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

Aims. The aim of this study was to compare the cost-effectiveness of surgical fixation with Kirschner (K-)wire ersus moulded casting after manipulation of a fracture of the distal radius in an operating theatre setting. Methods. An economic evaluation was conducted based on data collected from the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) multicentre randomized controlled trial in the UK. Resource use was collected at three, six, and 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from an NHS and personal social services perspective. Sensitivity analyses were conducted to examine the robustness of cost-effectiveness estimates, and decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. Results. In the base case analysis, surgical fixation with K-wire was more expensive (£29.65 (95% confidence interval (CI) -94.85 to 154.15)) and generated lower QALYs (0.007 (95% CI -0.03 to 0.016)) than moulded casting, but this difference was not statistically significant. The probability of K-wire being cost-effective at a £20,000 per QALY cost-effectiveness threshold was 24%. The cost-effectiveness results remained robust in the sensitivity analyses. Conclusion. The findings suggest that surgical fixation with K-wire is unlikely to be a cost-effective alternative to a moulded cast in adults, following manipulation of a fracture of the distal radius in a theatre setting. Cite this article: Bone Joint J 2022;104-B(11):1225–1233

We have modified the Ponseti casting technique by using a below-knee Softcast instead of an above-knee plaster of Paris cast. Treatment was initiated as soon as possible after birth and the Pirani score was recorded at each visit. Following the manipulation techniques of Ponseti, a below-knee Softcast was applied directly over a stockinette for a snug fit and particular attention was paid to creating a deep groove above the heel to prevent slippage. If necessary, a percutaneous Achilles tenotomy was performed and casting continued until the child was fitted with Denis Browne abduction boots. Between April 2003 and May 2007 we treated 51 consecutive babies with 80 idiopathic club feet with a mean age at presentation of 4.5 weeks (4 days to 62 weeks). The initial mean Pirani score was 5.5 (3 to 6). It took a mean of 8.5 weeks (4 to 53) of weekly manipulation and casting to reach the stage of percutaneous Achilles tenotomy. A total of 20 feet (25%) did not require a tenotomy and for the 60 that did, the mean Pirani score at time of operation was 2.5 (0.5 to 3). Denis Browne boots were applied at a mean of 10 weeks (4 to 56) after presentation. The mean time from tenotomy to boots was 3.3 weeks (2 to 10). We experienced one case of cast-slippage during a period of non-attendance, which prolonged the casting process. One case of prolonged casting required repeated tenotomy, and three feet required repeated tenotomy and casting after relapsing while in Denis Browne boots. We believe the use of a below-knee Softcast in conjunction with Ponseti manipulation techniques shows promising initial results which are comparable to those using above-knee plaster of Paris casts

Aims. Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care. Methods. This trial is a pragmatic, multicentre, randomized non-inferiority clinical trial with an embedded pilot, and with 12 months clinical follow-up and parallel economic analysis. A surveillance study using routinely collected data will be performed annually to five years post-treatment. Adult patients, aged 60 years and younger, with unstable ankle fractures will be identified in daily trauma meetings and fracture clinics and approached for recruitment prior to their treatment. Treatments will be performed in trauma units across the UK by a wide range of surgeons. Details of the surgical treatment, including how the operation is done, implant choice, and the recovery programme afterwards, will be at the discretion of the treating surgeon. The non-surgical treatment will be close-contact casting performed under anaesthetic, a technique which has gained in popularity since the publication of the Ankle Injury Management (AIM) trial. In all, 890 participants (445 per group) will be randomly allocated to surgical or non-surgical treatment. Data regarding ankle function, QoL, complications, and healthcare-related costs will be collected at eight weeks, four and 12 months, and then annually for five years following treatment. The primary outcome measure is patient-reported ankle function at four months from treatment. Anticipated impact. The 12-month results will be presented and published internationally. This is anticipated to be the only pragmatic trial reporting outcomes comparing surgical with non-surgical treatment in unstable ankle fractures in younger adults (aged 60 years and younger), and, as such, will inform the National Institute for Health and Care Excellence (NICE) ‘non-complex fracture’ recommendations at their scheduled update in 2024. A report of long-term outcomes at five years will be produced by January 2027. Cite this article: Bone Jt Open 2024;5(3):184–201

