Aims. Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization. Methods. A total of 110 patients with Weber B/SER4a ankle fractures will be randomized (1:1 ratio) to receive six weeks of functional orthosis treatment or cast immobilization with a two-year follow-up. The primary outcome is patient-reported ankle function and symptoms measured by the Manchester-Oxford Foot and Ankle Questionnaire (MOxFQ); secondary outcomes include Olerud-Molander Ankle Score, radiological evaluation of ankle congruence in weightbearing and gravity stress tests, and rates of treatment-related adverse events. The Regional Committee for Medical and Health Research (approval number 277693) has granted ethical approval, and the study is funded by South-Eastern Norway Regional Health Authority (grant number 2023014). Discussion. Randomized controlled trials are needed to evaluate alternative nonoperative treatment options for Weber B/SER4a ankle fractures, as current clinical guidelines are based on biomechanical reasoning. The findings will be shared through publication in peer-reviewed journals and presentations at conferences. Cite this article: Bone Jt Open 2023;4(9):713–719

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 aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion. Methods. A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis. Results. Our base case analysis found that patients randomized to early surgical fixation had statistically significantly higher mean costs to the NHS of £1,295 more than for the cast immobilization arm (p < 0.001), primarily due to the cost of surgery. They also had a marginally better quality of life, over the period, of 0.0158 QALYs; however, this was not statistically significant (p = 0.379). The mean combined cost per additional QALY was £81,962, well above the accepted threshold for cost-effectiveness used in the UK and internationally. The probability of early surgery being cost-effective in this setting was only 5.6%. Conclusion. Consistent with the clinical findings of SWIFFT, these results indicate that initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system. Cite this article: Bone Joint J 2021;103-B(7):1277–1283

Aims. To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years. Methods. A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, “satisfaction with wrist function” (score 0 to 10), and complications. Results. In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001). Conclusion. Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247–255

Aims. This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme. Methods. A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed. Results. Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported. Conclusion. The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe. Cite this article: Bone Joint J 2024;106-B(9):949–956

Aims. There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. Methods. This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. Results. A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). Conclusion. MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients. Cite this article: Bone Joint J 2024;106-B(4):387–393

Aims. To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically. Methods. A total of 209 children (mean age 6.84 years (SD 2.87)), who underwent surgical treatment for CMFs between March 2015 and March 2023 at six institutions, were retrospectively reviewed. Assessed risk factors included age, sex, laterality, dislocation direction and distance, preoperative proximal radial metaphysis width, time from injury to surgery, reduction method, annular ligament reconstruction, radiocapitellar joint fixation, ulnar osteotomy, site of ulnar osteotomy, preoperative and postoperative ulnar angulation, ulnar fixation method, progressive ulnar distraction, and postoperative cast immobilization. Independent-samples t-test, chi-squared test, and logistic regression analysis were used to identify the risk factors associated with unsuccessful RHR. Results. Redislocation occurred during surgery in 48 patients (23%), and during follow-up in 44 (21.1%). The mean follow-up of patients with successful RHR was 13.25 months (6 to 78). According to the univariable analysis, time from injury to surgery (p = 0.002) and preoperative dislocation distance (p = 0.042) were identified as potential risk factors for unsuccessful RHR. However, only time from injury to surgery (p = 0.007) was confirmed as a risk factor by logistic regression analysis. Receiver operating characteristic curve analysis and chi-squared test confirmed that a time from injury to surgery greater than 1.75 months increased the rate of unsuccessful RHR above the cutoff (p = 0.002). Conclusion. Time from injury to surgery is the primary independent risk factor for unsuccessful RHR in surgically treated children with CMFs, particularly in those with a time from injury to surgery of more than 1.75 months. No other factors were found to influence the incidence of unsuccessful RHR. Surgical reduction of paediatric CMFs should be performed within the first two months of injury whenever possible. Cite this article: Bone Jt Open 2024;5(7):581–591

Aims. The evidence demonstrating the superiority of early MRI has led to increased use of MRI in clinical pathways for acute wrist trauma. The aim of this study was to describe the radiological characteristics and the inter-observer reliability of a new MRI based classification system for scaphoid injuries in a consecutive series of patients. Methods. We identified 80 consecutive patients with acute scaphoid injuries at one centre who had presented within four weeks of injury. The radiographs and MRI scans were assessed by four observers, two radiologists, and two hand surgeons, using both pre-existing classifications and a new MRI based classification tool, the Oxford Scaphoid MRI Assessment Rating Tool (OxSMART). The OxSMART was used to categorize scaphoid injuries into three grades: contusion (grade 1); unicortical fracture (grade 2); and complete bicortical fracture (grade 3). Results. In total there were 13 grade 1 injuries, 11 grade 2 injuries, and 56 grade 3 injuries in the 80 consecutive patients. The inter-observer reliability of the OxSMART was substantial (Kappa = 0.711). The inter-observer reliability of detecting an obvious fracture was moderate for radiographs (Kappa = 0.436) and MRI (Kappa = 0.543). Only 52% (29 of 56) of the grade 3 injuries were detected on plain radiographs. There were two complications of delayed union, both of which occurred in patients with grade 3 injuries, who were promptly treated with cast immobilization. There were no complications in the patients with grade 1 and 2 injuries and the majority of these patients were treated with early mobilization as pain allowed. Conclusion. This MRI based classification tool, the OxSMART, is reliable and clinically useful in managing patients with acute scaphoid injuries. Cite this article: Bone Jt Open 2022;3(11):913–920

Aims. Distal radial fractures are the most common fracture sustained by the adult population. Most can be treated using cast immobilization without the need for surgery. The aim of this study was to assess the feasibility of a definitive trial comparing the commonly used fibreglass cast immobilization with an alternative product called Woodcast. Woodcast is a biodegradable casting material with theoretical benefits in terms of patient comfort as well as benefits to the environment. Methods. This was a multicentre, two-arm, open-label, parallel-group randomized controlled feasibility trial. Patients with a fracture of the distal radius aged 16 years and over were recruited from four centres in the UK and randomized (1:1) to receive a Woodcast or fibreglass cast. Data were collected on participant recruitment and retention, clinical efficacy, safety, and patient acceptability. Results. Over an eight-month period, 883 patients were screened, 271 were found to be eligible, and 120 were randomized. Patient-reported outcome measures were available for 116 (97%) of participants at five weeks and 99 (83%) at three months. Clinical outcomes and patient acceptability were similar between the two interventions and no serious adverse events were reported in either intervention arm. Conclusion. Both interventions were deemed efficacious and safe in the cohort studied. This study showed that a definitive study comparing Woodcast and fibreglass was feasible in terms of patient recruitment and retention. Cite this article: Bone Joint J 2020;102-B(1):48–54

Aims. To determine the role of early MRI in the management of suspected scaphoid fractures. Methods. A total of 337 consecutive patients presenting to an emergency department (ED) following wrist trauma over a 12-month period were prospectively included in this service evaluation project. MRI was not required in 62 patients with clear diagnoses, and 17 patients were not managed as per pathway, leaving a total of 258 patients with normal scaphoid series radiographs who were then referred directly from ED for an acute wrist MRI scan. Patient demographics, clinical details, outcomes, and complications were recorded at a minimum of a year following injury. Results. The median time from injury to ED presentation was one day and the median number of positive clinical signs was two out of three (snuffbox tenderness, tubercle tenderness, pain on telescoping). Of 258 patients referred for acute MRI, 208 scans were performed as 50 patients either did not tolerate (five patients) or did not attend their scan (45 patients). MRI scans demonstrated scaphoid fracture (13%), fracture of another bone (22%), scaphoid contusion (6%), other contusion/ligamentous injury (20%), or solely degenerative pathology (10%). Only 29% of scans showed no abnormality. Almost 50% of those undergoing MRI (100 patients) were discharged by ED with advice, with only one re-presentation. Of the 27 undisplaced occult scaphoid fractures, despite prompt cast immobilization, two experienced delayed union which was successfully treated with surgery. Conclusion. The use of MRI direct from ED enables prompt diagnosis and the early discharge of a large proportion of patients with normal radiographs following wrist trauma. Cite this article: Bone Jt Open 2021;2(6):447–453

Aims. This study sought to estimate the clinical outcomes and describe the nationwide variation in practice, as part of the feasibility workup for a National Institute for Health and Care Excellence (NICE) recommended randomized clinical trial to determine the optimal treatment of torus fractures of the distal radius in children. Methods. Prospective data collection on torus fractures presenting to our emergency department. Patient consent and study information, including a copy of the Wong-Baker Faces pain score, was issued at the first patient contact. An automated text message service recorded pain scores at days 0, 3, 7, 21, and 42 postinjury. A cross-sectional survey of current accident and emergency practice in the UK was also undertaken to gauge current practice following the publication of NICE guidance. Results. In all, 30 patients with a mean age of 8.9 years were enrolled over a six-week period. Of the 150 potential data points, data was captured in 146, making the data 97.3% complete. Pain scores were recorded at day 0 (mean 6.5 (95% confidence interval (CI) 5.7 to 7.3)), day 3 (4.4 (95% CI 3.5 to 5.2)), day 7 (3.0 (95% CI 2.3 to 3.6)), day 21 (1.2 (95% CI 0.7 to 1.7)) and day 42 (0.4 (95% CI 0.1 to 0.7)). Of the 100 units who participated in the nationwide survey, 38% were unaware of any local or national protocols regarding torus fractures, 41% treated torus fractures with cast immobilization, and over 60% of patients had follow-up arranged, both contradictory to national guidelines. Conclusion. We have demonstrated the severity, recovery trajectory, and variation in pain scores among children with torus fractures. We demonstrate excellent follow-up of patient outcomes using text messages. Despite national guidelines, there is significant variation in practice. This data directly informed the development of an ongoing nationwide randomized clinical trial – the FORearm Fracture Recovery in Children Evaluation (FORCE) study

Our study seeks to determine whether characteristics of radiographs taken post-reduction of a forearm fracture can indicate future risk of refracture or loss of reduction. We hypothesize that reducing forearm fractures too precisely may be counterproductive and provide less benefit than reductions left slightly offset prior to cast immobilization. We conducted a retrospective review of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. Percent fracture displacement, location, orientation, comminution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Patients treated with closed reduction were reduced from a mean displacement of 29.26±36.18% at an angulation of 22.67±16.57 degrees to 7.88±9.07% displacement and 3.89±6.68 degrees angulation post-reduction. Patients developing complications including a loss of reduction or refracture were found to have post-operative radiographs with a lower percent displacement (0.50±1.12) than those not developing complications (8.65±9.21)(p=0.0580). Post-reduction angulation (p=1.000), average reduction in angulation (p=1.000) and average reduction in displacement percent(p=0.2102) were not significantly associated with development of complications. Percent displacement of radial shafts was seen to be the most important metric to monitor in post-operative radiographs for patients undergoing closed reduction of a forearm fracture. We theorize a slight displacement provides greater surface area for osteoblastic expansion and callus formation leading to a decreased risk of refracture or loss of reduction. While our sample size precludes our ability to measure the ideal amount of post-reduction displacement for optimal healing, our results demonstrate that some degree of shaft displacement is required for optimal healing conditions

Distal radius fractures (DRFs) are common injuries that represent 17% of all adult upper extremity fractures. Some fractures deemed appropriate for nonsurgical management following closed reduction and casting exhibit delayed secondary displacement (greater than two weeks from injury) and require late surgical intervention. This can lead to delayed rehabilitation and functional outcomes. This study aimed to determine which demographic and radiographic features can be used to predict delayed fracture displacement. This is a multicentre retrospective case-control study using radiographs extracted from our Analytics Data Integration, Measurement and Reporting (DIMR) database, using diagnostic and therapeutic codes. Skeletally mature patients aged 18 years of age or older with an isolated DRF treated with surgical intervention between two and four weeks from initial injury, with two or more follow-up visits prior to surgical intervention, were included. Exclusion criteria were patients with multiple injuries, surgical treatment with fewer than two clinical assessments prior to surgical treatment, or surgical treatment within two weeks of injury. The proportion of patients with delayed fracture displacement requiring surgical treatment will be reported as a percentage of all identified DRFs within the study period. A multivariable conditional logistic regression analysis was used to assess case-control comparisons, in order to determine the parameters that are mostly likely to predict delayed fracture displacement leading to surgical management. Intra- and inter-rater reliability for each radiographic parameter will also be calculated. A total of 84 age- and sex-matched pairs were identified (n=168) over a 5-year period, with 87% being female and a mean age of 48.9 (SD=14.5) years. Variables assessed in the model included pre-reduction and post-reduction radial height, radial inclination, radial tilt, volar cortical displacement, injury classification, intra-articular step or gap, ulnar variance, radiocarpal alignment, and cast index, as well as the difference between pre- and post-reduction parameters. Decreased pre-reduction radial inclination (Odds Ratio [OR] = 0.54; Confidence Interval [CI] = 0.43 – 0.64) and increased pre-reduction volar cortical displacement (OR = 1.31; CI = 1.10 – 1.60) were significant predictors of delayed fracture displacement beyond a minimum of 2-week follow-up. Similarly, an increased difference between pre-reduction and immediate post reduction radial height (OR = 1.67; CI = 1.31 – 2.18) and ulnar variance (OR = 1.48; CI = 1.24 – 1.81) were also significant predictors of delayed fracture displacement. Cast immobilization is not without risks and delayed surgical treatment can result in a prolong recovery. Therefore, if reliable and reproducible radiographic parameters can be identified that predict delayed fracture displacement, this information will aid in earlier identification of patients with DRFs at risk of late displacement. This could lead to earlier, appropriate surgical management, rehabilitation, and return to work and function

