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

Aims. It is not clear which type of casting provides the best initial treatment in adults with a distal radial fracture. Given that between 32% and 64% of adequately reduced fractures redisplace during immobilization in a cast, preventing redisplacement and a disabling malunion or secondary surgery is an aim of treatment. In this study, we investigated whether circumferential casting leads to fewer fracture redisplacements and better one-year outcomes compared to plaster splinting. Methods. In a pragmatic, open-label, multicentre, two-period cluster-randomized superiority trial, we compared these two types of casting. Recruitment took place in ten hospitals. Eligible patients aged ≥ 18 years with a displaced distal radial fracture, which was acceptably aligned after closed reduction, were included. The primary outcome measure was the rate of redisplacement within five weeks of immobilization. Secondary outcomes were the rate of complaints relating to the cast, clinical outcomes at three months, patient-reported outcome measures (PROMs) (using the numerical rating scale (NRS), the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores), and adverse events such as the development of compartment syndrome during one year of follow-up. We used multivariable mixed-effects logistic regression for the analysis of the primary outcome measure. Results. The study included 420 patients. There was no significant difference between the rate of redisplacement of the fracture between the groups: 47% (n = 88) for those treated with a plaster splint and 49% (n = 90) for those treated with a circumferential cast (odds ratio 1.05 (95% confidence interval (CI) 0.65 to 1.70); p = 0.854). Patients treated in a plaster splint reported significantly more pain than those treated with a circumferential cast, during the first week of treatment (estimated mean NRS 4.7 (95% CI 4.3 to 5.1) vs 4.1 (95% CI 3.7 to 4.4); p = 0.014). The rate of complaints relating to the cast, clinical outcomes and PROMs did not differ significantly between the groups (p > 0.05). Compartment syndrome did not occur. Conclusion. Circumferential casting did not result in a significantly different rate of redisplacement of the fracture compared with the use of a plaster splint. There were comparable outcomes in both groups. Cite this article: Bone Joint J 2024;106-B(7):696–704

Torus (Buckle) fractures of distal radius are common in children and form a major workload of any fracture clinic. They are usually stable and do not displace. Recent evidence has shown that these fractures can be safely treated in a futura splint. In UK, many of the hospitals are still treating these patients with full plaster. Bringing back these patients to fracture clinic for plaster removal means more workload and places more financial burden in the NHS. Our study is a completed audit cycle where we successfully implemented treatment with futura splint. Over a period of 6 months, 25 torus fractures were diagnosed & treated in A/E back slab. Mean age was 8.24 (Range: 3–12 yrs). Most common MOI was fall on outstretched hand. All cases had presented to A/E within 24 hours. 5 were given futura splint at the fracture clinic. 21 cases received full plaster. They were seen back in clinic in 3–4 weeks for plaster removal. After this audit was presented, we started treating these fractures with futura splint. Reauditing 6 months later revealed that of 31 cases, we had successfully treated 28 with Futura splint. 2 were treated with plaster on parent's insistence. The remaining one was treated in plaster as we could not fit a futura splint. There were no problems reported with futura splint. By definition, torus fractures are stable. The major problem with these fractures lies in the correct diagnosis. We have treated this fracture successfully with futura splint. Recent papers have shown that every patient treated with futura splint saves nearly £53 when compared to plaster treatment. Implementing this treatment has reduced plaster related problems. We hope this audit will help in changing practice in other hospitals in NHS

Thermal shrinkage of the shoulder capsule requires postoperative joint immobilisation with the humeral head centred in the glenoid fossa for optimal proprioceptive recovery. Routinely applied commercial slings hold the arm internally rotated and lengthen the posterior capsule. The aim of our study was to develop and test the clinical effectiveness of a splint that would maintain the shoulder in an optimal position of neutral rotation after posterior capsular shrinkage. To our knowledge, no splint has been described for this purpose. We developed a new design fabricating the splint using thermoplastic material. The design was then modified to ensure ease of fitting and patient comfort. The custom-made splint is fashioned preoperatively and fitted in the operating room after the dressings are applied. Our study group consisted of 18 cases of multidirectional or posterior shoulder instability who were splinted for a period of three weeks after thermal capsular shrinkage. The comfort and compliance of the splint were assessed using a patient questionnaire. Constant scores for the study group were retrospectively compared with a similar patient group managed with a ‘polysling’