Introduction: Pressure relief is essential in treating plantar neuropathic ulcers in the diabetic foot. This can be achieved in an excellent way by total contact casting, therefore especially the longstanding, problematic ulcer-nonresponding to common methods (such as insoles, special shoeware etc,) is adressed by this method.A second indication for total contact casting is presented by the acute stage of neuroosteoarthropathy (Charcot’s foot) with or without ulceration. Methods: 19 patients with diabetes type II were treated by total contact casting. The mean age was 55 (46–75) years. Only 4 out of 19 patients were women We found plantar ulcers 12 of the 19 cases, 7 cases had no ulcer, but a Charcot’s foot stage I was present. Most ulcerations were classified as Wagner stage II and III without any sign of infection. The mean duration of casting was 8 (1–22) weeks. All patients were treated in an outpatient-clinc, no admission to the hospital was needed. The method of casting is exactly presented. Results: Complications were seen in only one of the cases due to skin problems.8 of the 12 ulcers healed completely under casting, 4 healed by a mean of 4 weeks later due to further treatment after casting. All the cases of osteoathropathy could be treated until reaching stage II without any progression of the foot-deformity. Conclusions: The total contact cast gives us the possibility to treat patients with plantar neuropathic ulceration and/or Charcot’s foot stage I with the advantage of good plantar pressure reduction and upkeeping the patient’s full mobility at the same time

We undertook a randomised clinical trial to compare treatment times and failure rates between above- and below-knee Ponseti casting groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below- or above-knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. A total of 26 children (33 feet) were entered into the trial. The above-knee group comprised 17 feet in 13 children (ten boys and three girls, median age 13 days (1 to 40)) and the below-knee group comprised 16 feet in 13 children (ten boys and three girls, median age 13 days (5 to 20)). Because of six failures (37.5%) in the below-knee group, the trial was stopped early for ethical reasons. The rate of failure was significantly higher in the below-knee group (p = 0.039). The median treatment times of six weeks in the below-knee and four weeks in the above-knee group differed significantly (p = 0.01). This study demonstrates that the use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times. Therefore, this technique is not recommended. Cite this article: Bone Joint J 2013;95-B:1570–4

Our aim was to evaluate the effect of adding inhibitory casting to the treatment of young children with cerebral palsy who received injections of botulinum neurotoxin A (BoNT-A) to gastrocnemius for equinus gait. Of the 20 patients in the series, 11 in group A had inhibitory casts applied on the day of the first set of BoNT-A injections and nine in group B did not have casting. Both groups received another BoNT-A injection four months later. The patients were followed for eight months and examined at five intervals. Both groups showed significant improvement in gait parameters and function (p < 0.0001) and selective motor control (p = 0.041, − 0.036) throughout the study. Group A had significantly better passive dorsiflexion of the ankle (p = 0.029), observational gait score (p = 0.006) and selective motor control (p = 0.036). We conclude that the addition of inhibitory casting enhances and prolongs the results of treatment and mainly influences the passive range of movement, while BoNT-A mostly influences the dynamic motion. The second injection further improved the results of most parameters. The gross motor function measure, the selective motor control test and the modified Tardieu scale correlated well with the results of treatment. We recommend the use of inhibitory casting whenever augmentation of the effect of treatment with BoNT-A is needed

The purpose of this study was to investigate the effectiveness of casting in achieving acceptable radiological parameters for unstable ankle injuries. This retrospective observational cohort study was conducted involving the retrieval of X-rays of all ankles taken over a 2 year period in an urban setting to investigate the radiological outcomes of cast management for unstable ankle fractures using four acceptable parameters measured on a single X- ray at union. The Picture Archiving and Communication System (PACS) was used, the X-rays were measured by a single observer. From the 1st of January 2020 to the 31st of December 2021, a total of 1043 ankle fractures were treated at the three hospitals with a male to female ratio of 1:1.7. Of the 628 unstable ankle injuries, 19% of patients were lost to follow up. 190 were managed conservatively with casts, requiring an average of 4 manipulations, with a malunion rate of 23.2%. Unstable ankle injuries that were treated surgically from the outset and those who failed conservative management and subsequently converted to surgery had a malunion rate of 8.1% and 11.0% respectively. Unstable ankle fractures pose a challenge with a high rate of radiological malunion, regardless of the treatment Casting surgery from the outset or converted to surgery, with rates of 23% and 8% and 11% respectively. In this multivariate analysis we found that conservative management was the only factor influencing the incidence of malunion, age, sex and type of fracture did not have a scientific significant influence