Purpose: The treatment of extension type II pediatric supracondylar humerus fractures remains controversial. Some argue that closed reduction and cast immobilization is sufficient to treat these fractures, while others advocate closed reduction and pinning. The purpose of this radiographic outcomes study was to determine whether closed reduction and cast immobilization could successfully obtain and maintain appropriate position of extension type II supracondylar humerus fractures. Method: The radiographs of 1017 pediatric patients treated for supracondylar fractures between 1987 and 2007 were retrospectively reviewed. Pre-reduction, immediate post-reduction, and final radiographs of 155 extension type II fractures were measured in order to assess the position and alignment of the fracture fragments. Measurements included the anterior humeral line, humeral-capitellar angle, Baumann’s angle, the Gordon index, and the Griffet index. The latter two indices calculate the rotational instability of the fracture, which can be predictive of reduction loss. Patients were excluded if insufficient radiographs failed to allow complete assessment of the measurement parameters, or if open reduction was required. Results: The average age of the subjects was 5.3 years (range 1–13 years) and had a mean follow-up of 5.3 months. Analysis of the final radiographs demonstrated that in 80% of subjects, the anterior humeral line remained anterior to the mid third segment of the capitellum (radiographic extension deformity), the mean humeral-capitellar angle was 23.8° (range – 11°–50°), the mean Baumann’s angle was 79.4° (range 62°–97°), the mean Gordon index was 4.59%, and 44% of subjects had a Griffet index between 1–3 (potentially indicative of unstable reduction due to malrotation of the fragments, which can allow the development of a cubitus varus deformity). Conclusion: From this radiographic review, a significant proportion of fractures treated with closed reduction and cast immobilization failed to achieve anatomic position and alignment on final x-rays. However, the clinical significance of these results and the potential for long-term re-modeling of these fractures remains unknown

Aims. The aim of this study was to assess and compare active rotation of the forearm in normal subjects after the application of a short-arm cast (SAC) in the semisupination position and a long-arm cast (LAC) in the neutral position. A clinical study was also conducted to compare the functional outcomes of using a SAC in the semisupination position with those of using a LAC in the neutral position in patients who underwent arthroscopic triangular fibrocartilage complex (TFCC) foveal repair. Methods. A total of 40 healthy right-handed volunteers were recruited. Active pronation and supination of the forearm were measured in each subject using a goniometer. In the retrospective clinical study, 40 patients who underwent arthroscopic foveal repair were included. The wrist was immobilized postoperatively using a SAC in the semisupination position (approximately 45°) in 16 patients and a LAC in 24. Clinical outcomes were assessed using grip strength and patient-reported outcomes. The degree of disability caused by cast immobilization was also evaluated when the cast was removed. Results. Supination was significantly more restricted with LACs than with SACs in the semisupination position in male and female patients (p < 0.001 for both). However, pronation was significantly more restricted with SACs in the semisupination position than with LACs in female patients (p = 0.003) and was not significantly different in male patients (p = 0.090). In the clinical study, both groups showed improvement in all parameters with significant differences in grip strength, visual analogue scale scores for pain, modified Mayo Wrist Score, the Disability of the Arm, Shoulder, and Hand (DASH) score, and the Patient-Rated Wrist Evaluation (PRWE) score. No significant postoperative differences were noted between LACs and SACs in the semisupination position. However, the disability caused by immobilization in a cast was significantly higher in patients who had a LAC on the dominant hand (p < 0.001). Conclusion. We found that a SAC in the semisupination position is as effective as a LAC in restricting pronation of the forearm. In addition, postoperative immobilization with a SAC in the semisupination position resulted in comparable pain scores and functional outcomes to immobilization with a LAC after TFCC foveal repair, with less restriction of daily activities. Therefore, we recommend that surgeons consider using a SAC in the semisupination position for postoperative immobilization following TFCC foveal repair for dorsal instability of the distal radioulnar joint. Cite this article: Bone Joint J 2022;104-B(2):249–256

Aims. To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS). Methods. A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods. Results. Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32). Conclusion. During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast. Cite this article: Bone Joint Open 2020;1-7:424–430

Introduction. The incidence of deep venous thrombosis (DVT) in patients with lower limb cast immobilization occurs in up to 20% of patients. This may result from altered calf pump function causing venous stasis. Our aim was to determine the effects of below knee cast on calf pump function. Method. Nine healthy participants were enrolled in this research and ethics approved prospective study. Four foot and ankle movements (toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion) and weight bearing were performed pre and post application of a below knee cast. Baseline and peak systolic velocity within the popliteal vein was measured during each movement. Participants with peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded. Results. The mean patient age was 34 years (range 28–58), the majority were female (n = 6). With cast in situ all movements resulted in a statistically significant increase in peak systolic velocity (p = <0.05). There was no significant difference in peak systolic velocity at the popliteal vein pre or post cast application. Discussion. This is the first study to examine the effect of a lower limb cast on calf muscle pump function. Despite cast immobilisation, toe and ankle flexion and extension movements significantly increase peak systolic velocity measured at the popliteal vein. Conclusion. Toe and ankle flexion and extension exercises significantly increase calf pump function in patients with below knee cast immobilization. We recommend that all patients treated in below knee cast immobilisation are advised to perform regular toe and ankle exercises to reduce venous stasis and risk of deep venous thromboembolism

Background: The treatment of congenital vertical talus has traditionally consisted of manipulation and application of casts followed by extensive soft-tissue releases. However, this treatment is often followed by severe stiffness of the foot and other complications. The purpose of this study was to evaluate a new method of manipulation and cast immobilization, based on principles used by Dobbs et al in patients with idiopathic congenital vertical talus, but applied in teratologic congenital vertical talus. Methods: Five consecutive cases of teratologic congenital vertical talus deformity were prospectively followed at a minimum of nine months post treatment with serial casting and limited surgery consisting of percutaneous Achilles tenotomy, fractional lengthening of the anterior tibial tendon, and percutaneous pin fixation of the talonavicular joint. The principles of manipulation and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied in the opposite direction. Clinical and radiographic assessments were carried out at the initial, immediate postoperative and the latest follow-up. Results: Initial correction was obtained both clinically and radiographically in all five feet. A mean of eight casts was required for correction. At the final evaluation, the mean ankle dorsiflexion was 20° and the mean plantar flexion was 31°. Radiographically, dorsal subluxation of the navicular recurred in one patient, but was functionally insignificant as the patient was a non-ambulator and required treatment for seating purposes only. At the time of the latest follow-up, there was a significant improvement in all of the measured radiographic parameters compared with the pretreatment values. Conclusions: Serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon provides excellent results, in terms of the clinical appearance of the foot, and deformity correction, in patients with teratologic congenital vertical talus

Introduction: Intraarticular fractures of distal radius are associated with high energy mechanisms, are severe and difficult to obtain a surgical reduction. The aim of our paper is to compare the clinical, radiographically and activity results in workers treated with surgical and conservative procedures. MATERIAL AND METHODS: A prospective study was organized in 43 heavy-labour workers (34 male and 9 female) with unstable fractures of distal radius, treated between 2003 and 2005. The minimal follow-up was of one year. The mean age were 40 years (22–65 years) and dominant limb was involved in 40% of the cases. To treatment groups were established. Group 1, conservative treated with indirect reduction and cast immobilization (n=20) and Group 2 surgically treated with indirect reduction and percutaneous fixation with K-wires and cast immobilization (n=24). Pain, mobility and radiograhs were evaluated and also strength (isokinetics), functionality (DASH score) and, finally, the return to work at 3, 6 and 12 months. RESULTS: Fracture healing was obtained at 7 weeks but the time to return to work were 14 weeks after surgery. Pain score, at 12 months, were 2,3 points for conservative treatment and 2,9 points for the surgically group. The flexion – extension mobility loss, in relation to the contralateral wrist, was lesser in the conservative group at 3 and 6 month but similar (11°) at 12 months in both groups. Radiographs corrections were anatomically in 38% of the cases of group 1 and in 80% of group 2. Functional and strength results were similar in both groups. All the patients return to the same work activity. CONCLUSIONS: Percutaneous fixation of unstable intraarticular distal radius fracture is comparable to the conservative treatment but the percentage of anatomical reductions was higher. It would be of importance in the evolution of the patients

Introduction: Mac Farland fracture is a joint fracture of the ankle in children, which involves the medial malleolus (Salter-Harris type III or IV) and is frequently associated with a fracture of the distal fibula. These injuries have a major risk of resulting in a medial epiphysiodesis bridge which, in turn, can lead to a varus deformity. As of today, recommended treatment for displacements wider than 2mm is open reduction with screw fixation. The aim of this study is to evaluate functional and radiological results of a new less invasive surgical procedure. Materials and Methods: We retrospectively analyzed a case series of patients who suffered from a Mac Farland fracture and underwent percutaneous screw fixation with arthrographic control. Data collected for each child included age at diagnosis, gender, mechanism and side of injury, radiological Salter-Harris classification of medial and lateral malleolus fracture, size of the fracture line gap before and after treatment, and duration of cast immobilization. Results are given according to the classification by Gleizes (2000), based on clinical and radiological criteria: good, fair, and poor. Results: There were twelve patients, five girls and seven boys, with a mean age of twelve years and six months (range: 10–15). Average follow-up was eighteen months (range: 9–57). Medial malleolus fracture was Salter-Harris type III in seven patients and type IV in five. The mean preoperative fracture line gap was 2.7mm (range: 2–4). All the patients underwent closed reduction and ankle arthrography to check for anatomical reposition. The fracture was then percutaneously fixed with two screws in nine patients and one screw in three. Duration of cast immobilization after surgery was forty-five days in average. At the time of last follow-up the functional and radiological results were good for all the patients according to Gleizes’ classification. Conclusion: Closed reduction combined to ankle arthrography followed by percutaneous osteosynthesis is, in our opinion, an interesting less invasive surgical alternative to classic open reduction and internal fixation for displaced Mac Farland fractures

Introduction: Talus fractures are rare, but because of its peculiar anatomy the complications rate is high. Its arterial vascularisation can be compromised by trauma in displaced fractures or by the surgical approaches. Material and methods: Between 2001 and 2005, 30 patients with talus fractures were surgically treated in the Department of Orthopedics and Traumatology of Bucharest University Hospital. Sex ratio was 3 men/27 men. 27 fractures were closed. The mean age was 37 years (extremes: 17 – 54 years). Fractures were classified according to Hawkins classification: type I – 9 cases, type II – 13 cases, type III – 8 cases. All patients underwent clinical and radiological examinations at 3, 6 and 12 months and every year after this interval. Results: Hawkins type I fractures were treated by cast immobilization without weight bearing for 6 to 8 weeks. Orthopedic reduction was performed in emergency in order to avoid vascular and cutaneous complications. Hawkins type II and III fractures were surgically treated. Anterior or transmaleolar internal surgical approaches were used. After reduction, osteosynthesis with 2 or 3 compression screws was performed. Avascular necrosis of talus was observed in 6 cases (5 type III fractures, 1 type II case). Cutaneous complications were observed more frequently in type II and III fractures and in the neglected ones. Sepsis occurred in one case. 80% of cases with avascular necrosis developed osteoarthritic changes. Radiological union was observed in average at 6 months. Conclusions: The prognosis of fracture-dislocation of talus is reserved, because of the high rate of avascular necrosis and osteoarthritis. The most important factors associated with good results are short time interval between trauma and surgical treatment and a perfect reduction. The surgical approach must avoid extensive devascularization of talus neck. Prolonged cast immobilization and long time avoidance of weight bearing favourably influenced fracture union. The most important complication is avascular necrosis

