Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study.

STUDY OBJECTIVE: Temporary lower limb immobilization may be a risk for venous thromboembolism. The purpose of this study was to examine the 90-day incidence of venous thromboembolism among patients discharged from an emergency department (ED) with ankle fractures requiring temporary immobilization. Secondary objectives were to examine individual factors associated with venous thromboembolism in this population and to compare the risk of venous thromboembolism in patients with ankle fractures against a priori-selected control groups. METHODS: This was a retrospective cohort study using province-wide health datasets from Ontario, Canada. We included patients aged 16 years and older discharged from an ED between 2013 and 2018 with closed ankle fractures requiring temporary immobilization. We estimated 90-day incidence of venous thromboembolism after ankle fracture. A Cox proportional hazards model was used to evaluate risk factors associated with venous thromboembolism, censoring at 90 days or death. Patients with ankle fractures were then propensity score matched to 2 control groups: patients discharged with injuries not requiring lower limb immobilization (ie, finger wounds and wrist fractures) to compare relative hazard of venous thromboembolism. RESULTS: There were 86,081 eligible patients with ankle fractures. Incidence of venous thromboembolism within 90 days was 1.3%. Factors associated with venous thromboembolism were older age (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39), venous thromboembolism or superficial venous thrombosis history (HR: 5.18; 95% CI: 4.33 to 6.20), recent hospital admission (HR: 1.33; 95% CI: 1.05 to 1.68), recent nonankle fracture surgery (HR: 1.58; 95% CI: 1.30 to 1.93), and subsequent surgery for ankle fracture (HR: 1.80; 95% CI: 1.48 to 2.20). In the matched cohort, patients with ankle fractures had an increased hazard of venous thromboembolism compared to matched controls with finger wounds (HR: 6.31; 95% CI: 5.30 to 7.52) and wrist fractures (HR: 5.68; 95% CI: 4.71 to 6.85). CONCLUSION: The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.

Postoperative pain with or without nasal splints after septoplasty and inferior turbinate reduction.

PURPOSE: To determine the effect of intranasal Doyle splints on postoperative pain following septoplasty and inferior turbinate reduction (ITR). Changes in Nasal Obstruction Symptom Evaluation (NOSE) scores were also evaluated. MATERIALS AND METHODS: A prospective cohort study conducted from January 2017 to January 2019. Patients were recruited if they experienced nasal obstruction due to septal deviation and inferior turbinate hypertrophy, and failed a one-month trial of intranasal corticosteroids. All patients underwent septoplasty with ITR, and either had Doyle splints or no splints placed. Patients were prescribed hydrocodone-acetaminophen 5-325 mg and asked to keep a daily log of pain medication use and visual analog scale (VAS) scores. Pain logs and NOSE scores were compared between patients who had splints versus patients who had no splints placed after septoplasty and ITR over the first postoperative week. NOSE scores were also collected at every postoperative visit (1 week, 1 month, and 6 months). RESULTS: Fifty-seven patients were enrolled (37 splints, 20 no-splints). The median postoperative pain VAS score was 3.0 (interquartile range [IQR] 2.0-5.0) for the splint group and 4.0 (IQR 2.0-5.0) for the no-splint group (P = 0.906). The median postoperative pain medication requirement in morphine equivalents at the first postoperative visit was 5.4 mg/day (IQR 2.0-13.3) for the splint group and 8.4 mg/day (IQR 1.8-15.3) for the no-splint group (P = 0.833). CONCLUSIONS: There were no statistically significant differences in postoperative pain VAS scores or pain medication use between the two groups. All patients experienced significant reductions in NOSE scores postoperatively.

Prevención de úlceras iatrogénicas por inmovilización terapéutica en niños con férula. Ensayo clínico / Prevention of iatrogenic ulcers produced by therapeutic immobilization with a lower limb splint in children. Clinical trial

INTRODUCCIÓN: La inmovilización con férula de yeso en miembro inferior es un procedimiento frecuente para niños en los servicios de urgencias, el cual no está exento de riesgos relacionados con la inmovilidad y presión, sobre estos factores los enfermeros tienen que adoptar cuidados preventivos. OBJETIVO: Comprobar la eficacia del parche-talonera polimérico en la prevención de úlceras iatrogénicas en niños inmovilizados con férula de yeso en miembro inferior. MATERIAL Y MÉTODO: Ensayo clínico aleatorio preventivo sobre pacientes pediátricos de 0 a 14 años que precisen inmovilización con férula de yeso en miembro inferior. Se realizó muestreo consecutivo no probabilístico simple ciego. Análisis estadístico descriptivo de las variables y test de la X 2 con las variables aplicación del parche y aparición de úlceras. RESULTADOS: Se obtuvo una muestra de n=74 pacientes. Se objetivó úlcera en 21.7% de pacientes, piel íntegra (48.2%) y eritema que palidece 30.1%. Se aplicó el test de la X2 para las variables aplicación de parche polimérico y aparición de úlcera, obteniendo X 2=0.135 con p = 0.713, y por tanto, no existe significación estadística entre estas dos variables. CONCLUSIONES: No existe relación directa entre la prevención de úlceras por presión en niños inmovilizados con férula de yeso y la aplicación de parche protector polimérico. Es fundamental que los enfermeros/as ofrezcan una educación sanitaria de calidad en los cuidados y mantenimiento de la férula para evitar complicaciones

