Purpose. Displaced midshaft clavicular fractures are a common injury with a high occurrence rate in young, active individuals. Non-operative care has traditionally been the standard of care for such fractures, but more recent studies have suggested benefits following primary operative fixation. The purpose of this study was to review the literature on displaced midshaft clavicle fractures, identify randomized controlled trials of operative versus non-operative treatment, and pool the functional outcome and complication rates (including nonunion and symptomatic malunion), to arrive at summary estimates of these outcomes. Method. A systematic review of the literature was performed to identify studies of randomized controlled trials comparing operative versus non-operative care for displaced midshaft clavicle fractures. Meeting abstracts were also searched and included in this study. Results. Six randomized controlled trials (n=421 patients, mean Detsky score= 15.2) were identified and included. The nonunion rate was higher in the non-operative group (28/207) then it was in patients treated operatively (3/214) (p<0.001). The rate of symptomatic malunion was higher in the non-operative group (15/207) than the operative group (0/214) (p<0.001). The total complication rate was 71 complications in 214 operative cases (33%), and 93 complications in 207 non-operative cases (45%)(p=0.016). The Constant Shoulder scores (CS) and Disability of the Arm, Shoulder and Hand (DASH) scores showed marginally improved (mean 4.1 point increase in CS at one year, mean 5.8 point decrease in DASH at one year) functional values in the operative group: this difference was especially marked in the early post operative period. Conclusion. Operative treatment provided lower complication rates (especially nonunion and symptomatic malunion) and an earlier functional return compared to non-operative treatment. However, there is little evidence at present to show that the long term effects of operative intervention are significantly superior to non-operative care

The primary objective of this study was to determine if paediatric proximal humerus fractures undergo significant displacement resulting in change in management. A retrospective analysis was performed on children who presented with proximal humeral fractures to our institution between 2009 and 2014. Patients were included if they were diagnosed with a fracture of the proximal humerus in the absence of an underlying bone cyst or pathological condition. Patients with open fractures, multiple fractures, neurologic, or vascular injuries were excluded. The primary endpoint was conversion to operative treatment after initial non-operative management. Secondary endpoints were a healed fracture with acceptable alignment at the final radiographic evaluation, as well as the number of follow-up radiographs obtained after the initiation of non-operative management. A decision to manage the fracture operatively at the initial presentation was made in 14 out of 239 patients. Of the 225 patients that were initially managed non-operatively, only 1 patient underwent subsequent surgical management. In this series, no non-unions, re-fractures, nor fracture-dislocations were identified. These data support that the majority of management decisions for paediatric proximal humeral fractures are made at the initial presentation. Once non-operative management is chosen, routine follow-up imaging rarely leads to any change in treatment

Acute achilles tendon ruptures are increasing in incidence and occur in 18 per 100 000 people per year, however there remains a lack of consensus on the best treatment of acute ruptures. Randomised studies comparing operative versus non-operative treatment show operative treatment to have a significantly lower re-rupture rate, but these studies have generally used non-weight bearing casts in the non-operative group. Recent series utilizing more aggressive non-operative protocols with early weight-bearing have noted a far lower incidence of re-rupture, with rates approaching those of operative management. Weight bearing casts may also have the advantages of convenience and an earlier return to work, and the purpose of this study was to compare outcomes of traditional casts versus Bohler-iron equipped weight-bearing casts in the treatment of acute Achilles tendon ruptures. 83 patients with acute Achilles tendon ruptures were recruited from three Auckland centres over a 2 year period. Patients were randomised within one week of injury to receive either a weight-bearing cast with a Bohler iron or a traditional non weight-bearing cast. A set treatment protocol was used, with a total cast time of eight weeks. Patients underwent detailed muscle dynamometry testing at 6 months, with further follow up at 1 year and at study completion. Primary outcomes assessed were patient satisfaction, time to return to work, and overall re-rupture rates. Secondary outcomes included return to sports, ankle pain and stiffness, footwear restrictions, and patient satisfaction. There were no significant differences in patient demographics or activity levels prior to treatment. At follow up, 1 patient (2%) in the Bohler iron group and 2 patients (5%) in the non weight bearing group sustained re-ruptures (p=0.62). There was a trend toward an earlier return to work in the weight-bearing group, with 58% versus 43% returning to work within 4 weeks, but the difference was not significant. 63% of patients in the weight bearing group reported freedom from pain at 12 months compared to 51 % in the non weight bearing group. There were no statistically significant differences in Leppilahti scores, patient satisfaction, or return to sports between groups. Weight-bearing casts in the non-operative treatment of Achilles tendon ruptures appear to offer outcomes that are at least equivalent to outcomes of non-weight bearing casts. The overall rerupture rate in this study is low, supporting the continued use of initial non-operative management in the treatment of acute ruptures

Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures. With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046). At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group. Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function

We aimed to assess the functional outcomes of elderly patients with isolated comminuted distal humerus fractures that were managed non-operatively. Retrospective analysis of patients over 65 years presenting to our unit between 2005–2015 was undertaken. 67 patients were identified, 7 had immediate TEA, 41 died and 5 were lost to follow-up leaving 14 available for review. Mean Follow-up was 55 months(range 17–131) Patient functional outcomes were measured using VAS scores for pain at rest and during activity, and the Oxford Elbow Score (OES). Need for conversion to TEA and complications were recorded. The mean age at injury was 76 years(range 65–90) of which 79%(11/14) were females. The mean score on the OES was 46(range 29 – 48). The mean VAS score at rest was 0.4(range 0–6) and the mean VAS score during activity was 1.3(range 0–9). 93%(13/14) of patients reported no pain (0 out of 10 on the numeric scale for pain) in their injured elbow at rest and 79%(11/14) reported no pain during activity. No patients converted to TEA and there were no complications. Non-operative management of comminuted distal humerus fractures should be considered for elderly patients, avoiding surgical risks whilst giving satisfactory functional outcomes in this low demand group

The purpose of this study was to examine five-year outcomes of patients previously enrolled in a non-operative rotator cuff study. Patients with chronic, full-thickness rotator cuff tears (demonstrated on imaging) who were referred to one of two senior shoulder surgeons were enrolled in the study between October 2008 and September 2010. Patients participated in a comprehensive non-operative, home-based treatment program. After three months patients were defined as “successful” or “failed”. “Successful” patients were essentially asymptomatic and did not require surgery. “Failed” patients were symptomatic and consented to surgical repair. All patients were followed up at one year, two years, and five-plus years. Original results of our study showed that 75% of patients were treated successfully with non-operative treatment, while 25% went on to surgery. These numbers were maintained at two-year follow-up (previously reported) and five-year follow-up. At five+ years, 88 patients were contacted for follow-up. Fifty-eight (66%) responded. The non-operative success group had a mean RC-QOL score of 80 (SD 18) at previously reported two-year follow-up. At five-year follow-up this score did not decrease (RCQOL = 82 (SD 16)). Furthermore, between two and five years, only two patients who had previously been defined as “successful” became more symptomatic and underwent surgical rotator cuff repair. From the original cohort of patients, those who failed non-operative treatment and underwent surgical repair had a mean RC-QOL score of 89 (SD 12) at five-year follow-up. The operative and non-operative groups at five-year follow-up were not significantly different (p = 0.07). Non-operative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. While some may argue that non-operative treatment delays inevitable surgical fixation, our study shows that patients can do extremely well over time