Background: Extra-articular fractures of the distal radius in children are most often treated with closed reduction and cast immobilization. The purpose of this retrospective study was to evaluate long term (> 12 years follow-up) objective and subjective outcomes in a consecutive series of pediatric patients treated with closed reduction with standardized outcome instruments. We hypothesized that children treated with closed reduction and cast immobilization have little or no objective functional impairment in later life and therefore subjective factors are the strongest determinants of outcome. Methods: Twenty-seven patients with an average age at time of injury of 9 years (range, five to sixteen years) were evaluated at an average of twenty-one years (range, twelve to twenty seven years) after injury (patients aged 21 to 39) after closed reduction of an extra-articular distal radius fracture. Patients were evaluated using 2 physician-based evaluation instruments (modified Mayo wrist score; MMWS, and the Sarmiento modification of the Gartland and Werley score; MGWS) and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand; DASH) questionnaire. Radiographic measurements were also made. Multivariable analysis of variance and multiple linear regression modelling were used to identify the degree to which various factors affect variability in the scores derived with these measures. Results: All fractures had healed without significant loss of alignment. Final functional results according to the MGWS were rated as excellent or good in all patients. The average MMWS score was 90 points, and the median DASH score was 0 points. Twenty patients (74%) considered themselves pain free. Bivariate analysis revealed pain -as rated according to scales used in the MMWS- and age at time of injury to be correlated with DASH scores, with pain as the only independent predictor of patient-based outcome in multivariable analysis. This explains almost three quarters of the variability in DASH scores. Pain, range of motion, and radiographic measurement of radial length correlated with the physician based scoring system MMWS;. Conclusions: Twenty-one years after injury 96% of patients have a satisfactory outcome according to physician-based MMWS categorical ratings and patient-based DASH scores. It is remarkable that pain explained 74% of the variation in DASH scores. Perhaps when there is very little impairment, subjective factors are more important determinants of disability

The problem: A few operative procedures were used for radiolunate fusion for stabilization of the rheumatoid wrist. Because of minor stability of these fixations, cast immobilization of the wrist is necessary for several weeks, which may lead to a limited wrist motion through the scar of the joint capsule. Non-union and loosening of the osteosynthesis material were described for all of these procedures. Method: a three dimensional bended mini-titanium-T-plate (produced by Martin/Germany) with an additional oblique screw withstands the forces acting on the fixed lunate, as there are palmar flexion, dorsal extension, radial and ulnar abduction, rotation along the longitudinal axis, palmar and ulnar shift. The high primary stability results from a three point fixation of the lunate an the form of the plate. Because of this very stable fixation, early exercise of the wrist is allowed from the third day after operation. After reduction of the soft tissue swelling the palmar cast is replaced by a ready-made wrist splint, which can be removed by the patient for exercise of the wrist three times a day. Results: 20 radiolunate fusions have been performed by this new technique since the year 2000. Bone healing was achieved in all. Cast immobilization after surgery was reduced from a period of 3 to 8 weeks for the first 9 wrists to the period of soft tissue swelling (6 to 10 days) for the 11 wrists operated at least. Through early exercise of extension and flexion of the wrist, the average range of wrist extension and flexion rose from 60 degrees in the first group to 70 degrees in the latter. Conclusion: The radiolunate fusion with a three dimensional bended minititanium-T-plate and an oblique screw neutralizes the forces on the lunate. Because of this, early exercise of the wrist is possible to minimize limitation of the wrist motion through the shrinking scar of the joint capsule. Furthermore the light wrist splint is very comfortable to the patient, because it gives low stress on the other joints and can be removed easily for exercise and skin care

Introduction: Management of acute rupture of the Achilles tendon is controversial. Conservative treatment has a higher re-rupture rate while surgery has complications like infection and wound breakdown. We devised a protocol in our hospital to decide between the surgical or non-surgical options. At our institution, a well-documented and structured program of non-operative or opeartive management of Achilles tendon rupture with use of either casts or operation has been devised based on Ultrasound findings of the ‘Gap/distance between the two ends of the Tear’. PURPOSE: The purpose of this study was to compare the incidence of Re-rupture in those treated by cast immobilization where the ends were approximating at ultrasound examination at our institution. METHODS: This study Prospectively assessed the results in 50 consecutive patients with a complete rupture of the Achilles tendon who had been treated with our regimen depending on the findings of the ultrasound examination, between 2003 and 2006. All ruptured Tendoachilles had ultrasound done in Full Equinus position to assess whether the ends are approximating or not. If ends were approximating they were treated in an equinus cast. Patients were evaluated on the basis of the subjective results and functional outcome measure, along with validated visual analogue scores. Re-rupture rates were measured at 06 months after injury. There were 35 Male and 13 females. This was followed by a final questionnaire to assess their return to pre-injury activities. Two patients were lost to follow-up as they moved out of the area. RESULTS: All the 48 re-ruptures available for analysis had their ultrasound done on initial presentation. 25 were treated non-operatively and 23 underwent surgery. The overall complication rate for Non Operative was minimal, with NO re-rupture or documented deep vein thromboses. In operative group there were 2 re-ruptures, 5 postoperative infection and discharge. CONCLUSION: The results of our non-operative treatment were better overall than published results of non operative & operative repair of acute Achilles tendon rupture. In this study the ends are approximating, confirmed on ultrasound before being assigned to Cast Immobilization. SIGNIFICANCE: The previous studies have not assigned patients into operative or non-operative groups based on whether the ends are approximating in full equines position. By assigning only those in whom the ends are approximating, to cast immobilization, re-rupture rates are less, thus resulting in better and stronger healing of TAs’ and avoiding risks of surgery

Patellar fractures account for approximately 1% of all fractures. Open reduction and internal fixation is recommended to restore extensor continuity and articular congruity. However, complications such as nonunion and symptomatic hardware, still exist. Furthermore, there is a risk of re-fracturing of the healed bone during the removal of the implants. Magnesium (Mg), a biodegradable metal, has elastic moduli and compressive yield strength that are comparable to those of natural bone. Our previous study showed that released Mg ions enhanced fracture healing. However, Mg-based implants degrade rapidly after implantation and lead to insufficient mechanical strength to support the fracture. Microarc oxidation (MAO) is a metal surface coating that reduces corrosion. We hypothesized that Mg pins, with or without MAO, would enhance fracture healing radiologically, mechanically, and histologically, while MAO would decrease degradation of Mg pins. Patellar fracture was performed on forty-eight 18-week-old female New Zealand White rabbits according to established protocol. Briefly, the patella is osteotomized transversely and a tunnel (1.1mm) was drilled longitudinally through the two bone fragments. A pin (1 mm, stainless steel, Mg, or MAO-Mg) was inserted into the tunnel. The reduced construct was stabilized with a figure-of-eight band wire (⊘ 0.6 mm stainless steel wire). Cast immobilization was applied for 6 weeks. The rabbits were euthanized at week 8 and 12 post-operation. Microarchitecture and mechanical properties of the repaired patella were analyzed with microCT and tensile testing respectively. Histological sections of the repaired patella were stained. To evaluate the effect of the MAO treatment on degradation rate of Mg pin, the volume of the Mg pins in the patella was measured with microCT. At week 8, both Mg and Mg-MAO showed higher ratio of bone volume to tissue volume (BV/TV) than the control while there was no significant different between Mg and Mg-MAO. At week 12, Control, Mg, and Mg-MAO groups showed enlarged patella when compared to the normal patella. Tissue volume (TV) and bone volume (BV) of the patella in Mg and Mg-MAO were larger than those in the Control group. However, the Control had higher ratio of bone volume to tissue volume (BV/TV), TV density, and BV density than Mg and Mg-MAO. Tensile testing showed that the mechanical properties of the repaired patella (failure load, stiffness, ultimate strength, and energy-to-failure) of Mg and Mg-MAO were higher than that of the control at both week 8 and week 12. Histological analysis showed that there was significant new bone formation in the Mg and Mg-MAO group compared with the Control group at week 8 and 12. The degradation rate of the MAO-coated Mg pins was significantly slower than those without MAO at week 8 but no significant difference was detected at week 12. Mechanical, microarchitectural, and histological assessments showed that Mg pins, with or without MAO, enhanced fracture healing of the repaired patella compared to the Control. MAO treatment enhanced the corrosion resistance of the Mg pins at the early time point

Purpose: To modify the technique of Sofield to minimize avascularity and to maximize stability. Introduction: Sofield and Millar described a technique for the correction of severe long bone deformity in osteogenesis imperfecta which involved removing the diaphysis from the limb and cutting it into several segments. These segments were then threaded on a rod without regard to their original position in the bone, their end to end orientation, or their rotation. The patient was then immobilized in a plaster cast. In order to avoid the extreme bone atrophy seen in some patients, sometimes called ‘disappearing bone disease’, and to provide sufficient stability to obviate cast immobilization we have modified Sofield’s technique. Surgical principles: Our technique follows the following guidelines: 1. Make as few osteotomies as possible; 2. Avoid, if possible, completely stripping any segment of bone; 3. In severely angulated bones which cannot be made straight without shortening, the part of the bone excised should include the area of maximum deformity; 4. In order to maximize angular stability make the cuts as far from the ends of the bone as possible; and 5. In order to achieve rotational stability make the cuts 45 degrees oblique. Material and methods: We reviewed 46 bones of 23 patients aged 1 to 20 years at the time of the study. There were 23 tibiae and 23 femora. We measured the angular deformity of the mechanical axis of the distal femur and the proximal and distal tibia. Six patients had only one bone corrected, 9 had two, 4 had 3, and 2 patients had corrections of both tibiae and both femora. We counted the number of cuts on the post-operative x-ray. Achieving shortening by removal of a piece was counted as one cut since it did not produce an additional segment. We noted whether or not a post-operative cast was used. Results: In no case, not even in the most severe deformities, were more than two cuts required. There was no difference in the tendency of the femur and tibia to require more than one cut. We observed no instances of ‘disappearing bone disease’. A few bones were so fragile that they tended to crumble during surgery and in these patients cast immobilization was employed. Conclusions: Viability of bone is enhanced by minimizing the number of osteotomies and periosteal stripping. Oblique osteotomies provide sufficient rotational stability that post-operative immobilization is unnecessary

Lower limb fractures are commonly treated with cast immobilization, and as a main consequence of strict immobilization this typically leads to loss in muscle mass, decrease of bone density and decline in functional abilities. Body-worn sensors are increasingly used to assess outcome in clinical trials by providing objective mobility parameters in a real-world environment. The aim of this study is to investigate the usability aspects and potential changes in mobility parameters in partial-immobilization patients in real-world conditions. Six healthy young males (age 22.2 ± 1.2 years; weight 76.5 ± 6.7 kg, height 185.8 ± 6.1 cm. Mean ± standard deviation) wore a leg cylinder cast with walker boot to immobilize their dominant leg for two consecutive weeks. Subjects were asked to continuously wear a tri-axial accelerometer on the waist (actibelt) during waking hours for 6 weeks including 2 weeks before, during and after cast immobilisation. The total amount of days of continuous recording was 339 days with a total wearing time of 120 days. Software packages which allow to detect steps and to estimate real-world walking speed were used to analyse the accelerometry data. It was suspected that knee immobilization would affect strongly the wave form of the signal with an impact on the accuracy of the speed algorithm, whereas the step detection should be more robust. This effect was confirmed in a preliminary study performed to quantify the accuracy under immobilization conditions. On the other hand, step numbers are known to be sensitive to fluctuations in wearing time which was not uniform throughout the entire study. We concluded that in this setting step frequency is the most reliable parameter. Step frequency showed a systematic decrease in the values during the immobilization period which recovered to pre-immobilisation values after cast removal. This confirms the usability of accelerometry and sensitivity of its mobility parameters for clinical outcome assessment

Introduction. The dichotomy between surgical repair and conservative management of acute Achilles tendon ruptures has been eliminated through appropriate functional management. The orthoses used within functional management however, remains variable. Functional treatment works on the premise that the ankle/hindfoot is positioned in sufficient equinus to allow for early weight-bearing on a ‘shortened’ Achilles tendon. Our aim in this study was to test if 2 common walking orthoses achieved a satisfactory equinus position of the hindfoot. Methods. 10 sequentially treated patients with 11 Achilles tendon injuries were assigned either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus corrected vacuum brace system (EEB). Weight bearing lateral radiographs were obtained in plaster and the orthosis, which were subsequently analysed using a Carestream PACS system. The Mann-Whitney test was used to compare means. Results. Initial radiographs of all patients in cast immobilization showed a mean tibio-talar angle (TTA) of 55.67° (SD1.21) and a mean 1. st. metatarsal-tibia angle (1MTA) of 73.83° (SD9.45). There were 6 Achilles tendons treated in the FAWW. Their measurements showed a mean TTA of 27.67°(SD7.71) and 1MTA 37.00 (5.22). 5 tendons were treated using an EEB; there was a statistically significant (p< .05) increase in both the TTA 47.6° (SD5.90) and 1MTA 53.67 (SD5.77) compared to the FAWW group. Discussion. Plantar-flexion at the ankle was significantly greater in the EEB comparative to the FAWW, and very similar to the initial equinus cast. The use of wedges produced an equinus appearance through the midfoot, without producing equinus in the hindfoot as the heel pad rests on the top wedge. We express caution in the use of wedges for Achilles treatment as they do not shorten the Achilles tendon and may result in a lengthened tendon and reduced plantar-flexion power in the long-term

