Pins and Rubbers Traction System for Treatment of Intraarticular Fractures of Distal Interphalangeal Joint.

Background: The pins and rubber traction system (PRTS) has proven effective in managing intra-articular fractures of the proximal interphalangeal joint. However, there is scant evidence in the literature regarding its efficacy in treating distal interphalangeal joint (DIPJ). This study aims to investigate the outcomes of PRTS in the treatment of comminuted intra-articular fractures of the DIPJ. Methods: We conducted a retrospective review of patients with comminuted intra-articular fractures of the DIPJ treated with PRTS between 2017 and 2021. At the final follow-up, we measured and compared the active range of motion (ROM) in both affected and non-injured contralateral fingers. The subjective evaluation utilised the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and the Visual Analogue Scale (VAS). Results: Ten patients with a mean follow-up of 13.2 months (range: 12-17) were included in the study. Fracture locations included the base of the distal phalanx in two patients, the condyle of the middle phalanx in seven and both in one patient. At the final follow-up, the average VAS score was 0.5 (range: 0-2). The average active motion of the DIPJ was 61° (range: 50°-70°) for the injured side and 76° (range: 75°-80°) for the opposite side. The mean range of DIPJ movement was 80% (range: 68%-87%) of the non-injured side. Extension deficits were observed in five patients, with a median deficit value of 10° (range: 5°-10°). The average Quick-DASH score was 2.9 (range: 0-11.3). Conclusions: The PRTS can be considered as an effective surgical technique in managing comminuted intra-articular fractures of the DIPJ. Level of Evidence: Level IV (Therapeutic).

Implant Choice and Outcomes of the Sinus Tarsi Approach for Displaced Intra-articular Calcaneal Fractures.

BACKGROUND: Operative fixation of displaced intra-articular calcaneal fractures is considered the gold standard, for which multiple fixation methods are available. This study compares the (functional) outcome of screw fixation (SF), plate fixation (PF), and anatomical plate fixation (APF) via the sinus tarsi approach (STA). METHODS: A total of 239 patients (265 fractured calcanei) who received surgical treatment of a displaced intra-articular calcaneal fracture via STA between 2011 and 2022 were included. RESULTS: Böhler angle (BA) measured immediately postoperatively (BA post-OR) and the decrease in BA at 1 year (∆BA) differed significantly in favor of PF/APF compared with SF (BA post-OR: SF vs PF P = .010 and SF vs APF P = .001; ∆BA: SF vs PF P = .032 and SF vs APF P = .042). Implant removal surgery was performed significantly less in the APF group as compared to the SF/PF groups (APF vs SF/PF; 9.9% vs 22.9%/23.7%, P = .015). Surgical site infections and secondary arthrodesis of the subtalar joint occurred equally in the 3 groups. Furthermore, the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index score, and EuroQOL-5D-index / visual analog scale score, did not differ notably between SF, PF, and APF. CONCLUSION: The results show that both PF and APF are favored over SF because of an improved correction of BA measured directly postoperatively, a lower secondary loss of BA and, for APF, a lower implant removal rate. There was no difference in the rate of surgical site infections, need for secondary arthrodesis, nor functional outcome scores between different implants using the STA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Volar Plate Fixation Versus Cast Immobilization in Acceptably Reduced Intra-Articular Distal Radial Fractures: A Randomized Controlled Trial.

BACKGROUND: The evidence for the treatment of acceptably reduced intra-articular distal radial fractures remains inconclusive. We therefore compared the functional outcomes of cast immobilization (nonoperative) and volar plate fixation (operative) for patients with these fractures. METHODS: This multicenter randomized controlled trial enrolled patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Patients were randomized to nonoperative treatment or to operative treatment. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after 12 months. Secondary outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; the Short Form-36 (SF-36) questionnaire; a visual analog scale for pain; range of motion; grip strength; radiographic parameters; and complications. Analyses followed the intention-to-treat principle. RESULTS: A total of 96 patients were randomized, and 90 (46 in the nonoperative group and 44 in the operative group) were included in the analysis. Patients treated in the operative group had significantly better functional outcomes measured with the PRWE at 6 weeks, 3 months, 6 months, and 1 year. Additionally, a 28% rate of subsequent surgery was identified in the nonoperative group. CONCLUSIONS: Adult patients with an acceptably reduced intra-articular distal radial fracture have better functional outcomes for 12 months when treated operatively instead of nonoperatively. We therefore recommend surgical treatment for patients with these fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

A comparative study of operative and conservative treatment of intraarticular displaced calcaneal fractures.