INTRODUCTION: Immobilization with plaster cast in lower limb is a frequent procedure for children in the emergency services, which is not without risks related to immobility and pressure, on these factors nurses have to adopt preventive care. OBJECTIVE: To verify the efficacy of the polymeric heel patch in the prevention of iatrogenic ulcers in children immobilized with a plaster splint in the lower limb. MATERIAL AND METHOD: Preventive randomized clinical trial on pediatric patients aged 0 to 14 years who require immobilization with a lower limb cast cast. Simple blind non-probabilistic consecutive sampling was performed. Descriptive statistical analysis of the variables and X2 test with the application variables of the patch and the appearance of ulcers. RESULTS: A total sample of n = 74 patients was obtained. Ulcer was observed in 21.7% of patients, whole skin (48.2%) and erythema that pales 30.1%. The X2 test was applied for the application of polymer patch and ulcer appearance variables, obtaining X2 = 0.135 with p = 0.713, and therefore, there is no statistical significance between these two variables. CONCLUSIONS: There is no direct relationship between the prevention of pressure ulcers in children immobilized with plaster splint and the application of polymeric protective patch. It is very important that nurses offer a quality health education in the care and maintenance of the splint to avoid complications

TWIST1-Reprogrammed Endothelial Cell Transplantation Potentiates Neovascularization-Mediated Diabetic Wound Tissue Regeneration.

Hypovascularized diabetic nonhealing wounds are due to reduced number and impaired physiology of endogenous endothelial progenitor cell (EPC) population that limits their recruitment and mobilization at the wound site. For enrichment of the EPC repertoire from nonendothelial precursors, abundantly available mesenchymal stromal cells (MSC) were reprogrammed into induced endothelial cells (iEC). We identified cell signaling molecular targets by meta-analysis of microarray data sets. BMP-2 induction leads to the expression of inhibitory Smad 6/7-dependent negative transcriptional regulation of ID1, rendering the latter's reduced binding to TWIST1 during transdifferentiation of Wharton jelly-derived MSC (WJ-MSC) into iEC. TWIST1, in turn, regulates endothelial gene transcription, positively of proangiogenic KDR and negatively, in part, of antiangiogenic SFRP4 Twist1 reprogramming enhanced the endothelial lineage commitment of WJ-MSC and increased the vasculogenic potential of reprogrammed endothelial cells (rEC). Transplantation of stable TWIST1 rEC into a type 1 and 2 diabetic full-thickness splinted wound healing murine model enhanced the microcirculatory blood flow and accelerated the wound tissue regeneration. An increased or decreased colocalization of GFP with KDR/SFRP4 and CD31 in the regenerated diabetic wound bed with TWIST1 overexpression or silencing (piLenti-TWIST1-shRNA-GFP), respectively, further confirmed improved neovascularization. This study depicted the reprogramming of WJ-MSC into rEC using unique transcription factor TWIST1 for an efficacious cell transplantation therapy to induce neovascularization-mediated diabetic wound tissue regeneration.

Oral splints for patients with temporomandibular disorders or bruxism: a systematic review and economic evaluation.