Two stage exchange treatment of the infected TKA involves two separate surgical procedures separated by an interval of several weeks of pathogen specific antibiotic therapy. The first stage involves removal of all of the infected arthroplasty components and any cement or foreign material, followed by aggressive debridement of nonviable bone and soft tissues. This is followed by placement of an antibiotic-laden spacer which may be either static (molded solid PMMA block) or mobile (shaped blocks or implants that allow knee motion). With both static and mobile spacers high local doses of antibiotic are delivered from the cement in addition to systemic antibiotic therapy usually employing an IV for around 6 weeks post debridement. The choice between static and mobile spacers is dictated by surgeon preference, soft tissue status (i.e. need for adjunctive muscle flaps), and by the severity of bone loss present with static spacers more likely to be used for more major soft tissue or bone defect cases. Mobile spacers have the advantage of allowing interval motion of the knee which may improve final range of motion. Static spacers usually require adjunctive brace or cast immobilization to prevent migration and bone damage. The second stage is performed at around 6 to 8 weeks after completion of systemic antibiotic therapy and preferably after normalization (or improvement) in laboratory indicators such as ESR and CRP. Routine repeat aspiration of all knees before reimplantation is not usual, but selective aspiration for culture may be helpful if concern exists that infection may still be present due to systemic signs, wound appearance or abnormal laboratory parameters. The second stage procedure involves removal of the antibiotic-laden spacer, repeat complete debridement of the knee, and insertion of revision knee components. Frequently adjunctive stems, blocks, cones or sleeves are needed to achieve adequate implant fixation due to associated bone loss. Careful attention to soft tissue balancing is required at the time of reimplantation in order to optimise motion and function while also avoiding laxity or maltracking. Two stage exchange remains the gold standard in North America for the management of infected TKA. While this method is used by some surgeons for all chronically infected TKA patients, it is employed even by most one stage exchange devotees when the infecting organism is unknown, infection involves a highly resistant or difficult to manage pathogen (i.e. fungal), is associated with a sinus track or marginal soft tissues, or in many cases of immunocompromised patients or those with multiple comorbidities

This work refers to a male patient, 25 years of age, admitted in the Emergency Department following a bicycle accident, of which resulted an open fracture of the right forearm bones – Gustillo & Anderson I. With this work, the authors have as objective the description of the patient's clinical condition – starting with the fracture, over to the osteomyelitis – as well as the surgical procedures and remaining treatments he was submitted to. The authors used the patient's records from Hospital's archives, namely records from the Emergency Department, Operating Room, Infirmary and Consultation, and also the diagnostic exams performed throughout the patient's clinical evolution. This clinical case began in May 2013, when the patient suffered an open fracture of the right forearm bones – Gustillo & Anderson I – due to a bicycle accident. At the time, the exposure site was thoroughly rinsed, a cast immobilization was made, and antibiotics were prescribed. In the fifth day following the trauma, the patient was submitted to an open reduction with internal fixation with plate and screws of both forearm bones. In the following period, the distal segment of the suture suffered necrosis, exposing the radial plate and the tendons of the first dorsal compartment. The Plastic Surgery team was then contacted, proposing the execution of a graft over the exposed area, which was made in August 2013. In the postoperative period, about half the graft lost its viability and it was noted that a radial pseudoarthrosis had developed – in the context of osteomyelitis – with a defect of about 9 centimeters. This condition prompted the extraction of the osteosynthesis material, about 4 months after its application, and at the same time the first stage of a Masquelet Technique was performed. The second stage of the aforementioned procedure was carried out two months later. Currently, the patient is clinically stable, with right hand mobility acceptable for his daily living activities. Analyzing the patient's clinical evolution, we concluded that, even though the adequate therapeutic decisions have been made in each stage, the development of osteomyelitis was inevitable. This realization, in association with the patient's young age, raises debatable questions of therapeutic order

Introduction. Ankle fractures are one of the commonest orthopaedic injuries. A substantial proportion of these are treated non-operatively at outpatient clinics with cast immobilization. Recent literature and NICE guidelines suggest risk assessment and provision of appropriate thromboembolism in patients with lower limb casts. We conducted this survey to assess the current practice in UK regarding thromboembolism prophylaxis in these patients. Materials/Methods. A telephonic survey was carried out on junior doctors within orthopaedic departments of 56 hospitals across the UK. A questionnaire was completed regarding venous thromboembolism risk assessment, prophylaxis and hospital guidelines etc. Results. Eighty-four percent (n=47) hospitals didn't routinely use any prophylaxis for these patients while 7% (n=4) hospitals used chemo-prophylaxis. Only 5.3% (n=3) hospitals had DVT prophylaxis guidelines regarding these patients while other 9% (n=5) hospitals were in process of developing such guidelines. In 64% (n=36) hospitals, no formal DVT risk assessment was carried out. Fifty percent (n=28) of the responders expressed that a DVT prophylaxis was not required in these patients, thirty-four percent (n=19) had opinion that prophylaxis should be prescribed, seven percent (n=4) said that prophylaxis was only required in the presence of additional DVT risk. Conclusion. A large variation exists across NHS hospitals and a poor risk assessment is being carried out in these patients. Development of local guidelines and extension of national guidelines to include high risk outpatients may improve the situation

The October 2023 Wrist & Hand Roundup³⁶⁰ looks at: Distal radius fracture management: surgeon factors markedly influence decision-making; Fracture-dislocation of the radiocarpal joint: bony and capsuloligamentar management, outcomes, and long-term complications; Exploring the role of artificial intelligence chatbot in the management of scaphoid fractures; Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations; Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial; Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study; On the road again: return to driving following minor hand surgery; Open versus single- or dual-portal endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.

Twenty-three patients with thirty hips of slipped capital femoral epiphysis were treated in our department, KK Women's and Children's Hospital, Singapore between 1997 and 2005. Except one patient lost of follow-up, twenty-four SCFEs with more than 2 years (25 to 73 months, average 38.5 months) follow-up were reviewed. This study is to evaluate the effectiveness and outcome of our protocol: Russell traction followed by gentle manipulative reduction with a single screw fixation & spica cast immobilization (for acute-on-chronic cases with unstable and reducible SCFE). In this series, there were 13 boys & 5 girls, mean age 12 year old ranging from 10 to 14 years. Among them 7 were Chinese, 6 Malays & 5 Indians. There were 12 unilateral cases (8 on the left & 4 right, 67%) & 6 bilateral cases (33%), including 2 patients found contralateral SCFE subsequently 1 year postoperatively. Acute-on-chronic SCFE were 16 & chronic SCFE 8. 16 were Grate I & 8 Grate II. Russell traction was on preoperatively with an average of 6 days. Gentle manipulative reduction under general anesthesia was performed in 20 SCFEs (12 GI & 8 GII) and 17 of them were successful. Fixation with a single screw was used for all cases except one hip with 2 screws. Average follow-up was 38.5 months. Good results achieved. All patient were symptom free with good function. No complications of AVN, chondrolysis, screw loosening and reslipping of the affective hips. Our protocol of management for SCFE has been largely successful in term of manipulative reduction and fixation

The aim of this study was to determine the outcome of patients treated with Achilles tendon rupture randomized to surgical or non-surgical treatment where both groups received the same early motion and weight bearing rehabilitation protocol. Fifty patients between the ages of 18 and 50 years with a clinical diagnosis of Achilles tendon rupture were randomized to surgical or conservative treatment. All injuries had occurred within ten days. Both groups received the same rehabilitation program with initial cast immobilization then splintage in a removable orthosis with ankle motion commencing at two weeks. Patients completed the MFAI, a validated outcome questionnaire and clinical assessment including range of motion and calf squeeze response at 2, 6 and 12 weeks, 6 months and one year. There was no difference between the surgical and non-surgical groups for difference in dorsiflexion and plantar flexion between the injured and non-injured sides. There was no difference in the MFAI quality of life scores for either treatment group. There was the same number of re-ruptures in both groups. There were no infections in the operated patients. Early motion rehabilitation after Achilles tendon rupture results in similar functional results and patient satisfaction in both surgically and non-surgically treated patients

Aims: Aware of good results recently obtained with synthetic biodegradable polymers, in order to avoid problems seen with the use of metal implants, we adopted an intramedullary absorbable poly-l-lactic acid pins þxation in displaced metatarsal fractures. This paper reports on the results we have obtained. Methods: Eleven patients underwent open reduction and internal þxation of the fracture fragments using biodegradable pins of the following sizes: diameter 3,2 millimetre x length 5.0–6.0–7.0 millimetre. Clinical examination and X-ray controls were done three, six, twelve weeks and one year after surgery. In addition all patients were followed up with magnetic resonance imaging (MRI). Results: All patients operated healed in about 2 months without cast immobilization or prolonged rest. Serial radiographs showed good alignment of the bone and solid union at the fracture site. No inßammatory foreign body reactions or local infections were observed. Conclusions: SR-PLLA pins can provide a good stable metatarsal fracture þxation during bone healing but our study needs a longer-term follow- up to demonstrate their biologic value

Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip. The purpose of the study was to evaluate a number of clinical and radiological risk factors for AVN after non-operative treatment of DDH. Clinical data and radiographs of 77 patients with103 abnormal hips treated because of developmental dysplasia of the hip by closed reduction followed by cast immobilization were reviewed retrospectively. The average age of patients at the time of reduction was 16 months (ranged, 4 to 28) and the average final follow up was 22,4 years (ranged from 13 to 47 years). Kalamchi and MacEwen classification system was used for evaluation of the AVN. Avascular necrosis was found in 35,9% of the treated hips. We established the influence of several radiological and clinical data on the incidence and severity of AVN. Conclusion: In our analysis the degree of initial dislocation according to Tönnis classification is an important risk factor for AVN. Age at the onset of treatment, presence and size of ossific nucleus, the use and period of preliminary traction, previous treatment with Frejka pillow or Pavlik splint, sex and side were not associated with the incidence and severity of ischemic necrosis. The results have been analysed statistically

Objective: The purpose of this study was to determine which factors may influence in the outcome of the surgical treatment of Carpal Tunnel Syndrome (CTS). Material and Methods: During 2005, 175 patients were treated with the diagnosis of CTS by open carpal release (short palmar incision) without ligament reconstruction. 113 cases were selected: 39 males and 74 females, with an average age of 41 years (21 to 64 years) and a follow-up of 24 months (12–36 months). The dominant hand was treated in 58%. The subcutaneous cellular tissue (SCT) was sutured in 14% and 11% were immobilized with a cast for 2 weeks after surgery. We considered factors such as: systemic conditions, functional work requirement, preoperative time, surgical technique, and their correlation with complications, clinical outcome and time to return to work and activity level. Results: Complications: 41% pillar pain, 9% suture dehiscence, 3,5% ulnar neuritis, 1,7% trigger finger, 1,7% reflex sympathetic dystrophy, and 1,8% wound infection. 5 patients were re-operated. Complications rate due to surgery was 3,5% after 12 months of follow-up. The average time out of work was 9 weeks (2–43 weeks) and was higher (13 weeks) in patients with post-operative immobilization. All patients, except one, returned to their previous activity level. History of systemic conditions and dominance had not influence on the final outcome. The suture of the SCT and the postoperative immobilization showed lower wound dehiscence and pillar pain cases. Conclusions: The surgical treatment of the CTS provides good clinical and labour results. Patients with suture of the SCT and cast immobilization show less post-operative surgical complications

Distal radial fractures represent 17% of fractures in the Italian E.R. In the last years many different techniques accompanied the traditional treatment of closed reduction and cast immobilization such as closed reduction + pinning + cast, “epi-block” fixation, ORIF with dorsal and/or volar plates, screws and external fixation. These techniques are mostly followed by a period of immobilization with cast which is optional in A.O. type A fractures and is usually necessary in type B and C fractures. At the University Hospital “Policlinico Umberto I” of Rome E.R. we have started treating these fractures with a new fixation system which we projected. This system provides a non-bridging external fixation. The synthesis is guaranteed by two or more K-wires which can be intramedullary or x-crossing the cortex and/or inter-fragmentary. These K-wires are connected with two radial pins by an external bar. This radial to radial system gives stability to the fracture and allows the patient to move the wrist immediately. We remove this fixation system after 40 days. From July 2008 to August 2009 we treated 56 distal radial fractures. Clinical assessment was performed every seven days until removal of external fixation system, then at 2, 3, 6 and 12 months. Radiographic assessment was performed at 30 and 40 days, consequently at 2, 3, 6 and 12 months. Outcome was measured on the basis of range of motion, grip and pinch strength, DASH and PRWE scores. A questionnaire was used to determine patient satisfaction, and a detailed analysis of complications was carried out. All patients had excellent or good results and were satisfied with the clinical outcome. At 60 days after surgery 90% of patients demonstrated complete clinical and functional recovery. After 3 months 100% of patients demonstrated complete clinical and functional recovery. After 6 months and 12 months no modification of the obtained result was detected

