Conservative treatment of scaphoid fracture: Protocol for a systematic review

The scaphoid is the most commonly fractured carpal bone. Fractures affecting this bone affect young and active patients between 15 and 40 years of age. Stable scaphoid fractures are treated conservatively by plaster cast immobilization or other type of orthosis for an average period of four to 12 weeks. Failure to treat scaphoid fractures may result in avascular necrosis, nonunion, and early secondary osteoarthritis, which may result in significant economic and social impact due to the affected population, formed by young people of productive age. The management of this type of fracture varies significantly between different Institutions and orthopedic surgeons. This article describes a protocol for a systematic review that aims to evaluate the effects (benefits and harms) of conservative interventions in the treatment of scaphoid fractures in adults.

Popliteal Artery Injury Following Traumatic Knee Dislocation – Case Report

Knee dislocation is a devastating injury that can compromise the limb's viability. This trauma is associated with muscular and ligamentar extensive lesions. Obese patients can suffer of knee dislocation resultant from falls at the same level, and these “super-low” energy dislocations are associated with a surprising rate of neurovascular complications. The popliteal artery may be involved in up to 60% of cases, and the prognosis is considerably worse. In these cases an emergent approach is mandatory. Delayed diagnosis and treatment can result in up to 80% of amputations of the extremity. The authors present a patient that was admitted at the Emergency Room with knee pain and deformity after a fall at the same high. After the diagnose and reduction of the anterior dislocation, an echo-doppler and CT angiography were performed, and revealed a lesion in popliteal artery. After immobilized with a long leg plaster cast, the patient was transferred to a hospital with Vascular Surgery Department, and underwent revascularization of the limb. Despite the severity of the vascular injury the patient had a very good outcome.

Cast OFF-2: 1 week of plaster cast immobilization for non-reduced distal radius fractures—a study protocol for an implementation study

Background The distal radius fracture (DRF) is a common fracture, with the majority of these fractures being stable. Of all diagnosed fractures, 17% is a DRF, of which a large part is extra-articular and one-third is non-displaced. There is a large variation in treatment advisements for non-reduced DRF. Four to 5 weeks of immobilization is often the usual practice. Existing evidence shows that 1 week of immobilization is safe and does not lead to an increase in secondary displacement. Additionally, shorter immobilization periods may lead to less outpatient clinic visits and less home care for elderly people and may lead to earlier return to work and other social activities. Therefore, shorter immobilization periods for non-reduced distal radius fractures may also prove to be cost-effective. In this study, we aim to successfully implement 1 week of plaster cast immobilization for non-reduced distal radius fractures in twelve medical centers and to evaluate the functional outcome and cost-effectiveness. Methods This study will be performed using a multicenter randomized stepped wedge design in 12 centers. We aim to include in the study 440 patients with an isolated non-reduced DRF between the age of 18 and 85 years old. The patients in the intervention group will be treated with plaster cast immobilization for 1 week. Acceptability of the study protocol, patient-reported outcomes, quality of life, complications, pain catastrophizing score, pain and patient satisfaction, and cost-effectiveness will be measured. The total follow-up will be 12 months. Discussion The strength of this study is the combination of implementing 1 week of plaster cast immobilization for non-reduced DRF and the evaluation of functional outcome, acceptability of the study protocol, and cost-effectiveness in actual practice. Trial registration Netherlands Trial Register NL9278. Registered on 17 February 2021

EP.FRI.771 National audit on VTE prophylaxis for lower limb injuries treated in a plaster cast

Aims Audit to assess Orthopaedic departments’ compliance with NICE guidelines on Venous thromboembolism (VTE) prophylaxis published in 2010, specifically looking at VTE practices for patients with lower limb injuries treated in a plaster cast. Methods A telephonic survey was carried out on junior doctors within orthopaedic departments of 66 hospitals across all regions of England. A questionnaire was completed regarding VTE risk assessment, prophylaxis and hospital guidelines etc. Data collected from August 2016 till February 2017. Results 83% (n = 55) of trusts routinely give VTE prophylaxis to these patients. 96% (n = 64) give Chemoprophylaxis of some sort. Formal VTE assessments are performed in 81% (n = 54) and 77% (n = 51) have a local VTE prophylaxis policy. Conclusions We conclude that Orthopaedic departments across England have increased compliance with NICE guidelines for VTE prophylaxis. However there is considerable variation in practice, especially in duration and chemoprophylaxis agent. We attribute this to the lack of specific NICE guidelines for this cohort of patients. We aim that this study can influence NICE to introduce added guidance that will standardise practice.

