Aims. Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room. Methods. A randomized controlled trial was conducted. A total of 255 patients were included, aged five to 17 years, who needed plaster treatment for a fracture of the upper or lower limb. Randomization was stratified for age (five to 11 and 12 to 17 years). The intervention group was distracted with VR goggles and headphones during the plaster treatment, whereas the control group received standard care. As the primary outcome, the post-procedural level of anxiety was measured with the Child Fear Scale (CFS). Secondary outcomes included the children’s anxiety reduction (difference between CFS after and CFS before plaster procedure), numerical rating scale (NRS) pain, NRS satisfaction of the children and accompanying parents/guardians, and the children’s heart rates during the procedure. An independent-samples t-test and Mann-Whitney U test (depending on the data distribution) were used to analyze the data. Results. The post-procedural CFS was significantly lower (p < 0.001) in the intervention group (proportion of children with no anxiety = 78.6%) than in the control group (56.8%). The anxiety reduction, NRS pain and satisfaction scores, and heart rates showed no significant differences between the control group and the intervention group. Subanalyses showed an increased effect of VR on anxiety levels in young patients, females, upper limb fractures, and those who had had previous plaster treatment. Conclusion. VR effectively reduces the anxiety levels of children in the plaster room, especially in young girls. No statistically significant effects were seen regarding pain, heart rate, or satisfaction scores. Cite this article: Bone Joint J 2024;106-B(7):728–734

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. Methods. A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires. Results. Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections. Conclusion. Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J 2021;103-B(5):902–907

Introduction and objectives: The most commonly used treatment for extraarticular fractures of distal radius is closed reduction and maintenance of reduction in a cast. Two types of casts are used: plaster splint for 7–10 days and later exchanged to a circular cast and the use of circular cast immediately. The objective of this work is to compare both types of treatment in terms of ability to achieve reduction and to maintain it during healing. Methods: A prospective, randomized and blinded study was designed. To date, 21 patients enrolled the study. Informed consent was given. The inclusion criteria were: older than 35 years, extraarticular distal radius fracture sustained less than 24 hours before and not previously treated. Exclusion criteria included previous injury in the same wrist, open fracture, and not compliance with the protocol. After intrafocal anesthesia with mepivacaine 1%, fracture was reduced under traction and immobilized in a dorsal short plaster splint (splint group) or a circular short plaster cast (circular group) randomly. After 10 days of immobilization, the plaster splint was changed to a circular short plaster cast. AP and lateral X-Rays were taken before reduction, after reduction, after 10 days (before changing cast), and at 21 days. Volar inclination of lunate fossa on the lateral X-Ray was obtained. On the AP proyection, the radial inclination and radial length was measured. Complications were recorded. Data was analysed through ANOVA between groups. Results: When comparing X-rays before and after reduction, the volar inclination of the lunate fossa on lateral projection changed from −21,4° to 8,60° (30° change) after reduction in splint group and from −15,22° to 1,78° (17° change) in circular group (p< 0.05). The other comparisons were N.S. When comparing after reduction and 10 days later, the radial inclination changed from 20,20° to 18,80° (1,40° change) in the splint group and from 20,89° to 20,44 (0,44° change) in the circular group (p< 0.05). Other comparisons were N.S. No differences were found between 10 days and 21 days in any X-Ray parameter. No complications were found. Conclusions: A better reduction was achieved with the plaster splint method in the immediate X-Ray control. Nevertheless, reduction was better maintained during the first 10 days with the circular plaster cast method

