Tratamento funcional das fraturas de tornozelo Weber B com carga e mobilização imediatas / Functional treatment of Weber B ankle fractures with weight-bearing and immediate mobilization

Introdução: As fraturas do tornozelo são lesões comuns, apesar de ocorrer em todas as idades, são mais comuns entre homens jovens e mulheres idosas, constituem cerca de 9% de todas as fraturas, com uma incidência de 107 a 187 por 100.000 pessoas por ano. A abordagem de tratamento selecionada ocorrerá de acordo com as condições do paciente e a opção do médico de acordo com cada situação em específico. Objetivo: Avaliar o desfecho do tratamento não cirúrgico e funcional de pacientes com fraturas estáveis e sem desvio do maléolo lateral tipo Weber B, com carga e mobilização articular imediatas. Método: estudo retrospectivo de uma série de pacientes com fratura estável e sem desvio do maléolo lateral tipo Weber B, que foram tratados de forma não cirúrgica com carga e mobilização articular imediatas, de janeiro 2016 a julho 2022. Os pacientes dessa pesquisa foram provenientes do Hospital do Servidor Público Municipal de São Paulo e da Clínica de Ortopedia e Traumatologia Ortocity. Resultados: Os pacientes tinham idade média de 54,7 anos, diagnosticados após eventos traumáticos (quedas, acidentes, etc.) por meio de exames radiográficos, 50% da amostra com comorbidades, especialmente HAS, 73,3% com desvio de 1mm, mais de 50% com consolidação em até 8 semanas, mais de 60% retornaram às atividades normais em até 16 semanas, as complicações ocorreram em aproximadamente 70% da amostra, porém todas leves e sem necessidade de nova abordagem de tratamento posterior. Conclusão: Nesse sentido, pode-se afirmar que a abordagem conservadora associado à mobilização e carga imediatas formam uma alternativa viável de tratamento, com bons resultados de recuperação funcional, semelhantes aos pacientes tratados por abordagens cirúrgicas, conforme a literatura levantada para este estudo. Palavras-chave: Fratura de tornozelo. Abordagem conservadora. Weber B. Resultados funcionais.

Evaluation of the Quality of Life of Patients Using Circular External Fixator in a Trauma Hospital / Avaliação da qualidade de vida dos pacientes em uso de fixador externo circular em um hospital de trauma

Abstract Objective To evaluate the quality of life of patients using an Ilizarov type external fixator for the treatment of complicated fractures and their sequelae. Method This is an observational and cross-sectional study, in which the 36-item short form survey (SF-36) questionnaire (translated into Portuguese) was applied during outpatient consultations in 2 periods, in the months of July 2018 and January 2019. The patients who participated in the study underwent their surgical procedures between January and June 2018. Results We evaluated 36 patients using an external Ilizarov fixator. We observed a predominance of male patients, with a mean age of 37.9 years. Fractures of leg bones and their complications represented half of the sample. Improvement in functional capacity and emotional aspects of the patients was observed throughout the treatment. Conclusion The use of the circular external fixator is an important and effective method for the surgical treatment of complex fractures and their sequelae. This study allowed us to conclude that, after treatment, patients achieved functional return to daily activities with adequate quality of life.

Resumo Objetivo Avaliar a qualidade de vida dos pacientes em uso do fixador externo do tipo Ilizarov para tratamento de fraturas complexas e de suas sequelas Método Trata-se de um estudo observacional e transversal, em que foi aplicado o questionário 36-item short form survey (SF-36) (traduzido para a língua portuguesa) durante as consultas ambulatoriais em 2 períodos, nos meses de julho de 2018 e janeiro de 2019. Os pacientes que participaram do estudo realizaram seus procedimentos cirúrgicos no período de janeiro a junho de 2018. Resultados Foram avaliados 36 pacientes em uso de fixador externo do tipo Ilizarov. Foi observado predomínio do sexo masculino e idade média de 37,9 anos. As fraturas de ossos da perna e suas complicações representaram metade da amostra. Foi observada melhora na capacidade funcional e nos aspectos emocionais dos pacientes ao longo do tratamento. Conclusão O uso do fixador externo circular constitui um método importante e eficaz para o tratamento cirúrgico de fraturas complexas e de suas sequelas. Este trabalho permitiu concluir que, após o tratamento, os pacientes alcançaram retorno funcional às atividades diárias com adequada qualidade de vida.

