We retrospectively evaluated the clinical and radiological outcomes of a consecutive cohort of patients aged > 70 years with a displaced fracture of the olecranon, which was treated non-operatively with early mobilisation. We identified 28 such patients (27 women) with a mean age of 82 years (71 to 91). The elbow was initially immobilised in an above elbow cast in 90° of flexion of the elbow for a mean of five days. The cast was then replaced by a sling. Active mobilisation was encouraged as tolerated. No formal rehabilitation was undertaken. At a mean follow-up of 16 months (12 to 26), the mean ranges of flexion and extension were 140° and 15° respectively. On a visual analogue scale of 1 (no pain) to 10, the mean pain score was 1 (0 to 8). Of the original 28 patients 22 developed nonunion, but no patients required surgical treatment. . We conclude that non-operative functional treatment of displaced olecranon fractures in the elderly gives good results and a high rate of satisfaction. . Cite this article: Bone Joint J 2014;96-B:530–4

Consecutive patients with a confirmed rupture of at least one of the lateral ligaments of the ankle were randomly assigned to receive either operative or functional treatment. They were evaluated at a median of 8 years (6 to 11). In total, 370 patients were included. Follow-up was available for 317 (86%). Fewer patients allocated to operative treatment reported residual pain compared with those who had been allocated to functional treatment (16% versus 25%, RR 0.64, CI 041 to 1.0). Fewer surgically-treated patients reported symptoms of giving way (20% versus 32%, RR 0.62, CI 0.42 to 0.92) and recurrent sprains (22% versus 34%, RR 0.66, CI 0.45 to 0.94). The anterior drawer test was less frequently positive in surgically-treated patients (30% versus 54%, RR 0.54, CI 0.41 to 0.72). The median Povacz score was significantly higher in the operative group (26 versus 22, p < 0.001). Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability

The most important determinant in the treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. Weber (2010) showed that weightbearing radiographs predicted stability in patients with undisplaced ankle fractures. We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. A consecutive, prospectively documented series of 37 patients chose functional brace treatment of potentially unstable fractures. Weightbearing radiographs were performed in the brace before treatment, and free of brace at clinical union (6–9 weeks in all patients). Patients were encouraged to bear full weight and actively exercise their ankles in the brace. All fractures healed without displacement. The risk of displacement was 0% (95% CI 0–11.2%). This preliminary series gives support for the use of weightbearing radiographs to guide treatment of undisplaced ankle fractures

Purpose of the study: Three-screw fixation is the classical treatment for true Garden I in the elderly patient. Complication rates have been high in the literature. Furthermore, in this context outcome for arthroplasty after failed osteosynthesis is less satisfactory than first-intention arthroplasty. This is why functional treatment of Garden I fractures of the neck of the femur has been proposed, including rapid return to the upright position and strict radiographic and clinical control. The purpose of this work was to first evaluate the results of this management option for true Garden I fractures in patients aged over 65 years and second to search for factors predictive of secondary displacement. Material and methods: All patients aged over 65 years and admitted to the unit for true Garden I fractures from January 2005 to December 2006 were included in this prospective study. A functional treatment including early return to the upright position and walking test on day 1 was instituted, followed by radiographic controls on days 2, 7, 14, 21, and 45 then at 3 months and one year. Referral to a rehabilitation centre at discharge on day 5 was scheduled if there was no displacement. In the event of a displacement, arthroplasty was performed. Fifty-seven patients, mean age 82.8±8.5 years (range 65–99) were included. The radiographic and clinical follow-ups were made by an independent observer. Results: The displacement rate was 29.8%. These patients were treated by arthroplasty. In the group of patients without displacement, at minimum one year follow-up, there has been no need for surgical revision excepting one case of osteonecrosis at one year requiring implantation of a total prosthesis. The mean Parker score in this group was 6.4 and the mean Harris score 83, it was 85 in the arthroplasty group. Among the predictive factors identified at multivariate analysis were: age, gender, side, type of fracture, fracture orientation, degree of valgus or sagittal displacement, general status. Displacement was not statistically predictive. Discussion: The results of our prospective study show that 70% of patients included were treated successfully without surgery, confirming reports in the literature and justifying utilisation of this management strategy