Introduction and Purpose. Metacarpal fractures constitute approximately one third of all hand fractures. The majority of these fractures are treated by conservative non-surgical methods. The aim of this study is to obtain the appropriate anatomical alignment of the fracture with dynamic metacarpal stabilization splint (DMSS) and to maintain the proper bone anatomy until the union is achieved. In addition, by comparing this method with short arm plaster splint (SAPS) application, it is aimed to evaluate whether patients are superior in terms of comfort, range of motion (ROM) and grip strength. Materials and Methods. In our study, SAPS or DMSS was applied to the patients with 5th metacarpal neck fracture randomly after fracture reduction and followed for 3 months. A total of 119 patients with appropriate criteria were included in the study. Radiological alignment of the fracture and amount of joint movements were evaluated during follow-up. Grip strength was evaluated with Jamar dynamometer. EQ-5D-5L and VAS scores were used for clinical evaluation. Results. 103 patients completed their follow-up. 51 patients were treated with SAPS and 52 patients were treated with DMSS. The mean age of the SAPS was 29.5 (SD ± 9.4; 16–53 years) and the mean age of the DMSS group was 27.8 (SD ± 11.6; 16–63). Pressure sores was seen in 5 patients in the DMSS group, while no pressure sore was seen in the SAPS (p = 0.008). There was no significant difference between the two groups in the VAS scores at all times. There was no significant difference between the mean dorsal cortical angulation (DCA) before the reduction, after the reduction and at the third month follow-ups. There was no statistically significant difference between the length of metacarps at first admittion before reduction, after reduction and at third month follow-ups. When the grip strength of the two groups were compared as a percentage, the grip strength of the patients in the DMSS group was found to be higher at 1st month, 2nd month and 3rd month (p <0.001). When the ROM values of the patients were evaluated, DMSS group had a higher degree of ROM in the first month compared to the SAPS group (p <0.001). No statistically significant difference was detected among groups at third month in the ROM of the IP and MP joints. However, wrist ROM was statistically higher in DMSS group at 3rd month (p <0.05). There was a statistically significant difference between EuroQol scores in favor of DMSA group (p <0.05). Discussion and Conclusion. In stable 5th metacarpal neck fractures, DMSA is as effective as SAPS to maintain bone anatomy. In addition, DMSA can be preferred for fixation plaster splint or circular plaster applications for the prevention of reduction in boxer fractures, with the advantage of having high clinical scores, which is an indication of early acquisition of grip strength, ease of use and patient comfort

Introduction: Early plaster immobilisation is important in fracture management to control pain and maintain alignment. In our institute, the initial plaster is routinely applied by junior trainees directly or is applied by Accident & Emergency (A& E) staff under the supervision of the junior trainees. In the U.K., plaster application technique has not been routinely and formally taught to the junior trainees in the hospital. Method: We aimed to review the adequacy of plaster applied or supervised by junior trainees. The criteria for an adequate of plaster immobilisation for tibial diaphyseal fractures have not been reported in the literature. We had chosen 3 simple parameters, namely, change in alignment of fracture fragments, position of the ankle and a gap index of less than 0.15, which in our view are important in terms of initial management of tibial fracture in the A& E. The gap index reflects the amount of padding applied in the plaster. These parameters were merely chosen to assess the adequacy of initial plaster immobilisation by junior trainees and should not predict the long term success or failure of the management of fracture with plaster. Sixty-five patients with tibial diaphyseal fractures were retrospectively included in the present study. The initial and post-plaster application radiographs were assessed by two senior trauma & orthopaedic specialist registrars separately. Result: Only forty-six percent (45%) of the cases had fulfilled all the three criteria. In subgroup analysis, position of the ankle is the most frequently neglected factor with 31% of the ankles held in equinus. Twenty eight percent (28%) of cases had worsening of the alignment of the fracture fragments. Fourteen percent (14%) of the cases had excessive padding applied as reflected by Gap Index of > 0.15. Conclusion: This study highlighted that the basic plastering technique by the junior trainees is inadequate. We suggest that every trainee rotating to Trauma & Orthopaedic Surgery must be taught this fast-fading away basic plaster application technique during the induction period

An inner tube was inflated and then surrounded with plaster wool and plaster-of-Paris bandages. The plaster and the wool were next progressively divided. There was no significant reduction of the pressure inside the tube until both the plaster and the wool had been divided and separated from the inner tube along the entire circumference. These findings demonstrated that wool and plaster applied to limbs likely to swell should be split right down to skin and widely separated immediately after their application. A plaster slab is safer still, but the wool must be cut before the crepe bandage is applied