Calcaneal fracture: results of earlier rehabilitation after open reduction and internal fixation.

INTRODUCTION: This study aimed to analyze the clinical and radiological outcomes of early weight-bearing and rehabilitation after open reduction and internal fixation (OR/IF) of calcaneal fracture. MATERIALS AND METHODS: This retrospective study was conducted on 78 patients with unilateral calcaneal fracture who underwent OR/IF. A mean follow-up period was 45.8 months (range 12-135). Two weeks after surgery, the range of motion (ROM) exercise was started, brace or heel off shoe was applied, and forefoot weight-bearing was allowed. Four weeks after surgery, tolerable weight-bearing ambulation without crutch was allowed. When the patient was not walking, the braces were removed to perform peritalar ROM exercises. Radiologic evaluation was performed by measuring the Böhler angle and incongruency of the subtalar joint surface. Paley grade was used to assess traumatic arthritis. Clinical evaluation was performed by measuring the foot and ankle outcome score (FAOS) and ankle ROM. RESULTS: The mean postoperative Böhler angle was 31.7° (P < 0.001) at 2 weeks, 31.2° at 3 months, and 30.1° at the last (P = 0.4). The average Paley grade of the subtalar OA was 1.12. CT imaging revealed that the average step-off of the subtalar joint was 1.26 mm in coronal and 0.84 mm in sagittal. The average ROM results were as follows (contralateral, affected side): there was no significant difference in dorsiflexion [16.9° vs. 16° (P = 0.6)], whereas plantarflexion and inversion were significantly decreased [39.5° vs. 35.3° (P = 0.049) and 50.5° vs. 34.8° (P = 0.04)]. The average FAOS score was 86.1 points, and the highest score was "function" (mean 92.5 points). CONCLUSIONS: Earlier rehabilitation after OR/IF is recommended for the treatment of calcaneal fracture.

Iliac intramedullary stabilization for Type IIIA fragility fractures of the pelvis.

There have been few reports on fixation of Rommens classification Type IIIA fragility fractures of the pelvis (FFPs). Here, we present our less invasive surgical technique, called iliac intramedullary stabilization (ILIS), for the internal fixation of Type IIIA FFPs. The technique involves a closed reduction, termed the femur internal rotation reduction method (FIRM), whereby the fracture fragments are repositioned using lateral rotators by internally rotating the femur while the patient is in the prone position. Two iliac screws are inserted on the ilium bilaterally via the supra-acetabular bone canal during FIRM and connected with two transverse rods and two cross connectors. We refer to this internal fixation procedure as ILIS. We retrospectively recruited patients with Type IIIA fractures, treated using this procedure, at our institute between October 2017 and October 2019. We evaluated operative and post-operative outcomes. We enrolled 10 patients (9 women and 1 man; mean age, 85.2 years) who were followed up for over 6 months. All patients suffered FFPs after falling from a standing position. The mean operative time was 145.1 (range, 94-217) minutes, and the mean blood loss was 258.5 (range, 100-684) ml. All patients were allowed full weight bearing from post-operative day 1. All patients achieved bone union and regained their pre-injury walking ability at 6 months after surgery without evident secondary displacement. In conclusion, our ILIS technique allows less invasive internal fixation of Type IIIA FFPs with adequate stability for full weight bearing from post-operative day 1.

Acute Fractures of the Glenoid.

Glenoid fractures are unique in which they span the fields of orthopaedic traumatology and sports medicine. Treatment of glenoid fractures, whether surgical or nonsurgical, may be challenging and have long-term implications on pain and shoulder function. Plain radiographs are always indicated, and most glenoid fractures will require advanced imaging in the form of CT scan. Two general categories of glenoid fractures exist and differ in mechanism of injury, fracture morphology, and treatment. The first category is glenoid fractures with extension into the scapular neck and body. These fractures are typically from high-energy trauma and are often associated with other orthopaedic and nonorthopaedic injuries. The second category includes glenoid rim fractures, which are typically consequent of lower energy mechanisms and are associated with shoulder instability events. Treatment of glenoid rim fractures is dictated by the size and displacement of the fracture fragment and may be nonsurgical or surgical with either open and arthroscopic techniques. The purpose of this review was to discuss the current evidence on glenoid fractures regarding diagnosis, classification, management, and outcomes.