BACKGROUND: Splints are a non-invasive, reversible management option for temporomandibular disorders or bruxism. The clinical effectiveness and cost-effectiveness of splints remain uncertain. OBJECTIVES: The objectives were to evaluate the clinical effectiveness and cost-effectiveness of splints for patients with temporomandibular disorders or bruxism. This evidence synthesis compared (1) all types of splint versus no/minimal treatment/control splints and (2) prefabricated versus custom-made splints, for the primary outcomes, which were pain (temporomandibular disorders) and tooth wear (bruxism). REVIEW METHODS: Four databases, including MEDLINE and EMBASE, were searched from inception until 1 October 2018 for randomised clinical trials. The searches were conducted on 1 October 2018. Cochrane review methods (including risk of bias) were used for the systematic review. Standardised mean differences were pooled for the primary outcome of pain, using random-effects models in temporomandibular disorder patients. A Markov cohort, state-transition model, populated using current pain and Characteristic Pain Intensity data, was used to estimate the incremental cost-effectiveness ratio for splints compared with no splint, from an NHS perspective over a lifetime horizon. A value-of-information analysis identified future research priorities. RESULTS: Fifty-two trials were included in the systematic review. The evidence identified was of very low quality with unclear reporting by temporomandibular disorder subtype. When all subtypes were pooled into one global temporomandibular disorder group, there was no evidence that splints reduced pain [standardised mean difference (at up to 3 months) -0.18, 95% confidence interval -0.42 to 0.06; substantial heterogeneity] when compared with no splints or a minimal intervention. There was no evidence that other outcomes, including temporomandibular joint noises, decreased mouth-opening, and quality of life, improved when using splints. Adverse events were generally not reported, but seemed infrequent when reported. The most plausible base-case incremental cost-effectiveness ratio was uncertain and driven by the lack of clinical effectiveness evidence. The cost-effectiveness acceptability curve showed splints becoming more cost-effective at a willingness-to-pay threshold of ≈£6000, but the probability never exceeded 60% at higher levels of willingness to pay. Results were sensitive to longer-term extrapolation assumptions. A value-of-information analysis indicated that further research is required. There were no studies measuring tooth wear in patients with bruxism. One small study looked at pain and found a reduction in the splint group [mean difference (0-10 scale) -2.01, 95% CI -1.40 to -2.62; very low-quality evidence]. As there was no evidence of a difference between splints and no splints, the second objective became irrelevant. LIMITATIONS: There was a large variation in the diagnostic criteria, splint types and outcome measures used and reported. Sensitivity analyses based on these limitations did not indicate a reduction in pain. CONCLUSIONS: The very low-quality evidence identified did not demonstrate that splints reduced pain in temporomandibular disorders as a group of conditions. There is insufficient evidence to determine whether or not splints reduce tooth wear in patients with bruxism. There remains substantial uncertainty surrounding the most plausible incremental cost-effectiveness ratio. FUTURE WORK: There is a need for well-conducted trials to determine the clinical effectiveness and cost-effectiveness of splints in patients with carefully diagnosed and subtyped temporomandibular disorders, and patients with bruxism, using agreed measures of pain and tooth wear. STUDY REGISTRATION: This study is registered as PROSPERO CRD42017068512. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 7. See the NIHR Journals Library website for further project information.

Treatment options for people experiencing temporomandibular disorders (pain and/or restricted movement in and around the jaw joint) include splints, which are removable appliances, often similar to a mouthguard. They are provided to patients to help ease pain in the mouth, face or jaws. They are also used to manage the symptoms of temporomandibular disorders, such as frequent headaches/migraines, clicking jaws, restricted mouth-opening or tooth wear from the grinding of teeth (bruxism). There are many types of splints. This research looked at the evidence addressing the primary question of whether or not splints work (regardless of type of splint) in reducing the pain associated with temporomandibular disorders and/or tooth wear, and if they offered value for money. Patients were involved in the research to ensure that the question and the outcomes that were measured were appropriate. A systematic review of the literature was undertaken to find all randomised controlled trials including patients with temporomandibular disorders or bruxism. Online databases of research publications were searched, and these searches were checked, to identify relevant trials. All stages of the review process were undertaken to the highest standards by two people, independently and in duplicate, using well-respected and recognised Cochrane methods. We conducted a value-for-money assessment, comparing the trial data with the costs of splints to see if splints are a cost-effective use of NHS funding. There was no evidence that splints reduced pain when compared with not wearing a splint or when compared with a minimal treatment (like jaw exercises, advice or education) in patients with temporomandibular disorders. The evidence was assessed as being of very low quality; therefore, it remains unclear whether or not splints are good value for money, or if they should be paid for by the NHS. This research showed that more well-conducted trials on temporomandibular disorder patients are needed.

Análise do equilíbrio postural estático e da intensidade das dores musculoesqueléticas após o uso de palmilhas proprioceptivas por militares do serviço ostensivo / Análisis del equilibrio postural estático y de la intensidad de los dolores musculoesqueléticas después del uso de plantillas propioceptivas por militares del servicio ostensivo / Analysis of static postural balance and of intensity of musculoskeletal pains after the use of proprioceptive insoles by ostensive service militaries