Introduction: Acute Achilles tendon rupture is very much associated with sports practice and it’s a common lesion between young people. Despite of much Discussion: in the literature, the correct treatment of the complete ruptures of this tendon in the acute phase remains controversial. The objective of this work is to accomplish a comparative analysis between the results obtained with both techniques: open versus percutaneous. Materials and Methods: This work included 81 patients (6 women e 75 men) with acute rupture of the Achilles tendon between January of 1999 and December of 2008 and that were submitted 51 to surgical treatment with open technique and 30 with the percutaneous with the technique of Ma and Griffith modified. This patients had medium age of 35,6 years with a greater incidence between 30 and 39 years and with medium time follow-up of 1,9 years. The diagnostic of the lesion was based in clinic criteria and when there was a doubt an ecography was realized. In both Methods: was used posteoperative cast immobilization with 20° of plantar flexion during 6 weeks. The patients were analysed according to clinical e functional evaluations and the American Orthopaedic Foot and Ankle Society scale and the Holtz score. Results: The patients included in the percutaneous group had better functional results with more precocious weight bearing, better ankle range of movement e more earlier return to sports practice (p< 0,001). In the open technique there were more complications in comparison with the percutaneous one (15,7% vs 6,7%). In the open technique there were no rerupture and in the percutaneous technique there were 6. The results in both scales were better in the percutaneous group but it wasn’t statistically significative. Discussion: Good functional results and a low percentage of complications recommend the use of surgical techniques in the treatment of this disease. Better functional and aesthetic results were obtained in the percutaneous group but at expense of a more percentage of reruptures. Open surgery is indicated in the reruptures after the utilisation of the percutaneous technique

Chronic Achilles tendonosis is a common but difficult condition to successfully treat. Platelet rich plasma (PRP), a concentrated bioactive component of autologous blood that is rich in cytokines and other growth factors, was examined in this study to assess its ability to promote healing in severe cases of Achilles ten-donosis resistant to traditional non-operative treatment paradigms. Twenty-seven patients (16 males 11 females) with an average age of 46 (36–66) and who had failed an average of 8 months (6–10) of standard non-operative management for Achilles tendonosis (rest, heel lifts, PT, NSAIDS, cam walker / cast immobilization, night splinting, local modalities) were prosepectively included in the study. All patients had pre-treament MRI and ultrasound studies and clinical scoring was completed using the AOFAS hindfoot scoring system. Patients were treated by injecting a single dose of 4 cc of unbuffered PRP under local anesthesia directly into the injured zone of the Achilles tendon using ultrasound probe guidance. All patients were then immobilized fully weight bearing in a cam walker for 48 hours and then allowed to return to normal activites as tolerated and without support. Pre-treatment AOFAS scores averaged 34 (26–60), all patients had MRI and ultrasound evidence of chronic tendonosis and 9/27 had partial tears of the Achilles. All patients were considering operative intervention due to clinical dissatisfaction. Post-treatment AOFAS scores improved to 84 (80–87), at 1 month, 87 (84–90), at 2 months, 88 (87–100) at 3 months, and 92 (90–100) at 6 months with resolution of abnormalities seen in 25/27 post treatment MRI and ultrasound studies. All patients except one were clinically satisfied with their clinical results and no complications were reported. This study suggests that platelet rich plasma can be effective in the treatment of severe achilles tendonosis refractory to traditional non-operative management

This study is to evaluate the effectiveness and outcome of our protocol: Russell traction followed by gentle manipulative reduction with a single screw fixation & spica cast immobilization. Twenty-three patients with thirty hips of slipped capital femoral epiphysis were treated in our department, KK Women’s and Children’s Hospital, Singapore between 1997 and 2005. Except one patient lost of follow-up, twenty-four SCFEs with more than 2 years follow-up were reviewed. In this series, there were 13 boys & 5 girls, mean age 12 year old ranging from 10 to 14 years. Among them 7 were Chinese, 6 Malays & 5 Indians. There were 12 unilateral cases (8 on the left & 4 right, 67%) & 6 bilateral cases (33%), including 2 patients found contralateral SCFE subsequently 1 year postoperatively. Acute-on-chronic SCFE were 16 & chronic SCFE 8. 16 were Grate I & 8 Grate II. Russell traction was on preoperatively with an average of 6 days. Gentle manipulative reduction under general anesthesia was performed in 20 SCFEs (12 GI & 8 GII) and 17 of them were successful. Fixation with a single screw was used for all cases except one hip with 2 screws. Average follow-up was 38.5 months. Good results achieved. All patient were symptom free with good function. No complications of AVN, chondrolysis, screw loosening and reslipping of the affective hips. Our protocol of management for SCFE has been largely successful in term of manipulative reduction and fixation. This is a safe, simple and effective management

Aims

Eccentric reductions may become concentric through femoral head ‘docking’ (FHD) following closed reduction (CR) for developmental dysplasia of the hip (DDH). However, changes regarding position and morphology through FHD are not well understood. We aimed to assess these changes using serial MRI.

Purpose of the study: Infection is a leading cause of morbidity and mortality in sickle cell anemia children. It often triggers an acute episode of anemia with thrombosis. Bone and joint infections are particularly frequent. Diagnosis can be difficult and is sometimes established late. Material and methods: We analyzed retrospectively the cases of 39 children with sickle cell anemia who presented one or more bone and joint infections during a six-year period (January 1998-December 2003). Results: Bone and joint infection involved 14% of all sickle cell children hospitalized during the study period. Mean age was nine years, with no gender predominance. Homozygous subjects were more exposed to infection (73%). The infection revealed the disease in 13% of the children. The rate of bone and joint infection was 62% compared with 38% for osteomyelitis; salmonella were isolated in 38% of cases. Medical treatment with adapted antibiotics and plaster cast immobilization were instituted in all cases and associated with surgical treatment in 25% (arthrotomy for evacuation of purulent collections, cleaning, resection of infected tissue). Outcome was favorable in 77% of cases (cured infection, resumed school activities). Discussion: The frequency of bone and joint infections in sickle cell anemia children in our series was similar to that reported in the literature (10–19%). Compared with children with normal hemoglobin, bone and joint infection in sickle cell anemia children present specific features in terms of localization, blood chemistry findings, causal bacteria, radiographic signs, and therapeutic modalities and sequelae. Conclusion: Sickle cell anemia is a serious hereditary disease. The risk of complications should lead to the development of preventive measures (screening at risk couples, institution of a prenuptial certificate, allogenic bone marrow graft)

Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment. Material: There were 17 patients with an average age of 42 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but two fractures were closed. The level of the tibia fracture included midshaft (two), middle-distal third (ten), distal third (five). Eleven ankle fractures were classified as Weber B, five as Weber C and one Pilon. Two fractures were treated by cast immobilization, eleven with internal fixation of both fractures and four with a combination of internal and external fixation. Seven fractures were treated initially in long leg casts, but each required surgical intervention to control fracture alignment. Results: The average follow up was twenty-three months. The non-operatively treated fractures resulted in a malunion and decreased ankle mobility. Of the cases managed operatively, nine had complete structural and functional recovery; two patients regained 70% of ankle mobility and one developed post-traumatic ankle arthritis. Discussion: The resulted experience from the treatment of these injuries showed their extremely unstable nature. It has been our experience that the nature of the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, progressive slippage of the fragments occurs. We believe that stable fixation of both fractures should be the treatment of choice

Aims: We aimed to compare conventional rigid cast immobilization with the semi-rigid functional treatment method with respect to calf muscle atrophy, ankle range of motion (ROM) and patient satisfaction in patients who had acute lateral ligament injury of the ankle. Methods: Sixty patients were randomized into the functional immobilization group (Group SC) or conventional belowthe- knee walking cast (Group R). Muscle atrophy was evaluated by axial Computerized Tomography and ankle ROM were recorded before and after treatment. A brief questionnaire for the evaluation of patient satisfaction was applied after the casts were removed. Results: A reduction in muscle area indicating atrophy was detected for both groups (p< 0.001). However, the atrophy was more pronounced in Group R for anterior and superþcial posterior muscle groups. There was also a reduction in ankle ROM for both groups. The loss of ROM for Group R was more evident and differences between the groups were statistically signiþcant. The patients who were treated with functional immobilization techniques were more satisþed. Mean score for Group SC was 67±12 where as it was 28±7 for Group R (p< 0.001). Conclusions: Functional immobilization has shown better results on patient satisfaction and ankle ROM. Although not statistically signiþcant, functional group also showed better results with respect to muscle atrophy for all muscle groups except the lateral. Regarding the previous literature on the effectiveness of functional immobilisation on ankle stability, this technique additionally brings advantages to the treatment of ankle ligamentous lesions with regard to patient satisfaction and facilitation in rehabilitation

Aims: The purpose of this presentation is to report our protocol for staged exchange nailing of delayed-unions and non-unions of the tibia complicated by multifocal osteomyelitis from infected pin tracts. Methods: Twenty-four patients with delayed or non-union of the tibia initially treated by external þxation were retrospectively reviewed. Fifteen males and 9 females with an average age of 40 years (range 20–74) and at least 1 year of follow up (range 1–7). External þxation was maintained until the soft tissues healed. External þxation time averaged 116 days (range 28–288). Multiple gross pin tract infection developed in all the casesl. Non-unions and delayed-unions were treated by exchange reamed intramedullary nailing. The exchange protocol consisted in the removal of the external þxator, debridement and culture of bone from the pin sites, cast immobilization, speciþc IV antibiotics for 6 weeks, and a negative post-antibiotics biopsy. Outcome measurements included recurrence of infection and healing of the delayed union or non-union. Results: Twenty-three of the fractures healed at the þrst nailing attempt on an average time of 4 months (range 2–7). One case required re-nailing at 4 months and þnally healed at 6 months from the initial procedure. No recurrence of deep infection was identiþed. Two patients developed superþcial infections, suppressive antibiotics were used until complete bone healing and subsequent nail removal. Discussion: By using our staged protocol we were able to perform exchange nailing for non-unions and delayed unions of the tibia complicated by multiple foci osteomyelitis from infected pin tracts with a considerable rate of success

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is the gold standard treatment of a wide range of pathologies involving the 1st MTPJ. Numerous methods of internal fixation and bone end preparation have been reported to perform this procedure, however there is no universal technique. Therefore in an effort to bring together the best features of the different surgical techniques, a low profile contoured titanium plate (Hallu-S plate), with a compression screw, with a ball and socket bone end preparation were designed. A prospective study was carried out to determine the efficacy of using the Hallu-S plate for 1st MTPJ arthrodesis. 1st MTPJ arthrodesis, using the Hallu-S plate, was carried out in 11 consecutive patients. The procedure was performed in isolation and with other forefoot procedures. Cast immobilization was not used in patients with an isolated 1st MTPJ arthrodesis and the patients were allowed to mobilize (heel walking – full weight bearing) between 2 and 6 weeks postoperatively. The changes in the level of pain and activities of daily living using the AOFAS Hallux score, pre-operatively and at the last assessment, and the time to bone union were assessed. The mean follow-up time was 10 months (STD 6 months) and there was statistically significant increase in the AOFAS Hallux score. All radiographs at 6 weeks showed bone union and an appropriate degree of dorsiflexion in relation to 1st metatarsal (20–25). The combination of the Hallu-S plate and a ball and socket preparation has both operative and biomechanical advantages over previously described techniques. This combination ensures the biomechanics of the 1st ray are maintained and a better functional result is achieved

Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment. Material: There were 11 patients with an average age of 40 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but one fracture ware closed. The level of the tibia fracture included midshaft (two), middle-distal third (seven), distal third (two). Seven of the ankle fractures were classified as Weber B, three as Weber C and one Pilon. One fracture was treated by cast immobilization, eight with ORIF of both fractures and two with a combination of internal and external fixation. Of the patients treated operatively, five were treated initially in long leg casts, but each required surgical intervention to control fracture alignment. Results: The average follow up was twenty- three months. The non-operatively treated fracture resulted in a mal-union and a severe loss of ankle mobility. Of the cases managed operatively, seven had complete structural and functional recovery, two patients regained 70% of ankle mobility and one developed ankle arthritis. Discussion: The resulted experience from the treatment of these injuries shows their extremely unstable nature. It has been our experience that the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, a progressive slippage occurs over the time. We believe that stable fixation of both fractures should be the treatment of choice