The treatment of intra-articular displaced calcaneal fracture is debatable. We conducted a prospective study to compare operative and non-operative treatment for intra-articular displaced calcaneal fractures. Patients were assigned to two groups based on the treatment given (operative and nonoperative) and were regularly followed for a period of 1 year. The outcome measures were assessed by Modified Rowe's Score (MRS), Visual Analogue e Scale (VAS) and The American Orthopaedic Foot and Ankle Society (AOFAS) scale. The outcome related to patient's job was noted after one year and compared with pre-injury status. Fifty five patients with 61 calcaneal fractures were studied. Thirty of them were operated and 31 were treated conservatively. Out of 30 operated cases, Bohler's angle was restored in 25 cases and these had good results with all three outcome scores at 1 year follow up and remaining 5 cases showed fair results (Mean MRS: 74.783, VAS: 3.348, AOFAS: 78.783). Thirty one cases treated with cast also showed fair results (Mean MRS: 57.368, VAS: 4.944, AOFAS: 71.211). The overall outcome of operated cases were better than non-operated cases (unpaired T test MRS: 5.807 p < 0.001, VAS: 4.387 p < 0.001, AOFAS: 2.728 p = 0.008) . Operative treatment of displaced intra-articular calcaneal fractures gave good results at one year follow up, provided Bohler's angle was restored to normal range. Non operative treatment gave fair results. Complications were seen both with operative and non-operative treatment.

Low-Intensity Pulsed Ultrasound Suppresses Synovial Macrophage Infiltration and Inflammation in Injured Knees in Rats.

This study was designed to investigate how low-intensity pulsed ultrasound (LIPUS) suppresses traumatic joint inflammation and thereafter affects the progression of posttraumatic osteoarthritis. Intra-articular fracture (IAF) was created in the right knee of rats. LIPUS was applied to the knees with IAFs for 20 min/d for 2 wk-LIPUS(+) group. The study controls included rats that underwent sham surgery but no LIPUS treatment (control group) or underwent IAF surgery without LIPUS treatment-LIPUS(-) group. By histology, at 4 wk, leukocyte infiltration in the synovium was reduced in the LIPUS(+) group. Furthermore, LIPUS treatment reduced CD68+ macrophages in the synovium and limited their distribution mostly in the subintimal synovium. Measured with enzyme-linked immunosorbent assay, interleukin-1ß (IL-1ß) in the joint fluid of the LIPUS(+) group was reduced to about one-third that in the LIPUS(-) group. By reducing synovial macrophages and lowering IL-1ß in the joint fluid, LIPUS is potentially therapeutic for posttraumatic osteoarthritis.

Evaluation of Long-Term Quality of Life Using the Foot and Ankle Outcome Score (FAOS) Questionnaire in Patients Treated by Minimally Invasive Reduction and Percutaneous Stabilization of Intra-Articular Calcaneal Fractures.

BACKGROUND Treatment of displaced intra-articular calcaneal fractures is controversial. Choosing the optimal surgical technique is very important for patient quality of life and activity. In this study, we asked the question: "What is the long-term quality of life of patients after intra-articular calcaneal fractures treated by minimally invasive reduction and percutaneous stabilization (MIRPS)?". MATERIAL AND METHODS We included 51 patients - 45 males (88%) and 6 females (12%) - who underwent MIRPS of intra-articular calcaneal fractures. The males were ages 22-63 years, with a mean age of 46 years, while the females were aged 31-63, with a mean age of 47 years. The FAOS (Foot and Ankle Outcome Score) survey was used. RESULTS Women's FAOS scores were 72-95%, with a mean of 82%, and varied according to type of fracture, surgery method used, and comorbid fractures. Men's FAOS scores were 50-95%, with a mean of 84%, and varied according to type of fracture, surgery method used, and comorbid fractures. CONCLUSIONS According to set criteria regarding the FAOS scale, mainly good and very good results were observed in patients treated surgically for intra-articular calcaneus fractures using MIRPS. Westhues' method scored a significantly higher foot rating than W-R (Westhues'-Rapala method). Patients with TTF (tongue-type fracture) scored higher in the FAOS than patients treated with JDTF (joint depression-type fracture). In other cases, no significant differences were observed.