RESUMO Para a manutenção do equilíbrio, o organismo utiliza os sistemas visuais, vestibulares e proprioceptivos, que enviam informações para o sistema nervoso central acerca das condições do corpo com o objetivo de estabilizá-lo. Este estudo avaliou o efeito das palmilhas proprioceptivas sobre o equilíbrio postural estático e as dores musculoesqueléticas após dois meses de uso, por meio de uma pesquisa analítica longitudinal com 15 militares saudáveis do sexo masculino com média de idade de 34±7,5 anos. Eles foram submetidos à avaliação do equilíbrio por meio da plataforma Medicapteurs® e pelo protocolo CNT. Não houve diferença estatística para os desvios do corpo e velocidade do centro de pressão. A pressão plantar teve mudança estatisticamente significante para o pé esquerdo e o pé direito correspondendo a p=0,0001 e p=0,0007, respectivamente. Houve redução das médias de dores nos joelhos, pés e calcanhares e diminuição significativa da dor lombar, com p=0,0180. O equilíbrio estático não foi alterado significativamente com o uso das palmilhas proprioceptivas pelos militares, contudo elas proporcionaram melhor redistribuição das pressões plantares e parecem atenuar as dores musculoesqueléticas das extremidades inferiores. Por isso as palmilhas podem ser consideradas para esse grupo uma terapêutica de prevenção contra lesões relacionadas à sua atividade laboral.

RESUMEN Para mantener el equilibrio el cuerpo utiliza los sistemas visuales, vestibulares y propioceptivos, que envían información al sistema nervioso central sobre las condiciones del cuerpo para estabilizarlo. Este estudio evaluó el efecto de las plantillas propioceptivas sobre el equilibrio postural estático y los dolores musculoesqueléticas después de dos meses de uso, a través de una investigación analítica longitudinal con 15 soldados sanos con una edad media de 34±7.5 años. Ellos fueron sometidos a evaluación de equilibrio a través de la plataforma Medicapteurs® y por el protocolo CNT. No hubo diferencia estadística para las desviaciones del cuerpo y para la velocidad del centro de presión. La presión plantar tuvo un cambio estadísticamente significativo para el pie izquierdo y el pie derecho correspondiente a p=0.0001 y p=0.0007, respectivamente. Hubo una reducción en las promedio de los dolores en las rodillas, pies y talones y una disminución significativa en el dolor lumbar, con p=0.0180. El equilibrio estático no se modificó significativamente con el uso de plantillas propioceptivas por los militares, sin embargo, proporcionaron una mejor redistribución de las presiones plantares y parecen ablandar los dolores musculoesqueléticas en las extremidades inferiores. Por lo tanto las plantillas pueden considerarse para ese grupo como una terapia de prevención contra lesiones relacionadas con su actividad laboral.

ABSTRACT To maintain the balance, the body uses visual, vestibular and proprioceptive systems, which send information to the central nervous system about the body's conditions in order to stabilize it. This study evaluated the effect of proprioceptive insoles on static postural balance and musculoskeletal pains after two months of use, through a longitudinal analytical study with 15 healthy male soldiers with a mean age of 34±7.5 years. They were subjected to balance evaluation through the Medicapteurs® platform and by CNT protocol. There was no statistical difference for the deviations of the body and speed of the center of pressure. Plantar pressure had a statistically significant change for the left and the right feet, corresponding to p=0.0001 and p=0.0007, respectively. There was a reduction in the mean values of the pains in the knees, feet and heels and a significant decrease in lumbar spine pain, with p=0.0180. The static balance was not significantly altered with the use of proprioceptive insoles by the militaries; however, these insoles provided a better redistribution of plantar pressures and seem to attenuate the musculoskeletal pains of the lower extremities. Therefore, insoles can be considered as a prevention therapy against injuries for this group related to their work activity.

Effect of Side Struts on the Strength of Long Arm Plaster Splints: A Biomechanical Study.

BACKGROUND: There are multiple methods of achieving upper extremity immobilization after pediatric elbow injuries; however, no biomechanical study has established an optimal construct. The goal of this study was to compare the strength of commonly used long arm splints and to evaluate the effect of reinforcing plaster splints with side struts. METHODS: Five categories of long arm posterior slab splints were tested: 4-inch plaster without side struts, 4-inch plaster with a medial side strut, 4-inch plaster with medial and lateral side struts, 5-inch plaster without side struts, and 4-inch fiberglass splint material without side struts. There were 4 splints in each group. As a control, 4 half fiberglass long arm casts were also tested. Each splint or cast was mounted on a single-column tensile tester and a 3-point bending load was applied to simulate an extension moment at the elbow. The maximum load before failure was measured and an ANOVA model was used to analyze the differences between groups. Additionally, a retrospective chart review was performed of pediatric patients who were immobilized postoperatively in a long arm plaster splint with side struts. We collected data on patient age, type of fracture, time from splint application in the operating room to removal in clinic, length of follow-up, and any complications. RESULTS: The 4-inch plaster splints reinforced with 2 struts had the highest average maximum load to failure (731±143 N), which was significantly higher than the 4-inch plaster splints with one strut (505±48 N) (P=0.01) and the 4-inch plaster splints without struts (100±10 N) (P<0.001). The half fiberglass casts failed at an average maximum load of 655±96 N, however there was no statistically significant difference compared with 4-inch plaster splints with 2 struts (P=0.10). The 5-inch plaster splints without side struts failed at a greater average maximum load (341±110 N) compared with the splints constructed with fiberglass material without side struts (233±61 N) (P=0.03). A total of 140 patients were identified in the retrospective review. Splint-related complications occurred in 2 patients. CONCLUSIONS: The addition of both 1 and 2 side struts to a 4-inch long arm plaster splint significantly increased the load to failure. The strength of 4-inch plaster splints with 2 side struts was comparable to that of half fiberglass casts. LEVEL OF EVIDENCE: NA (biomechanical study).