The use of serial casting in the management of early onset scoliosis (EOS) has been well described. Our aim was to evaluate outcomes of plaster jacket therapy in patients with EOS from a tertiary referral centre. A retrospective review of hospital records and PACS images of 27 patients to identify patients treated with serial casting over a five year period. The primary outcome measure was the need for surgical intervention, with change in Cobb angle used as a secondary outcome measure. Mean age at presentation was 14 months (range 10 – 42), including 14 male and 13 female patients, with an average follow-up of 34 months. Curves were categorised according to aetiology: 16 idiopathic, 6 syndromic, 3 congenital and 2 neuromuscular curves. The mean Cobb angle at diagnosis was 43.7° (range 22 – 115) and mean rib vertebral angle difference (RVAD) was 22.2° (8 – 70). Duration of treatment was 9.9 months (range 3 – 27), with an average of two plaster jacket changes per child. At the time of review, patients fell into one of three groups. Group one (10 patients) failed conservative treatment due no improvement in Cobb angle (mean 48.4° compared with pre-op 53.9°, p value 0.55) and either had insertion of growing rods or had been listed for this procedure, at a mean age of 51.8 months. Group two (12 patients) had a mean Cobb angle of 38.9° pre-treatment which improved to 23.5° (p value <0.05) and were either treated in a brace or had discontinued treatment. The mean RVAD at initial diagnosis was 36.6° in group 1 compared with 13.8° in group 2 (p<0.05). All patients in group one requiring surgical treatment had an RVAD of greater than 20°. Serial casting is on-going for five patients (group three). Complications occurred in 30% of patients including pressure sores, chest infection and respiratory compromise requiring intubation. Current NICE guidance recognises that serial casting ‘rarely corrects scoliosis’ but recommends it may be used ‘to allow growth before a more permanent treatment is offered’. In our experience, serial casting did not allow any patients with a progressive scoliosis (determined by an RVAD of greater than 20°), to reach a single definitive fusion. However serial casting appeared to halt to curve progression until the child was suitable for the insertion of a growing rod system

Congenital Talipes Equinovarus (CTEV) occurs in approximately 1 in 1000 live births. Most cases occur as an isolated birth defect and are considered idiopathic. The widespread adoption of the Ponseti technique of serial casting followed by Achilles tenotomy and long term bracing has revolutionised the outcomes in CTEV. In most cases, plantigrade, flexible, pain-free feet may be produced without the need for extensive surgery. It is estimated that about 10% of cases of CTEV are not idiopathic. These feet are stiffer and more challenging to treat. In particular, there is little evidence in the literature concerning the efficacy of the Ponseti method in these cases. In our institution, a dedicated weekly Ponseti clinic has operated since 2005. To date 140 patients have been treated. We prospectively enter all details regarding their management onto an independent international database. The aim of this study was to audit the non-idiopathic cases of CTEV and to assess the effectiveness of the Ponseti technique in these challenging cases. Outcome measures included the Pirani score and eventual need for surgical intervention. We identified 29 cases (46 feet) with non-idiopathic CTEV. This comprises 21% of our workload. Seventeen were bilateral. The commonest diagnoses were neuromuscular conditions such as spina bifida (5 cases) and cerebral palsy (3 cases). There were 4 cases of Trisomy 21. Other causes included Nail Patella syndrome, Moebius syndrome, Larsen syndrome and Ito syndrome. In approximately 12% of cases, the underlying disorder remained undiagnosed despite thorough medical and genetic testing. In cases of non-idiopathic CTEV, the mean starting Pirani score was 5.5 (out of 6). After serial casting and Achilles tenotomy, the average score was 2.0. Twenty-one of 46 feet (46%) ultimately required further surgical intervention (mostly posteromedial release). We found that certain conditions were more likely to be successfully treated with the Ponseti method – these included conditions characterised by ligamentous laxity such as Trisomy 21 and Ehlers Danlos syndrome. All patients showed some improvement in Pirani score after serial casting. We believe that it is essential to attempt the Ponseti method of serial casting in all cases of CTEV. More than half of all non-idiopathic cases will not require further surgical intervention – and those that do are not as stiff thanks to the effects of serial casting. Thus, the surgery required is not as complex as it might otherwise have been. This is the largest series of its kind in the current medical literature

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. The study was undertaken to compare the efficacy of Woodcast splints and plaster-of-Paris casts in maintaining correction following sequential manipulation of idiopathic clubfeet. Methods. In this randomized prospective trial, 23 idiopathic clubfeet were immobilized with plaster-of-Paris casts and 23 clubfeet were immobilized with a splint made of Woodcast that encircled only two-thirds the circumference of the limb. The number of casts or splints needed to obtain full correction, the frequency of cast or splint-related complications, and the time taken for application and removal of the casts and splints were compared. Results. The mean number of casts required to obtain full correction of the deformity (Pirani Score 0) was 4.35 (95% confidence interval (CI) 3.74 to 4.95) when plaster-of-Paris was used and 4.87 (95% CI 4.33 to 5.41) when the Woodcast splint was used (p = 0.190). The time required for application and removal of the Woodcast splint were significantly less than that required for application and removal of plaster-of-Paris casts (p < 0.001). Woodcast splint-related complications were not more frequent than plaster-of-Paris cast related complications. Conclusion. Though Woodcast splints covering two-thirds of the circumference of the lower limbs of infants were effective in maintaining the correction of clubfoot deformity during serial manipulation and casting treatment, the superiority of Woodcasts over plaster-of-Paris could not be established. Cite this article: Bone Joint J 2020;102-B(10):1399–1404