Functional Outcomes of Tillaux and Triplane Fractures with 2 to 5 Millimeters of Intra-Articular Gap.

BACKGROUND: The treatment of transitional ankle fractures (Tillaux and triplane) is often dictated by the amount of displacement at the articular surface. Although >2 mm is a common indication for operative management, this practice has not been strongly supported by either the pediatric or adult literature. The purpose of this study was to determine whether operative treatment of transitional fractures with 2 to 5 mm of intra-articular gap leads to superior functional outcomes compared with cast management. METHODS: A retrospective review of all patients treated for distal tibial fractures at a single institution between 2009 and 2017 was conducted. Computed tomographic images obtained after closed reduction were reviewed to identify patients with 2 to 5 mm of displacement (either gap or step-off) at the articular surface of the tibial plafond. Complications were classified according to the modified Clavien-Dindo system. Only patients with functional outcome data (Foot and Ankle Ability Measure [FAAM]) at a minimum of 2 years after treatment were included. Two multivariable linear regression models were developed using backward stepwise regression with either the FAAM Sports score or the Single Assessment Numerical Evaluation (SANE) Sports score as the dependent variables. RESULTS: Fifty-seven patients (34 with triplane fractures and 23 with Tillaux fractures) with a mean follow-up of 4.5 years (range, 2.0 to 9.2 years) met inclusion criteria. Thirty-four patients were treated operatively, and 23 patients were treated with closed reduction and cast application. Nonoperative treatment, greater intra-articular gap, and presence of a grade-III complication were associated with worse functional outcomes in both multivariable regression models. A gap after closed reduction remained a negative predictor of functional outcome even in patients who were treated operatively. Patients who were treated nonoperatively and had ≤2.5 mm of gap had a significantly higher mean SANE Sports score at 90% than those patients with >2.5 mm of gap at 75% (p = 0.03). CONCLUSIONS: In Tillaux and triplane fractures with 2 to 5 mm of gap at the tibial plafond, a greater gap after closed reduction, nonoperative treatment, and complications were negative predictors of functional outcome at a mean follow-up of 4.5 years. Surgical management likely conveys the greatest functional benefit when the intra-articular gap exceeds 2.5 mm. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Laboratory Monitoring of Bone Tissue Remodeling after Augmentation of Impression Intraarticular Fracture with Different Types of Bone Graft.

The effects of bone graft materials on the inflammatory response and biochemical markers of bone remodeling were studied on a rabbit model of fracture augmentation with the following grafts: ß-tricalcium phosphate, demineralized bone matrix, nanostructured carbon implant, and porous titanium implant made by additive 3D printing. The markers of bone remodeling and the blood system response in the postoperative period were studied. It was found that porous titanium implant and ß-tricalcium phosphate induced osteogenesis and minimized osteoclastic resorption. Augmentation with nanostructured carbon implant and demineralized bone matrix stimulated the processes of osteoclastic resorption.

Operative Versus Nonoperative Management Of Traumatic Arthrotomies from Civilian Gunshot Wounds.

Background: Although the rate of non-fatal gunshot wounds (GSW) has increased, few studies have compared the effectiveness of operative and nonoperative treatment with specific focus on infection. We compared the risk of septic arthritis in patients with traumatic arthrotomies caused by GSW treated operatively with irrigation and debridement versus nonoperatively with antibiotics and wound care. Methods: From 2009 to 2016, 46 patients at our institution sustained traumatic arthrotomies from low-velocity GSW with at least 90-day follow-up. Medical records were reviewed for demographic information, imaging, type and duration of antibiotics, details of operative and nonoperative interventions, and evidence of infection at follow-up visits. We measured the rate of septic arthritis using a 2-tailed t test. Results: The knee was the most commonly affected joint (34 patients; 73.9%). Eight patients (17.4%) were treated nonoperatively and 38 (82.6%) were treated operatively. In the nonoperative group, one patient (12.5%) developed a superficial wound infection that resolved with oral antibiotics. In the operative group, one patient (2.6%) developed a superficial wound infection requiring operative irrigation and debridement. There was no statistically significant difference in risk of infection between the two groups (P = 0.32). No patient developed septic arthritis. Conclusions: In select patients, nonoperative treatment with wound care and antibiotics may be sufficient for preventing infection after GSW-related traumatic arthrotomies. Findings of randomized studies and treatment algorithms are needed to further evaluate this relatively common injury.Level of Evidence: IV.