Purpose. Conservative treatment of minimally displaced distal radius fractures (DFR) remains controversial. Circumferential casting (CC) in the acute setting is believed to supply superior support compared to splinting, but is generally cautioned due to the limited capacity of a cast to accommodate ongoing limb swelling possibly leading to complications. However, there is no conclusive data on which to base these beliefs. Moreover, the appropriate management of cast complications while minimizing risk to fracture integrity remains unclear. This retrospective study of distal radius fractures treated conservatively with circumferential cast in the acute setting aims to: A. Determine demographic, fracture dependant or management risk factors for CC complications. B. Determine the natural history for both patients with CC and those with CC necessitating cast modification. Method. Hospital records and radiographic data of 316 patients with DRFs treated with CC at a tertiary-care university hospital between the years 2006 to 2009 were reviewed. Our primary outcome was to access risk factors for cast complications including swelling, pressure sores, neuropathies and loss of cast immobilization. Our secondary outcome accessed reduction stability in patients undergoing cast re-manipulation. Results. 31% of patients experienced cast related complications within the first two weeks of treatment. 22% of patients had their cast manipulated (replaced, split, trimmed or windowed). Increasing patient age or polytrauma were both associated with an increased risk of developing cast complications. Polytrauma was also associated with a poor overall rate of fracture reduction following non-operative management. Patient gender, physician specialty placing the cast as well as fracture type (AO classification) did not influence risk. Overall, patients with acute cast complications had no increased risk of losing reduction compared to patients with normal management. However, patients who complained of pressure in cast had a higher risk of loss reduction if their cast was split as opposed to being replaced. Conclusion. Circumferential casting in the acute setting of minimally displaced DRF reduces the workload of an orthopedic department. No previous study has shown improved fracture outcome compared to CC using other immobilization methods. This study has identified that elderly patients and polytrauma patients are at greater risk of returning to clinic for cast complications. Furthermore, replacing a cast as opposed to splitting it when accommodating painful swelling may aid in maintaining reduction integrity

Background: 75% of Achilles tendon ruptures are related to physical activities. The best method of treatment for acute Achilles tendon rupture is still debated. Treatment options can be classified as Nonoperative based on cast immobilization, open surgery, and percutaneous surgery based on passing sutures through several stab incisions. Common complications include re-ruptures, infection, wound problems and sural nerve injury. Recent reports of percutaneous surgery show good functional outcome, low incidence of re-ruptures, fewer wound healing problems and prompt recovery. Objective: Assessment of percutaneous operative treatment outcome. Methods: 73 patients treated for acute Achilles tendon rupture with percutaneous surgery in the past eight years are followed. Evaluations were preformed at an average of 34.6 months postoperatively (range, 17 to 54 months). Outcome was evaluated by analyzing Epidemiologic, subjective and objective parameters. Results: The patients demonstrated good functional outcome, with none – to mild limitations in recreational activities. Ankle range of motion was not statistically different between both ankles. Evaluation of strength and power with the Cybex II dynamometer revealed a difference at 240 deg/sec for plantar flexion power between the injured and healthy leg, but no difference at 30 and 90 deg/sec, or in dorsiflexion power and strength. Complication rate was low: sural nerve injury (1 patient), superficial wound infection (2 patients), suture granuloma (4 patients) and re-rupture (1 patient). Conclusions: In our series, percutaneous operative treatment was found to be simple, fast and can be done under local anesthesia. Our low complication rate and excellent functional results make this treatment an appealing alternative to either conservative or open surgical suture

Scaphoid fractures are rare injuries in the pediatric population. A clinical and radiographic review over a six-year period at our institution revealed ninety-nine suspected scaphoid fractures. All of these patients presented with post-traumatic tenderness in the anatomic snuffbox and were treated with thumb spica cast immobilization. Only 9% of these patients demonstrated radiographic evidence of scaphoid fracture on initial presentation. At subsequent follow-up, six additional patients revealed radiographic evidence of scaphoid fracture. Positive predictive value of snuffbox tenderness for scaphoid fracture was 6% for patients with initially normal radiographs. To review the clinical and radiographic results of suspected pediatric scaphoid fractures, as well as to determine the predictive value of anatomic snuffbox tenderness for occult fracture. Pediatric scaphoid fractures are rare injuries that were found to be non-displaced and to involve the waist and distal scaphoid in most cases. Snuffbox tenderness had a positive predictive value of 6% in the identification of occult fracture. In cases of suspected scaphoid fracture and normal radiographs, reliance on anatomic snuffbox tenderness alone will result in unnecessary immobilization in the majority of children. Ninety-nine potential injuries were identified. Average age was 13.9 years. Although all patients in this group had tenderness in the snuffbox, only nine of the original x-rays revealed a true scaphoid fracture. The ninety “clinical scaphoid fractures” were immobilized for twenty-three days on average. Of these, only six demonstrated future radiographic evidence of fracture. No injuries required surgery for non-union. All pediatric scaphoid fractures that were diagnosed clinically or radiographically at our institution between 1998 and 2003 were reviewed. Initial and follow-up radiographs were examined for evidence of fracture. Given the sequelae of untreated scaphoid fractures in adults, tenderness in the snuffbox has been used to diagnose “clinical scaphoid fractures”. Although never validated in children, this test continues to be used in this population. As the natural history of scaphoid fracture in children is more favorable than in adults, reliance on snuffbox tenderness alone has resulted in the over-treatment of this injury

Purpose: Knee dislocation is associated with blunt popliteal artery trauma in almost 30% of cases. In such injuries, prompt diagnosis and appropriate management is essential for limb salvage. Both our methods and outcomes of popliteal artery thrombosis treatment after knee dislocation are presented in this retrospective study. Methods: During the last six years, eight patients (all male, average age 25 years) were admitted to our hospital with knee dislocation and associated blunt popliteal artery thrombosis following automobile accidents (7/8) and fall from height (1/8). The average delay before accessing the emergency room was 14 hours (ranging from 2 to 24 hours). Seven patients were experiencing signs of distal ischemia (absence of distal pulses, motor and sensory loss) and one patient, admitted two hours after vehicle accident, was presented with absent distal pulses but maintained motor and sensory ability. Seven patients underwent external fixation and one plaster cast immobilization. In all cases, digital subtraction arteriography was performed. Results: All patients were treated by performing below knee femoropopliteal bypass, using reversed saphenous vein in seven cases and a vscs graft in one. All patients underwent fasciotomies. One above knee amputation was performed postoperatively while three patients experience permanent neurologic discrepancy. Conclusions: In any case of knee dislocation, there must be a high clinical suspicion of popliteal artery thrombosis. Meticulous and repeated physical examination and rapid admission to a department of vascular surgery are of vital importance for limb salvage and minimization of amputation rate and permanent neurologic deficiency

The February 2024 Wrist & Hand Roundup³⁶⁰ looks at: Occupational therapy for thumb carpometacarpal osteoarthritis?; Age and patient-reported benefits from operative management of intra-articular distal radius fractures: a meta-regression analysis; Long-term outcomes of nonsurgical treatment of thumb carpometacarpal osteoarthritis: a cohort study; Semi-occlusive dressing versus surgery in fingertip injuries: a randomized controlled trial; Re-fracture in partial union of the scaphoid waist?; The WALANT distal radius fracture: a systematic review; Endoscopic carpal tunnel release with or without hand therapy?; Ten-year trends in the level of evidence in hand surgery.

The August 2023 Trauma Roundup³⁶⁰ looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

Various studies report a correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 250 and radiocarpal malalignment with ERLF > 250. The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (one week) and late failure (six weeks) in an attempt to predict the final radiological outcome accurately. Radiographic alignment parameters were compared before and after reduction using paired t-tests and then also analysed in a multiple logistic regression analysis. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at one week. Age, gender, presence of dorsal comminution, ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. Late failure group: We found radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome at six weeks. Age, Gender, flattening of radial angle, ulnar styloid fracture as factors for secondary displacement when analyzed independently or in combination were not found to be significant predictors of late failure. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and both at one and six weeks when analysed independently or in combination (p< 0.01). Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options

Background: A recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. We studied impairment and disability an average of twenty-one years after injury in a cohort of Dutch patient, with the hypothesis that both impairment and disability would be lower in patients that were skeletally immature at the time of injury. Methods: Seventy-one patients were evaluated an average of 21 years after injury. The majority of the 35 skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the 36 skeletally mature patients were treated with plate and screw fixation. Objective evaluation included radiographs and measurements of range of motion and grip strength. Questionnaires were used to measure arm-specific disability (Disabilities of the Arm, Shoulder and Hand: DASH), misinterpretation or over interpretation of pain (Pain Catastrophizing Scale-PCS-), and depression (CES-D). Multivariable analysis of variance and multiple linear regression were used to compare patients that were skeletally mature and immature at the time of injury and to identify predictors of arm-specific disability (SPSS 17.0, SPSS inc., Chicago). Results: There were 44 men and 27 women with a an average age of forty-one at time of follow-up (range, 20 to 81). Fractures were classified as AO/OTA-type A3 in 46 patients (simple), B3 in 18 (including wedge fragment) and C fractures in 7 patients (comminuted). The average DASH score was 8 points (0 to 54) and 73% reported no pain. Both rotation and wrist flexion/extension were 91% of the uninjured side; grip strength was 94%. There were small, but significant differences in rotation (151 versus 169 degrees, p=0.004) and wrist flexion/extension (123 versus 142 degrees, p=0.002), but not disability between skeletally mature and immature patients. The best predictors of DASH score were nerve damage, pain and grip strength, explaining 56% of the variation in DASH scores. Disability did not correlate with depression or misconceptions about pain. Conclusions: Twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over 90% motion and grip strength) and disability after non operative and operative treatment respectively. Patients that were skeletally immature at the time of injury had better motion, but comparable disability. Disability correlated with pain rather than motion, but did not correlate with psychosocial measures

Purpose: We conducted the first, multicentre, prospective cohort study to define the incidence of symptomatic venous thromboembolism (VTE) in patients with tibia and ankle fractures treated conservatively and relatively minor lower leg fractures. The reported incidence of deep vein thrombosis (DVT) using routine venography in patients with lower leg injury requiring cast immobilization is approximately 20–40%, which has lead to the routine use of anticoagulant prophylaxis for several weeks in many such patients. However the vast majority of venographically-detected DVTs are asymptomatic, distal thrombi whose clinical relevance is uncertain. Therefore venography is not the best outcome measure to assess the burden of clinically important VTE. Method: Consecutive patients with tibia and fibula fractures (treated non-operatively) and patella and foot fractures, (treated operatively or conservatively) were assessed for eligibility at 5 Ontario hospitals. Patients were enrolled after informed consent within 96 hours of injury and were followed prospectively, by telephone, at 2, 6 and 12 weeks. Those with major trauma, active cancer, and previous VTE were excluded. Thromboprophylaxis was not allowed. Education regarding symptoms of VTE was provided at study entry and patients were asked about VTE symptoms at follow up. Suspected VTE was investigated in a standardized manner. Results: From August 2002 to June 2005, 1200 patients were enrolled from 2446 consecutively screened patients. 98% of patients completed 3-month follow-up. The mean age was 45 years (16 to 93) and 60% were female. The most common fractures were fibular (39%) and most injuries were caused by falls (75%). 99 % of these fractures were unilateral. Most fractures did not require surgical repair (93%), and 82% of patients were immobilized by cast or splint for an average of 42 ±32 days. Overall, 7 patients had symptomatic, objectively confirmed VTE (2 proximal DVT, 3 calf DVT, 2 PE) with no fatal PE – an incidence of 0.6 % (95% CI 0.2 to 1.2). Conclusion: Symptomatic VTE is an infrequent complication after these fractures without thromboprophylaxis. Therefore routine thromboprophylaxis is neither warranted, nor likely to be cost-effective in these patients. This study also highlights the significant discrepancy between clinical endpoint studies and studies using venography

Purpose of the study: The pathophysiology of reflex dystrophy or type I complex regional pain syndrome remains poorly understood, but the cost is considerable in terms of public health expenditures both for programmed and emergency orthopedic surgery. We present a historical cohort assessed to evaluate the usefulness of vitamin C for the prevention of reflex dystrophy in programmed foot and ankle surgery. Material and methods: The study included two groups of patients treated in two successive periods: July 2002 to June 2003 and July 2003 to June 2004. All patients underwent foot and ankle surgery performed by the same senior surgeon. Diabetic feet were excluded. The first group (185 feet, 177 patients) was not given any particular preventive treatment. The second group (235 feet, 215 patients) was given one gram vitamin C for 45 days. The diagnosis of reflex dystrophy was retained on the basis of clinical and radiological arguments noted at follow-up visits with the operator. Several factors were studied: gender, age, type of disease condition, history of reflex dystrophy, psychological context, duration of tourniquet, cast immobilization. Results: Reflex dystrophy occurred in 18 feet in group. 1 (9.6%) and in 4 (1.7%) in group 2. The difference was significant. Presence of a history of dystrophy was significantly associated with development of dystrophy (RR=10.4). A psychological context appeared to increase the risk of dystrophy (RR 2.6) but did not reach significance. There was no statistical relationship with age, gender, duration of tourniquet, type of disease condition, or surgical procedure performed. Discussion: Vitamin C has been found to be effective in the prevention of reflex dystrophy after wrist fractures. Data in the literature is scarce on dystrophy of the foot and ankle. Our study provided objective evidence of the usefulness of vitamin C for the prevention of reflex dystrophy in foot and ankle surgery patients, a complication frequently observed in our control group (9.6%). The psychological context and history of dystrophy increase the risk of dystrophy. Conclusion: Vitamin C is associated with a lower risk of reflex dystrophy in the postoperative period after foot and ankle surgery. We advocate preventive treatment with vitamin C