Região metafisária da tíbia de coelhos: uma opção para estudos dos substitutos ósseos / Metaphyseal region of the tibia of rabbits: an option for bone substitutes studies

Apresenta-se um modelo experimental de ostectomia de tíbia em coelhos para estudo de biomateriais em processos de reparação óssea. Foi realizada falha segmentar de 6mm de diâmetro na região metafisária medial proximal de tíbia de 72 coelhos as quais foram preenchidas com substituto ósseo e avaliadas clinicamente, por exame radiográfico e por meio de tomografia computadorizada feixe cônico, em diferentes tempos. Conclui-se que a metáfise medial proximal de tíbia de coelhos é adequada como modelo para estudos que avaliem o comportamento de enxertos e/ou biomateriais em falhas ósseas.

Is presented an experimental model of tibial ostectomy in rabbits to study biomaterials during bone repair process. Segmental failure of 6 mm diameter was performed in the medial proximal tibial metaphyseal region of 72 rabbits, which were filled with bone substitute and evaluated by clinical exam, X-ray, and cone beam computed tomography at different times. It is concluded that the medial proximal tibial metaphysis region of rabbits is suitable as a model for studies that evaluate the behavior of grafts and/or biomaterials on bone defects.

Current Concepts in Rehabilitation Protocols to Optimize Patient Function Following Musculoskeletal Trauma.

Musculoskeletal (MSK) trauma is a major cause of disability and pain worldwide. Despite surgical advances following MSK injuries, poor functional outcomes following surgery remain a major public health concern. Traditional methods of rehabilitation involving bed rest and immobilization led to muscle weakness, joint stiffness, and an inability to return to previous levels of activity. Recent research has provided evidence that early rehabilitation with a multidisciplinary team can prevent these negative outcomes and improve functional outcomes following MSK trauma. In order to continue to optimize recovery, standardized rehabilitation protocols and technological advances are required.

Importancia de la angiogénesis en el diseño de scaffolds para ingeniería de tejido óseo / Importance of angiogenesis in the design of scaffolds for bone tissue engineering

Hematoma, inflamación, angiogénesis y osteogénesis son distintas etapas que se superponen durante el proceso de reparación de una fractura ósea. Durante las primeras etapas se liberan distintos factores de crecimiento quimioatractantes que producen el reclutamiento de diversas células para generar la formación de un hueso funcional con su respectiva vasculatura. Debido a la importancia que posee la angiogénesis en el desarrollo de una adecuada red vascular, tanto para la formación ósea como en su reparación, en los últimos años los especialistas en ingeniería de tejido óseo han estudiado la manera de fomentar tanto la osteogénesis como la angiogénesis durante la reparación ósea. En este trabajo de revisión, se recopilan y discuten los principales conceptos sobre distintas estrategias a fin de lograr un implante sintético con funcionalidad dual promoviendo los procesos que garanticen la angiogénesis y la osteogénesis en forma acoplada utilizando distintos tipos de scaffolds y sistemas de liberación de drogas osteoinductoras y angioinductoras. La liberación dual de factores osteoinductores y angioinductores debe producirse en forma témporo-espacial controlada para garantizar los efectos deseados sin producir efectos adversos como tumores o hueso ectópico. Se deben tener en cuenta varios factores como el tipo y la arquitectura de hueso, tipo de daño, edad, sexo y condiciones patológicas del paciente. En cuanto a los materiales se debe considerar el tipo de material para usar como scaffold, los factores inductores seleccionados, su combinación y sistemas de liberación. El avance en estos estudios hará que la Ingeniería de Tejido Óseo sea una alternativa terapéutica en el futuro. (AU)