Clinical, radiological and patient-reported outcomes in intra-articular calcaneal fractures: Comparison of conservative and surgical treatment.

OBJECTIVES: This study aims to compare the radiological, clinical and patient-reported outcomes of patients with intra-articular calcaneus fractures treated conservatively or surgically. PATIENTS AND METHODS: Fifty-four patients (30 males, 24 females; mean age 41.0 years; range, 18 to 73 years) treated due to calcaneus fracture were included in the study. Twenty-nine patients underwent conservative treatment (group 1) and 25 patients underwent surgical treatment (group 2). The fractures were classified according to Sanders. At the final follow-up, patients' Bohler's angle, The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Foot Function Index (FFI) were used to evaluate their radiological, clinical and patient-reported outcomes. Postoperative complications were also noted. RESULTS: The fracture was at the right foot in 28 patients and the left foot in 26 patients. The mean follow-up duration was 41.1±23.2 months (range, 24 to 126 months). No statistically significant differences were found between the groups in terms of gender, fracture side, mean age, or follow-up duration (p=0.951, p=0.571, p=0.326, and p=0.620, respectively). According to Sanders classification, 18 patients were type 2 and 11 patients were type 3 in group 1, while 11 patients were type 2 and 14 patients were type 3 in group 2. However, there was no statistically significant difference between the groups in terms of the type of the fracture (p=0.184). On the other hand, the outcomes were significantly better for group 2 compared to group 1 in terms of the Bohler's angle, AOFAS and FFI scores (p=0.004, p=0.003 and p=0.006, respectively). In group 1, subtalar arthritis developed in three patients. In group 2, wound healing problems and superficial infection developed in three patients, while subtalar arthritis developed in two patients. CONCLUSION: Surgical treatment is more effective in intra-articular calcaneus fractures compared to conservative treatment according to clinical, radiological and patient-reported outcomes. In addition, wound problems should be considered in surgical management.

Evaluating the Utility of Follow-up Radiographs for Isolated Radial Head Fractures Undergoing Initial Nonoperative Treatment.

OBJECTIVES: To evaluate the utility of follow-up radiographs in patients with isolated partial articular radial head fractures (OTA/AO 2R1B1 or 2R1B3). DESIGN: Retrospective cohort study. SETTING: Academic Level 1 Trauma Center. PATIENTS: Adult patients (≥18 years) with isolated partial articular radial head fractures indicated for initial nonoperative treatment. INTERVENTION: Analysis of elbow radiographs at initial presentation and at postinjury follow-up of 3-8 weeks. VARIABLES MEASURED: Articular gap and step-off. MAIN OUTCOME MEASURE: Radiographic articular displacement between initial and follow-up radiographs. RESULTS: For 72 included patients, initial radiographs were obtained on average 2.6 days after injury and follow-up radiographs 33.7 days thereafter. Equivalence tests evaluating gap and step-off thresholds of <1 mm were both significant, indicating that the cohort displaced <1 mm for both parameters between initial and follow-up radiographs. No patients proceeded to surgical treatment following the repeat radiographs. CONCLUSIONS: These fractures do not displace in the early postinjury period, as defined as a <1 mm of change in both intra-articular gap and step-off, as compared to initial radiographs. Routine follow-up radiographs for these injuries is a source of cost, but with limited utility in detecting interval displacement or leading to a change in management. Selective use of radiographs to evaluate specific clinical concerns may lead to cost savings. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pediatric Hand and Wrist Fractures.

Hand and wrist fractures are common in the pediatric population. Accurate diagnosis relies on the understanding of the physeal anatomy and carpal ossification. Treatment of these fractures is largely influenced by physeal biology and compliance with treatment. A majority have a favorable outcome with nonoperative treatment. Operative treatment should be considered in patients with clinical deformity, open fractures, and significant fracture displacement. Physeal-friendly surgical approaches and implants should be used to minimize the sequelae of physeal injury.

Matrix-associated stem cell transplantation is successful in treating talar osteochondral lesions.

