Temporarily double-pin external fixator fixation following unstable ankle fracture

This study designed a new type of double-pin external fixator for temporary fixation of unstable ankle fractures, and the safety and effectiveness of this fixation method were explored. Cases were included in patients with ankle fractures treated in the Department of Traumatology and Orthopedics at Peking University People's Hospital from February 2016 to February 2020. Two groups of cases were obtained (cast group, n=19; double-pin external fixator group, n=21). All cases received the same postoperative care, and the VAS score before and after temporary fixation, the maintenance of fracture reduction, the complications of temporary fixation and the interval time were recorded. All patients completed follow-ups. There were 4 cases and 0 cases of complications in the cast and double-pin external fixator groups respectively. 6 cases and 1 case each had a loss of reduction in the cast and double-pin external fixator groups respectively. There was no difference in interval time for final open reduction with internal fixation between the two groups. The post-fixation VAS score of the double-pin external fixator group was significantly lower than that of the cast group. This technique is a simple, safe, and effective treatment for the temporary reduction of unstable ankle fractures with double-pin external fixator which can relieve patients' pain, effectively maintain the length of the lateral malleolus, and create good soft tissue conditions for elective surgery under the state of grasping the indications strictly.

Management of Distal 1/3rd Closed Forearm Fractures in Children above Elbow Plaster Cast versus Below Elbow Plaster Cast

Objective: To determine if below-elbow casts are as effective as above-elbow casts in the treatment of the distal third closed forearm fractures in children. Materials and Methods: This was a prospective comparative study and was conducted at orthopaedic department of Liaquat University of Medical and Health Sciences (LUMHS). Children 4 to 12 years of age who presented to, distal 1/3rd fractures of the forearm were randomized in order to manage with either an above-elbow or below-elbow cast after closed reduction under fluoroscopic guidance. Radiographic analysis was done for angulation and displacement at the injury time, following reduction, and at subsequent intervals of follow-up. At the fracture level, the cast index for evaluating the cast moulding quality was assessed from the post-reduction radiographs. Variations between post-reduction and final values for displacement and angulation, the range of motion of elbow, forearm and wrists and cast indices between the two groups were compared. Results: Of total 50 study subjects, 26 underwent above-elbow cast and 24 subjects underwent below-elbow cast techniques. Mean age of above-elbow cast group patients was 9.42 year and the mean age in of below-elbow cast group patients was 9.13 years. 15 male and 11 female patients were present in above-elbow cast group; 14 male and 10 female patients were present in below-elbow cast group. The mean cast index of above-elbow cast group was 0.71 and the mean cast index of below-elbow cast was 0.70. In terms of patient demographics, injury mechanism, characteristics of initial fracture, cast index or shift in displacement and angulation during treatment, no significant variances were observed between both groups. In above-elbow cast group, the mean elbow arc of motion on cast removal at six weeks was only 78° compared to 141.6° in below-elbow cast group. There was a significant decline in arc of motion of elbow joint in above-elbow cast group compared to below-elbow cast group in six weeks which became normal at final follow-up in three months. The complication rates in both the groups were similar. Conclusion: Below-elbow cast is the safe reliable and cost-effective method of cast immobilization in distal third forearm fractures in the children of 4 to 12 years of age.

Comparing the Results of Treatment Methods of Casting and Bandage of Ankle Sprain in the Patients Who Referred to the Emergency Department of Poursina Hospital in the First Half of Year 2019

Background: The purpose of this study is a comparative survey of the effect of casting and bandage treatments in ankle sprain in order to be effective in determining the more desirable method for returning the patients to work and activities as fast as possible especially in important sport activities. Methods: In this study the referents to Emergency Department of Poursina hospital whose diagnosis was ankle sprain and needed treatment have been used. The patients who have been examined, categorised based on Clanton and Mcgravey classification and the intensity of ligaments injury in type II, group II, type A. (type II: unstable ankle with positive anterior drawer test or positive talar tilt test or both, group II: athlete or high demand patient, type A: negative radiographic stress test; functional treatment). The patients who had necessary criteria to enter this study have been divided into two groups A (casting) and B (bandage) randomly. Then, they have been re-examined after 3, 6 and 12 weeks of treatment and their cast or bandage has been removed and re-examined and the results of treatment have been assessed and compared in terms of total treatment or recurrent sprain and returning to work and activities and pain intensity. Results: Pain intensity based on VAS had lower average in cast group comparing to bandage group after 3 and 6 weeks and this difference was statistically significant. AHS criterion in both groups had the same average after 3, 6 and 12 weeks. Activity restriction time was lower in cast group comparing to bandage group significantly. Conclusions: This study showed that cast therapy led to reduction of activity restriction time and consequently fast returning to work and daily activities, but in bandage group pain intensity reduced faster.

Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT

Background Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased. Objective To compare the clinical effectiveness and cost-effectiveness of surgical fixation with cast treatment and early fixation in adults with scaphoid waist fractures that fail to unite. Design Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and a nested qualitative study. Setting Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013, with final follow-up in September 2017. Participants Adults (aged ≥ 16 years) presenting within 2 weeks of injury with a clear, bicortical fracture of the scaphoid waist on plain radiographs. Interventions Early surgical fixation using Conformité Européenne-marked headless compression screws. Below-elbow cast immobilisation for 6–10 weeks and urgent fixation of confirmed non-union. Main outcome measures The primary outcome and end point was the Patient-Rated Wrist Evaluation total score at 52 weeks, with a clinically relevant difference of 6 points. Secondary outcomes included Patient-Rated Wrist Evaluation pain and function subscales, Short Form questionnaire 12-items, bone union, range of movement, grip strength, complications and return to work. Results The mean age of 439 participants was 33 years; 363 participants were male (83%) and 269 participants had an undisplaced fracture (61%). The primary analysis was on 408 participants with valid Patient-Rated Wrist Evaluation outcome data for at least one post-randomisation time point (surgery, n = 203 of 219; cast, n = 205 of 220). There was no clinically relevant difference in the Patient-Rated Wrist Evaluation total score at 52 weeks: the mean score in the cast group was 14.0 (95% confidence interval 11.3 to 16.6) and in the surgery group was 11.9 (95% confidence interval 9.2 to 14.5), with an adjusted mean difference of –2.1 in favour of surgery (95% confidence interval –5.8 to 1.6; p = 0.27). The non-union rate was low (surgery group, n = 1; cast group, n = 4). Eight participants in the surgery group had a total of 11 reoperations and one participant in the cast group required a reoperation for non-union. The base-case economic analysis at 52 weeks found that surgery cost £1295 per patient more (95% confidence interval £1084 to £1504) than cast treatment. The base-case analysis of a lifetime-extrapolated model confirmed that the cast treatment pathway was more cost-effective. The nested qualitative study identified patients’ desire to have a ‘sense of recovering’, which surgeons should address at the outset. Limitation There were 17 participants who had initial cast treatment and surgery for confirmed non-union, which in 14 cases was within 6 months from randomisation and in three cases was after 6 months. Three of the four participants in the cast group who had a non-union at 52 weeks were not offered surgery. Conclusions Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Patients should be followed up at 5 years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life. Trial registration Current Controlled Trials ISRCTN67901257. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 52. See the NIHR Journals Library website for further project information.

Complementary Cast Immobilization Is Not Necessary after Intramedullary Fixation of Unstable Tibial Shaft Fractures in Pediatric Patients

Introduction Some surgeons believe that patients with benefit of additional stability provided by a cast after the treatment of pediatric tibia fractures with elastic stable intramedullary nails. Whereas in some institutions, complementary immobilization is not used after elastic stable intramedullary nails (ESIN). At our trauma center, half of our surgeons treat tibia fractures with ESIN alone and half use complementary casting. We hypothesized that our outcomes are the same between the two groups. Materials and Methods Patients with tibia shaft fractures were treated in accordance with the preference of attending surgeon with one of two initial interventions: ESIN or ESIN and complementary immobilization with long-leg cast. Outcomes of these two treatment groups were compared. The main outcome variables were redisplacement and angulation at the time of union. Results Treatment groups did not differ significantly on sex, type of fracture, or on age. Four patients developed a varus malalignment exceeding 10 degrees during first 2 weeks of follow-up and were corrected in the outpatient clinic by application of wedging cast. Three out the four were originally in the no cast group (p = 0.3). Final angulation and time to union were higher in no cast group, but there was no statistical significance (p = 0.5 and p = 0.4). Conclusion This study showed good outcomes in both treatment methods without any surgical deformity correction after operative treatment. Though we could not find any advantages in complementary casting.