There is conflicting information regarding the recommendations of bracing, physical therapy and cessation of sports for young athletes with symptomatic spondylolysis. The purpose of this study was to identify factors affecting the prognosis and to find the optimal method of non-operative treatment. The patients in our study were athletes who visited our children's hospital for low back pain with lumbar spondylolysis and were treated non-operatively from 1990 to 2002. Clinical and radiological outcomes were reviewed retrospectively. The effects of bracing, physical therapy, cessation of sports, duration of symptoms before the first hospital visit, lateralisation of spondylolysis, age, gender, onset of low back pain after lumbar trauma during sports, bone scan uptake, vertebral level of the lesion, associated scoliosis or spina bifida and radiological bony healing were analysed using univariate and multivariate analysis with logistic regression. The mean age of patients was 13 years (range 7 to 18 years). The mean follow-up was 4.2 years (range 1.2 to 12 years). Of 132 patients, 48 patients had excellent results with no pain during sports, 76 good, 6 fair, and 4 poor. Cessation of sports, early non-operative intervention, and a unilateral spondylolysis appeared to be factors associated with excellent outcomes. However, bracing, physical therapy, age, gender, level of lesion, history of trauma, increased uptake on bone scan, or associated scoliosis or spina bifida were not factors. Bony healing was not related to the clinical outcome. The non-operative treatment of spondylolysis in children can yield excellent clinical outcomes, and the absence of bony healing has no influence on clinical outcome. Factors in this study found to correlate with an excellent outcome include unilateral spondylolysis, acute spondylolysis, and treatment with cessation of sports for 12 weeks

Mid-shaft humeral fractures in adults are common these days and often present with a management dilemma between operative and non-operative treatment. This study evaluates the outcome of such fractures treated non-operatively over a span of 10 years. In this retrospective study, a review of case notes and radiographs of patients whose mid-shaft humerus fractures were treated non-operatively between 1994 and 2004 was done. Those younger than 16 years and/or who had surgery primarily were excluded. Various factors including patient demographics, mechanism of injury, AO fracture classification and time to union were studied. Mean patient follow-up was 4 years and 6 months. The Oxford shoulder score was used for functional assessment. There was a total of 43 patients, mostly men with involvement of the dominant arm. 5 patients required open reduction and internal fixation with bone grafting for non-union. The average Oxford shoulder score was 18. The majority of patients could resume their jobs and the average time to union was 9 weeks. We conclude from this study that there is a high union rate in the mid-shaft humeral fractures in adults treated non-operatively, with an acceptable functional outcome

Patella fractures constitute 1% of all fractures and may disrupt the extensor mechanism of the knee. The mainstay of treatment for most patella fractures is operative fixation; however, patients with intact extensor mechanisms may be treated with splinting. We describe a series of patients with patella fractures managed non- operatively, without restricted weight bearing or splinting.

A consecutive series of 21 patients presenting with a patella fracture to two metropolitan hospitals were included in this study. All patients had an intact extensor mechanism but no distinction was made on age or fracture type. All patients were treated non-operatively with analgesia, were allowed to fully weight-bear and were not splinted. A retrospective review of the case notes was performed and data was collected with phone interview. The main outcome measure was the Western Ontario and McMaster Universities

Osteoarthritis (WOMAC) index, which has a maximum (worst) possible score of 240, and which provides an aggregate score of pain, stiffness and function. Mean time at follow up was 24 months (range 5–49 months). WOMAC scores were excellent (mean=18 of possible maximum 240; range 0–84). Only one patient had a significant complication related to their fracture (deep venous thrombosis), which was detected during hospital admission. Most patients had returned to usual work (9/14). No patients required operative fixation. There was no association between adjusted WOMAC score and age, sex, compensation status, time of follow up, or whether the patient had a significant ipsilateral injury. Patients who had returned to work (p=0.02) or who had lower levels of education (p=0.03) had better WOMAC scores.

Management of patella fractures with an intact extensor mechanism does not require restricted weight bearing or splinting.

Despite the publication of numerous studies, controversy regarding the non- operative treatment of type II dens fractures remains. The halo-thoracic vest (HTV) and cervical collar are the most commonly used devices. We sought to compare the outcomes of patients managed with these devices in terms of non-union risk factors and associated complication rates.