PURPOSE: Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to try and treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix-associated stem cell transplantation (MAST) is one such treatment described for larger lesions > 15 mm2 or failed alternative therapies. This cohort study describes a 3 year review of the outcomes of talar lesions treated with MAST. METHODS: A review of all patients treated with MAST by a single surgeon was conducted. Pre-operative radiographs, MRIs, and FAOS outcome questionnaire scores were reviewed. Intraoperative classification was undertaken to correlate with imaging. Post-operative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment, and progression to ankle fusion. RESULTS: In this study, 38 OCLs in 32 patients were identified. Median patient age was 35 years of which (68.8%) were male. Median length of follow-up was 36.7 months (range 12-64 months). (83%) returned to playing sport. Twenty-three patients underwent MAST in the setting of a failed previous operative attempt, with just nine having MAST as a first option. Nine patients out of 32 had a further procedure. Improvements were seen in all domains of the FAOS (p < 0.05). CONCLUSION: MAST has demonstrated encouraging results in lesions which prove challenging to treat, even in a "failed microfracture" cohort. LEVEL OF EVIDENCE: IV.

Displaced intra-articular fractures of the calcaneus: ORIF through an extended lateral approach.

INTRODUCTION: Displaced intra-articular calcaneal fractures (DIACF) represent a challenging and controversial issue in traumatology. Conservative treatment has been recommended to avoid surgical problems and complications. The final result, however, is often a painful malunioun of the calcaneus with peroneal impingement. Surgical treatment is gaining acceptance since it offers a chance to restore bone anatomy improving function as long as complications are avoided. MATERIAL AND METHOD: We reviewed a series of 59 DIACF treated by a single surgeon during a 9 years period. A clinical and radiological follow-up was obtained in 44 cases (74,6%) (average of 5,5 years; range 2-9). There were 29 males and 15 females with an average age of 54 years (range 25-74). Patients were operated through an extended l-shaped lateral approach and fixation was achieved with lag screws and plate. Outcome measures method included the AOFAS score, the Maryland Foot Score, the Foot Function Index and the SF-36. RESULTS: The average AOFAS score was 80,5 points. The result was excellent in 18 cases (40,9%), good in 14 cases (31,8%), fair in 10 cases (22,7%) and poor in 2 (4,6%). The mean score for pain was 33,5/40 points, for function 40/50 and for alignment 7/10. Pain was absent in 17 cases (38%), 19 patients (43%) had no functional limitations and 11 (25%) could walk on uneven ground without difficulties. The average FFI score was 25/100 points. The average MFS score was 89/100 points. Subtalar motion was reduced. Reconstruction of the calcaneus was anatomic in 20 cases (45,5%) with an improved clinical outcome. Eight patients (17%) had minor wound healing complications. Three patients (6,8%) required a subtalar arthrodesis after the procedure. CONCLUSIONS: Ostheosytesis through an extended lateral approach restored bone morphology with a reasonable complications rate. The clinical results were good but a normal function and complete subtalar motion were rarely achieved.

Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures.

Performing a thorough clinical evaluation following an acute displaced intra-articular calcaneal fracture is paramount for optimal surgical timing and long-term outcome. Initial survey must entail a comprehensive evaluation to rule out concurrent injuries. Focused lower extremity examination must involve a complete neurovascular and soft tissue evaluation to identify such conditions as compartment syndrome or compromised integument, which necessitate urgent intervention. Establishing baseline radiographs and advanced imaging is vital for surgical planning. Once deemed stable, protocol-driven treatment is best to ensure proper control of pain and edema and adequate management of economic and patient safety concerns.

Telesurveillance: Exploring the Use of Mobile Phone Imaging in the Follow-Up of Orthopedic Patients with Hand Trauma.