Delaying Premolar Extraction for Conservation of Anchorage: A Prospective Case Control Study

Introduction: Anchor loss (AL) is the most common side effect of orthodontic treatment. Anchorage planning is the vital step of every orthodontic treatment. The aim of this study was to evaluate the amount of anchor loss of maxillary first permanent molar in early v/s delayed premolar extraction cases treated using fixed orthodontic mechanotherapy. Materials & Method: Sixty orthodontic patients, having either Class I or Class II Division 1 malocclusion with no or minimal crowding were divided equally into early extraction and the delayed extraction group (30 each). The patients were treated using MBT prescription 022” slot brackets with standard wire sequencing until 0.019”x 0.025” stainless-steel wire. Pre and post levelling study models were used for assessing the amount of space loss using palatal rugae as a stable point from the points marked on the 1st molar (point A on mesiobuccal cusp and point B on the distobuccal cusp). The obtained data was tabulated and was subjected to statistical t test (p<0.05). Result: The distance of point A to the 3rd rugae reduced after treatment by 0.39mm (3.4%) and by 0.48 mm (3.24%) in delayed and early extraction groups respectively. Similarly, the distance from point B was reduced by 0.48 mm (3.24%) and by 1.77mm (6.28%) in delayed and early extraction group respectively. The change in point A and point B in Early extraction cast group was 76% and 71% more respectively than the delayed Extraction cast group. All the findings were statistically significant (p<0.05). Conclusion: Anchor loss is an inevitable after effect following premolar extraction. Greater chances of anchor loss in early extraction group is noted. And delaying premolar extraction in cases with mild crowding (<4mm) can effectively help in anchorage preservation.

Below-elbow or above-elbow cast for conservative treatment of extra-articular distal radius fractures with dorsal displacement: a prospective randomized trial

Background Distal radial fractures are common traumatic injuries, but their management remains controversial also in case of conservative treatment regarding the type of immobilisation. Hence, we conducted a two-arm, parallel-group, prospective randomised trial to compare the capacity of long casts (above-elbow) and short casts (below-elbow) to maintain the reduction of extra-articular distal radius fractures with dorsal displacement (AO/OTA classification: 2R3A2.2). Methods Seventy-four eligible patients with AO/OTA 2R3A2.2 fractures treated with closed reduction and cast immobilisation were randomised to the long cast group (n°= 37) or to the short cast group (n°= 37). Baseline radiological parameters, radial inclination (RI), radial height (RH), ulnar variance (UV) and palmar tilt (PT) were taken, and compared with clinical (DASH, Mayo Wrist and Mayo Elbow) and radiological scores taken at 7–10 days, 4 weeks and 12 weeks. Furthermore, to evaluate correlations between radiological parameters and functional outcomes, patients were divided into two groups according to whether or not their radiological parameters at Follow-ups 2 and 3 were acceptable, i.e. within the range 11–12 mm for RH, 16°–28° for RI, − 4–+ 2 mm for UV and 0°–22° for PT. Results Patient demographic and baseline radiological parameters were similar between groups. At follow-up, there were no statistically significant differences between the two types of cast in terms of RI, RH, UV or PT, or Mayo wrist or DASH scores. Short cast group patients displayed better Mayo elbow score at follow-up 2 (4 weeks), but this difference was no longer statistically significant at follow-up 3 (12 weeks). No statistically significant differences in clinical outcomes were found between patients who presented acceptable radiographic parameters at follow-up and those who did not. Conclusion As there were no significant differences between short casts and long casts in terms of fracture reduction maintenance or clinical outcomes, short casts are an effective method of post-reduction immobilisation in AO/OTA 2R3A2.2 fracture of the radius. Radiological parameters outside the range conventionally considered acceptable do not preclude a satisfactory clinical outcome. Trial registration ClinicalTrials.gov PRS, NCT04062110. Registred 20 August 2019.

