Non- or Minimally Displaced Distal Radial Fractures in Adult Patients: Three Weeks versus Five Weeks of Cast Immobilization-A Randomized Controlled Trial.

Background Patients with non- or minimally displaced distal radial fractures, that do not need repositioning, are mostly treated by a short-arm cast for a period of 4 to 6 weeks. A shorter period of immobilization may lead to a better functional outcome. Purpose We conducted a randomized controlled trial to evaluate whether the duration of cast immobilization for patients with non- or minimally displaced distal radial fractures can be safely shortened toward 3 weeks. Materials and Methods The primary outcomes were patient-reported outcomes measured by the Patient-Related Wrist Evaluation (PRWE) and Quick Disability of Arm, Shoulder and Hand (QuickDASH) score after 1-year follow-up. Secondary outcome measures were: PRWE and QuickDASH earlier in follow-up, pain (Visual Analog Scale), and complications like secondary displacement. Results Seventy-two patients (male/female, 23/49; median age, 55 years) were included and randomized. Sixty-five patients completed the 1-year follow-up. After 1-year follow up, patients in the 3 weeks immobilization group had significantly better PRWE (5.0 vs. 8.8 points, p = 0.045) and QuickDASH scores (0.0 vs. 12.5, p = 0.026). Secondary displacement occurred once in each group. Pain did not differ between groups ( p = 0.46). Conclusion Shortening the period of immobilization in adult patients with a non- or minimally displaced distal radial fractures seems to lead to equal patient-reported outcomes for both the cast immobilization groups. Also, there are no negative side effects of a shorter period of cast immobilization. Therefore, we recommend a period of 3 weeks of immobilization in patients with distal radial fractures that do not need repositioning.

Functional treatment for acute ankle sprains: Softcast wrap versus MOK-cast. A prospective randomized single-center trial.

BACKGROUND: The outcome of a removable (MOK-cast) versus a non-removable polyester wrap for acute lateral ankle ligament injury is unknown. METHODS: Patients with grade II-III lateral ankle ligament injuries were randomized between treatment with a MOK-cast and a wrap. Primary outcome is the Karlsson score for function. Secondary outcomes are patient satisfaction and pain at 4 months follow-up. RESULTS: Randomisation resulted in 53 and 54 patients per arm. Four month follow up was completed by 92% (n=100). The mean Karlsson score improved from 20 to 87 (p<0.01) in the wrap group and 20 to 90 (p<0.01) in the MOK-cast group. In the MOK-cast group treatment satisfaction was higher (8.2 vs 7.8 p 0.04). Reported pain was higher in the first thirty days after injury (p<0.01). CONCLUSIONS: Both wrap and MOK-cast are effective functional treatment options in acute lateral ankle ligament injury. MOK-cast is associated with increased patient satisfaction but higher VAS pain scores. LEVEL OF EVIDENCE: I.

Spinal injuries in an airplane crash: a description of incidence, morphology, and injury mechanism.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Spinal injuries of the survivors of an airplane crash are described. On the basis of injury morphology and knowledge of the conditions of the accident, injury mechanisms are described and prevention measures are discussed. SUMMARY OF BACKGROUND DATA: The most common causes of spinal fractures are a high energy fall (incidence 21.2%-39%) and motor vehicle accidents (21.7%-33.61%). Detailed reports solely on spinal injuries, as a result of an airplane crash, are scarce in literature. METHODS: An analysis was performed on the spinal injuries of all 126 survivors of a commercial airplane (Boeing 737) crash near Amsterdam in 2009. Level of injury and fracture classification by morphology, independently performed by 4 specialists in spinal trauma, was documented. An analysis was done on the type of injuries and the suggested mechanism of injury by evaluating the crash characteristics analysis. RESULTS: Twenty-three (18.3%) of the survivors sustained a total of 27 spinal injuries. Four (17.1% of the patients with spinal injury) experienced a single cervical spine fracture. Eight (29.6%) injuries were at the thoracic spine and 15 (55.6%) at the lumbar spine level. More than half of the injuries included a burst component. CONCLUSION: A high number of spinal injuries was found after this airplane crash. The morphology of the injuries consisted of a high rate of burst-type fractures presumably caused by a mainly vertical trauma mechanism as shown by the accident analysis. LEVEL OF EVIDENCE: 4.

Radiological work-up after mass casualty incidents: are ATLS guidelines applicable?

