BET 1: Functional treatment is non-inferior to below the knee cast in adults with acute closed proximal fifth metatarsal fractures.

A short cut review was carried out to establish whether functional treatment is better than conservative treatment with a below knee cast at decreasing time to functional recovery and fracture union in adults with an acute closed proximal fifth metatarsal fracture. Four papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that in proximal (zone 1 and 2) fractures of the fifth metatarsal functional treatment with immediate mobilisation is at least non-inferior to immobilisation in a cast.

[Occult fractures of extremities in adults and children. Exemplified by foot and ankle injuries]. / Okkulte Extremitätenfrakturen im Erwachsenen- und Kindesalter. Am Beispiel von Fuß- und Sprunggelenkverletzungen.

BACKGROUND: Occult fractures in children and adults cannot by definition be diagnosed by conventional radiographs. These injuries are usually recognized as bone marrow edema by magnetic resonance imaging (MRI). There are no randomized controlled trials or prospective cohort studies concerning the correct management of occult fractures and, therefore, no evidence-based treatment guidelines can be drafted. OBJECTIVES: This article summarizes the current diagnostic and treatment concepts for occult fractures under special consideration of foot and ankle injuries. METHODS: A selective search of the current literature was performed and also taking own experience into consideration. RESULTS AND CONCLUSION: The clinical prognosis of occult fractures is generally good and there is no evidence that these lesions need specific treatment. Besides forensic applications and problems pursuant to insurance law, MRI examination is only indicated when conventional radiographs are unremarkable, pain persists for an unusually long period of time and when a relevant therapeutic consequence can be expected from the MRI results. Classical pitfalls are combinations of occult fractures with potentially unstable ligamentous injuries and patients with disordered pain perception as in cases of diabetic polyneuropathy, as the common therapeutic concept of weight bearing according to pain is not suitable for these patients and can lead to severe complications.

Management of simple (types A and B) closed tibial shaft fractures using percutaneous lag-screw fixation and Ilizarov external fixation in adults.

PURPOSE: Although intramedullary fixation of closed simple (type A or B) diaphyseal tibial fractures in adults is well tolerated by patients, providing lower morbidity rates and better mobility, it is associated with some complications. This study evaluated the results of managing these fractures using percutaneous minimal internal fixation using one or more lag screws, and Ilizarov external fixation. METHODS: This method was tested to evaluate its efficacy in immediate weight bearing, fracture healing and prevention of any post-immobilisation stiffness of the ankle and knee joints. This randomised blinded study was performed at a referral, academically supervised, level III trauma centre. Three hundred and twenty-four of the initial 351 patients completed this study and were followed up for a minimum of 12 (12-88) months. Patient ages ranged from 20 to 51 years, with a mean of 39 years. Ankle and knee movements and full weight bearing were encouraged immediately postoperatively. Solid union was assessed clinically and radiographically. Active and passive ankle and knee ranges of motion were measured and compared with the normal side using the Wilcoxon signed rank test for matched pairs. Subjective Olerud and Molander Ankle Score was used to detect any ankle joint symptoms at the final follow-up. RESULTS: No patient showed delayed or nonunion. All fractures healed within 95-129 days. CONCLUSIONS: Based on final clinical and radiographic outcomes, this technique proves to be adequate for managing simple diaphyseal tibial fractures. On the other hand, it is relatively expensive, technically demanding, necessitates exposure to radiation and patients are expected to be frame friendly.

Nonoperative Treatment of Closed Extra-Articular Distal Humeral Shaft Fractures in Adults: A Comparison of Functional Bracing and Above-Elbow Casting.

Diaphyseal fractures of the distal humerus have a high rate of union when treated with a functional brace or an above-elbow cast (AEC). This study compares alignment of the humerus and motion of the elbow after functional brace or AEC treatment. One-hundred and five consecutive patients with a closed, extra-articular fracture of the distal humeral diaphysis were identified in the orthopedic trauma databases of 3 hospitals between 2003 and 2012. Seventy-five patients with a follow-up of at least 6 months or with radiographic and clinical evidence of fracture union were included (51 treated with functional bracing and 24 treated with an AEC). All of the fractures healed. The average arc of elbow flexion was 130° ± 9° in braced patients vs 127° ± 12° in casted patients. Four patients (8%) in the bracing group and 4 (17%) in the casting group lost >20° of elbow motion. The average varus angulation on radiographs was 17° ± 8° in braced and 13° ± 8° in casted patients, while the average posterior angulation was 9° ± 6° vs 7° ± 7°, respectively. Closed extra-articular distal diaphyseal humerus fractures heal with both bracing and casting and there are no differences in average elbow motion or radiographic alignment.