To Compare the Functional Outcome of Intra Articular Distal end of Radius Fracture Treated by Conventional pop cast and External Fixatator Fixatation

Introduction: Distal end of radius fractures frequently have a high degree of comminution, instability, and associated with soft tissue injuries. Treatment of this distal radius fracture is controversial and there is no single definitive treatment method that is considered the standard of care. Objective: 1. To compare the functional results of the conventional POP cast and external fixator fixation of intra articular distal end of radius fracture. 2. To compare the radiological changes with that of functional outcome. Methodology: It was a prospective study comparing the functional outcome of distal intra-articular radius fracture when managed by conventional POP cast and external fixatator fixation. The final outcome was decided on the basis of modified Gartland and Werley scoring system. Total 50 patients (19 – 54 years) were recruited. 30 were treated by closed reduction and POP cast and 20 by external fixation. Radiological parameters were graded according to Schecks criteria and fracture comminution was classified according to Frykman's classification. Results: The functional outcome of the treatment was a subjective evaluation in which 80% of the patients had pain in external fixation as compared to 63% in closed reduction POP cast group. The restriction of activities was in 10% of the patient in external fixation group as compared with 33% in closed reduction POP cast group. The final scoring system as modification of Gartland and Werley point system had 5 ± 3 conventional pop cast group and 4 ± 4 in external fixation group. (p = 0.3764). On radiological evaluation, there was no significant difference in radial length, radial angle and volar tilt in two groups. Conclsion: The results show no statistically significant difference between the two modes of interventions. External fixation provides easy mobilization of fingers and reduces edema and stiffness of joints. The active ranges of movements at the wrist joints were significantly better in external fixation group.

Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial

ObjectiveTo determine whether treatment of isolated stable Weber B type ankle fractures with a cast or a simple orthotic device for three weeks produces non-inferior outcomes compared with conventional immobilisation in a cast for six weeks.DesignRandomised, pragmatic, non-inferiority, clinical trial with blinded outcome assessment.SettingTwo major trauma centres in Finland, 22 December 2012 to 6 June 2016.Participants247 skeletally mature patients aged 16 years or older with an isolated Weber B type fibula fracture and congruent ankle mortise in static ankle radiographs.InterventionsParticipants were randomly allocated to conventional six week cast immobilisation (n=84) or three week treatment either in a cast (n=83) or in a simple orthosis (n=80).Main outcome measuresThe primary, non-inferiority, intention-to-treat outcome was the Olerud-Molander Ankle Score at 12 months (OMAS; range 0-100; higher scores indicate better outcomes and fewer symptoms). The predefined non-inferiority margin for the primary outcome was −8.8 points. Secondary outcomes were ankle function, pain, quality of life, ankle motion, and radiographic outcome. Follow-up assessments were performed at 6, 12, and 52 weeks.Results212 of 247 randomised participants (86%) completed the study. At 52 weeks, the mean OMAS was 87.6 (SD 18.3) in the six week cast group, 91.7 (SD 12.9) in the three week cast group, and 89.8 (SD 18.4) in the three week orthosis group. The between group difference at 52 weeks for the three week cast versus six week cast was 3.6 points (95% confidence interval −1.9 to 9.1, P=0.20), and for the three week orthosis versus six week cast was 1.7 points (−4.0 to 7.3, P=0.56). In both comparisons, the confidence intervals did not include the predefined inferiority margin of −8.8 points. The only statistically significant between group differences observed in the secondary outcomes and harms in the two primary comparisons were slight improvement in ankle plantar flexion and incidence of deep vein thrombosis, both in the three week orthosis group versus six week cast group.ConclusionImmobilisation for three weeks with a cast or orthosis was non-inferior to conventional cast immobilisation for six weeks in the treatment of an isolated stable Weber B type fracture.Trial registrationClinicalTrials.govNCT01758835.

Conventional vs 3-Dimensional Printed Cast Wear Comfort

Background: The objective of this study was to determine the functionality of 3-dimensional (3D) printed orthoses for upper extremity immobilization compared with conventional immobilization. Methods: Twelve healthy volunteers were fitted with a 3D custom printed short arm cast and a short arm fiberglass cast in separate sessions. The Jebsen Hand Function Test (JHFT) was used to test function and dexterity in each cast. All volunteers completed a modified version of the Patient-Rated Wrist Evaluation (PRWE). Skin complications were recorded. Results: There were no significant differences during the JHFT between casts, although one-third of the participants in the 3D cast could perform the tasks in a normal time, which they could not in the fiberglass cast. The average PRWE function score was lower in the 3D cast group than in the fiberglass group (45.5 vs. 80.8). Minor skin irritation was noted in 42% of patients in the fiberglass cast group compared with only 1 patient (8%) in the 3D cast group. One patient in the fiberglass group required a cast change due to inappropriate fit. Conclusions: Both casting techniques demonstrate similar objective function based on the JHFT. Patient satisfaction, comfort, and perceived function are superior in the 3D printed casts.