Background. One of the prime concerns when managing patients in plaster casts is loss of reduction. There have been studies showing that proper moulding of the plaster cast is critical in maintaining reduction. Recent studies have negated concerns that fibreglass (FG) casts do not allow swelling, when compared to plaster of Paris (POP) casts. However, their potential in maintenance of reduction has not been investigated. Materials and methods. We compared the three-point bending properties of FG casts with POP casts over the first 48 hours. The effect of splitting the casts, at one hour and 24 hours, was studied. Three identical jigs with hinged metal rods were designed to simulate a Colles fracture. The bending force was provided by 0.5 kg weight applied at one end of the jig. The resultant displacement was measured to nearest 0.01 mm over the next 48 hours. Each test was repeated 6 times (total 6 groups and 36 tests). Results. Most deformation occurred within 1 hour for FG casts and 24 hours for POP casts. The total deformation in FG cast (mean 2.4 mm) was significantly less than in POP casts (mean 4.7 mm) (p < 0.01). Splitting at 1 hour increased the final deformation of the POP cast and not of the FG cast (p < 0.05). No significant difference was noticed if the casts were split at 24 hours. Conclusion. Three-point moulding with FG casts can provide better constant loading at the fracture site than the POP casts. Early setting of FG cast allows earlier splitting. We recommend clinical trials to ascertain the safety and efficacy of split FG casts

1. Between 1936 and 1945, 525 patients with sciatic pain were treated at the Princess Elizabeth Orthopaedic Hospital, Exeter. Of these, 225 had neurological signs and they were selected for review; 147 were traced. 2. Of these, 123 were treated by means of plaster jackets and twenty-four were treated by other methods. The late results of treatment in the two groups were about the same, roughly one-third being "cured," one-third "relieved," and one-third "not relieved.". 3. Nevertheless examination of the immediate results suggests that protection by means of a plaster jacket had at least a palliative effect, relieving acute symptoms and allowing early rehabilitation. Moreover it should be emphasised that in limiting the investigation to cases of sciatica with evidence of nerve root pressure only the more severe cases have been included. 4. Permanent relief after immobilisation in plaster was greatest when the duration of symptoms was short, and when the patient was treated during his first attack. It was least in patients who showed all three signs of nerve root pressure—diminished ankle jerks, hypo-aesthesia, and muscle hypotonicity. 5. Absence of tendon reflexes due to nerve root pressure, and areas of hypo-aesthesia, tend to remain permanently; but diminution of reflexes and loss of muscle power may recover

Aims. Describe a statistical and economic analysis plan for the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) randomized controlled trial. Methods. DRAFFT2 is a multicentre, parallel, two-arm randomized controlled trial. It compares surgical fixation with K-wires versus plaster cast in adult patients who have sustained a dorsally displaced fracture of the distal radius. The primary outcome measure is the Patient-Rated Wrist Evaluation (PRWE, a validated assessment of wrist function and pain) at 12 months post-randomization. Secondary outcomes are measured at three, six, and 12 months after randomization and include the PWRE, EuroQoL EQ-5D-5L index and EQ-VAS (visual analogue scale), complication rate, and cost-effectiveness of the treatment. Results. This paper describes the full details of the planned methods of analysis and descriptive statistics. The DRAFFT2 study protocol has been published previously. Conclusion. The planned analysis strategy described records our intent to conduct statistical and within-trial cost-utility analyses. Cite this article: Bone Joint Open 2020;1-6:245–252

BACKGROUND: One of the prime concerns when managing patients in plaster casts is loss of reduction. There have been studies showing that proper moulding of plaster cast is critical in maintaining reduction. Recent studies have negated concerns that fibreglass (FG) casts do not allow swelling, when compared to plaster of Paris (POP) casts. However, their potential in maintenance of reduction has not been investigated. MATERIALS AND METHODS: We compared the three-point bending properties of FG casts with POP casts over the first 48 hours. The effect of splitting the casts, at one hour and 24 hours, was studied. Also, the tolerance to handling was assessed by moving the hinge joint while the casts were setting. Three identical jigs with hinged metal rods were designed to simulate Colle’s fracture. The bending force was provided by 0.5 kg weight applied at one end of the jig. The resultant displacement was measured to nearest 0.01 mm over the next 48 hours. Each test was repeated 6 times (total 8 groups and 42 tests). RESULTS: Most deformation occurred within 1 hour for FG casts and 24 hours for POP casts. The total deformation in FG cast (mean 3.4 mm) was significantly less than in POP casts (mean 6.2 mm) (p > 0.05). Splitting at 1 hour increased the final deformation of the POP cast and not of the FG cast (p > 0.05). No significant difference was noticed if the casts were split at 24 hours. CONCLUSION: Three-point moulding with FG casts can provide better constant loading at the fracture site than the POP casts. Early setting of FG cast allows earlier splitting. We recommend clinical trials to ascertain the safety and efficacy of split FG casts