A Comparative evaluation of CBCT outcomes of two closed treatment methods in intracapsular condylar fractures.

PURPOSE: The cone beam computed tomography (CBCT) images of 2 closed treatments are compared for intracapsular condylar fractures (ICFs) to learn whether splint treatment could promote better radiologic outcomes. PATIENTS AND METHODS: Fifty-four patients with 60 sides of ICF were divided into 2 groups. In the control group (C-group), patients had a liquid diet for 1 month. In the trial group (T-group), patients wore splints with anterior elastic traction. Local CBCT images of the temporomandibular joint were obtained at T0 (mean 8.8 days), T1 (mean 37.4 days), and T3 (mean 3.3 months) after trauma. Six parameters, including 2 horizontal, 1 sagittal, and 3 vertical distances, were calculated using the coordinates of 10 points marked on CBCT sections. Statistical analysis included intragroup comparison at T0, T1, and T3, and intergroup comparison among subgroups classified by age and ICF types. RESULTS: Compared to C-group, vertical distances were significantly changed in T-group, specifically in adults and patients with ICF type B. Significant changes at stage T1 were also observed in T-group. CONCLUSION: During the natural healing process, ICF healed in the displaced position and the stump tended to move closer to the joint fossa in the vertical dimension. Splint treatment with elastic traction was helpful to increase joint space and promote better radiologic healing shape.

[Acute PIP joint fractures]. / Fractures récentes des articulations IPP.

Recent PIP fractures are challenging trauma in terms of diagnosis as well as treatment. It must be remembered that the final outcome will have a considerable impact on the global finger and hand function. Immediate mobilization and rehabilitation are mandatory, and may justify a surgical approach and fixation in selected cases. A good understanding of the fracture type is essential and relies in good part on precise, focused and standardized radiographs. Non-displaced fractures are generally treated conservatively. In the proximal phalanx, the orientation of the fracture line dictates the stability of the fracture. Thus non-displaced fractures can occasionally be preventively stabilized, in order to allow early mobilization. Displaced fractures should always be anatomically reduced and surgically fixed. A temporary joint stabilization is optional. In the middle phalanx, one must consider palmar and dorsal fractures differently. Palmar fractures include a distal palmar plate avulsion. The degree of impaction will dictate the stability of the joint towards dorsal subluxation. Dorsal fractures include central slip avulsion of the extensor tendon. An antomical reduction and surgical fixation is mandatory to avoid a progressive boutonniere deformity. Prognosis of all the middle fractures is closely dependent on the degree of impaction. When direct osteosynthesis is not possible, distraction devices, bone graft or palmar plate reconstruction may be useful alternatives. In complex fractures, bone fixation and joint stabilization must be combined in order to prevent secondary displacement and joint instability.

Comparison of two analgesia protocols for the treatment of pediatric orthopedic emergencies.

OBJECTIVE: to compare the efficacy of two analgesia protocols (ketamine versus morphine) associated with midazolam for the reduction of dislocations or closed fractures in children. METHODS: randomized clinical trial comparing morphine (0.1mg/kg; max 5mg) and ketamine (2.0mg/kg, max 70mg) associated with midazolam (0.2mg/kg; max 10mg) in the reduction of dislocations or closed fractures in children treated at the pediatrics emergency room (October 2010 and September 2011). The groups were compared in terms of the times to perform the procedures, analgesia, parent satisfaction and orthopedic team. RESULTS: 13 patients were allocated to ketamine and 12 to morphine, without differences in relation to age, weight, gender, type of injury, and pain scale before the intervention. There was no failure in any of the groups, no differences in time to start the intervention and overall procedure time. The average hospital stay time was similar (ketamine = 10.8+5.1h versus morphine = 12.3+4.4hs; p=0.447). The median pain (faces pain scale) scores after the procedure was 2 in both groups. Amnesia was noted in 92.3% (ketamine) and 83.3% (morphine) (p=0.904). Parents said they were very satisfied in relation to the analgesic intervention (84.6% in the ketamine group and 66.6% in the morphine group; p=0.296). The satisfaction of the orthopedist regarding the intervention was 92.3% in the ketamine group and 75% in the morphine group (p=0.222). CONCLUSION: by producing results similar to morphine, ketamine can be considered as an excellent option in pain management and helps in the reduction of dislocations and closed fractures in pediatric emergency rooms.