Hematoma, inflammation, angiogenesis, and osteogenesis are different stages that overlap during the healing process of a bone fracture. During the first stages, different chemoattractant growth factors are released which produce the recruitment of various cells that will induce the formation of a functional bone with its respective vasculature. Due to the importance of angiogenesis for the development of an adequate vascular network in both bone formation and repair, in recent years specialists in bone tissue engineering have studied how to promote both osteogenesis and angiogenesis during bone repair. In this review, the main concepts on different strategies developed to achieve a synthetic implant with dual functionality, promoting processes that guarantee angiogenesis and osteogenesis in a coupled way using different types of scaffolds and osteo-drug delivery systems and angioinductors, are collected and discussed. The dual release for osteoinductive and angioinductive factors must ensure the release of them in a controlled time-space manner to guarantee the desired effects without producing adverse effects such as tumors or ectopic bone. Several factors must be taken into account, such as bone type and architecture, type of damage to be repaired, age, sex, and pathological conditions of the patient. Regarding the materials, the type of material to be used as scaffolds, selected inducing factors and drug release system must be considered. Advances in these studies will make Bone Tissue Engineering a therapeutic alternative in the future. (AU)

Release Rates and Complications for Birds of Prey With Antebrachial Fractures at a Veterinary Teaching Hospital.

A retrospective case series that included 253 free-ranging birds of prey admitted to a rehabilitation center was conducted to describe the treatment and outcome of antebrachial fractures. Medical records from birds of prey belonging to 21 species admitted with antebrachial fracture between 1989 and 2015 at the University of California, Davis, were reviewed. Species distribution on admission, treatment, outcome, and complications were described by fracture category and species. Among 134 birds treated after initial triage on the day of admission, 4 bone/ wing categories were identified: 83 birds had an ulnar fracture only; 18 birds had a radial fracture only; 28 birds had a concomitant fracture of the radius and ulna on the same wing; and 5 birds had bilateral antebrachial fractures. Logistic regressions were performed to determine which factors were associated with a positive outcome within each of these 4 categories. Among birds having only an ulnar fracture, those with a closed fracture were significantly more likely to be released than birds with open fractures (P = .03; odds ratio = 5.43, 95% confidence interval: 1.29-28.12). In addition, birds with a fracture of the middle third of the ulna were significantly more likely to be released than birds diagnosed with a single fracture of the proximal third of the ulna (P = .02; odds ratio = 4.54, 95% confidence interval: 1.35-16.64). No significant prognostic factor was detected in other fracture categories.

[Ipsilateral Fractures of the Coracoid and Acromion Process of the Scapula Combined with the Distal Clavicle End Fracture, Treatment Options]. / Ipsilaterální zlomenina processus coracoideus a akromionu lopatky v kombinaci se zlomeninou laterální cásti klavikuly, terapeutická moznost resení.

Superior Shoulder Suspensory Complex (SSSC) is a bone and soft-tissue ring securing the connection of the upper extremity to the axial skeleton via the clavicle and sternoclavicular joint. An isolated injury to one component of SSSC is usually stable. An injury to 2 of its components is a potential source of shoulder girdle instability and requires surgical stabilisation. An injury affecting 3 and more components is extremely rare and surgical stabilisation should be indicated. Our study presents the case of a 50-year-old man who fell off the bicycle and sustained a direct blow to his left shoulder resulting in an ipsilateral fracture of the coracoid and acromion process combined with the fracture of the distal end of the clavicle. Following a standard clinical examination and a subsequent X-ray and a CT scan with three-dimensional shoulder reconstruction, an open reduction and stabilisation of all the injured SSSC components was performed. Later, early and gradual rehabilitation of the shoulder girdle was commenced. At 48 weeks after the surgery, almost full range of motion of the shoulder joint was achieved and the muscle strength of the operated upper extremity was comparable to that of the healthy one. Key words:Superior Shoulder Suspensory Complex, fracture, acromion, coracoid process, clavicle.

Evidence-based rehabilitation therapy following surgery for (peri-)articular fractures: A systematic review.

OBJECTIVE: To assess the availability of explicitly reported protocols describing post-surgery rehabilitation of (peri-)articular fractures of the proximal humerus, acetabulum and/or tibial plateau, and to critically review any scientific evidence on the effectiveness of these protocols. DATA SOURCES: MEDLINE (PubMed), Cochrane databases, CINAHL, PEDro and Embase (Ovid) were searched to November 2018. Furthermore, stakeholder internet sites, clinical guidelines and standard textbooks were searched. STUDY SELECTION: Screening was performed independently by 2 researchers based on a priori defined eligibility criteria. DATA SYNTHESIS: Five papers addressed post-surgical rehabilitation of proximal humerus fractures, 1 paper that of acetabulum fractures. No eligible information was found on stakeholder sites or in standard textbooks. Overall, the main focus of the protocols identified was on the International Classification of Functioning, Disability and Health (ICF) Body Functions and Structures level. In general, little information about therapy dosage was reported. None of the protocols provided scientific evidence on which the content of described rehabilitation programmes was based. CONCLUSION: This review reveals a paucity of explicitly formulated protocols focussing on post-surgical rehabilitation of common (peri-)articular fractures targeting patient-centred care at all ICF levels. There is a need for more scientific evidence on which to base protocols regarding common (peri-)articular fracture rehabilitation.