Introduction: Aim of this study is to evaluate the results of the treatment using the technique of dual cortical graft. Material and Methods: Twenty-one patients (13 boys, 8 girls, age 3–8 years) were treated in period 1996–2008 in our institution. In seventeen patients, dual cortical graft harvested from tibia of parents was used for reconstruction of pseudarthrosis. NF type I was the cause of pseudarthrosis in 13 patients. After resection of the hamartomatous fibrous tissue, sclerotic bone ends and periosteum and reduction of angulations, the cortical grafts are placed on lateral and medial side of the tibia and are fixed thru the tibia proximally and distally with conventional screws. Cast immobilization follows for 9–12 weeks. In concomitant fibular pseudarthrosis, intra-medullary fixation and cancelous bone grafting treat the pseudarthrosis. In 11 patients, this technique represented the 1st surgical procedure, whereas in 6 cases (including 2 failed vascularised fibular transfers), 1–15 previous surgical procedures were used in treatment. Further surgical procedures followed for correction of the leg length discrepancy and deformity of the ankle. Results: The fusion of non-union was achieved in 16 patients. 12 patients reached skeletal maturity (59%) whereas 4 patients (24%) did not finished the growth and are still in treatment. 10 patients use the protection brace and intramedullar nail was used in 2 patients to prevent refracture. One patient refused further treatment and amputation followed in another institution. Concerning functional outcome, 14 patients walk unlimited, 2 patients walk more then 1 hour and 1 patient walks less then 1 hour. 13 patients did not use the walking aid, 2 patients use 1 cane a 2 patients the crutches. The complication rate of this method is similar to the other methods, mainly due to the refractures. Only in one patient, the pseudarthrosis primarily fused after single procedure. In 3 patients, second procedure was necessary. In remaining 12 patients, 3–6 further surgical procedures were used for the healing of pseudarthrosis due the delayed-union of grafts or refracture of the tibia. In these cases, cancelous bone grafting and various techniques of fixation were used to achieve the union. Discussion: and conclusion: The results of the dual cortical grafting technique are comparable to other effective methods like Ilizarov method and the method is useful also after previous failed procedures. The complication rate is similar to other methods. The prevention of the refracture by bracing or rodding is recommended in all patients. This surgical procedure should be delayed until 4 years of age. Significance: The method of dual cortical grafting represents still effective method of treatment of CPT

Pyogenic arthritis of the hip in childhood despite improved antibiotic therapy remains a serious disorder which demands early diagnosis and prompt treatment. The most serious complication of the pyogenic arthritis of the hip in childhood and especialy in newborns and infants is the avascular necrosis of the femoral head which can lead to partial or complete destruction of the capital femoral epiphysis or the growth plate or both. This destruction may lead to hip joint deformity, leg length discrenpancy and dysfunction. The PURPOSE of this study was an effort to determine the factors which affect the outcome of the hip joint in pyogenic arthritis.In the present study included 37 children, 24 boys and 13 girls, with 37 involved hips. Their ages ranged from 10 days to 1 year old in 17 children and from 1y–11 years old in 20 children. All patients were hospitalized and treated in our Orthopaedic Department with proven pyogenic arthritis. All children were suspected to have pyogenic arthritis of the hip from the history, clinical features, laboratory and imaging findings and were confirmed with positive aspiration in 35 patients. In two negative aspirations the pyogenic arthritis was confirmed of the performed surgical interventions. The treatment consisted of I.V. and oral administration of appropriate antibiotics and cast immobilization for about six weeks. In 23 only patients was performed immediate incision and surgical drainage with debridement of the hip joint, wipping the panus of the cartilage. The length of the follow up was 2–9 years. The hips were classified according to radiographic findings into 3 groups. TYPE I (31 Patients, 84%) Normal overgrown femoral head. TYPE II (3 Patients, 8%) Deformed femoral head. TYPE III (3 Patients, 8%) Partial or complete destruction of the proximal femoral epiphysis. The evaluation and analysis of the results revealed primarily that the delayed diagnosis lead in delayed treatment especialy in neonates and infants. Other factors which have unfavorable outcome in the pyogenic hip arthritis are the multiple location, osteomyelitis of the hip region and the causative organism. Of course the rapid diagnosis followed of immediate aspiration with surgical drainage and early administration of apropriate antibiotics lead to good or excellent results

Pyogenic arthritis of the hip in childhood despite improved antibiotic therapy remains a serious disorder which demands early diagnosis and prompt treatment. The most serious complication of the pyogenic arthritis of the hip in childhood and especialy in newborns and infants is the avascular necrosis of the femoral head which can lead to partial or complete destruction of the capital femoral epiphysis, the growth plate or both. This destruction may lead to hip joint deformity, leg length discrenpancy and dysfunction. The PURPOSE of this study was an effort to determine the factors which affect the outcome of the hip joint in pyogenic arthritis. The present study included 37 children, 24 boys and 13 girls, with 37 involved hips. Their ages ranged from 10 days to 1 year old in 17 children and from 1y-11 years old in 20 children. All patients were hospitalized and treated in our Orthopaedic Department during 1983–1995 with proven pyogenic arthritis. All children were suspected to have pyogenic arthritis of the hip from the history, clinical features, laboratory and imaging findings and were confirmed with positive aspiration in 35 patients. In two negative aspirations the pyogenic arthritis was confirmed after surgical intervention. The treatment consisted of I.V. and oral administration of appropriate antibiotics and cast immobilization for about six weeks. In only 23 patients was immediate incision and surgical drainage performed with debridement of the hip joint, and removal of the panus on the cartilage. The length of the follow up was 7–16 years. The hips were classified according to radiographic findings into 3 groups. TYPE I (31 Patients, 84%) Normal overgrown femoral head. TYPE II (3 Patients, 8%) Deformed femoral head. TYPE III (3 Patients, 8%) Partial or complete destruction of the proximal femoral epiphysis. The evaluation and analysis of the results revealed primarily that delay in diagnosis lead to delayed treatment particularly in neonates and infants. Other factors which have an unfavorable outcome in the pyogenic hip arthritis are the multiple location, osteomyelitis of the hip region and the causative organism. Rapid diagnosis followed by immediate aspiration with surgical drainage and early administration of an appropriate antibiotics lead to good or excellent results

Introduction: Acute traumatic separation of the greater trochanter is a rare childhood injury with associated morbidity. Although the risk for femoral head avascular necrosis and morbidity following femoral neck fractures in childhood is well understood, the risk to femoral head blood supply in the much less common greater trochan-teric fracture is not widely known. Materials and Methods: Three adolescents with greater trochanteric fracture were evaluated and treated. The first, a complete separation incurred in football, was fixed by open surgery using two large A-O screws plus washers. The patient developed severe avascular necrosis requiring further treatment including bone grafting of the femoral head plus shelf acetabuloplasty. The prognosis is guarded. A second patient had a similar injury following a fall from a ladder. Because of our experience with the prior case, she was treated with a careful, minimal open reduction with greater trochanter reat-tachment using a tension band technique. Follow-up has shown a normal femoral head. A third patient presented with progressive pain in the greater trochanter in sporting activities with early separation documented by radiograph. This picture was similar to slipped capital femoral epiphysis. Treatment was by emergent in-situ screw fixation. The hip has developed normally. Discussion: The growth centers of the femoral head and greater trochanter are conjoined at birth with a similar blood supply The blood supply to the femoral head and neck as well as to the greater trochanter have been carefully studied but with little attention paid to the effect that greater trochanteric fracture might have on femoral head blood supply. The ascending branches of the medial femoral circumflex, which supply the blood to the femoral head via their course to the posterior femoral neck, can readily be injured with traumatic avulsion of the greater trochanter. Femoral head avascular necrosis can result from the fracture itself and/or to the methods of re-attachment. Recognizing the risk , patients with this injury should be treated with a gentle open reduction with a minimal added trauma from reduction methods or fixation. K-wires and a tension band technique may be the best choice. The child should then be immobilized in a hip spica cast to allow full healing, rather than relying on large internal fixation devices in an attempt to avoid cast immobilization. Adolescents with this injury must be followed for two years to be certain that avascular necrosis does not develop

Introduction: The treatment of comminuted intra-articular fractures around the knee is one of most difficult areas of Orthopaedic traumatology. Open reduction and internal fixation is recommended by many authors. However, in severe comminuted fractures sometime it is difficult to achieve stable fixation and most cases need an additional cast immobilization following surgery. We present our experience with arthroscopic assisted closed reduction in severe comminuted knee fractures followed by fixation with Ilizarov frame. Materials and Methods: Since 1998, 17 patients with comminuted intra-articular fractures around the knee were treated by this method. 8 patients had comminuted intra-articular fractures of the distal femur and 9 patients had comminuted fractures of the tibial plateau, one of them with fractures of both knees. There were 4 males and 4 females with femoral fractures (age: 22– 56Y; mean -31Y) and 8 males and 1 female with tibial plateau fractures (age: 34–68Y; mean – 51Y). Three fractures of the distal femur and 2 of the tibial plateau were open fractures. 5/17 Pts had polytrauma. We used AO classification for distal femoral fractures and Schatzker classification for tibial plateau fractures. All patients were operated within 48 hours after injury. Results: In all patients, except two with unstable knee, closed reduction and Ilizarov external fixation was performed without knee immobilization, under knee arthroscopic control. In two cases split thickness skin graft was done following leg fasciotomies. Weight bearing was allowed 6 to 8 weeks following surgery. A second look arthroscopy was performed in 3 cases. The average time of fixation in Ilizarov frame was 4.5 months (range 3–6.5 months). On follow up of 2 to 8 years, 6/17 patients (35%) had excellent results, 8/17 patients (47%) had good results and 3 patients (17%) had fair results. No cases of osteomyelitis, neuro-vasular injuries or deep wound infection were observed. Conclusions: Based on this study it seems that arthroscopic assisted closed reduction and Ilizarov fixation is very useful for severe intra-articular comminuted knee fractures. Arthroscopy of knee enables accurate reduction of these fractures, removal of free bone fragments and treatment of other intra-articular injuries. There is an early restoration of motion in injured knee, with short immobilization time, and there are no major complications

The standard of treatment for most fractures of distal radius remains closed reduction and immobilization. It is essential to discern which fracture patterns are more susceptible to failure so that surgical intervention can be considered when an acceptable reduction cannot be achieved or has a risk of secondary displacement. A correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization is reported. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 25 and radio-carpal malalignment with ERLF > 25. The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (I week) and late failure (six weeks). Radiographic alignment parameters were compared using paired t-tests and then also analysed in a multiple logistic regression analysis. There was a significant improvement in all the parameters measured (p< 0.01) with mean correction falling within acceptable limits. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at six weeks. Age, gender, presence of dorsal comminution and ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) at one week when analysed independently or in combination(p< 0.01). In the late failure group:Radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome. Age, Gender, flattening of radial angle, ulnar styloid fracture, for secondary displacement when analyzed independently or in combination were not found to be significant predictors of failure at 6-week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and at 6weeks when analysed independently or in combination.(p< 0.01) Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability & anticipate the radiological outcome. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options