All children with a fracture of both bones of the forearm who underwent general anaesthetic manipulation and plaster (GAMP) at the Launceston General Hospital over a four-year period from 2005–2008 were reviewed. Casting technique was determined according to the treating surgeon, with three casting techniques used: flexion, extension and a mid-flexed position. The primary end-point was defined as re-manipulation or progression to open reduction and internal fixation. The secondary end-point of residual angulation was also assessed. A total of 123 patients with 124 fractures were treated with GAMP. Seventy-seven cases were treated in a traditional flexion cast, 28 in extension and 19 were treated in a dorsoradial slab in a mid-flexed position. Ten patients required repeat intervention. Six failures were initially cast in flexion, four were in the mid flexed position and none of the fractures in the extension group required re-manipulation. The difference between the groups was statistically significant (p<0.001). There was significantly greater residual angulation at follow up in the flexed group compared to the extension group for both the radius (p=0.049) and the ulna (p=0.046). Closed reduction and cast immobilisation with the elbow extended is a safe and more effective technique in maintaining position in both bone forearm fractures in children

Serial casting (SC) and Botulinum toxin-A (Btx-A) have been used to treat ankle equinus contractures in cerebral palsy. Previous studies that examined the effects of combining Btx-A injections with SC and either one of the treatments alone in terms of passive ankle range of motion (PROM) have shown mixed results [two-four]. Therefore, the goal of this study is to examine PROM and gait characteristics in children with CP who have undergone SC, either with or without Btx-A injections to the plantarflexors. Patients who underwent SC +/− Btx-A injections were evaluated for improvement in PROM at the end of treatment. The participants’ age at beginning of SC treatment, Gross Motor Function Classification System (GMFCS) level, treatment duration, PROM, and gait characteristics observed by the treating physiotherapist were obtained from the charts. Only one side per treatment is included in this study (treated side for unilateral treatments, randomly chosen side for bilateral treatments). Table One shows the characteristics of the two groups. Independent samples t-tests showed that the two groups are similar in terms of age, treatment duration and pre PROM. A repeated measures ANCOVA, using the pre- and post- treatment range of motion as the within subject variables, treatment type as the between subject variable, and GMFCS and age as the covariates showed that the PROM changed significantly regardless of treatment type (p< 0.001). However, the treatment type does not influence the outcome (p=0.411). The changes in range of motion obtained from the two types of treatments were not significantly different using the independent t-test (p=0.957). Based on these results, it appears that both types of interventions resulted in significant changes in ankle passive range of motion, which is in agreement with Kay et al [4]. Similar ranges of motion at the end of the treatment were obtained from both treatments, and the treatments have similar success rates. Future work is needed to further explore the outcomes associated with serial casting only and Btx-A and serial casting treatments

Purpose: Currently, clubfoot is initially treated with non-operative methods including Ponseti casting and the French physical therapy program (PT). Our purpose was to evaluate the function of children treated with these techniques. Methods: Seventy-six idiopathic clubfoot patients were enrolled. Successful non-operative outcomes were achieved in 32 patients (44 feet) treated with casting and 44 patients (66 feet) treated by PT. Initial Dimeglio scores were 10–17. At average age 2.3 years (1.9–3.3yr), subjects’ gait was evaluated with a VICON 512 motion analysis system. Cadence and kinematic data was classified as abnormal if it fell outside of one standard deviation from normal. Results: No statistical differences for cadence parameters were found between the two groups. Two kinematic patterns were identified: Children treated with PT walked with knee hyperextension (41% of feet)*, equinus (17%)*, and foot-drop (28%)*; whereas zero casted patients walked in equinus and only one demonstrated foot-drop. In contrast, the casted group demonstrated increased stance dorsiflexion (47%)* and calcaneus (18%). More PT feet had increased internal foot progression angle (34% vs. 13%)* and increased shank-based foot rotation (56% vs. 33%)*. Both groups had equal rates of normal sagittal-plane ankle motion (59% PT vs. 55%). [*p< 0.05]. Conclusions: Half of the two year-old patients treated non-operatively for clubfoot had normal sagittal-plane ankle motion. Less than 20% in each group experienced calcaneus and equinus gaits, respectively. These differences may be the result of performing percutaneous tendo Achilles lengthening as part of the Ponseti casting technique, but not as part of the PT program