Effects of psychological factors on the clinical outcomes of fifth metacarpal neck fractures and their relation to injury etiology.

BACKGROUND: The fifth metacarpal neck fracture injuries are commonly found in patients who applied to emergency clinics. The mechanism of trauma in these types of injuries seems to be different and, in some cases, appears to be intentional. Psychological factors play an important role in the treatment and rehabilitation, as well as in the etiology of metacarpal neck fractures. However, to the best of our knowledge, no research has yet compared the clinical outcomes of patients with fifth metacarpal neck fractures caused intentionally with those of patients with such fractures caused by unintentional injuries. Our goal is to investigate the relationships between the mechanism of injury, socioeconomic status, and clinical outcomes of patients with fifth metacarpal neck fractures. METHODS: The study included 59 patients with fifth metacarpal neck fractures. The patients were separated into two groups. Group 1 consisted of patients with intentional injuries, and Group 2 consisted of patients with unintentional injuries. Both groups were evaluated in terms of the anger analysis, impulsivity, and the level of anxiety in relation to somatic findings Visual Analogue Scale (VAS) and The Disabilities of the Arm, Shoulder and Hand Score (QDASH). In addition, the relationship between anger, impulsivity, and anxiety scores with the socioeconomic status and educational level was assessed. RESULTS: It was observed that the anger and impulsivity values of Group 2 patients were lower than the Group 1, and the decrease in Group 2 was correlated with the VAS and Q-DASH values. Group 1 barrat impulsivity score 61.5 (42-78), anxiety score 64 (55-77), state anger score 20 (16-30), and Group 2 barrat impulsivity score 61 (55-69), anxiety score 66 (58-72), and anger score 19 (14-26) were found as mean values. The impulsivity score and anger score were found to be lower in Group 2 at the low educational level. The number of patients with a low income was found to be high in both groups, and the impulsivity score and the anger score were higher in Group 1, while the anxiety score was higher in Group 2. CONCLUSION: Sociodemographic factors and the etiology of intentional injuries could not be detected, but psychological factors play a role in the clinical sequelae of intentional fifth metacarpal fractures, their effects thereof on the hand function and the pain course after treatment.

The effect of a heel-unloading orthosis in short-term treatment of calcaneus fractures on physical function, quality of life and return to work - study protocol for a randomized controlled trial.

BACKGROUND: There are no standardized therapy guidelines for rehabilitation of calcaneus fractures. While there is consensus on non or partial weight-bearing, the use of supporting devices such as specific foot ankle orthosis is still a matter of debate. Recently, a heel-unloading orthosis ("Settner shoe") was introduced for aftercare of these fractures, allowing walking by shifting the load to the middle-foot and forefoot. This orthosis enables early mobilization of patients suffering from either one-sided or two-sided fractures. The Settner shoe can be applied in non-operative therapy and after surgery. Specifically in calcaneus fractures, early regain of physical activity has been highlighted as one of the key factors for quality of life and the ability to return to work. Thus, we hypothesize that mobilization with the Settner shoe results in improved quality of life and greater physical activity within the first 3 months. METHODS: This is going to be analyzed by a randomized controlled study comparing treatment with and without this specific orthosis. The secondary outcome measure is the time point of return to work in patients aged between 18 and 60 years, with calcaneus fracture. Furthermore, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 3-dimensional gait analysis, and the Euroqol-5 dimension-3 level (EQ-5D-3 L) questionnaire for quality of life are assessed. DISCUSSION: This is the first trial applying a standardized rehabilitation protocol in patients with calcaneus fractures, aiming to improve the non-operative part of treatment by use of an orthosis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03572816 . Registered on 27 July 2018.

