Objectives:. To measure compliance with the Trauma Unit guideline relating to the early application of the Thomas splint in patients with a femur shaft fracture on clinical examination. Design:. Retrospective review of clinical and radiological records of patients presenting from 01 January 2012 to 31 December 2012 at a Level 1 Trauma Unit. Patients:. We included all patients with femur shaft fractures independently of their mechanism of injury. Exclusion criteria were: ipsilateral fracture of the lower limb, neck and supracondylar fractures, pathological, periprosthetic and incomplete fractures. The database available for review included demographic information, mechanism of injury, side injured, surgical procedure and time when a radiological study (Lodox and/or x-ray) was performed. Outcome measures:. Primary outcome measure was the application of a Thomas splint before the first radiological examination was performed. Secondary outcome measure was the increase in patients immobilized with a Thomas splint before their second radiological examination was performed. Results:. We identified 160 fractures, 107 (66.9%) had a femur or pelvis x-ray as the first radiological exam. In 44 (41.1%) of these fractures, a Thomas splint had already been applied. Of the 160 fractures, 53 (33.1%) had a Lodox as first radiological examination. In 16 (30.2%) of these fractures, a Thomas splint had already been applied. The remaining 37 fractures where no Thomas splint was applied prior to the Lodox had been immobilized with either a different type of splint (backslab or Kramer wires) or not immobilized at all. Of these “incorrectly” immobilized or not immobilized fractures, 17 (45.9%) were then correctly immobilized with a Thomas splint prior to the x-ray (x-ray as second radiological exam). Conclusion:. Out of 160 fractures, 60 were immobilized with a Thomas splint prior to the first radiological examination, corresponding to a 37.5% compliance rate with internal guidelines

Purpose. To determine, in skeletally immature children with acceptably angulated (< = 15 degrees deformity at presentation) distal radius fractures, if a pre-fabricated wrist splint is at least as effective as a cast. Methods. A randomised controlled, non-inferiority, single blinded, single-centre trial was performed. The primary outcome was physical function at six weeks. Secondary outcomes included angulation, wrist range of motion, strength, pain, and patient preferences. Results. 93 of 97 randomised patients completed full follow-up. ASK scores at six weeks were 92.8 in the splint group and 91.4 in the cast group. Among patients treated in a cast, the average angular deformity at follow-up was 11.0 degrees, compared with an average of 6.6 degrees angulation among patients treated in a splint (p=0.02, t-test). Complications did not differ between groups, nor did range of motion. Conclusion. Splinting was not inferior to casting, and in fact may be superior to casting, for maintaining the position of a minimally displaced distal radial metaphyseal fracture. Significance. The benefits of splinting over casting have been previously established for undisplaced distal radius and ulnar fractures (Plint), this is the first study which extends the benefits of splinting to the large group of children with minimally displaced distal radius fractures

We have previously reported on the medium-term outcomes following a non-operative protocol of a short period of splinting followed by early movement to treat simple dislocations of the elbow. We undertook extended follow up of our original patient study group to determine whether the excellent results previously reported were maintained in the very long-term. A secondary question was to determine the rate and need for any late surgical intervention. We attempted to contact all patients in the original patient study group. Patients were requested to complete the Oxford elbow score (OES), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a validated patient satisfaction questionnaire. Patients were requested to attend a face-to-face assessment where they underwent a clinical examination including neurovascular assessment, range-of-motion and an assessment of ligamentous stability. Seventy-one patients (65%) from the original patient study group agreed to participate in the study. The mean duration of follow-up was 19.3 years. At final follow-up patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbows. The mean DASH score was 5.22 points and the mean Oxford Elbow Score was 91.6 points. The mean satisfaction score was 90.9 points. Our study shows that the excellent outcomes following treatment with a protocol of a short period of splinting and early movement remain excellent and are maintained into the very long term. These findings support our hypothesis that this treatment protocol is appropriate and suitable for most patients with simple dislocations of the elbow. The role for primary ligamentous repair for this patient group should be carefully considered. Work to more clearly define the anticipated benefits of surgery for specific patient groups or injury patterns would help to support informed decision making