Objectives:. To measure compliance with the Trauma Unit guideline relating to the early application of the Thomas splint in patients with a femur shaft fracture on clinical examination. Design:. Retrospective review of clinical and radiological records of patients presenting from 01 January 2012 to 31 December 2012 at a Level 1 Trauma Unit. Patients:. We included all patients with femur shaft fractures independently of their mechanism of injury. Exclusion criteria were: ipsilateral fracture of the lower limb, neck and supracondylar fractures, pathological, periprosthetic and incomplete fractures. The database available for review included demographic information, mechanism of injury, side injured, surgical procedure and time when a radiological study (Lodox and/or x-ray) was performed. Outcome measures:. Primary outcome measure was the application of a Thomas splint before the first radiological examination was performed. Secondary outcome measure was the increase in patients immobilized with a Thomas splint before their second radiological examination was performed. Results:. We identified 160 fractures, 107 (66.9%) had a femur or pelvis x-ray as the first radiological exam. In 44 (41.1%) of these fractures, a Thomas splint had already been applied. Of the 160 fractures, 53 (33.1%) had a Lodox as first radiological examination. In 16 (30.2%) of these fractures, a Thomas splint had already been applied. The remaining 37 fractures where no Thomas splint was applied prior to the Lodox had been immobilized with either a different type of splint (backslab or Kramer wires) or not immobilized at all. Of these “incorrectly” immobilized or not immobilized fractures, 17 (45.9%) were then correctly immobilized with a Thomas splint prior to the x-ray (x-ray as second radiological exam). Conclusion:. Out of 160 fractures, 60 were immobilized with a Thomas splint prior to the first radiological examination, corresponding to a 37.5% compliance rate with internal guidelines

Aims. A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening. Methods. A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group. Results. A total of 60 statements were graded by 128 clinicians in the first round and 132 in the second round. Consensus was reached on 30 out of 60 statements in the first round and an additional 12 in the seond. This was summarized in a consensus statement and distilled into a flowchart to guide clinical practice. Conclusion. We identified agreement in an area of medicine that has a long history of controversy and varied practice. None of the areas of consensus are based on high-quality evidence. This document is thus a framework to guide clinical practice and on which high-quality clinical trials can be developed. Cite this article: Bone Joint J 2023;105-B(2):209–214

Aims. We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. Methods. All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted. Results. Overall 71/101 patients completed the telephone consultation; no patients required surgery, and the mean and median PRWE scores were 23.9/100 (SD 24.9) and 17.0/100 (interquartile range (IQR) 0 to 40), respectively. Mean patient satisfaction with treatment was 34.3/40 (SD 9.2), and 65 patients (92%) were satisfied or highly satisfied. In total there were 16 contact calls, 12 requests for a consultant review, no formal complaints, and 15 minor adjustment suggestions to improve patient experience. A relationship was found between intra-articular injuries and lower patient satisfaction scores (p = 0.025), however no relationship was found between PRWE scores and the nature of the fracture. Also, no relationship was found between the type of immobilization and the functional outcome or patient satisfaction. Cost analysis of the self-care pathway V traditional pathway showed a cost savings of over £13,500 per year with the new self-care model compared to the traditional model. Conclusion. Our study supports a VFC self-care pathway for patients with minimally displaced distal radius fractures. The pathway provides a good level of patient satisfaction and function. To improve the service, we will make minor amendments to our patient information sheet. Cite this article: Bone Jt Open 2022;3(9):726–732

Purpose: In skeletally immature children with acceptably angulated (< = 15 degrees angular deformity at presentation) distal radius and/or ulnar fractures, to determine if a pre-fabricated wrist splint is at least as effective as a cast. The primary outcome was recovery of physical function six weeks after the injury as measured by the validated Activities Scale for Kids. Secondary objectives included determining differences in angulation of fracture, wrist range of motion, wrist strength, pain with movement, return to baseline activities, and patient preferences at six weeks. Method: A randomized controlled, non-inferiority, single (evaluator) blinded, single-centre trial in a tertiary care pediatric emergency department. Minimal required sample size of 76 patients with was based on testing the null hypothesis (H0) that the brace is 7% less effective at the 2.5% level. Physical function was tested by a t-test for a non-zero difference. For the other outcomes, proportions and means were compared with the Fisher Exact and Student s t-test, respectively. Results: Of the 100 randomized patients, 3 were excluded due to non-eligibility on radiographic review. 93 of the 97 completed full clinical, radiographic, and patient determined followup. ASK scores at six weeks were 92.8 in the splint group and 91.4 in the cast group, neither clinically nor statistically significantly different. Among patients treated in a cast, the average angular deformity at followup was 11.0 degrees and compared with an average of 6.6 degrees angulation among patients treated in a splint (p=.02, t-test). These groups were equal at baseline, with an average of 7.5 degrees of angulation in the cast group and 6.7 degrees in the splint group. Complications did not differ between groups, nor did range of motion with the exception that pronation was slightly better (84 versus 74 degrees) in the splint group at the end of treatment. No patient required any operative procedure. Parents preferred splinting over casting (p< 0.001) and children preferred splinting over casting (p=0.028). Conclusion: Splinting was non-inferior to casting, and in fact may be superior to casting, for maintaining the position of a minimally displaced distal radial metaphyseal fracture. Significance: The benefits of splinting over casting have been previously established for undisplaced distal radius and ulnar fractures (Plint), this is the first study which extends these benefits to the large group of children with minimally displaced distal radius fractures. Splint treatment simplifies care for children, reduces cost, and improves short term outcomes