Introduction. Venous thromboembolism (VTE) is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. This incidence should in theory reduce if the patients are ambulatory early in the treatment phase. The aim of this study was, therefore, to identify a difference in the incidence of symptomatic VTE by treating acute Achilles tendon rupture patients with conventional non-weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were retrospectively reviewed and prospectively followed. The patients' demographics, treatment modality (non-weight bearing plaster versus weight bearing boot), and the type of plaster immobilisation was compared to assess whether they affect the incidence of clinical VTE. The predisposing risk factors were also analysed between the treatment groups. Out of 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a conventional non-weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. On the other hand, 41 patients were treated with functional weight bearing mobilisation (Vacupad). Patients who did have a symptomatic thromboembolic event also had an ultrasound scan to confirm a deep vein thrombosis of the lower limb or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients had a thromboembolic event (19.1%). On the other hand, out of the 41 patients who were treated with functional weight bearing mobilisation, only 2 patients had a symptomatic thromboembolic event (4.2%). This was statistically significant (p=0.012). This shows that patients who are treated in a non-weight bearing plaster have about five times increased risk of developing a sypmptomatic VTE compared to those treated by functional weight bearing mobilisation. There was however no difference in the predisposing factors in patients who developed VTE compared to those who did not. Conclusion. The incidence of symptomatic VTE after acute Achilles tendon rupture is high and under-recognised. Asymptomatic VTE after this injury is probably even higher. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non-weight bearing cast. There is a need for further research to define the possible benefit of thromboprophylaxis in patients treated by non-weight bearing plasters

In a five-year period, 153 feet in 101 patients were treated by a Wilson's osteotomy of the first metatarsal for hallux valgus. Postoperative support was provided by either a below-knee or a forefoot plaster, and was continued for either three weeks or six weeks. The results showed overall success in 91% with no significant difference between the four groups. We suggest that a forefoot plaster for three weeks is adequate support after a Wilson's osteotomy

Introduction. Peri prosthetic fracture is a recognised complication following Total ankle arthroplasty (TAA). There is limited literature on post operative management following TAA and controversies exist based on surgeon preferences. This project reports the incidence of peri- prosthetic fractures in patients managed with 2 different post-operative protocols. Materials and Methods. Patients undergoing primary TAA with a diagnosis of Osteoarthritis (OA) or Post-traumatic Osteoarthritis (PTOA) were recruited into a randomized controlled trial. These patients did not require any additional procedures. Patients were consented for the trial and randomized to one of two treatment groups (Early mobilisation after surgery vs. immobilisation in a plaster cast for 6 weeks post operatively). Plaster group patients underwent a graduated physiotherapy program from 6-12 weeks and early mobilisation group patients from 1-12 weeks. Complications any were recorded at 2, 4, 6 and 12 weeks post-operatively. Results. A total of 16 ankle replacements were done for a diagnosis of OA (10) and PTOA (6). Mean age was 58 years (±11.75) for the plaster group and 64 years (± 9.32) for the early mobilisation group. 7 patients were randomized to the plaster group and 9 patients were randomized to the early mobilisation group. Of the plaster group 1 patient sustained an intra-operative fracture tibia and 2 patients reported with a fractured medial malleolus. Of the early mobilisation group, 1 patient reported with a peri prosthetic fracture tibia at 6 weeks and 3 patients reported a fractured medial malleolus at 3 months follow up. The percentage of fracture incidence between plaster versus early immobilisation group was 42.8% and 44.4 % respectively. Conclusions. These early results demonstrate no significant differences in the incidence of fracture rates between groups. Further studies of post-operative management are needed to study the correlation with peri-prosthetic fracture rates after TAA