The Superiority of Removable Contact Splints in the Healing of Diabetic Foot during Postoperative Care.

OBJECTIVE: Off-loading is one of the crucial components of diabetic foot (DF) therapy. However, there remains a paucity of studies on the most suitable off-loading for DF patients under postoperative care. The aim of our study was to evaluate the effect of different protective off-loading devices on healing and postoperative complications in DF patients following limb preservation surgery. METHODS: This observational study comprised 127 DF patients. All enrolled patients had undergone foot surgery and were off-loaded empirically as follows: wheelchair+removable contact splint (RCS) (group R: 29.2%), wheelchair only (group W: 48%), and wheelchair+removable prefabricated device (group WP: 22.8%). We compared the primary (e.g., the number of healed patients, healing time, and duration of antibiotic (ATB) therapy) and secondary outcomes (e.g., number of reamputations and number and duration of rehospitalizations) with regard to the operation regions across all study groups. RESULTS: The lowest number of postoperative complications (number of reamputations: p = 0.028; rehospitalizations: p = 0.0085; and major amputations: p = 0.02) was in group R compared to groups W and WP. There was a strong trend toward a higher percentage of healed patients (78.4% vs. 55.7% and 65.5%; p = 0.068) over a shorter duration (13.7 vs. 16.5 and 20.3 weeks; p = 0.055) in the R group, as well. Furthermore, our subanalysis revealed better primary outcomes in patients operated in the midfoot and better secondary outcomes in patients after forefoot surgery-odds ratios favouring the R group included healing at 2.5 (95% CI, 1.04-6.15; p = 0.037), reamputations at 0.32 (95% CI, 0.12-0.84; p = 0.018), and rehospitalizations at 0.22 (95% CI, 0.08-0.58; p = 0.0013). CONCLUSIONS: This observational study suggests that removable contact splint combined with a wheelchair is better than a wheelchair with or without removable off-loading device for accelerating wound healing after surgical procedures; it also minimises overall postoperative complications, reducing the number of reamputations by up to 77% and the number of rehospitalizations by up to 66%.

Injury to the inferior vena cava as a complication of ureteral splint insertion - case report.

The authors describe a rare complication of ureteral stenting is the case study of a patient admitted to the hospital for congestion in the outlet system of both kidneys due to external ureteral compression by tumorous mass in the retroperitoneum. Histology confirmed the B-lymphoma of the retroperitoneum as a cause of the patients problems. The ureteral stent was perforated in the course of inserting the stent into the ureter and the end of the splint was introduced into the inferior vena cava. The patient was asymptomatic, and this complication was detected as late as on day 12 on the follow-up CT scan. Stent extraction was without complications and without bleeding.

The efficacy, safety, and cost benefits of splints for fractures of the distal radius in children: A systematic review and meta-analysis protocol.

BACKGROUND: Distal radius fractures (DRFs) is one of the most common bone injuries in children, which may lead to deformity and other complications if the treatment is not prompt or appropriate. Splints external fixation is a common conservative treatment for such fractures. Therefore, we conducted a systematic review and meta-analysis to explore the efficacy, safety and cost benefits of splints in the treatment of DRFs in children. METHODS: PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, Chinese National Knowledge Infrastructure Database (CNKI), Wanfang Database, and VIP Database were searched for eligible randomized controlled trials (RCTs). The methodological quality of the included studies and the level of evidence for results were assessed, respectively, using the risk bias assessment tool of Cochrane and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Statistical analysis was conducted with Revman 5.3. RESULTS: This study will analyze and integrate the existing evidence for effectiveness, safety and cost benefits of splints on DRFs in children. CONCLUSION: The conclusion of this study will provide evidence to effectiveness, safety and cost benefits of splints on DRFs in children, which can further guide the selection of appropriate interventions. PROSPERO REGISTRATION NUMBER: CRD42019123429.