OBJECTIVES. In elderly patients the temporary loss of function of the upper extremity due to immobilization for treatment of unstable proximal humeral fractures is a very disabling condition. Stable fixation of such fractures allowing immediate functional aftercare may contribute to early social reintegration in this group of patients. Aim of this study is to present the surgical technique of humeral blade plate fixation and the clinical and radiographic results after fixation of unstable surgical neck fractures with this implant followed by immediate functional treatment in patients older than 60 years. PATIENTS. 20 patients (4 male, 16 female) with a mean age of 74 years (59y–93y) were included in this study and treated consecutively for an unstable/displaced surgical neck fracture with a humeral blade plate. Postoperatively functional treatment was allowed. All but one patient had a clinical and radiographic follow-up 6 weeks po. At an average final follow-up of 18,8 months (12–24 months) 4 patients had died from causes unrelated to surgery. RESULTS. Surgery was performed in all patients without local or general complications despite comorbidities. In all patients anatomic reduction and stable fixation could be achieved. 6 weeks po all patients (N=20) were free of pain at rest, 7 patients had low pain (VAS < 4) when actively moving the arm. All patients used their operated arm for ADL and were back home or in the institution they came from at the time of trauma. All fractures were deamed to be healed without implant failure. In two cases a clinically asymptomatic 1–2mm protrusion of the blade through the subchondral bone was observed, but did not required further surgery. At final follow-up (N=8) the average absolute Constant/Murley Score was 68,6 points (contralateral 71,4). Radiographically all fractures had healed without complications. Implant removal was not required. CONCLUSION. Humeral blade plate fixation combined with suture tension-banding of the rotator cuff allows indirect reduction, dynamic and stable osteosynthesis of unstable surgical neck fractures even in osteoporotic bone. In our small series, this technique has shown to be a safe and reliable therapeutic option allowing immediate functional treatment and thus early social reintegration in elderly patients

Introduction: The treatment of the recently ruptured Achilles tendon is still controversial. Surgical procedures are commonly considered to restore excellent functional capacity and suffer low re-rupture rates, but are potentially associated with significant complications like wound infection and paraesthesia. Recent studies report very good results with a conservative treatment in rigid casts. Our aim was to evaluate a new method of functional and conservative treatment using immobilisation in an articulated cast. Patients and Methods: Between March 1998 and August 2005, 12 women and 45 men with an average age of 45 (24–73), underwent a functional and conservative treatment for a recently ruptured Achilles tendon. After an immobilisation with a cast in equinus for 10 days, the patients were authorised to walk with full weight-bearing, protected by a commercial orthosis (VACO®ped, OPED). The equinus angle was set at 30° plantar flexion until the end of week 3, and at 15° until the end of week 4. At the 5th week the system was unlocked to allow ankle mobilisation of 30-15-0°, and at 30-0-0° at the seventh week. The orthosis was removed after 8 weeks. All patients had follow-up examinations up to 12 months after the trauma. The first 30 patients underwent a clinical examination and muscular testing with a Cybex isokinetic dynamometer at 6 and 12 months. In June 2006 all 57 patients were contacted and received a questionnaire. Their subjective opinions of the outcome, any change in their sport activities and eventual late complications were investigated. We evaluated the questionnaire and medical records using a scoring system based on the Leppilahti Ankle Score. Results: After one year there was not any difference in the motion of the ankle in comparison with the healthy side. There was no substantial calf amyotrophy and we found very little difference in muscular capacity. The average overall satisfaction with the outcome was 8.1 out of 10. We observed 5 complete re-ruptures (9%), 2 partial re-ruptures and 1 deep venous thrombosis complicated by pulmonary embolism. We observed few minor skin complications. Conclusions: The present treatment resulted in good to excellent functional results in most of the cases. It requires an active participation of the patient and a systematic medical follow-up during the first 6 months. The complication rate is acceptable. We think that early ankle mobilisation in the dynamic cast promotes better functional results than a rigid immobilisation technique. There is a place for conservative functional treatment in the acute rupture of the Achilles tendon. But prospective comparison with modern surgical techniques, like minimal invasive suture, is still required, especially in patients with high functional demand