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

Purpose. To determine, in skeletally immature children with acceptably angulated (< = 15 degrees deformity at presentation) distal radius fractures, if a pre-fabricated wrist splint is at least as effective as a cast. Methods. A randomised controlled, non-inferiority, single blinded, single-centre trial was performed. The primary outcome was physical function at six weeks. Secondary outcomes included angulation, wrist range of motion, strength, pain, and patient preferences. Results. 93 of 97 randomised patients completed full follow-up. ASK scores at six weeks were 92.8 in the splint group and 91.4 in the cast group. Among patients treated in a cast, the average angular deformity at follow-up was 11.0 degrees, compared with an average of 6.6 degrees angulation among patients treated in a splint (p=0.02, t-test). Complications did not differ between groups, nor did range of motion. Conclusion. Splinting was not inferior to casting, and in fact may be superior to casting, for maintaining the position of a minimally displaced distal radial metaphyseal fracture. Significance. The benefits of splinting over casting have been previously established for undisplaced distal radius and ulnar fractures (Plint), this is the first study which extends the benefits of splinting to the large group of children with minimally displaced distal radius fractures

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

In a prospective randomized trial, we divided a group of patients with a clinically suspicious, although radiographically normal, acute fracture of the scaphoid into 2 groups, 1 treated with a cast (group I), the other with a splint (group II). There were 14 patients in group I, and 18 in group II. Patients were reviewed at 2,6, and 12 weeks for range of movement, grip strength, pain and satisfaction rating. Work disability costs were also calculated for both groups. Patients in group II had better range of movement and grip strength at 2 weeks, although complained of more pain. There was no difference in range of movement, grip strength, or pain at 6 or 12 weeks. Group II was more satisfied at 2 weeks, although not at 6 or 12 weeks. Group I required more time off work, and disability costs were significantly higher [€15,209 per person compared to €3,317 per person]. We recommend that all patients, with only a clinical suspicion of a fractured scaphoid, should have a short period of splint immobilization until symptoms resolve, or until further investigations reveal a fracture which can be appropriately treated. This policy is cost efficient and improves the short term outcome

To assess patient/parent satisfaction with treatment of radial Forearm Buckle Fractures without the necessity of fracture clinic visits. A+E staff were provided with definitions and suitable example X-Rays of radial forearm buckle fractures. The A+E staff were asked to mark the films with a green dot for Radiological review if the patient was included in the study, and these films were seen within 24 hours by a consultant radiologist. Over a three month period all patients with radial forearm buckle fractures seen in A+E were treated with an Alder Hey splint rather than plaster, they were then given a fracture clinic appointment for three weeks later. At this visit the medical staff completed a proforma with the following information, appropriateness of the diagnosis, side, bone/cortex involved, degree of angulation as well as the mode of injury. The patients and their parents were asked whether they were happy with the level of support that the splint gave and whether they would have been happy to remove the splint without visiting the fracture clinic. 72 (86.7%) had suffered low energy injuries, 5 (6%) high energy injuries, 5 (6%) did not attend their clinic appointment. 65 of 78 (83%) of parents and 65 of 72 (90%) of patients felt that the level of provided support was adequate (6 patients too young to answer). 58 of 78 (74%) of parents and 53 of 72 (74%) of patients would have been happy to make the decision to remove the splint themselves (6 patients too young to answer). 5 (6%) of the diagnoses were deemed to be inappropriate, of these 2 were picked up in radiology review and sent to clinic and 3 were soft tissue injuries. We feel that the results show that the majority of patients with radial forearm buckle fractures (appropriate guidelines available to A+E staff) do not need to be seen in the fracture clinic, as long as their X-Rays are reviewed and any inappropriately diagnosed fractures sent to clinic. This has significant implications both for fracture clinic workload and also financially for hospitals

Aims

Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK.

Aims

The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius.

We have previously reported on the medium-term outcomes following a non-operative protocol of a short period of splinting followed by early movement to treat simple dislocations of the elbow. We undertook extended follow up of our original patient study group to determine whether the excellent results previously reported were maintained in the very long-term. A secondary question was to determine the rate and need for any late surgical intervention. We attempted to contact all patients in the original patient study group. Patients were requested to complete the Oxford elbow score (OES), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a validated patient satisfaction questionnaire. Patients were requested to attend a face-to-face assessment where they underwent a clinical examination including neurovascular assessment, range-of-motion and an assessment of ligamentous stability. Seventy-one patients (65%) from the original patient study group agreed to participate in the study. The mean duration of follow-up was 19.3 years. At final follow-up patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbows. The mean DASH score was 5.22 points and the mean Oxford Elbow Score was 91.6 points. The mean satisfaction score was 90.9 points. Our study shows that the excellent outcomes following treatment with a protocol of a short period of splinting and early movement remain excellent and are maintained into the very long term. These findings support our hypothesis that this treatment protocol is appropriate and suitable for most patients with simple dislocations of the elbow. The role for primary ligamentous repair for this patient group should be carefully considered. Work to more clearly define the anticipated benefits of surgery for specific patient groups or injury patterns would help to support informed decision making

Aims. Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results. From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion. A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

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