This study was a retrospective review of adult patients with type II dens fractures treated non-operatively at a level one trauma centre between 2001 and 2007. The patients were identified using a hospital trauma database. Each patient included in the study had a minimum follow up of six months. Patient medical records and imaging studies were reviewed. Union was defined as stable fibrous union or bony union, measured at three months. A p-value of < 0.05 was considered statistically significant.

Sixty-seven patients were included. Thirty-five patients were treated using a HTV and 32 with a collar. Non-union was found to be associated with increased time in HTV or collar (p = 0.011) and with a mechanism of injury involving a low fall (p = 0.008). In addition, the proportion of patients with stable union at three months was 60% for the HVT group versus 35% for the cervical collar group (p = 0.10). There were trends to support an increased risk of non-union with a patient age of greater than or equal to 65 years at the time of presentation (p = 0.13) as well as with a fracture displacement of greater than or equal to 2 mm at time of presentation (p = 0.17). Clinically significant complications of the HTV were of greater prevalence than those experienced by collar patients. Sixty percent of HTV patients suffered one or more complications compared with 6% of collar patients.

We were unable to demonstrate any clear advantage or disadvantage of either device. Further investigation of mortality would be beneficial, particularly in the patient group injured with a mechanism involving a low fall (which tends to include more elderly patients).

Congenital talipes equinovarus occurs in 1.2 per 1000 live births in Europe and is twice as common in boys. Over the last decade, non-surgical management has re-established itself as the first line treatment; after long-term follow-up of surgically treated patients, revealed high rates of over correction, stiffness and pain. The commonly practiced non-surgical approaches are the Ponseti technique of serial manipulation and casting, and French taping. Ram's technique of taping is a truly conservative approach with a higher success rate to address this problem. Unlike French taping, it involves taping alternate days during the first week followed by twice in the second week, then once the following week, which is left in situ for a further two weeks. After the initial five weeks of taping, patients are provided with talipes splint for all time use, up till a year. This is followed by talipes shoes for walking and splint for nighttime use for another year. At the end of two years patients can wear normal shoes.

The study includes 225 patients with 385 clubfeet, who were treated with Ram's taping technique from September 1991 to August 2008. Inclusion criteria were age up to three months and previously untreated clubfeet. Average follow up was of 5.6 years. Outcome ratings at a minimum of two years were performed. Initial correction rate at the end of five weeks was 99%. A relapse of 21% was noted, two-third of which was salvaged via further taping and exercise, while remaining one third needed some form of surgical intervention. The comparative outcome for Ram's taping is better to Ponseti or French taping with good outcome in 93%, in comparison to 72% and 67% respectively.

To conclude Ram's taping is a fast, more effective, less cumbersome and fully conservative approach of correcting the clubfoot deformity.

There is ongoing debate regarding the optimal management of displaced distal radius fractures in the elderly. The aim of this review was to compare outcomes of operatively versus non-operatively managed displaced extra-articular or undisplaced intra-articular distal radius fractures in patients 65 years and older.

All patients over the age of 65 years with displaced extra-articular or undisplaced intra-articular fractures seen in Tauranga Hospital between 1^st January 2009 and 31st December 2009 were included in the study. Patients from out of town, with incomplete radiographs or who had since passed away were excluded as were patients with comminuted intra-articular or undisplaced/minimally displaced extra-articular fractures. Patients attended follow-up where clinical assessment was carried out by a single Hand Therapist who was blinded to the side of injury and previous management, completed the Patient Rated Wrist Evaluation (PRWE) and DASH questionnaires and a visual analogue satisfaction score.

There were 91 distal radius fractures in patients 65 years and older seen in Tauranga Hospital over this 1 year period. 44 were excluded leaving 47 patients. 6 declined follow-up and 5 failed to attend. 36 patients (3 males, 33 females, average age 74.7 years) were included in the study – 23 had been treated non-operatively with casting +/− manipulation while the remaining 13 patients had undergone open reduction and internal fixation.