Aim. To assess if Osteoset (CaSO4) improves graft incorporation after shelf procedure and whether spica immobilisation is necessary. Methods/results. 49 patients with acetabular dysplasia treated by shelf procedure were reviewed retrospectively. Group 1 (19 children) and group 2 (12 adults) had shelf acetabuloplasty using autogenous bone graft and CaSO4. Group 3 (18 children) underwent shelf acetabuloplasty using autogenous bone graft alone. Group 2 was assessed separately to avoid age bias. Within group 3 we compared 10 patients managed in plaster for six weeks with 8 mobilized on crutches post operatively. Total shelf and graft area, total shelf length, extra-osseous shelf length and speed of graft incorporation were measured radiologically. There was no difference in shelf indices between patients treated in plaster and those mobilized on crutches. Use of CaSO4 significantly enlarged shelf volume by 3 months post-operative with less resorption, which was maintained throughout follow-up. In contrast the non-CaSO4 group showed a steady decrease in shelf volume. The extra-osseous shelf length was initially similar in groups 1 & 3. By 6 weeks the group 1 extra-osseous shelf was significantly greater than for group 3 and was maintained throughout follow-up. Graft incorporation was faster in group 1. Shelf area and extra-osseous shelf length improved significantly in group 2. However total shelf length decreased slightly by 6 months. Conclusions. The ‘shelf procedure’ is used to contain the femoral head in acetabular dysplasia. The technique described by Staheli recommended plaster spica immobilization for 6 weeks to prevent graft resorption. Our results suggest this is unnecessary. CaSO4 improves graft volume, graft incorporation and reduces resorption in children compared to controls, with similar results in adults using CaSO4

Clinical trials and experiments with a new plaster-of-Paris bandage which can be used in the normal manner are described. Only about two-thirds of the usual number of bandages are required to produce a plaster case of equivalent strength

Stable fractures of the ankle can be successfully treated non-operatively by a below-knee plaster cast. In some centres, patients with this injury are routinely administered low-molecular-weight heparin, to reduce the risk of deep-vein thrombosis (DVT). We have assessed the incidence of DVT in 100 patients in the absence of any thromboprophylaxis. A colour Doppler duplex ultrasound scan was done at the time of the removal of the cast. Five patients did develop DVT, though none had clinical signs suggestive of it. One case involved the femoral and another the popliteal vein. No patient developed pulmonary embolism. As the incidence of DVT after ankle fractures is low, we do not recommend routine thromboprophylaxis

Objectives: To show that the treatment of buckle fracture in children in a soft bandage, rather than a plaster cast, is an effective and safe method of treatment, with an earlier return to normal function. Methods: In order to determine the difference between the two groups it was decided to compare the range of movement at three weeks. Power calculations were performed using the minimum difference for a two-sample t-test method and assuming a non-central distribution. The calculation was performed on Minitab release version 12.1 Assuming a required difference of 5 degrees and a standard deviation of 5 degrees also with a required power of 0.9(90%) this gave a required sample size of 23 for each group i.e a total of 46 patients. Guidelines for the parents, consent forms, doctor and nurse protocols, a guidance poster for the A& E, treatment profiles for each patient and a questionnaire for parents were written. The project was submitted for ethical approval in July 1999 and granted at the end of that month. Patients enter the trial after parents agree and sign the consent form. Allocation to either plaster or bandage is random and parents draw previously sealed envelopes themselves. Those allocated to bandage are seen each week and measurements taken of their range of movement. Results: Thirty seven patients have completed the study. 17 have been allocated to bandage the rest to cast. Those in bandage show an excellent range of movement at the first week with no reported problems on their questionnaires. One patient has transferred from bandage to plaster at the request of the parents. Problems encountered have been compliance of those in bandage to return for follow up after two weeks and, ensuring all patients enter the trial and attend the right clinic. Conclusion: Results suggest a positive result for treatment in bandage with no reported adverse effects and, a highly desirable result for the patient. We would hope to suggest a change in treatment policy for such fractures