Bilateral anterior inferior iliac spine avulsion fractures.

A case of bilateral groin pain of sudden onset in a 14-yr-old boy is presented. The patient reported sudden onset of pain in both inguinal regions during a 100-m dash. He presented a week later to the clinic where physical examination revealed a shuffling gait, bilateral hip flexion contractures, limited active and passive hip extension, and bilateral weakness of hip flexion and knee extension. Plain radiographs of the pelvis revealed avulsion fragments minimally displaced from both anterior inferior iliac spines (AIIS). Pain relief in the acute phase was achieved by limiting ambulation until weight bearing was painless. The patient was treated conservatively and returned to full speed running in 10 wk. Only one case of bilateral AIIS avulsion fractures has previously been reported. AIIS avulsion fractures that are not widely displaced may be treated conservatively. Following a careful program of rehabilitation, full functional recovery following AIIS avulsion fractures may be achieved in 4-6 wk.

Non-operative management of acetabular fractures. The use of dynamic stress views.

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45 degrees, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients' other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment.

Hematoma block for ankle fractures: a safe and efficacious technique for manipulations.

The purpose of this study was to examine the safety and efficacy of the hematoma block technique for closed ankle fracture manipulation. Twenty-three patients received a hematoma block with or without supplemental analgesia and/or sedation for the manipulative reduction of an ankle fracture, and 37 patients received parenteral agents alone. At an average of 12 months post-reduction, patients were administered a questionnaire concerning their level of discomfort surrounding the manipulation of their acute injury. Their experienced level of pain was recorded on a pain analog scale at the time of injury, at the time of reduction, and at the time of the questionnaire. Other queries were made regarding their recall of other aspects of their acute care treatment. The hematoma block group noted their pain differential to be 3.4 less during reduction compared with the time of injury. In the 17% subgroup of hematoma block patients who received no supplemental parenteral analgesia, the pain differential was noted to be 4.5 less during reduction. This was in contrast to the non-hematoma block group, which rated their pain differential to be 0.6 between injury and reduction. In addition, the hematoma block procedure resulted in no associated complications. The results of this study led us to conclude that the hematoma block with or without supplemental analgesia for the manipulation of ankle fractures was safe and effective and is a useful technique. This is particularly true in those patients in whom an adequate dosage of parenteral medication is contraindicated or unsafe.

Bracing of stable shaft fractures of the ulna.

In the laboratory an ulnar osteotomy was performed in 10 cadaveric specimens, which included 5 distal-third junctions and 5 middle-third junctions. The interosseous membrane was left intact. Each specimen was rotated through full pronation and full supination. Displacement less than half shaft width was considered stable. The interosseous membrane was subsequently released 2 cm proximal and 2 cm distal to the osteotomy. Repeated pronation and supination range of motion documented gross displacement greater than half of the width of the shaft and was diagnosed as unstable. To evaluate this hypothesis, a clinical trial of 30 stable ulnar shaft fractures of the middle and distal thirds were treated with functional bracing between 1984 and 1990. A simple protocol was followed: A long arm cast was applied for approximately 5-7 days until the patient experienced only mild pain. At 5-7 days, a prefabricated forearm brace was fitted and the patient began physical therapy, advancing the upper extremity to full functional use. The bracing was continued until radiographic union had occurred. Twenty-nine clinical cases were evaluated to fracture union. The mean time to union was 7.3 weeks (range: 6-9 weeks). One delayed union was reported in the series. At 16 weeks surgical intervention was recommended and an open reduction and internal fixation with cancellous bone grafting was performed. Twenty-nine patients regained full range of motion, and one had limited supination/pronation due to a previous injury of the radial head. In conclusion, functional bracing of stable ulnar shaft fractures leads to a high incidence of fracture union and achieves good to excellent functional results.(ABSTRACT TRUNCATED AT 250 WORDS)

Trapezio-lunate external fixation for scaphoid fractures. An experimental and clinical study.

Trapezio-lunate external fixation for scaphoid fractures has been investigated experimentally and clinically. Six below-elbow fresh amputation specimens in which proximal, waist and distal scaphoid fractures were created, displaced, reduced and externally fixed were used for an experimental study and after 10,000 extension-flexion movements of the wrist, no displacement was observed. A strain-gauge study confirmed the strains at the fracture site. Seven patients were treated in this way. No immobilization was necessary and all patients returned to their regular employment within 3 days and all fractures were united without displacement. The technique overcomes certain disadvantages of plaster fixation and internal fixation of scaphoid fractures.