Comparing the injured with the uninjured wrist in the operatively managed group there was an average loss of 5.8 degrees flexion, 1.2 degrees extension, 1.7 degrees ulnar deviation and 3.8 degrees supination with a gain of 0.7 degrees radial deviation, no change in pronation and a loss of 1.2kg in grip strength. These operatively managed patients had an average PRWE score of 6.5, DASH score of 31.5 and satisfaction score of 8.8. Conversely, in the non-operatively managed group there was an average loss of 17.5 degrees flexion, 9.4 degrees extension, 11.3 degrees ulnar deviation and 10.9 degrees supination with a gain of 0.1 degrees radial deviation, no change in pronation and a loss of 4.7kg in grip strength. These non-operatively managed patients had higher PRWE (42.5) and DASH (56) scores and were in general less pleased with their outcomes (mean satisfaction score – 5.6).

Patients in the operatively managed group at 12–24 months post-injury had less significant loss of function as well as lower PRWE and DASH scores and higher satisfaction outcome scores.

There is very limited literature describing the outcomes of management for proximal humerus fractures with more than 100% displacement of the head and shaft fragments as a separate entity. This study aimed to compare operative and non-operative management of the translated proximal humerus fracture. A prospective cohort study was performed including patients managed at a Level 1 trauma centre between January 2010 to December 2018. Patients with 2, 3 and 4-part fractures were included based on the degree of translation of the shaft fragment (≥100%), resulting in no cortical contact between the head and shaft fragments. Outcome measures were the Oxford Shoulder Score (OSS), EQ-5D-5L, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, and non-union/malunion. Linear and logistic regression models were used to compare management options. There were 108 patients with a proximal humerus fracture with ≥100% translation; 76 underwent operative management and 32 were managed non-operatively with sling immobilisation. The mean (SD) age in the operative group was 54.3 (±20.2) and in the non-operative group was 73.3 (±15.3) (p<0.001). There was no association between OSS and management options (mean 38.5(±9.5) operative vs mean 41.3 (±8.5) non-operative, p=0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference 0.16 (95%CI 0.04-0.27, p=0.008); EQ-5D VAS adjusted mean difference 19.2 (95%CI 5.2-33.2, p=0.008). Operative management was further associated with a lower odds of non-union (adjusted OR 0.30, 95%CI 0.09-0.97, p=0.04), malunion (adjusted OR 0.14, 95%CI 0.04-0.51, p=0.003) and complications (adjusted OR 0.07, 95%CI 0.02-0.32, p=0.001). Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes following surgical fixation. Patients with this injury should be considered for operative intervention

This systematic review and meta-analysis aimed to compare the outcome of operative and non-operative management in adults with distal radius fractures, with an additional elderly subgroup analysis. The main outcome was 12-month PRWE score. Secondary outcomes included DASH score, grip strength, complications and radiographic parameters. Randomised controlled trials of patients aged ≥18yrs with a dorsally displaced distal radius fractures were included. Studies compared operative intervention with non-operative management. Operative management included open reduction and internal fixation, Kirschner-wiring or external fixation. Non-operative management was cast/splint immobilisation with/without closed reduction. Version 2 of the Cochrane risk-of-bias tool was used. After screening 1258 studies, 16 trials with 1947 patients (mean age 66yrs, 76% female) were included in the meta-analysis. Eight studies reported PRWE score and there was no clinically significant difference at 12 weeks (MD 0.16, 95% confidence interval [CI] −0.75 to 1.07, p=0.73) or 12 months (mean difference [MD] 3.30, 95% CI −5.66 to −0.94, p=0.006). Four studies reported on scores in the elderly and there was no clinically significant difference at 12 weeks (MD 0.59, 95% CI −0.35 to 1.53, p=0.22) or 12 months (MD 2.60, 95% CI −5.51 to 0.30, p=0.08). There was a no clinically significant difference in DASH score at 12 weeks (MD 10.18, 95% CI −14.98 to −5.38, p<0.0001) or 12 months (MD 3.49, 95% CI −5.69 to −1.29, p=0.002). Two studies featured only elderly patients, with no clinically important difference at 12 weeks (MD 7.07, 95% CI −11.77 to −2.37, p=0.003) or 12 months (MD 3.32, 95% CI −7.03 to 0.38, p=0.08). There was no clinically significant difference in patient-reported outcome according to PRWE or DASH at either timepoint in the adult group as a whole or in the elderly subgroup