Introduction. To investigate if the gap index measured in the follow-up X-rays predicts the reduction of swelling in the plaster cast thereby increasing the risk of re-displacement of fracture treated by manipulation alone. Materials/Methods. We selected for this study a cohort of children who presented with a traumatic displaced fracture of distal radius at the junction of metaphysis and diaphysis who were treated with manipulation alone. This cohort was chosen because of the high risk of re-displacement following closed manipulation of this unstable fracture and to maintain uniformity of the fracture type. Cast index and Gap index was measured in the intra-operative radiograph and at two-weeks to note the change in these indices. Gap index which is measured by summing radial and ulnar translation/inner diameter of cast in the AP X-ray and similar translation on the lateral x-ray/inner diameter of cast, with a measure of <0.15 considered to be a satisfactory cast. Results. Forty-one children with a mean age of 9 years (mode-8, range 4–15 yrs) admitted between Jan 2008 and Feb 2010 with the above described fracture and were treated with manipulation alone were included in this study. Serial radiographs show a gradual loss of reduction in 34 (83%) children and 17 (41%) of these children required re-manipulation. As the plaster cast was not changed the cast index remained same while the gap index increased in the follow-up x-rays as the swelling subsided. In those children whose reduction remained satisfactory, the initial gap index was 0.14 which changed to 0.18 (n=7, p>0.05) while in children in whom the fracture lost reduction, the initial gap index was 0.18 and changed to 0.25 (n=34, p=0.0092) at two weeks. Conclusion. Gap index can easily be calculated on follow-up radiographs and can be used to assess the adequacy of plaster cast. From this study we can conclude that it is effective in assessing the adequacy of plaster cast as the swelling subsides

Background. Patients presenting to fracture clinic who have had initial management of a fracture performed by Accident and Emergency (A+E) often require further intervention to correct unacceptable position. This usually takes the form of booking a patient for a general anaesthetic to have manipulation under anaesthesia (MUA) or open surgery. Methods. Prospective data collection over a 6-month period. Included subjects were those that had initial management of a fracture performed by A+E, who went on to require re-manipulation in fracture-clinic. Manipulations were performed by trained plaster technicians using entonox analgesia followed by application of moulded cast. Radiographs were reviewed immediately post-manipulation by treating surgeon and patient managed accordingly. A retrospective review of radiograph images was performed by two doctors independently to grade the outcomes following manipulation. Results. 38 patients with 39 fractures included in study. Sites of fracture included 32 distal radius, 2 ankle, 1 spiral distal tibia and fibula, 3 metacarpal and 1 proximal phalanx of finger. 22 patients had anatomical/near-to anatomical reduction at post fracture-clinic manipulation of fracture and was the as well as definitive management (satisfactory outcome). 13 patients had a outcome 2 (minimally displaced but and satisfactory reduction of the fracture) at post fracture-clinic reduction. 12 of these were deemed acceptable went onto outcome 1 for definitive management with 1 going to outcome 2 (requiringed further manipulation). 4 patients had unsatisfactory reduction of fracture outcome 3 at post fracture-clinic reduction and all of these patients went onto outcome 3 (required surgery). Conclusions. This study supports the practice of possible primary reduction and if required, re-manipulation and cast moulding using only entonox analgesia, of selected patient cases fractures by trained plaster technicians. Without this intervention, almost all of these cases will have required an MUA or additionally Kirscher wire or open fixation. There is potential to utilise a plaster technician in A+E, reducing the need for further fracture clinic appointments, being more acceptable to patients and having a resultant cost-saving implication. Level of Evidence. Level 3

The use of Orthoplast cast-bracing to allow early hand function in the treatment of displaced Colles' fractures was investigated in 243 patients. They were randomly allocated into three groups: in the first a conventional Colles' type plaster was used; in the second an above-elbow cast-brace with the forearm in supination; and in the third a below-elbow cast-brace. Radiographic measurements were made at each stage of treatment, and the final anatomical result was scored using Sarmiento's (1975) criteria. Function was assessed at three months and at six months. The anatomical result was not influenced by the method of immobilisation but was related to the efficacy of reduction. Loss of position in the braces was no greater than in plaster. The functional result at three months also was uninfluenced by the method of immobilisation; it was, however, related to the severity of the initial displacement, and (to a lesser degree) to the anatomical result, an effect which was lost at six months. Early hand function and the supinated position advocated by Sarmiento were found to confer no anatomical or functional advantage; we could see no reason to change from the use of conventional plaster casts in the treatment of uncomplicated Colles' fractures