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

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

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

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

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

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

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