Aim. To investigate the impact of waiting for surgical treatment for bone and joint infection (BJI) on patient self-reported quality of life (QoL). Method. Patients presenting to clinic between January 2019 and February 2020 completed the EuroQol EQ-5D-5L questionnaire. Patients were divided into three groups: surgery performed; on the waiting list for surgery; or decision for non-operative management. All patients were followed-up for 2 years. The EQ-index score was calculated and change from presentation to 1-year and 2-year follow-up was compared across the 3 groups. Mortality at final follow-up was measured in all groups. Results. 188 patients were included. Of these, 98 had an operation performed, 50 were on the waiting list for surgery but did not receive an operation and 40 were treated non-operatively. At presentation, all three groups had similar EQ-5D-5L index scores (surgery:0.412 SD0.351; waiting list:0.510 SD0.320; non-operative management: 0.467 SD0.354; p=0.269). There was a significant improvement in QoL in patients who underwent surgery when compared to their pre-operative state (mean increase of EQ-index score +0.241 in the first year (SD0.333, p<0.001) and +0.259 (SD0.294, p<0.001) in the second year. Patients on the waiting list for surgery had a small time-dependent decrease in EQ-index score at 1 year (−0.077, SD0.282, p=0.188) and 2 years (−0.140, SD0.359, p=0.401). Patients treated non-operatively had similar changes in EQ-index scores at 1 year (−0.052, SD0.309, p=0.561) and 2 years (−0.146, SD 0.234, p=0.221). Patients who had surgery had significantly better QoL at 2-years after treatment compared to other groups (mean EQ-index scores: surgery performed 0.671 vs. waiting list 0.431, p<0.001; surgery performed vs. non-operative management 0.348, p<0.001). Mortality in the operated group was 3.1%, which was similar to patients who were on the waiting list for surgery (6.5%, p=0.394) but lower than patients who were non-operatively managed (14.7%, p=0.014). Conclusions. The Covid-19 pandemic created long waiting times for some patients. Selecting patients with BJI who can safely wait for surgery is difficult. QoL for patients with BJI deteriorates over time if surgery is delayed or not performed. When patients decline surgery, they should be counselled that their QoL is likely to be impaired over time. The relationship between waiting time and mortality merits further study

Minimally displaced paediatric proximal humerus fractures (PHFs) can be reliably managed non-operatively, however there is considerable debate regarding the appropriate management of severely displaced PHFs, particularly in older children and adolescents with limited remodelling potential. The purpose of this study was to perform a systematic review to answer the questions: “What are the functional and quality-of-life outcomes of paediatric PHFs?” and “What factors have been associated with a poorer outcome?”. A review of Medline and EMBASE was performed on 4. th. July 2021 using search terms relevant to PHFs, surgery, non-operative management, paediatrics and outcomes. Studies including ≥10 paediatric patients with PHFs, which assessed clinical outcomes by use of an established outcome measure, were selected. The following clinical information was collected: participant characteristics, treatment, complications, and outcomes. Twelve articles were selected, including four prospective cohort studies and eight retrospective cohort studies. Favourable outcome scores were found for patients with minimally displaced fractures, and for children aged less than ten years, irrespective of treatment methodology or grade of fracture displacement. Older age at injury and higher grade of fracture displacement were reported as risk factors for a poorer patient-reported outcome score. An excellent functional outcome can be expected following non-operative management for minimally displaced paediatric PHFs. Prospective trials are required to establish a guideline for the management of severely displaced PHFs in children and adolescents according to fracture displacement and the degree of skeletal maturity