Background: Intra-articular phalangeal fractures involving the proximal interphalangeal joint (PIPJ) are notoriously difficult injuries to treat and often require regular follow-up to assess progress, guide treatment, and determine outcomes. Some patients often have to travel long distances for follow-up care. The aim of our study was to assess the clinical outcomes of intra-articular fractures of the PIPJ through use of clinical pictures sent through a mobile phone.Methods: A retrospective study was conducted of a consecutive group of patients treated with a static external fixator (Micro Hoffman-2 Stryker®) between 2006 and 2016 for an intra-articular fracture of the PIPJ. Range of motion (ROM) at the PIPJ was assessed through clinical pictures taken on a mobile phone.Results: Clinical images were received from 15 patients with a mean age of 31.9 years (range 15-51), of which 73.3% of patients were male. Mean length of follow-up was 39 months. Around 73.3% of injuries occurred while playing a sport. Mean PIPJ ROM assessed through the clinical images was 67°.Conclusion: Our study shows that it was possible to assess ROM at the PIPJ through the use of clinical pictures taken by mobile phone. The use of mobile phones to take images provided a simple, easy, and convenient means of assessing outcome in this cohort of patients. We describe a method of follow-up that may have a greater role in the future.

Fractures of the anterior process of the calcaneum; a review and proposed treatment algorithm.

BACKGROUND: There remains a lack of recognition of these fractures, which leads to a delay in diagnosis and appropriate management. METHODS: A comprehensive literature search was performed. Following inclusion and exclusion criteria, 23 studies were available for analysis. RESULTS: Delay in diagnosis is common and has a negative impact on outcome. If an APC fracture is suspected; anteroposterior, lateral and oblique plain radiographs should be requested. Further investigation with computed tomography or magnetic resonance imaging is indicated if plain radiographs are inconclusive and patient remains symptomatic. Non-operative measures are usually adequate for most undisplaced fractures, however surgical intervention maybe required for large, intra-articular fractures in the acute setting and for non-union. CONCLUSIONS: A treatment algorithm is suggested that may help with the diagnosis and management of these injuries. LEVEL OF EVIDENCE: Level IV.

A structured exercise programme combined with proprioceptive neuromuscular facilitation stretching or static stretching in posttraumatic stiffness of the elbow: a randomized controlled trial.

OBJECTIVES:: To compare the different stretching techniques, proprioceptive neuromuscular facilitation (PNF) stretching and static stretching, in patients with elbow stiffness after a treated elbow fracture. DESIGN:: Randomized-controlled, single-blind study. SETTING:: Department of physiotherapy and rehabilitation. SUBJECTS:: Forty patients with posttraumatic elbow stiffness (24 women; mean age, 41.34 ± 7.57 years). INTERVENTION:: PNF stretching group ( n = 20), hold-relax PNF stretching combined with a structured exercise programme (two days per week for six weeks); static stretching group ( n = 20), static stretching combined with a structured exercise programme (two days per week for six weeks). MAIN MEASURES:: The primary outcome is the Disabilities of the Arm, Shoulder and Hand (DASH). The secondary outcomes are active range of motion (AROM), visual analogue scale (VAS), Tampa Scale for Kinesiophobia, Short Form-12 and Global Rating of Change. Participants were assessed at baseline, after a six-week intervention period and one-month later (follow-up). RESULTS:: After treatment, improvement in the mean DASH score was slightly better in the PNF stretching group (8.66 ± 6.15) compared with the static stretching group (19.25 ± 10.30) ( p = 0.03). The overall group-by-time interaction for the 2 × 3 mixed-model analysis of covariance (ANCOVA) was also significant for elbow flexion AROM (mean change for PNF stretching group; static stretching group; 41.10, 34.42, p = 0.04), VAS-rest (-1.31, -1.08, p = 0.03) and VAS-activity (-3.78, -3.47, p = 0.01) in favour of PNF stretching group. The other outcomes did not differ significantly between the two groups. CONCLUSION:: The study demonstrated that the structured exercise programme combined with PNF stretching might be effective in patients with posttraumatic elbow stiffness with regard to improving function, elbow flexion AROM, pain at rest and during activity.

Traumatic Injury to the Subtalar Joint.

Traumatic injury to the subtalar joint occurs during subtalar dislocations, talar and calcaneal fractures, and fracture-dislocations. After closed reduction of subtalar dislocations, peripheral talar or calcaneal fractures need to be ruled out by computed tomography scanning. In fractures and fracture-dislocations of the talus and calcaneus involving the subtalar joint, anatomic reconstruction of joint congruity is essential for functional rehabilitation. Failure to anatomically reduce the subtalar joint potentially leads to chronic instability, subtalar arthritis and posttraumatic hindfoot deformity. Despite adequate management, subtalar arthritis may develop as a result of primary cartilage damage at the time of injury.