Gait characteristics and functional outcomes during early follow-up are comparable in patients with calcaneal fractures treated by either the sinus tarsi or the extended lateral approach.

BACKGROUND: To overcome the substantial functional loss after calcaneal fractures (CF), surgical treatment currently consists of two strategies, namely the commonly used extended lateral approach (ELA) and the less invasive sinus tarsi approach (STA). Despite the comparable anatomical restoration, the biomechanical and functional outcome of these strategies during early rehabilitation has not yet been investigated. RESEARCH QUESTION: To evaluate changes in gait characteristics and functional development in patients with CF treated by either STA or ELA. METHODS: A total of 56 patients with unilateral CF were included in this retrospective study. 26 patients were treated by ELA while 30 patients underwent surgery through the STA. Functional and biomechanical measurements were performed at follow-up periods of three and six months. Foot and ankle kinetics and kinematics were extracted using instrumented gait analysis with a multi segment foot model. Physical and mental components of the Short Form 36 (SF-36) and total scoring of the AOFAS hindfoot scale were used for functional evaluation. Statistical analysis was performed using Mann Whitney and Student's t-test. Effect sizes of group differences were calculated using Cohen's d. RESULTS: Comparisons between ELA and STA showed no significant difference regarding the biomechanical and functional outcome. Within-group comparisons showed significant (p < 0.05) improvements from three to six month follow-up. Ankle joint and hindfoot kinematics showed increased mobility during walking of up to 34% and 26%, respectively. Maximum ankle joint moment also improved by up to 34% while vertical ground reaction force increased by 8%. Functional outcome only revealed significant changes in the physical component of SF-36. SIGNIFICANCE: ELA and STA treatments revealed comparable functional improvements in patients with unilateral intraarticular calcaneal fractures during early rehabilitation. The less invasive STA provides adequate restoration of dynamic foot function and could serve as a viable alternative to the commonly used ELA.

Wide-Awake Surgical Management of Hand Fractures: Technical Pearls and Advanced Rehabilitation.

Most unstable metacarpal and phalangeal fractures for which operative treatment is indicated can be reduced and stabilized with either open or closed techniques using local anesthetic with epinephrine instead of intravenous sedation or general anesthesia. With the patient wide-awake during surgery, the hand can be taken through active range of motion to assess fracture stability. In this article, the authors review the rationale and technique for wide-awake, local anesthesia, no tourniquet surgery in the treatment of phalangeal and metacarpal fractures and impart pearls to optimize the patient experience and illustrate common fixation techniques using percutaneous Kirschner wires. The intraoperative assessment of fracture stability permits an accelerated, protected-range-of-motion protocol that minimizes postoperative stiffness and facilitates expedient recovery.

Utility of early active motion for flexor tendon repair with concomitant injuries: A multivariate analysis.

INTRODUCTION: Flexor tendon injury often occurs with concomitant injuries such as fracture, vascular injury, and extensor tendon injury. These injuries are repaired independently, without a comprehensive strategy. We aimed to identify the effect of concomitant injuries and treatment choice on the outcome of flexor tendon repair. PATIENTS AND METHODS: We evaluated 118 fingers of 102 adult patients with zone 1-3 flexor digitorum profundus (FDP) tendon injuries who underwent primary surgery at our hospital between April 2009 and December 2017. The 2-strand pull-out, 4-strand Tsuge, 6-strand Lim & Tsai, and 8-strand cross-locked cruciate suturing techniques were used. We performed multivariate analyses, with the active range of motion (AROM) of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints as dependent variables, and age, existence of concomitant injuries, and their treatment as independent variables. RESULTS: The average AROM of the PIP + DIP joints was 130° at the last follow-up, and 'excellent' or 'good' function was obtained in 74 (63%) of 118 fingers by using the Strickland criteria. Old age, concomitant diaphyseal fractures, and specific methods of osteosynthesis, such as pinning, flexor digitorum superficialis injury, and immobilisation for 3 weeks, significantly worsened the results. However, wiring for osteosynthesis and early active motion protocol improved postoperative functional outcome. Although the outcome did not differ among the suture techniques, the 4-strand Tsuge procedure was performed for the two surgically confirmed ruptures of repair that occurred in our series. DISCUSSION: We clarified the superiority of early mobilisation protocols with rigid osteosynthesis procedure, other than pinning. To minimise tendon adhesion or joint stiffness, surgeons should repair the tendon and fractured bone appropriately, to ensure early mobilisation without serious complications.