Lisfranc injuries account for 0.2% of all fractures and have been linked to poorer functional outcomes, in particular resulting in post-traumatic arthritis, midfoot collapse and chronic pain. This study assesses the longitudinal functional outcomes in patients with low and high energy Lisfranc injuries treated both operatively and non-operatively. Patients above 16 years with Lisfranc injuries from January 2008 and December 2017 were identified through the Victorian Orthopaedic Trauma Outcomes (VOTOR) registry. Follow-up performed at 6, 12 and 24 months through telephone interviews with response rate of 86.1%, 84.2% and 76.2% respectively. Longitudinal functional outcome data using Global Outcome Assessment, EQ-5D-5L, numerical pain scale, Short-Form 12, the WHO Disability Assessment Schedule and return to work status were collected. Univariate analysis was performed and variables showing a significant difference between groups (p < 0.25) were analysed with multivariable mixed effects regression model. 745 patients included in this retrospective cohort study. At 24 months, both the operative and non-operative groups demonstrated similar functional outcomes trending towards an improvement. Mixed effect regression models for the EQ items for mobility (OR 1.80, CI 0.91 – 3.57), self-care (OR 1.95, 95% CI 1.09-3.49), usual activities (OR 1.10, 95% CI 0.99-1.03), pain (OR 1.07, 95% CI 0.61-1.89), anxiety (OR 1.29, 95% CI 0.72-2.34) and pain scale (OR 1.07, 95% CI 0.51 – 2.22) and return to work (OR 1.28, 95% CI 0.56-2.91) between groups were very similar and not statistically significantly different. We concluded that there was no statistically significant difference between operative and non-operative patients with low and high energy Lisfranc injuries. Current clinical practices in Lisfranc injury management are appropriate and not inadvertently causing any further harm to patients. Future research comparing fracture patterns, fixation types and corresponding functional outcomes can help determine gold standard Lisfranc injury management

Introduction. Mode of non-operative management of thoracolumbar spine fracture continues to remain controversial with the most common modality hinging on bracing. TLSO is the device with a relative extension locked position, and many authors suggest they may have a role in the healing process, diminishing the load transferred via the anterior column, limiting segmental motion, and helping in pain control. However, several studies have shown prolonged use of brace may lead to skin breakdown, diminished pulmonary capacity, weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without brace. Aims. To identify number of spinal braces used for spinal injury and cost implications (in a DGH), to identify the impact on length of stay, to ascertain patient compliance and quality of patient information provided for brace usage, reflect whether we need to change our practice on TLSO brace use. Methods. Data collected over 18-month period (from Jan.2020 to July 2021). Patients were identified from the TLSO brace issue list of the orthotic department, imaging (X-rays, CT, MRI scans) reviewed to confirm fracture and records reviewed to confirm neurology and non-operative management. Patient feedback was obtained via post or telephone consultation. Inclusion criteria- patients with single or multi -level thoracolumbar osteoporotic or traumatic fractures with no neurological involvement treated in a TLSO brace. Exclusion criteria- neurological involvement, cervical spine injuries, decision to treat surgically, concomitant bony injuries. Results. 72 braces were issued in the time frame with 42 patients remaining in the study based on the inclusion/exclusion criteria. Patient feedback reflected that 62% patients did not receive adequate advice for brace usage, 73% came off the brace earlier than advised, and 60% would prefer to be treated without a brace if given a choice. The average increase in length of stay was 3 days awaiting brace fitting and delivery. The average total cost burden on the NHS was £127,500 (lower estimate) due to brace usage. Conclusion. If there is equivalence between treatment with/without a brace, there is a need to rethink the practice of prescribing brace for all non-operatively treated fractures and a case-by-case approach may prove more beneficial