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Introduction. Sheffield Children's Hospital specialises in limb lengthening for children. Soft tissue contracture and loss of range of motion at the knee and ankle are common complications. This review aims to look at therapeutic techniques used by the therapy team to manage these issues. Materials & Methods. A retrospective case review of therapy notes was performed of femoral and tibial lengthening's over the last 3 years. Included were children having long bone lengthening with an iIntramedullary nail, circular frame or mono-lateral rail. Patients excluded were any external fixators crossing the knee/ankle joints. Results. 20 tibial and 25 femoral lengthening's met the inclusion criteria. Pathologies included, complex fractures, limb deficiency, post septic necrosis and other congenital conditions leading to growth disturbance. All patients had issues with loss of motion at some point during the lengthening process. The knee and foot/ankle were equally affected. Numerous risk factors were identified across the cohort. Treatment provided included splinting, serial casting, bolt on shoes, exercise therapy, electrical muscle stimulation and passive stretching. Conclusions. Loss of motion in lower limb joints was common. Patients at higher risk were those with abnormal anatomy, larger target lengthening's, poor compliance or lack of access to local services. Therapy played a significant role in managing joint motion during treatment. However, limitations were noted. No one treatment option gave preferential outcomes, selection of treatment needed to be patient specific. Future research should look at guidelines to aid timely input and avoid secondary complications

Over 500 supracondylar humerus fractures (SCHF) are treated at our institution each year. Our standard post-operative pathway includes a 3-week visit for splint removal, wire removal, and radiographs. Subsequent follow-up occurs at 12 weeks for a clinical examination. In an effort to minimize unnecessary follow-up visits, we investigated whether photographs and/or patient-reported outcome measure (PROM) scores could identify patients who do not need routine 3-month in-person follow-up. At the 3-month visit, 248 SCHF patients (mean 6.2 yrs; 0.75-11yrs) had bilateral elbow motion (ROM) and carrying angles measured; and photographs documenting frontal and sagittal alignment of both injured and uninjured upper extremities, in both maximum elbow flexion and extension. Two independent assessors made the same measurements off the clinical photographs to compare these with the clinical measurements. Two PROMs: Self-Assessment Questionnaire (SAQ: 0 best to 14 worst) and QuickDASH (0 best to 100 worst) were completed at the 3-month visit. Inter-rater reliability of the photograph measurements was excellent (Kappa: 0.88-0.93), but weakly concordant with clinical measurements (carrying angle Kappa=0.51;max flexion Kappa=0.68;max extension Kappa=0.64). SAQ moderately correlated with QuickDASH (Kappa=0.59) and performed better at identifying patients with abnormalities. SAQ score ≥ 4 identified patients meeting 3-month follow-up criteria, with sensitivity: 36.1%; specificity: 96.8% and negative-predictive-value (NPV): 87%. We did not find that photographs were reliable. Although SAQ-score has high NPV, a more sensitive fracture-specific PROM is needed to identify patients who do not need a 3-month follow-up visit

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

Softcast is an attractive alternative to POP for unstable forearm fractures, providing a comfortable, water-resistant splint that can be removed without a plaster saw. Unreinforced Softcast has, however, only been recommended for buckle fractures. A laboratory study was undertaken to compare standardised POP, Softcast and reinforced Softcast splints at clinically relevant endpoints. The load at clinical failure of a 6-wrap Softcast forearm splint was 504N in bending, 202N in kinking, and 11Nm in torsion (equalling 30.4%, 26% and 42.2% of the equivalent values for a circumferential 4-wrap POP). Softcast was however stronger in all modes than a fibreglass-reinforced Softcast splint, such has been recommended for acute fractures. Furthermore, the load to failure in all modes exceeds that which can be exerted by body weight in many paediatric patients. Softcast demonstrated complete recovery of its original shape on unloading, and was 4% lighter than POP. A 6-wrap Softcast splint provides adequate mechanical stability and protection for paediatric patients up to 20kg, not engaged in high-risk activities. The primary risk is not of fracture angulation and loss of position, but temporary indentation of the splint, causing discomfort or pain. Considering its ease of removal, Softcast may be preferable for younger paediatric patients

Background. Proximal phalangeal fractures are caused by an injury to the dorsum of the hand. This usually causes volar angulation which is unstable when reduced. K-wiring or external fixation can damage the soft tissue envelope, can introduce infection and can loosen or displace. Traction splinting is not well described for these fractures. Objectives. Functional and radiographic assessment of all patients with proximal phalangeal fractures treated with traction splinting. Methods. Theatre records were examined for relevant injuries over a 2 year period. These patients were then assessed using a QuickDASH score, a questionnaire specific to traction splinting and with pre-op, intra-op, post-op and follow-up radiographs. Results. A total of 7 patients were treated with traction splinting, all by the senior author (FJS). Clinical follow was 16 months (range12-20). QuickDASH scores were 0, 0, 0, 0, 0, 2.5, 25/100. With regard to work (n=6), all patients but one scored 0/100 for disability with one patient describing mild work related difficulties. Those participating in sports/performing arts (n=6) scored 0/100. There were no finger-tip pain or numbness issues. Finger length perception was satisfactory in all patients. The splint slipped in 3 patients, secondary to horse riding, showering and through scratching. Two patients reported having a measurable loss of motion in the affected digit (follow-up 18 and 20 months), both with mild functional deficit. Radiographic outcomes showed that traction achieved acceptable length restoration, with no angular deformities. Finger length was maintained in all but one patient who had a shortening of 3.2mm. Conclusions. Traction splinting is a non-invasive, safe and inexpensive method of treating proximal phalangeal fractures. Results of our follow-up study show excellent functional and radiographic outcomes with minimal long term morbidity for this treatment option