Background: This prospective study was done to evaluate functional outcomes after acute avulsion fractures of the fifth metatarsal base. The objective was to compare the results of two different casting methods adopted as a treatment of non-displaced avulsion fractures of the fifth metatarsal. Methods: Fifty-two patients who sustained an avulsion fracture of the fifth metatarsal base and presented to the outpatient clinic of our hospital system were treated according to the advice of the attending clinicians. A total of 49 patients were available for 3 months follow up. There were eight men and 41 women with an average age of 41.9 (range 17 to 81) years. The lower extremity was placed in a below knee [n=28] or slipper cast [n=21] and patients were allowed to bear weight as tolerated. Baseline data collection consisted of demographic information, and radiographic, and functional evaluation. Patients were seen at regularly scheduled visits for 6 weeks and then at 3 months to obtain follow up information. A Short Musculoskeletal Function Assessment (SMFA) questionnaire was obtained at 3/12 year. Analyses were performed to determine differences in outcome based on demographics and injury information. Results: Based on self-reports, 10 patients with slipper cast had returned to pre-injury functional status by 3 weeks, compared to 22 patients with below knee cast by 6 weeks. An average of 22 days were lost from work, with 9 patients taking up to 10 days, 13 taking 3 weeks or longer off work. Twenty eight patients were losing more than 6 weeks of work in the other group. All were provided with pain killers, crutches if needed and none required thromboembolic prophylaxis with low molecular heparin. After twelve weeks none of the patients complained about pain. Radiographic consolidation of the fracture was noticed after 7 weeks for the avulsion fractures. As regard to the costing approximately 4 pounds for the slipper cast and 12 pounds were spent on the below knee casting. Conclusions: Fracture of the fifth metatarsal base often is a source of lost work productivity. Patients can be expected to return to their preinjury level of function with slipper type of cast earlier than below knee cast. Slipper types of casting are cost effective, efficient and offer greater mobility to the patients

The use of a forearm cast for paediatric buckle fractures of the distal radius is widespread practice. These fractures do not displace and follow-up in Fracture Clinic is only for cast removal. This may mean missed school for the child, or work for parents. Modern materials allow a robust lightweight back-slab to be used for protection of these stable, though painful, injuries. Unlike a plaster of Paris backslab, Prelude? (Smith and Nephew) is removed by unwrapping the outer bandage. Parents can do this at home. We prospectively studied 41 consecutive children aged 12 or less with buckle fractures of the distal radius, presenting to Fracture Clinic. After the diagnosis of isolated buckle fracture was confirmed, a Prelude? cast was applied. Parents were given a full explanation and written instructions, which were also sent to the GP. Telephone follow-up was carried out at 3–4 weeks. Forty of forty-one parents expressed satisfaction with both the treatment and the instructions. The parents of one patient misunderstood the instructions, re-presented to fracture clinic and were dissatisfied for this reason. With modern casting materials and adequate instructions at Fracture Clinic, routine follow-up of patients with buckle fractures is unnecessary. Resource savings can be made in this way with no compromise to patient care and increased patient/ parent satisfaction

A casting method for measuring the intra-articular space in the loaded hip is described. The results of tests on 22 hips from 22 cadavers show that the joint space is variable both in location and size and can disappear under light loads. It seems likely that the size and shape of the space influence how much access synovial fluid has for lubrication and nutrition

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

Statement of purpose:. A randomised clinical trial was undertaken to find out if treatment time and failure rate in children treated by the Ponseti method differed between below-knee vs above-knee cast groups. Methods and Results:. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below knee or above knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. Twenty-six children (33 feet) were entered into the trial, with a mean age of 17 days (range 1–40) in the above knee and 11 days (range 5–20) in the below knee group. Because of six failures in the below knee group (38%), the trial was stopped early for ethical reasons. Failure rate was significantly higher in the below-knee group (P 0.039). The median treatment times of six weeks in the below knee and four weeks in the above knee group differed significantly (P 0.01). Statement of conclusion:. Below knee plaster of Paris casts in conjunction with the Ponseti method showed significantly higher rates of failure than above knee plaster casts, requiring conversion to above knee casts, and a significantly longer treatment time. This higher rate of failure of below knee casts forced an early end of the trial. This study shows that a well moulded above knee plaster cast is safe and superior to a below knee plaster cast in conjunction with the Ponseti method. We do not believe that modifying the original Ponseti method in this manner is beneficial. Level of evidence: I