Unstable chest wall injuries have high rates of mortality and morbidity. These injuries can lead to respiratory dysfunction, and are associated with high rates of pneumonia, sepsis, prolonged ICU stays, and increased health care costs. Numerous studies have demonstrated improved outcomes with surgical fixation compared to non-operative treatment. However, an adequately powered multi-centre randomized controlled study using modern fixation techniques has been lacking. We present a multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries with the current standard of non-operative management. Patients aged 16–85 with a flail chest (3 or more consecutive, segmental, displaced rib fractures), or severe deformity of the chest wall, were recruited from multiple trauma centers across North America. Exclusion criteria included: severe pulmonary contusion, severe head trauma, randomization>72 hours from injury, inability to perform surgical fixation within 96 hours from injury (in those randomized to surgery), fractures of the floating ribs, or fractures adjacent to the spine not amendable to surgical fixation. Patients were seen in follow-up for one year. The primary outcome was days free from mechanical ventilation in the first 28 days following injury. Secondary outcomes were days in ICU, rates of pneumonia, sepsis, need for tracheostomy, mortality, general health outcomes, pulmonary function testing, and other complications of treatment. A sample size of 206 was required to detect a difference of 2 ventilator-free days between the two groups, using a 2-tailed alpha error of 0.05 and a power of 0.80. A total of 207 patients were recruited from 15 sites across Canada and USA, from 2011–2018. Ninety-nine patients were randomized to non-operative treatment, and 108 were randomized to surgical fixation. Overall, the mean age was 53 years, and 75% of patients were male, with 25% females. The commonest mechanisms of injury were: motor vehicle collisions (34%), falls (20%), motorcycle collisions (14%), and pedestrian injuries (11%). The mean injury severity score (ISS) at admission was 26, and patients had a mean of 10 rib fractures. Eighty-nine percent of patients had pneumothorax, 76% had haemothorax, and 54% had pulmonary contusion. There were no differences between the two groups in terms of demographics. The final results will be available and presented at the COA meeting in Halifax. This is the largest randomized controlled trial to date, comparing surgical fixation to non-operative treatment of unstable chest wall and flail chest injuries. The results of this study will shed light on the best treatment options for patients with such injuries, help understand outcomes, and guide treatment. The final results will be available and presented at the COA meeting in Halifax

Abstract. Non-operative management of AIS can present practical and psychological challenges, as effective bracing requires a considerable investment of time in adolescence which is a formative point of physical and emotional development. The management team lacks input from the psychological team and thus, it would be prudent for the spinal teams to appreciate and deal with the psychosocial effects associated with bracing. We sought to investigate how bracing as a part of non-operative management of idiopathic scoliosis, is perceived among adolescents. We performed a search of CINAHL, Medline, AMED, PsychARTICLES, Psychology and Behavioral Sciences Collection and PsychINFO databases to identify qualitative research investigating the thoughts, feelings and experiences and attitudes of those undergoing bracing for AIS. Keywords used were (((“adoles∗” OR “young pe∗”) AND “idiopathic scoliosis”) AND “brac∗”) AND (“perce∗” OR “experience∗” OR “perspective∗” OR “attitude∗”). Ten research articles were identified using our search strategy. Only one article addressed our research question specifically. This reported that almost all adolescent patients experienced psychological difficulties during treatment and received most of their support from family and friends rather than health professionals. Our interpretation of the literature on this subject has yielded three recommendations for service providers. First, the policy ought to change to ensure that psycholological support is engrained within the treatment process; second, more information and advice must be given to patients and their families; and third, health professionals should appreciate and directly address in their consultations the psychological difficulties involved in brace wearing and the need for adequate support