OBJECTIVES: In mass casualty incidents (MCI) a large number of patients need to be evaluated and treated fast. Well-designed radiological guidelines can save lives. The purpose of this study was to evaluate the Advanced Trauma Life Support (ATLS) radiological guidelines in the MCI of an aeroplane crash. METHODS: Medical data of all 126 survivors of an aeroplane crash were analysed. Data included type and body region of the radiological studies performed on the survivors, Abbreviated Injury Score (AIS) and Injury Severity Score (ISS) codes and trauma care level of the hospitals. RESULTS: Ninety patients (72 %) underwent one or more imaging studies: in total 297 radiographs, 148 CTs and 18 ultrasounds were performed. Only 18 % received diagnostic imaging of all four body regions as recommended by ATLS. Compliance with ATLS was highest (73.3 %) in severely injured victims (ISS ≥16); this group underwent two thirds of the (near) total body CTs, all performed in level I trauma centres. CONCLUSION: Overall compliance with ATLS radiological guidelines was low, although high in severely injured patients. Level I trauma centres frequently used (near) total body CT. Deviation from ATLS guidelines in radiological work-up in less severely injured patients can be safe and did not result in delayed diagnosis of serious injury. KEY POINTS: • Radiological imaging protocols can assist the management of mass casualty incidents needs. • Advanced Trauma Life Support (ATLS) radiological guidelines have been developed. • But radiological guidelines have not frequently been applied in aeroplane crashes. • Aircraft accidents are of high energy so ATLS guidelines should be applied. • Following mass casualty incidents total body CT seems appropriate within ATLS protocols.

Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome.

The purpose of this study was to assess the association between arm-specific disability measured with the QuickDASH questionaire and radiological criteria in patients with extra-articular distal radial fractures. A consecutive series of 385 patients were initially treated non-operatively for an extra-articular distal radial fracture and 257 (69 %) patients were included in the study. In 203 of these patients (78%) the quality of radiographic reduction was judged to be adequate by radiological parameters, which included dorsal tilt, radial inclination, and radial shortening. In 54 patients (22%) the quality of radiographic alignment was judged to be inadequate. We observed no effect of radiographic parameters on the functional outcome. Female sex and longer duration of follow-up (>35 months) were the only independent prognostic factors significantly associated with a worse QuickDASH score.

Delayed diagnosis of injury in survivors of the February 2009 crash of flight TK 1951.

INTRODUCTION: On 25th February 2009, a Boeing 737 crashed nearby Amsterdam, leaving 126 victims. In trauma patients, some injuries initially escape detection. The aim of this study was to evaluate the incidence of Delayed Diagnosis of Injury (DDI) and the tertiary survey on the victims of a plane crash, and the effect of ATLS(®) implementation on DDI incidence. PATIENTS AND METHODS: Data from all victims were analysed with respect to hospitalisation, DDI, tertiary survey, ISS, Glasgow Coma Score (GCS), injuries (number and type) and emergency intervention. Clinically significant injuries were separated from non-clinically significant injuries. The data were compared to a plane crash in the UK (1989), which occurred before ATLS(®) became widely practiced. RESULTS: All 126 victims of the Dutch crash were evaluated in a hospital; 66 were hospitalised with a total of 171 clinically significant injuries. Twelve (7%) clinically significant DDIs were found in 8 patients (12%). In 65% of all patients, a tertiary survey was documented. The incidence of DDI in patients with an ISS ≥ 16 (n=13) was 23%, vs. 9% in patients with ISS <16. Patients with >5 injuries had a DDI incidence of 25%, vs. 12% in patients with ≤ 5 injuries. Head injury patients had a DDI incidence of 19%, patients without head injury 10%. Fifty percent of patients who needed an emergency intervention (n=4) had a DDI; 3% of patients who did not need emergency intervention. Eighty-one survivors of the UK crash had a total of 332 injuries. DDIs were found in 30.9% of the patients. Of all injuries 9.6% was a DDI. The incidence of DDI in patients with >5 injuries was 5%, vs. 8% in those with ≤ 5 injuries. CONCLUSION: DDI in trauma still happen. In this study the incidence was 7% of the injuries in 12% of the population. In one third of the patients no tertiary survey was documented. A high ISS, head injury, more than 5 injuries and an emergency intervention were associated with DDI. The DDI incidence in our study was lower than in victims of a previous plane crash prior to ATLS implementation.