Avulsion fracture of the anterior half of the foramen magnum involving the bilateral occipital condyles and the inferior clivus--case report.

A 38-year-old male presented with an avulsion fracture of the anterior half of the foramen magnum due to a traffic accident. He had palsy of the bilateral VI, left IX, and left X cranial nerves, weakness of his left upper extremity, and crossed sensory loss. He was treated conservatively and placed in a halo brace for 16 weeks. After immobilization, swallowing, hoarseness, and left upper extremity weakness improved. Hyperextension with a rotatory component probably resulted in strain in the tectorial membrane and alar ligaments, resulting in avulsion fracture at the sites of attachment, the bilateral occipital condyles and the inferior portion of the clivus. Conservative treatment is probably optimum even for this unusual and severe type of occipital condyle fracture.

[Femoral shaft fracture in children: treatment with early spica cast]. / Fracture de la diaphyse fémorale de l'enfant: traitement par plâtre pelvi-pédieux d'emblée.

PURPOSE OF THE STUDY: Fractures of the femoral shaft are frequent in children and prognosis is good. For children aged less than 7 years, most authors propose orthopedic treatment using prolonged traction then cast immobilization, or orthopedic reduction under general anesthesia and early cast immobilization. The purpose of the present work was to analyze results of orthopedic treatment using a spica early for children aged less than 7 years in comparison with other published series with similar age or management. MATERIAL AND METHOD: Forty-seven unselected children aged less than 7 years with a closed fracture of the femoral shaft were treated by orthopedic reduction under general anesthesia and immobilization with a spica cast after a short period (<48 hr) of traction in the plane of the bed. Hip immobilization was set in flexion and minimal abduction, knee in flexion. The children were discharged the day the cast was installed or the next day. Follow-up examinations (tolerance) with x-rays cast in place were scheduled for day 8 and day 15. Clinical and radiological assessment was also recorded at removal of the cast, at 3 months, at 1 year, and at maximum follow-up. RESULTS: Mean age was 37 months (range 2-83 months). Boys predominated (n=34, 73%). Mean duration of traction was 1.13 days (range 0-5 days). Mean duration of cast immobilization was 45.4 days (range 28-78 days). Mean hospital stay was 2.8 days (range 1-10 days). Four patients (8%) were rehospitalized for secondary displacement under the cast. Weight bearing was effective at day 49 (range 33-78). Mean follow-up was 12.1 months (range 3 months-6 years). Five children (10.5%) developed leg length discrepancy greater than 10 mm. The anatomic axis of the femur in the saggital and frontal planes exhibited deviation in 7 children measuring less than 8 degrees in all cases. DISCUSSION: The localization and type of fracture observed in this series of children was similar to that reported in epidemiological studies. There were no treatment-related complications. In respect to healing time, deviation, and residual leg length discrepancy, results in this series were equivalent to those reported by others, irrespective of the treatment method employed. The major advantage of early spica is a short hospital stay allowing cost containment and rapid return to the child's everyday environment.

A comparison of two approaches for the closed treatment of low-energy tibial fractures in children.

BACKGROUND: Many orthopaedic surgeons treat tibial shaft fractures in children with a period of non-weight-bearing after application of a long leg cast, presumably to prevent fracture angulation and shortening. We hypothesized that allowing children to immediately bear weight as tolerated in a cast with the knee in 10° of flexion would lessen disability, without increasing the risk of unacceptable shortening or angulation. METHODS: We divided eighty-one children, between the ages of four and fourteen years, with a low-energy, closed tibial shaft fracture into two groups. One group (forty children) received a long leg cast with the knee flexed 60° and were asked not to bear weight. The second group (forty-one children) received a long leg cast with the knee flexed 10° and were encouraged to bear weight as tolerated. All patients were switched to short leg walking casts at four weeks. We compared time to healing, overall alignment, shortening, and physical disability as determined by the Activities Scale for Kids-Performance (ASK-P) questionnaire. RESULTS: The mean time to fracture union was 10.8 weeks in both groups (p = 0.47). At the time of healing, mean coronal alignment was within 1.3° in both groups, mean sagittal alignment was within 1°, and mean shortening was <0.5 mm, with no significant differences. The ASK-P scores showed that both groups had overall improvement in physical functioning over time. However, at six weeks, the children who were allowed to bear weight as tolerated had better overall scores (p = 0.03) and better standing skills (p = 0.01) than those who were initially instructed to be non-weight-bearing. CONCLUSIONS: Children with low-energy tibial shaft fractures can be successfully managed by immobilizing the knee in 10° of flexion and encouraging early weight-bearing, without affecting the time to union or increasing the risk of angulation and shortening at the fracture site.