A Randomized Controlled Trial of Surgical Rib Fixation in Polytrauma Patients With Flail Chest.

BACKGROUND: Flail chest (FC) is known to account for high mortality and morbidity and is typically treated with conservative care. Operative fixation of FC has been advocated as an alternative treatment choice. This prospective randomized controlled trial aims to compare surgical and nonsurgical management of FC in patients with severe polytrauma. METHODS: Severe polytrauma patients with FC admitted between January 2015 and July 2017 to our trauma center were investigated. The enrolled patients were randomly assigned to the surgical or nonsurgical group. Basic characteristics of injury and clinical outcomes were compared. RESULTS: Fifty patients entered final analysis, with 25 patients in each group. Operative rib fixation was associated with shorter duration of mechanical ventilation (7 d [interquartile range {IQR} 6-10] versus 9 d [IQR 7-12], P = 0.012), shorter ICU stay (10 d [IQR 7-12] versus 12 d [IQR 9-15], P = 0.032), lower risk of adult respiratory distress syndrome (28% versus 60%, P = 0.045), pneumonia (48% versus 80%, P = 0.038), and thoracic deformity (8% versus 36%, P = 0.037) and less pain while coughing (pain score 6 [IQR 3-8] versus 8 [IQR 4-9], P = 0.029) and deep breathing (pain score 5 [IQR 3-9] versus 7 [IQR 3-9], P = 0.038). Subgroup analysis was conducted by presence of pulmonary contusion. Shorter time on the ventilator use and ICU stay associated with rib surgery was not observed in patients with pulmonary contusion. CONCLUSIONS: This study reveals that surgical rib fixation may provide some critical care benefits for severe polytrauma patients with FC, including less medical resource use and lower risk of complications. Further studies should be designed to optimally identify patients who are most likely to benefit from this surgery.

Semirigid cervical spine collar and risk of missing significant soft tissue injuries.

We report the case of an initial misdiagnosis of significant scalp soft tissue hidden beneath a semirigid cervical collar. A 16-year-old unrestrained rear seat passenger was involved in an RTA sustaining a subdural haematoma, cervical spine fractures and what was initially diagnosed as a significant degloving scalp injury. The patient was admitted to the intensive care unit intubated sedated, and with a cervical collar. The scalp injury was dressed with a view that potential reconstructive surgery would be needed subsequently.This case demonstrates that while cervical collars remain a fundamental aspect of initial prehospital care in trauma, they have potential drawbacks to their use, which need to be carefully noted. Some of these drawbacks have been reported extensively in the literature. This case outlines the necessity of a thorough secondary survey in the trauma patient as the cervical collar can obscure the assessment of significant head and neck soft tissue injuries.

Treatment of tendinous mallet fingers using a Stack splint versus a dorsal glued splint.

The goal of this study was to compare the results of a Stack splint compared to a dorsal glued splint in the treatment of tendinous mallet fingers. Our series included 100 patients, aged 47 years in average, among which 40 are women, with a 9-week follow-up. The first 50 patients (group I) were treated with a dorsal glued splint, and the 50 following patients (group II) were treated with a Stack splint. The average lack of active extension of the distal phalanx was 3.1° in group I and 1.74° in group II. The average pain was rated 0.22/10 in group I and 0.26/10 in group II. There were seven cases of nail dystrophies, 18 cases of macerations and five cases of swan neck deformities in group I. There were six cases of macerations and four cases of swan neck deformities in group II. The dorsal nail-glued splint gives comparable results to the Stack splint with the added advantage of leaving the fingertip free.

Study on application of ear correction model to infantile cryptotia.

OBJECTIVE: To study the clinical application of ear correction model in infantile cryptotia. METHODS: A total of 108 children including 135 ears were selected from October 2016 to January 2018. The age of the children ranged from 7 days to 840 days, with an average age of 100.88 days. The children were divided into four groups based on age: group A (<28 days), group B (28 days-90 days), group C (90 days-180 days), and group D (>180 days). All the children were corrected by using ear correction models. The effective time, consolidated time and completely corrected time were calculated based on the auricular morphology. RESULTS: The auricle morphology of the affected ears was nearly the same as the normal after correction by ear correction model. Statistical differences were observed on treatment time between the groups (P < 0.05), except for group B and group C (P > 0.05). In terms of complications, statistical differences were observed between the groups (P < 0.05), except for group A and group B (P > 0.05). CONCLUSION: The ear correction model is remarkably effective in infants with cryptotia of not only less than 6 months, but also for children with cryptotia of more than 6 months. Infants under 6 months had shorter treatment time and lower complications, while infants beyond 6 months had more treatment time and higher complications.