Isolated Weber B fractures usually heal uneventfully but traditionally require regular review due to the possibility of medial ligament injury allowing displacement. Following recent studies suggesting that delayed talar shift is uncommon we introduced a functional treatment protocol and present the early results. 86 patients presenting acutely with Weber B fractures without talar shift between January and July 2015 were included. Patients were splinted in a removable boot and allowed to weight bear. ED notes and radiographs were reviewed by an Orthopaedic consultant. Patients without signs of medial injury were discharged with an information leaflet and advice. If signs of medial ligament injury were noted or the medial findings were not documented the patient was reviewed in fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. MOXFQ and EDQ5 scores were collected. 50 patients had signs of medial ligament injury or no documented medial findings and of these 43 attended fracture clinic. Of 36 patients without signs of medial ligament injury 28 were discharged according to protocol and 8 patients attended fracture clinic. One discharged patient re-accessed care. Of 52 patients reviewed in the fracture clinic none developed delayed talar shift and all continued with non-operative treatment. The outcome scores were comparable to those in the published literature. We conclude the risk of delayed talar shift is low and satisfactory outcomes can be safely achieved with our functional protocol. Additional tests/imaging to establish the integrity of the medial ligament may be unnecessary

Purpose of the study: The purpose of this work was to study outcome at the end of grow after surgical treatment for idiopathic congenital equinovarus club foot. Material and methods: From 1983 to 1991, 63 children (85 club feet) given functional treatment underwent surgery because of insufficient results. At birth, the Dimeglio classification was II:11.7%; III:40%; IV:25.8%. Surgery was performed before the age of 2 years for 52 fee (61%) and after 2 years for 33. The indication for surgery was a triple deformity: equin (8.1±15.2, varus (8.2±13.1, adductus (32.5±13.8). Surgery was associated as needed with posterolateral release (94.1%), anteromedial release (92.9%), plantar release (61.1%) and Lichtblau shortening of the lateral column (42%). The tendon of the tibialis anterior was lengthened for 86% of the feet. Functional, clinical, and radiographic outcomes were noted at last follow-up. Results: Mean follow-up was 15 years (8–22). Fifteen feet (17.6%) had a second operation: 13 for recurrence (repeat release), one for over correction (lengthening of the calcaneum) and one for metatarsus adductus (metatarsal osteotomies). One foot had a third operation for recurrence (repeat release). Three feet (3.5%) did not have surgery; a double arthrodesis followed progressive aggravation during growth. In the first group (surgery before 2 years), outcome was very good, good or fair for 76.9, 17.3 and 5.8% of the feet. The “fair” outcomes concerned three children who had more than one operation. In the second group (surgery after 2 years), the outcomes were 78.8%, 18.2% and 3% (n=1) respectively. The “fair” result concerned the double arthrodesis. There was no significant difference for the final outcome as a regards age at surgery (p=0.07). Among the four feet with a “fair” outcome, two were initially Dimeglio III and two Dimeglio IV. Discussion: Soft tissue release enables correct results at the end of growth for the majority of these club feet. While the Dimeglio score is an element predictive of an indication for surgery, it is not a prognostic element for the final outcome. Age at surgery does not have a significant impact on the final outcome

Aims: We aimed to compare conventional rigid cast immobilization with the semi-rigid functional treatment method with respect to calf muscle atrophy, ankle range of motion (ROM) and patient satisfaction in patients who had acute lateral ligament injury of the ankle. Methods: Sixty patients were randomized into the functional immobilization group (Group SC) or conventional belowthe- knee walking cast (Group R). Muscle atrophy was evaluated by axial Computerized Tomography and ankle ROM were recorded before and after treatment. A brief questionnaire for the evaluation of patient satisfaction was applied after the casts were removed. Results: A reduction in muscle area indicating atrophy was detected for both groups (p< 0.001). However, the atrophy was more pronounced in Group R for anterior and superþcial posterior muscle groups. There was also a reduction in ankle ROM for both groups. The loss of ROM for Group R was more evident and differences between the groups were statistically signiþcant. The patients who were treated with functional immobilization techniques were more satisþed. Mean score for Group SC was 67±12 where as it was 28±7 for Group R (p< 0.001). Conclusions: Functional immobilization has shown better results on patient satisfaction and ankle ROM. Although not statistically signiþcant, functional group also showed better results with respect to muscle atrophy for all muscle groups except the lateral. Regarding the previous literature on the effectiveness of functional immobilisation on ankle stability, this technique additionally brings advantages to the treatment of ankle ligamentous lesions with regard to patient satisfaction and facilitation in rehabilitation