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

We present a complete audit cycle of Emergency Department (ED) management of paediatric buckle fractures of the distal radius at Derriford Hospital. Local hospital management guidelines state that the limb should be supported in a wrist splint for 3 weeks following injury and, provided parents are adequately educated, no formal follow-up is required. Auditable standards were obtained from the local guidance. An initial audit cycle of 54 cases identified shortcomings in compliance with guidelines. These included: Inappropriate immobilisation in 34 (63%) cases, omission of written advice in 35 (65%) cases and arrangement of unnecessary follow-up in 31 (57%) cases. Following circulation of the results, ‘aide-memoir’ icons were added to the emergency department computer coding system, teaching sessions for emergency department staff were organised and new paediatric specific wrist splints were introduced. A re-audit of 33 patients evaluated the effect of the changes. This demonstrated a 27% improvement in correct wrist support usage (27/33, 82%) and 25% fewer unnecessary referrals to fracture clinic (27/33, 82%). Staff training and provision of appropriate wrist splints were crucial to improving the adherence to guidance. This resulted in standardisation of care, fewer unnecessary appointments for patients and cost savings to the hospital trust

The Gartland extension-type supracondylar humerus fracture is the most common elbow fracture in the paediatric population. Depending on fracture classification, treatment options range from nonoperative treatment such as taping, splinting or casting to operative treatments such as closed reduction and percutaneous pinning or open reduction. Classification variability between surgeons is a potential contributing factor to existing controversy over nonoperative versus operative treatment for Type II supracondylar fractures. The purpose of this study was to investigate levels of agreement in classification of extension-type supracondylar humerus fractures using the Gartland classification system. A retrospective chart review was conducted on patients aged 2–12 years who had sustained an extension-type supracondylar fracture and received either operative or nonoperative treatment at a tertiary children's hospital. De-identified baseline anteroposterior (AP) and lateral plain elbow radiographs were provided along with a brief summary of the modified Gartland classification system to surgeons across Canada, United States, Australia, United Kingdom and India. Each surgeon was blinded to patient treatment and asked to classify the fractures as Type I, IIA, IIB or III according to the classification system provided. A total of 21 paediatric orthopaedic surgeons completed one round of classification, of these, 15 completed a second round using the same radiographs in a reshuffled order. Kappa values using pre-determined weighted kappa coefficients were calculated to assess interobserver and intraobserver levels of agreement. In total, 60 sets of baseline elbow radiographs were provided to survey respondents. Interobserver agreement for classification based on the Gartland criteria between surgeons was a mean of 0.68, 95% CI [0.67, 0.69] (0.61–0.80 considered substantial agreement). Intraobserver agreement was a mean of 0.80 [0.75, 0.84]. (0.61–0.80 substantial agreement, 0.81–1 almost perfect agreement). Radiographic classification of extension-type supracondylar humerus fractures at baseline demonstrated substantial agreement both between and within surgeon raters. Levels of agreement are substantial enough to suggest that classification variability is not a major contributing factor to variability in treatment between surgeons for Type II supracondylar fractures. Further research is needed to compare patient outcomes between nonoperative and operative treatment for these fractures, so as to establish consensus and a standardized treatment protocol for optimal patient care across centres

Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury. We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status. 70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up. Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures

Background. The British Orthopaedic Association Standards for Trauma (BOAST) for peripheral nerve injuries. 1. states:. “A careful examination of the peripheral nervous and vascular systems must be performed and clearly recorded for all injuries. This examination must be repeated and recorded after any manipulation or surgery.”. This study investigated whether this standard was met for patients with upper limb trauma at a busy London Accident and Emergency (A&E) Department. Method. Data was gathered prospectively from A&E admission notes for 30 consecutive patients with upper limb injuries from the week beginning 11. th. March 2013. Eligibilty: All patients with upper limb injuries. Results. 30 patients: 18 Males mean age of 39.2 and 12 Females mean age of 40.1. 17 patients (56.6%) had documentation of examination of neurovascular status. 14 patients required manipulation and/or splinting of their injury. Of these, no patients had their neurovascular examination documented after the procedure. Poor adherence to the standard is evident across all grades of doctors: FY2, SHO and SpR. Conclusion. There is clear scope to improve documentation of neurovascular status in upper limb injuries. It is especially important to clearly document neurovascular status following manipulation or splinting from a medico-legal perspective. This applies to all grades of staff in A&E. Recommendations. 1. Education of A&E staff of all grades at the departmental induction. 2. Posters in A&E with simple treatment algorithm for managing fractures and dislocated joints. 3. Re-audit in 6 months

Aims

Weightbearing instructions after musculoskeletal injury or orthopaedic surgery are a key aspect of the rehabilitation pathway and prescription. The terminology used to describe the weightbearing status of the patient is variable; many different terms are used, and there is recognition and evidence that the lack of standardized terminology contributes to confusion in practice.