Investigating the time-lapsed effects of rigid cervical collars on the dimensions of the internal jugular vein.

Protocol advocates the use of rigid cervical collars (RCCs) in head trauma patients as they are at risk of concomitant cervical spine injury. Literature has shown RCCs to be a potential cause of venous outflow obstruction, changing internal jugular vein (IJV) cross-sectional area (CSA), and raising intracranial pressure (ICP). This study aims to investigate the effects of applying a RCC, for a period of four hours, on the dimensions of the IJV, in healthy participants. Seventeen participants (nine male, eight female) took part in this study. Circumference and CSAs of the IJV were measured bilaterally by a single observer using a GE LOGIQ e ultrasound system. Measurements were taken pre-RCC application, immediately after, every hour over four hours, and five minutes postcollar removal. The CSA of the IJV was 8.3 ±6.0 mm2 pre-RCC application. The CSA of the IJV doubled (18.92 ±10.55 mm2 ) after four hours and decreased back to 9.36 ±6.8 mm2 five minutes postcollar removal. The circumference of the IJV was 17.29 ±6.03 mm pre-RCC application, increasing to 20.34 ±5.59 mm by the end of the fourth hour and returning to 16.14 ±5.16 mm five minutes postcollar removal. Related-samples Friedman's ANOVA test showed statistically significant differences for both left and right CSAs and circumferences of the IJV measured across the four hours (P-value<0.05). Ultrasound assessment of CSA of the IJV may correlate with changes in ICP. Further studies may provide insight into the effects of collar design, and guide future trauma protocol to minimize intracranial pressure fluctuations. Clin. Anat. 32:196-200, 2019. © 2018 Wiley Periodicals, Inc.

Upper Extremity Immobilization and Driving: Limitations and Liability.

Orthopaedic injuries of the upper extremity remain common, often requiring prolonged immobilization after surgical or nonsurgical management. Upper extremity immobilization often has a profound effect on a patient's daily life, including one's ability to safely operate a motor vehicle. Current literature on the safety of driving while immobilized is varied, although above-elbow immobilization of the upper extremity is generally thought to present a particular hazard to safe driving. Unfortunately, as common as this situation is, currently little to no guidance exists for patients, physicians, or lawmakers with regard to deciding whether a patient is safe to return to driving with upper extremity immobilization. Similar discord exists with the issue of patient and physician liability in such cases. In this review, we seek to present both historical precedent and a contemporary update of this complex, though a frequently encountered situation.

Should the restoration of adjacent implants be splinted or nonsplinted? A systematic review and meta-analysis.

STATEMENT OF PROBLEM: The decision to splint or to restore independently generally occurs during the planning stage, when the advantages and disadvantages of each clinical situation are considered based on the proposed treatment. However, clinical evidence to help clinicians make this decision is lacking. PURPOSE: The purpose of this systematic review and meta-analysis was to assess the marginal bone loss, implant survival rate, and prosthetic complications of splinted and nonsplinted implant restorations. MATERIAL AND METHODS: This study was designed according to the Cochrane criteria for elaborating a systematic review and meta-analysis and adopted the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Also, this review was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42017080162). An electronic search in the PubMed/MEDLINE, Cochrane Library, and Scopus databases was conducted up to November 2017. A specific clinical question was structured according to the population, intervention, comparison, outcome (PICO) approach. The addressed focused question was "Should the restoration of adjacent implants be splinted or nonsplinted?" The meta-analysis was based on the Mantel-Haenszel and inverse variance methods to assess the marginal bone loss, implant survival, and prosthetic complications of splinted and nonsplinted implant restorations. RESULTS: Nineteen studies were selected for qualitative and quantitative analyses. A total of 4215 implants were placed in 2185 patients (splinted, 2768; nonsplinted, 1447); the mean follow-up was 87.8 months (range=12-264 months). Quantitative analysis found no significant differences between splinted and nonsplinted restorations for marginal bone loss. The assessed studies reported that 75 implants failed (3.4%), of which 24 were splinted (99.1% of survival rate) and 51 were nonsplinted (96.5% of survival rate). Quantitative analysis of all studies showed statistically significant higher survival rates for splinted restorations than for nonsplinted restorations. Ceramic chipping, screw loosening, abutment screw breakage, and soft tissue inflammation were reported in the selected studies. The quantitative analysis found no statistically significant difference in the prosthetic complications of splinted and nonsplinted restorations. CONCLUSIONS: Within the limitations of this systematic review and meta-analysis, it was concluded that there was no difference in the marginal bone loss and prosthetic complications of splinted and nonsplinted implant restorations; this is especially true for restorations in the posterior region. However, splinted restorations were associated with decreased implant failure.