Introduction: The modified Lapidus-arthrodesis with standard AO screw-fixation is well known for the treatment of severe metatarsus primus varus deformity respectively a hypermobile or an arthrotic first tarso-metatarsal joint. High rates of non-union and malunion (range 3 to 12%) due to improper or poor fixation despite the postoperative course of nonweightbearing were reported in literature. The immediate postoperative weightbearing protocol varies from 2 to 6 weeks of cast immobilization. To our knowledge, this prospective investigation comprises the largest cohort of patients undergoing the Lapidus-arthrodesis, fixed with the Lapidus-Orthner locking plate. Methods: 130 feet with an average patient’s age of 52 years (range 23 – 83 years), underwent the Lapidus fusion with the locking Orthner-plate. Indications were severe hallux valgus deformities respectively moderate hallux valgus deformities with a hypermobile first TMT 1- joint or an arthrotic first tarsometatarsal joint. The surgical technique was standardized, and the operations were performed by the inventor of the plate. All patients had a failed trial of nonoperative management (shoe-wear modification). The 130 feet were divided into 2 groups. Group I was without TMT 1 – compression screw (n= 60) and group II with an additional compression-screw (n=70). Average age of group I was 54-years. The average age of group II was 50-years. The American-Orthopaedic-Foot and Ankle Society (AOFAS) Forefoot-Score, Visual-analog-pain-scale and foot radiographs were assessed preoperatively and after a mean of 23 months for group I and 39 months for group II. All 130 feet were treated immediately postoperative with a postoperative Darco orthowedge ® shoe. Results: The average AOFAS score improved significantly from preoperative to follow up time-point in both groups. AOFAS pain-subscore significantly improved in both groups. The intermetatarsal-angle (IMA) of all 130 feet decreased significantly from 14° to 6° after surgery. At time of follow-up 9 % of non-unions were seen in group I whereas 0% were seen in group II with proximal compression screw, the difference is significant (p=0,024). The mean immobilisation with the Darco-Ortho® wedge shoe was 7,2 weeks (range 6 to 14 weeks) in group I and 6,3 weeks (range 5 to 12 weeks) in group II. Conclusion: The prospective mid-term results from this study show that the locking Lapidus-Orthner plate is a very good and promising technique for the Lapidus-arthrodesis. The modified technique with compression screw has shown none non-union, despite of immediate weight-bearing in a post-op shoe after surgery. The procedure significantly reduced pain, the hallux valgus and intermetatarsal angle and increased the patient’s ambulatory capacity and patient satisfaction

Introduction: In the management of patients with bone neoplasm, we are confronted with various status which is difficult to treat. External fixation is useful for such status, and result in succes. The purpose of this study is to report that patients of bone neoplasms were treated with external fixation. Materials and methods: Fifteen patients with bone neoplasm who had treated by external fixation are an objective of this study, between 1989 and 2000. Clinical and pathological diagnosis is osteosarcoma in 7, giant cell tumor in 4, Ewing’s sarcoma in 1, chondrosarcoma in1, osteochondroma in 1, enchondroma in 1. Patients were divided into 4 groups depends on difference of indication of external fixation. Result. Group 1. Immobilization of pathological fracture. Two patients with osteosarcoma of femur and one patient with GCT of humerus were treated by external fixation for their pathological fracture. Group 2. Bone lengthening or correction for bone defect or deformity. We performed external fixation with Ilizarov fixator for bone lengthening following bone defect after tumor excision in 4 patients. Mean length of bone defect was 83.5 (22–150) mm. Two in 4 cases were stopped bone lengthening owing to local recurrence and progression of disease. And in 2 patients, we performed correction with external fixation for bone deformity arised by enchondroma of humerus and osteochondroma of ulna. Group 3. Stabilization for vascularized bone graft. We performed vascularized fibular graft after wide resection and stabilized with external fixator in 2 patients with humeral sarcoma. Group 4. Salvage of infected prosthesis. There were 4 patients with infected prosthesis. Three of them were treated by bone lengthening technique after removal of prosthesis. Mean length of bone defect was 264 (220–330) mm and mean term of fitting external fixator was 583.7 (442–726) days. Discussion: Advantages of treatment with external fixation for bone defect, bone deformity and pathological fracture arise from bone neoplasm are mentioned as follows. It could immobilize pathological fracture that is difficult for plaster cast immobilization. It could compensate for bone defect following tumor resection. It is useful method for salvage of the infected prosthesis. Disadvantages of using of external fixation are mentioned as follows. In case of bone lengthening, it is need to perform a complete tumor control. Treatment term is longer. It is need pin site management. Treatment with external fixation is one of the useful method for pathological fracture, bone deformity, shortening, bone defect and infected prosthesis arise from bone neoplasm

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

Cite this article: Bone Joint J 2023;105-B(5):471–473.

The December 2022 Children’s orthopaedics Roundup³⁶⁰ looks at: Immobilization of torus fractures of the wrist in children (FORCE): a randomized controlled equivalence trial in the UK; Minimally invasive method in treatment of idiopathic congenital vertical talus: recurrence is uncommon; “You’re O.K. Anaesthesia”: closed reduction of displaced paediatric forearm and wrist fractures in the office without anaesthesia; Trunk range of motion and patient outcomes after anterior vertebral body tethering versus posterior spinal fusion: comparison using computerized 3D motion capture technology; Selective dorsal rhizotomy for individuals with spastic cerebral palsy; Scheuermann’s kyphosis and posterior spinal fusion; All-pedicle-screw constructs in skeletally immature patients with severe idiopathic early-onset scoliosis; Proximal femoral screw hemiepiphysiodesis in children with cerebral palsy.

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Can you treat type IIA supracondylar humerus fractures conservatively?; Bone bruising and anterior cruciate ligament injury in paediatrics; Participation and motor abilities after treatment with the Ponseti method; Does fellowship training help with paediatric supracondylar fractures?; Supracondylar elbow fracture management (Supra Man): a national trainee collaborative evaluation of practice; Magnetically controlled growing rods in early-onset scoliosis; Weightbearing restrictions and weight gain in children with Perthes’ disease?; Injuries and child abuse increase during the pandemic over 12,942 emergency admissions.

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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.

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To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

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There is no level I evidence dealing with the optimal period of immobilization for patients with a displaced distal radial fracture following closed reduction. A shorter period might lead to a better functional outcome due to less stiffness and pain. The aim of this study was to investigate whether this period could be safely reduced from six to four weeks.

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The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

The April 2023 Wrist & Hand Roundup³⁶⁰ looks at: MRI-based classification for acute scaphoid injuries: the OxSMART; Deep learning for detection of scaphoid fractures?; Ulnar shortening osteotomy in adolescents; Cost-utility analysis of thumb carpometacarpal resection arthroplasty; Arthritis of the wrist following scaphoid fracture nonunion; Extensor hood injuries in elite boxers; Risk factors for reoperation after flexor tendon repair; Nonoperative versus operative treatment for displaced finger metacarpal shaft fractures.

The December 2022 Wrist & Hand Roundup³⁶⁰ looks at: Anti-tumour necrosis factor therapy for early-stage Dupuytren’s disease; Patient experiences of scaphoid waist fractures and their treatment; Postoperative complications following open a1 pulley release for a trigger finger or thumb; How certain are findings in distal radius fractures: a systematic review of randomized controlled trials; Partial wrist denervation in wrist osteoarthritis: patient-reported outcomes and objective function; Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures; How is reduction lost in distal radius fractures in females aged 50 years and older; The HAND-Q: psychometrics of a new patient-reported outcome measure for clinical and research applications.

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The aim of this study was to identify the information topics that should be addressed according to the parents of children with developmental dysplasia of the hip (DDH) in the diagnostic and treatment phase during the first year of life. Second, we explored parental recommendations to further optimize the information provision in DDH care.

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The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion.

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The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

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Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy.

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Current National Institute for Health and Clinical Excellence (NICE) guidance advises that MRI direct from the emergency department (ED) should be considered for suspected scaphoid fractures. This study reports the current management of suspected scaphoid fractures in the UK and assesses adherence with NICE guidance.

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The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures.

Complications of distal radius fractures range from 20 to 30% and are consequence of injury or of treatment. Management of these complications must be individualised and the multitude of proposal treatments prove that this problem is controversial. Complications may involve soft tissue (tendon, nerve, arterial or fascial complication, reflex symphatetic distrophy) or bone and joint (malunion, nonunion, osteoarthritis). Tendon complications following distal radius fractures, range from minor adhesions to complete rupture. Peritendinous adhesions will become apparent after cast removal. Diagnosis is based on the limitation of the range of movement for individual fingers.This complication can be avoided with a proper cast technique allowing full range of motion to the digits. Treatment consists of rehabilitation techniques and only rarely, in severe cases, operative tenolysis may be a treatment of choice. Tendons may be entrapped either in the fracture site or in the distal radioulnar joint. Most common tendon entrapment are for extensor carpi ulnaris and extensor digiti minimi. If early recognition is made, open reduction with freeing the tendon must be the choice. Late diagnosis will require more complex tenolysis procedures. Tendon rupture may occur at the time of injury due to sharp fracture fragments. Diagnosis is based on identification of functional loss and, whenever possible, primary tendon suture is recommended. If the diagnosis is late the treatment is free tendon graft or tendon transfer. The late rupture of extensor pollicis longus is the most common possibility. Since it is not related with comminution or displacement of fracture it is possible that an ischemic mechanism is involved. Solutions are free tendon graft or the transfer of extensor indicis proprius. Direct tendon repair is not recommended after few weeks. Nerve complications. Careful neurological investigations demonstrated that nerve injuries associated with distal radius fractures are more common than it is believed. Median nerve is most frequently involved. Primary mechanisms of injury are: direct lesions due to fracture fragments, lesions related to forced manipulation and nonanatomical position of immobilization. Late injuries, occurring a long time after the fracture are more frequent and are related to carpal tunnel syndrome or paraneural adhesions. Carpal tunnel pressure could be measured and ethiologic factors must be identificated in order to establish the proper treatment, usually based on relise of carpal tunnel. Ulnar and radial neuropathy are less common and treatment may vary from cast removal to relise of Guyon’s canal. Vascular complications are uncommon, arise usually in relation with high energy trauma and the treatment is complex, involving different speciality surgeons. Some authors presented rare cases of entrapment of vasculare structures or radial artery pseudoaneurism after the use a volar plate. Compartment syndrome after distal radius fracture is rare and is likely to occur in young adults suffering a high energy trauma. Clinical diagnosis is based on the classical 5 “P’s” (pain, pallor, paresthesias, paralysis, and pulselessness) but treatment must start before all symptoms are present. Anytime when compartment syndrome is suspected, intracompartimental pressure must be measured. The treatment must start immediately and consist in removal of constrictive devices (bandage, cast) and fasciotomy. Indications for fasciotomy are intracompartmental pressure of 15–25mmHg in presence of clinical signs or over 25mmHg in absence of clinical signs. If there is doubt, it is better to perform an unnecessary fasciotomy than to wait until lesions becomes irreversible. Reflex sympathetic distrophy is described with many terms such as algodistrophy, cauzalgia, Sûdeck’s atrophy, shoulder-hand syndrome. Recently, the term complex regional pain syndrome was proposed to replace all the exiting synonyms. Despite many theories, the pathogeny of this disease is uncertain. The diagnosis is mainly clinical, based on presence of pain, trophic changes (atrophy, stiffness, edema) and functional impairment but plain x-ray demonstrating osteopenia and bone scintigraphy showing abnormal bone turnover may be helpful. Since the patogeny is unclear, the treatment is targeting the symptoms rather then the disease. Treatment must be individualized and may consist of: physical therapy of the hand, pain control with general or local drugs, corticosteroids, and symphatectomy. Prevention of reflex symphatetic dystrophy in the first days of a distal radial fracture is very important and include: prevention of the edema (elevation of the hand, early mobilization of fingers), decrease of pain, cast removal to relive pression, non-traumatic surgery. Malunion is the most common complication of distal radius fracture and it usually occurs after close treatment. The malalignament may be extraarticular or it may involve the joint (radiocarpal or distal radioulnar joint). Axial shortening and dorsal or radial malalignament are the most common. Clinical signs are wrist pain, loss of grip strength, limitation of wrist mobility. Osteoarthritis is likely to develop in both types of malunions. For extraarticular nonunions osteotomy is usually the treatment of choice. Many types of osteotomies have been proposed but the most commonly used are opening wedge osteotomy and Watson osteotomy. Intraarticular malunion is more difficult to treat and many surgical solutions have been proposed: intraarticular osteotomy, bone resections (styloid, anterior or posterior rim, radiolunate or radioscapholunate limited arthrodesis, proximal row carpectomy, wrist denervation, wrist arthroplasty, total wrist arthrodesis). Salvage procedures on the distal radioulnar joint may be resection of distal cubitus (Darrach) or Sauve-Kapandji technique. Nonunion is an extremely rare complication and is likely to occur in patients with multiple comorbid conditions such as diabetes, peripheral vascular disease or alcoholism. In most cases the initial treatment was close reduction and cast immobilization or external fixation. Diagnosis is based on the absence of radiographic signs of union at 6 months. Treatment must be individualized but basic options are reconstructive procedures or wrist arthrodesis. Reconstructive procedures consist of debridement of nonunion site, realignment with distractor, plate and screw fixation and iliac crest bone grafting. Since the bone is of poor-quality, new implants providing fixation in orthogonal planes may be useful. Usually, malalignement is present, so some authors recommend to take in to consideration the possibility to associate reconstructive procedures with additional techniques such as: dividing brachioradialis tendon, incision of the dorsal or volar joint capsule or Darrach operation in presence of severe shortening of the radius. Wrist arthrodesis should be chosen when the distal fragment has less then 5 millimeters of subchondral bone supporting the articular surface

Aims

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

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The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications.

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The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius.

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Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

Aims

Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation.

Aims

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.