Cast-OFF Trial: One Versus 4 to 5 Weeks of Plaster Cast Immobilization for Nonreduced Distal Radius Fractures: A Randomized Clinical Feasibility Trial

Background Distal radius fracture is a common fracture of which the incidence appears to be increasing worldwide. This pilot study investigated whether 1 week of plaster cast is feasible for nonreduced (stable fractures including nondisplaced and displaced fractures) distal radius fractures. Methods The study was a multicenter randomized clinical feasibility trial including patients from regional acute care providers. Patients with a nonreduced distal radius fracture were included in the study. Nonreduced fractures meant intra-articular or extra-articular fractures and including nondisplaced and minimal displaced fractures (dorsal angulation less than 5°-10°, maximum radial shortening of 2 mm, and maximum radial shift of 2 mm) not needing a reduction. Forty Patients were included and randomized. After 1 week of plaster cast, patients were randomized to 1 of the 2 treatment groups: plaster cast removed (intervention group) versus 4 to 5 weeks of plaster cast (control group). Results The analysis shows no significant differences between the 2 groups in having less pain, better function after 6 weeks, and better overall patient satisfaction. No difference was shown in secondary displacement between the 2 groups (control 1 vs intervention 0) Conclusion One week of plaster cast treatment for nonreduced distal radius fracture is feasible, preferred by patients, with at least the same functional outcome and pain scores. Level of Evidence According to the Oxford 2011 level of evidence, the level of evidence of this study is 2.

Inveterate elbow dislocation: surgical reduction with triceps lengthening

Inveterate elbow dislocations remain common in developing countries. We report the case of a 17-year-old child who consulted us after six months of trauma to the left elbow. Clinical examination revealed a deformed elbow, locked in extension with a mobility sector of 5°. The Mayo Clinic Elbow performance score was sixty-six; the downstream vasculo-nervous examination was normal. The face and profile X-ray of the elbow showed a pure posterolateral elbow dislocation. We used the posterior medial para-tricipital and lateral approach, a first stage of arthrolysis was performed. A complete reduction was achieved by progressive and non-traumatic gentle maneuvers. Intraoperative elbow flexion was less than 80°, indicating a retraction of the triceps muscle, so a Z-lengthening plasty was necessary. This reduction was then fixed with two olecranon-humeral K-wires. At the third week, the plaster cast and K-wires were removed. The patient was subsequently referred to a physical therapist. After a ten-month follow-up, an undistorted and functional elbow with a gain of twenty-one points according to the Mayo Clinic score was obtained. Surgical reduction of a neglected elbow dislocation with triceps lengthening plasty, followed by a codified physical therapy program, results in a remarkable restoration of elbow function and stability. Keyword : elbow, dislocation, inveterate, reduction, triceps.

An overview on the treatment and outcome factors of ankle fractures in elderly men and women aged 80 and over: a systematic review

Introduction This article is a systematic review of the literature on elderly aged 80 and over with an ankle fracture. Low energy trauma fractures are a major public health burden in developed countries that have aged populations. Ankle fractures are the third most common fractures after hip and wrist fractures. The purpose of this review is to provide an overview of the treatments and the used outcome factors. Methods PubMed, Embase, Cochrane Library, and CINAHL were searched to retrieve relevant studies. Studies published in English or Dutch concerning the treatment of ankle fractures in patients aged 80 and over were included. Results Initially 2054 studies were found in the databases. After removing duplicate entries, 1182 remained. Finally, after screening six studies were included, of which three cohorts studies and three case series. Six different treatments were identified and described; ORIF, transarticular Steinmann pin, plaster cast with or without weight-bearing, Gallagher nail and the TCC nail. Furthermore, 32 outcome factors were identified. Discussion The various studies show that practitioners are careful with early weight-bearing. However, if we look closely to the results and other literature, this seems not necessary and it could potentially be of great value to implement early weight-bearing in the treatment. Furthermore, quality of life seems underreported in this research field. Conclusions ORIF with plaster cast and permissive weight-bearing should be considered for this population since it seems to be a safe possibility for a majority of the relatively healthy patients aged 80 and over. In cases where surgery is contra-indicated and a plaster cast is the choice of treatment, early weight-bearing seems to have a positive influence on the outcome in the very old patient.

A New Technique of Osteosynthesis in Case of the Posterior Facet Fracture of the Distal Tibial Metaepiphysis

The authors presented the results of surgical treatment of 103 patients with posterior facet fractures of the distal tibial metaepiphysis, treated at the BNICTO from 2014 to 2021. 58 (56.3%) patients made up the control group, who underwent osteosynthesis of the posterior facet fractures of the distal tibial metaepiphysis using previously known methods. In the postoperative period, the ankle joint was immobilized with a plaster cast and the patients received rehabilitation according to the traditional method. The main group included 45 (43.7%) patients. He underwent osteosynthesis of the posterior margin fracture using a new technique, postoperative rehabilitation was carried out using an improved rehabilitation technique. Complex treatment of patients with posterior facet fractures of the distal tibial metaepiphysis, including a new method of osteosynthesis of the posterior facet fractures of the distal tibial metaepiphysis made it possible to increase the number of excellent treatment results from 8.7% to 16.3% 3 times (1.9%), good results from 56.5% to 70.3% 2 times (1.2%), reduce the percentage of unsatisfactory results from 17.3% to 5.4% – in 2 times (by 3.2%) (p <0.001), the average length of hospital stay is 1.5 times (from 11.5 to 7.6 days) (p <0.001) and to increase the efficiency of restoring the function of the ankle joint in 1, 2 times (p <0.001) compared with patients in the control group.