Comparación del tratamiento conservador y quirúrgico en la rotura aguda del tendón de Aquiles / Comparison of conservative and surgical treatment in acute Achilles tendon rupture

El objetivo de esta revisión fue comparar el tratamiento quirúrgico y el tratamiento conservador para ver cuál era más eficaz ante la nueva rotura. Hubo resultados contradictorios. La pieza clave parece ser el protocolo de rehabilitación posterior a la intervención.Se realizó una búsqueda en bases de datos (Pubmed, Cochrane y PEDro) para encontrar artículos que comparasen ambos tratamientos. Se hizo criba de los mismos según los criterios de inclusión y exclusión.Encontramos que los estudios que no usan un protocolo de rehabilitación con carga temprana tuvieron un resultado a favor del tratamiento quirúrgico para evitar la recidiva (P=0,002). En cambio, los estudios que sí usaron este protocolo no encontraron tanta diferencia de nueva rotura entre el tratamiento conservador y el quirúrgico (P=0,05). Se vio que el tratamiento quirúrgico sí está relacionado con el aumento de las complicaciones (P=0,004).En conclusión, el tratamiento quirúrgico está relacionado con una menor tasa de nueva rotura, a no ser que haya un protocolo de rehabilitación con carga temprana. En este caso, la tasa de recidiva sería similar para ambos tratamientos, siempre teniendo en cuenta que la cirugía abierta está relacionada con más complicaciones

The objective of this review was to compare the surgical treatment and the conservative treatment to see which was the most effective in a new rupture. There were contradictory results. The key seems to be the rehabilitation protocol after the intervention. A search was made in databases (Pubmed, Cochrane and PEDro) to find articles comparing both treatments. They were screened according to the inclusion and exclusion criteria. We found out that studies that do not use a rehabilitation protocol with loading had a result in favor of surgical treatment to avoid recurrence (P = 0.002). However, the studies that used this protocol didn’t find as much difference of new rupture between conservative and surgical treatment (P = 0.05). It was found that the surgical treatment was related to the increase in complications (P = 0.004). In conclusion, the surgical treatment is related to a lower rate of new rupture, unless there were a rehabilitation protocol of early weighting. In this case, the recurrence rate is similar for both treatments, always bearing in mind that open surgery is related to more complications

Quality of life and nasal splints after primary cleft lip and nose repair: Prospective assessment of information and tolerance.

Splints are commonly used after primary cleft surgery in order to secure the position of the nasal cartilages. Although the importance of splints is more and more stressed in the literature, many questions remain unanswered relative to the psychological impact of this device on children and families. Two questionnaires, Information and Tolerance, were used in order to measure the quality of life (QoL) associated with the use of nasal splints after primary cleft surgery. Information assessed the understanding of the parents the day before the procedure. Tolerance assessed their experience 3 months after splint placement. We prospectively included 41 consecutive patients from a Paris cleft center, 21 consecutive patients from a Russian center (Moscow) and 10 consecutive patients form a another French center (Nantes). In Paris and Nantes, an initial fixed splint was placed during the procedure until day 10, and then replaced by a removable splint for a period of 4 months. In the Moscow group, removable splints were used primarily for a total period of 4 months. Three types of removable splints were considered: commercial anatomical self-retentive splints (Nose-Fit™, Moscow, Russian Federation), in-house anatomical self-retentive splints and commercial Talmant-type splints requiring taping (Sebbin, Boissy-l'Aillerie, France). The data was analyzed as Likert scales and internal consistency was assessed using the Cronbach coefficient. Age at surgery, uni- or bilateral cleft, type of splint, number of splint changes and complications were tested against the scores of the questionnaires using multivariate models. We did not find correlations between the factors assessed by the multivariate analysis and the splint type. Information and Tolerance scores were high and showed satisfactory QoL associated with the use of splints. The internal consistency of the combination of the two forms was good. While the effects of splints on nasal morphology still need to be confirmed based on a controlled prospective study, we show here that this device is well tolerated by families and is not associated with specific complications.

Forgotten Post Operative Nasal Splint & Oro-Nasal Fistula.

of the oral cavity. It may develop as a congenital defect e.g. cleft palate, or rarely, consequent to an operative procedure like a sub muco-perichondrial resection surgery of the nasal septum. After nasal septal corrective surgery, follow up of the patient with meticulous nasal toilet and detailed examination is mandatory. In operated patients who do not report to follow up, and later on present with persisting nasal discharge, pain, nasal blockage and exsanguination must alert a clinician for any evidence of a possibly retained foreign object. Inadvertently retained nasal splints can cause long lasting morbidity due to a possible chronic sinusitis, toxic shock syndrome and palatal perforation.