immobilisation, or explode plaster, or explode surgery). As no randomised or controlled studies were identified, the search was limited to observational studies based on consecutive cases with displaced scaphoid fractures treated in a plaster cast. The criterion for displacement was limited to gap or step of more than 1mm. The ‘random effects’ calculation was used to allow for the possibility that the results from the separate studies differ more than would be expected by chance. Results. Of the 27 articles identified, seven studies were eligible for the meta-analysis with a total of 1401 scaphoids. 93% (1311 scaphoids) of these scaphoid fractures healed in a plaster cast. 207 (15%) of all scaphoid fractures showed displacement of at least 1mm (Gap/step) between fracture fragments. Nonunion was identified in 18% (37/207) of displaced scaphoid fractures treated in a plaster cast. The pooled odds ratio of fracture nonunion between the displaced and undisplaced groups was five times higher with fracture displacement (pooled odds ratio: 5.5, 95%CI: 2.5–12.3; p=0.00, I. 2. =54.6%). The pooled relative risk of fracture nonunion was 4.4 (95%CI: 2.3–8.7; p=0.00 I. 2. =54.3%). Conclusions. Displaced fractures of scaphoid have a four times higher risk of nonunion when treated in a plaster cast and the patients should be advised of this potential risk