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

Aims

As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach.

Chronic plantar fasciitis is a common condition but can be difficult to successfully treat. Platelet rich plasma (PRP), a concentrated bioactive component of autologous blood rich in cytokines and other growth factors, was compared with cortisone injection in the treatment of severe cases of plantar fasciitis resistant to traditional non-operative paradigms. Thirty-six patients (16 males 20 females) were prospectively randomized into two study groups. All patients had pre-treatment MRI and ultrasound studies consistent with plantar fasciitis. The first group was treated with a single ultrasound guided injection of 40 mg Depo-Medrol at the injury site and the second group was treated with a single ultrasound guided injection of un-buffered autologous PRP at the injury site. The cortisone group had an average age of 59 (24–74) and had failed 4 months (3–24) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 52 (24–60). The PRP group had an average age of 51 (21–67) and had failed 5 months (3–26) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 37 (30–56). All patients were then immobilized fully weight bearing in a cam walker for 2 weeks, started on eccentric home exercises and allowed to return to normal activities as tolerated and without brace support. Post-treatment AOFAS scores were PRP 95 (84–100) and cortisone 81(60–90) at 3 months (CI 95% p< .0001), PRP 95 (86–100) and cortisone 81 (60–90) at 6 months (CI 95% p< .0001), and PRP 94 (86–100) and cortisone 58 (45–77) at 12 months (CI 95% p< .0001). Platelet rich plasma injection is more effective and durable than cortisone injection for the treatment of severe chronic plantar fasciitis refractory to traditional non-operative management

The etiology of the flexion contracture is related to recurrent effusions present in a knee with end-stage degenerative joint disease secondary to the associated inflammatory process. These recurrent effusions cause increased pressure in the knee causing pain and discomfort. Patients will always seek a position of comfort, which is slight flexion. Flexion decreases the painful stimulus by reducing pressure in the knee and relaxing the posterior capsule. Unfortunately, this self-perpetuating process leads to a greater degree of contracture as the disease progresses. Furthermore, patients rarely maintain the knee in full extension. Even during the gait cycle the knee is slightly flexed. As their disease progresses, patients limit their ambulation and are more frequently in a seated position. Patients often report sleeping with a pillow under their knee or in the fetal position. All of these activities increase flexion contracture deformity. Patients with excessive deformity >40 degrees should be counseled regarding procedural complexity and that increasing constraint may be required. Patients are seen preoperatively by a physical therapist and given a pre-arthroplasty conditioning program. Patients with excessive flexion contracture are specifically instructed on stretching techniques, as well as quadriceps rehabilitation exercises. The focus in the postoperative physiotherapy rehabilitation program continues toward the goal of full extension. Patients are instructed in appropriate stretching regimes. Patients are immobilised for the first 24 hours in full extension with plaster splints, such as with a modified Robert Jones dressing. This dressing is removed on postoperative day one. The patient is then placed in a knee immobiliser and instructed to wear it at bed rest, during ambulation and in the evening, only removing for ROM exercises. In cases of severe flexion deformity >30 degrees, patients are maintained in full extension for 3–4 weeks until ROM is begun. Patients are encouraged to use a knee immobiliser for at least the first 6 weeks postoperatively. Treating patients with flexion contracture involves a combination of bone resection and soft tissue balance. One must make every effort to preserve both the femoral and tibial joint line. In flexion contracture the common error is to begin by resecting additional distal femur, which may result in joint line elevation and mid-flexion instability. The distal femoral resection should remove that amount of bone being replaced with metal. Attention should be directed at careful and meticulous balance of the soft tissues and release of the contracted posterior capsule with re-establishment of the posterior recess, which will correct the majority of flexion contractures. Inability to achieve ROM after TKA represents a frustrating complication for both patient and surgeon. Non-operative treatments for the stiff TKA include shoe lift in contralateral limb, stationery bicycle with elevated seat position, extension bracing, topical application of hand-held instruments to areas of soft tissue-dysfunction by a trained physical therapist over several outpatient sessions, and use of a low load stretch device. Manipulation under anesthesia is indicated in patients after TKA having less than 90 degrees ROM after 6 weeks, with no progression or regression in ROM. Other operative treatments range from a downsizing exchange of the polyethylene bearing to revision with a constrained device and low-dose irradiation in cases of severe arthrofibrosis