A complex injury of the distal ulnar physis: a case report and brief review of the literature.

Physeal fractures of the distal forearm are common injuries in children and adolescents. However, Salter-Harris type III and type IV fractures of the distal ulnar epiphysis are often high-energy injuries that require open reduction for restoration of anatomical alignment. These injuries are uncommon and there are few descriptions of them in the contemporary literature. Here we report the case of a 13-year-old boy with a type IV distal ulna fracture not diagnosed with standard radiography. After closed manipulation, an incompletely reduced physis was suspected on the basis of fluoroscopic imaging and comparison radiographs of the contralateral wrist. Computed tomography showed a large, displaced physeal fragment. The patient underwent open reduction and internal fixation. Thorough radiographic assessment should be conducted when there is a high suspicion for these fracture patterns. Appropriate diagnosis can lead to expedient reduction and expectant management of sequelae associated with these injuries.

Comparison of two analgesia protocols for the treatment of pediatric orthopedic emergencies / Comparação de dois protocolos de analgesia para tratamento de emergências ortopédicas pediátricas

SummaryObjective:to compare the efficacy of two analgesia protocols (ketamine versus morphine) associated with midazolam for the reduction of dislocations or closed fractures in children.Methods:randomized clinical trial comparing morphine (0.1mg/kg; max 5mg) and ketamine (2.0mg/kg, max 70mg) associated with midazolam (0.2mg/kg; max 10mg) in the reduction of dislocations or closed fractures in children treated at the pediatrics emergency room (October 2010 and September 2011). The groups were compared in terms of the times to perform the procedures, analgesia, parent satisfaction and orthopedic team.Results:13 patients were allocated to ketamine and 12 to morphine, without differences in relation to age, weight, gender, type of injury, and pain scale before the intervention. There was no failure in any of the groups, no differences in time to start the intervention and overall procedure time. The average hospital stay time was similar (ketamine = 10.8+5.1h versus morphine = 12.3+4.4hs; p=0.447). The median pain (faces pain scale) scores after the procedure was 2 in both groups. Amnesia was noted in 92.3% (ketamine) and 83.3% (morphine) (p=0.904). Parents said they were very satisfied in relation to the analgesic intervention (84.6% in the ketamine group and 66.6% in the morphine group; p=0.296). The satisfaction of the orthopedist regarding the intervention was 92.3% in the ketamine group and 75% in the morphine group (p=0.222).Conclusion:by producing results similar to morphine, ketamine can be considered as an excellent option in pain management and helps in the reduction of dislocations and closed fractures in pediatric emergency rooms.

ResumoObjetivo:comparar a eficácia de dois protocolos de analgesia (cetamina versus morfina) associados ao midazolam para a redução de luxações ou fraturas fechadas em crianças.Métodos:ensaio clínico randomizado comparando morfina (0,1 mg/kg; máx. 5 mg) e cetamina (2,0 mg/kg; máx. 70 mg) associados a midazolam (0,2 mg/kg; máx. 10 mg) na redução de luxações ou fraturas fechadas em crianças atendidas em emergência pediátrica, no período de outubro de 2010 a setembro de 2011. Os grupos foram comparados segundo os seguintes indicadores: tempo para realizar os procedimentos, analgesia, satisfação de pais e da equipe ortopédica.Resultados:treze pacientes foram alocados para cetamina e 12 para morfina, sem diferenças em relação a idade, peso, gênero, tipo de lesão e escala da dor antes da intervenção. Não houve falha em nenhum dos grupos, sem diferenças no tempo para iniciar a intervenção e no tempo total de procedimento. O tempo médio de hospitalização foi similar (cetamina=10,8±5,1 h versus morfina=12,3±4,4 h; p=0,447). A mediana de dor (escala de faces da dor) após o procedimento foi de 2 em ambos os grupos. Amnésia foi observada em 92,3% (cetamina) e 83,3% (morfina) (p=0,904). Os pais declararam estar muito satisfeitos em relação à intervenção analgésica (84,6% no grupo cetamina e 66,6% no grupo morfina; p=0,296). A satisfação do ortopedista em relação à intervenção foi de 92,3% no grupo cetamina e 75% no grupo da morfina (p=0,222).Conclusão:a cetamina, ao apresentar resultados semelhantes à morfina, pode ser considerada uma excelente opção no manejo da dor e no auxílio da redução de luxações e fraturas fechadas em salas de emergência pediátrica.