Outcomes of Conservatively Managed Coracoid Fractures in Wild Birds in the United Kingdom.

Coracoid fractures are a frequent presentation in wild birds, commonly caused by collisions with motor vehicles, windows, or other obstacles such as pylons. Despite this, there are few reports of outcomes, and those published consist of small numbers of birds with conflicting results when comparing conservative management with surgical intervention. To determine outcome success of conservative management in a larger population of wild birds, records of 232 adult wild birds in the United Kingdom (UK) with closed unilateral coracoid fractures confirmed on radiography and surviving more than 48 hours after admission were retrospectively analyzed. Conservative management had a high success rate, with 75% (n = 174/232; 95% confidence limits [CL]: 69%, 80%) of all birds successfully released back to the wild. The proportion of raptors successfully returned to the wild was even higher at 97% (n = 34/35; 95% CL: 85%, 99%). A significant difference of 26% (95% CL: 18%, 34%, Fisher exact test, P < .001) was demonstrated when comparing the outcome success of raptors (97%, n = 34/35) to nonraptors (71%, n = 140/198). The median time in captive care until released back to the wild was 30 days (95% CL: 27, 33). Conservative management of coracoid fractures in wild birds in the UK, and in particular in raptors, appears to result in good outcomes. The approach is low cost and noninvasive, in contrast to surgery, and is recommended as the first-line approach of choice in these cases.

[Simultaneous fracture of the acromion and coracoid process : Rare variant of double disruption of the superior shoulder suspensory complex]. / Gleichzeitige Frakturen von Acromion und Korakoid : Seltene Variante der doppelten Unterbrechung des "superior shoulder suspensory complex".

INTRODUCTION: Simultaneous fracture of the acromion and coracoid process represents a double disruption of the superior shoulder suspensory complex (SSSC). To date, the two largest reported series have comprised five and eight cases. The aim of this study was to investigate the functional outcome in patients who sustained this rare injury and to provide a review of the relevant literature. MATERIAL AND METHODS: In this retrospective study, patients who were surgically treated between 2009 and 2014 were identified from medical records and the patients were asked to attend a follow-up examination. Functional results, measured as the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score, were the main outcomes of the study. RESULTS: A total of six patients underwent surgery for this type of double disruption of the SSSC. All but one patient suffered a high-impact trauma with other associated injuries. The coracoid fracture was classified as type I according to Ogawa in all cases, and the acromion fracture was type III according to Kuhn in 5 out of 6 cases. At least one of the fracture sites was stabilized. Of the patients one showed a concurrent lateral clavicle fracture, representing a third disruption of the SSSC, and another had a fracture of the medial third of the clavicle, representing a strut fracture. In these cases, two fracture sites were operated on. At an average follow-up period of 47 months all but one fracture had healed. In one patient, asymptomatic non-union of the acromion was found. The average DASH score was 22 points and the average Constant score was 74 points. CONCLUSION: This rare injury pattern is usually caused by high-impact trauma, and concomitant injuries frequently occur. Nevertheless, surgical stabilization of at least one of the fracture sites showed satisfactory functional results.

Postoperative treatment of metacarpal fractures-Classical physical therapy compared with a home exercise program.

STUDY DESIGN: Prospective cohort randomized controlled trial. PURPOSE OF THE STUDY: Is either a home exercise (HE) program or traditional physical therapy (PT) more effective in the postoperative management of metacarpal fractures? METHODS: Sixty patients suffering from nonthumb metacarpal fractures who received mobilization-stable open reduction and internal fixation were included. All patients were prospectively randomized into either the PT group or the HE group. Follow-up examinations at 2, 6 and 12 weeks postoperatively. RESULTS: After 2 weeks, the range of motion (ROM) in both groups was still severely reduced. Twelve weeks after surgery the ROM improved to 245° (PT) and 256° (HE). Grip strength after 6 weeks was 68% (PT) and 71% (HE) when compared to the non-injured hand, improving to 91% (PT) and 93% (HE) after 12 weeks. CONCLUSION: Study results show that both HE program and traditional PT are effective in the postoperative management of metacarpal fractures. LEVEL OF EVIDENCE: II.