Aims: Analyse our results of the treatment of humeral shaft fractures treated solely with functional brace. Methods: The patients 16 years or more in age admitted in Tampere University Hospital because of fracture of diaphysis of the humerus between January1997 and December 2000 were included in this study. The fractures were treated solely using functional brace. Results: There were 94 closed fractures with 38 (42%) male and 52 (58%) female patients whose ages were between 16 and 90 (median 50) years in this study. The fracture configuration was spiral (A1) in 54 (60%), transverse in 31 (34%) (A3) and comminuted in 5 (6%) (C1). The fractures located in the proximal third of the diapysis of the humerus in 12 (13%), in the middle third in 57 (63%), and in distal third in 21 (23%) of the patients. From 90 fractures 69 (81%) consolidated without problems. In 6 fractures of the 12 (50%) at the proximal third, 48 of the 57 (87%), and 17 of the 21 (85%) bony union achieved using functional brace. There was significant difference with respect of consolidation between proximal and middle third (p< 0.01) and between proximal and distal third (p< 0.05) of the humeral shaft. There was no significant difference between fractures of middle and distal third of the diaphysis of the humerus. From spiral, transverse and comminuted fractures, 22of the 28 (78%), 28 of the 31 (90%), 5 of the 5 (100%) consolidated without problems using functional brace. Conclusion: The management of middle and distal third humeral shaft fractures solely with functional brace is justified. Our series indicated that consolidation is achieved also in transverse fractures, even though those fractures have often been considered as a relative indication for operation.

Aims. Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization. Methods. A total of 110 patients with Weber B/SER4a ankle fractures will be randomized (1:1 ratio) to receive six weeks of functional orthosis treatment or cast immobilization with a two-year follow-up. The primary outcome is patient-reported ankle function and symptoms measured by the Manchester-Oxford Foot and Ankle Questionnaire (MOxFQ); secondary outcomes include Olerud-Molander Ankle Score, radiological evaluation of ankle congruence in weightbearing and gravity stress tests, and rates of treatment-related adverse events. The Regional Committee for Medical and Health Research (approval number 277693) has granted ethical approval, and the study is funded by South-Eastern Norway Regional Health Authority (grant number 2023014). Discussion. Randomized controlled trials are needed to evaluate alternative nonoperative treatment options for Weber B/SER4a ankle fractures, as current clinical guidelines are based on biomechanical reasoning. The findings will be shared through publication in peer-reviewed journals and presentations at conferences. Cite this article: Bone Jt Open 2023;4(9):713–719

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review

Aims. Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications. Methods. Patients with this type of fracture were identified retrospectively over a period of six years (January 2016 to December 2021). The following data were collected: demographic characteristics, date of insertion of the prosthesis, details of the intervention, date of the trauma, characteristics of the fracture, and type of treatment. Functional results were assessed with the Harris Hip Score (HHS). Data concerning complications of treatment were collected. Results. Our series included 20 patients, with a mean age of 77 years (46 to 90). All the patients had at least one comorbid condition. Radiographs showed that 75% of the fractures were pure transverse fractures, and a transverse component was present in 90% of patients. All our patients underwent surgical treatment: open reduction and internal fixation, revision of the acetabular component, or both. Mean follow-up was 24 months, and HHS at last follow-up was 75.5 (42 to 95). The principal complications observed were dislocations of the prosthesis (30%) and infections (20%). A need for revision surgery was noted in 30% of patients. No dislocation occurred in patients undergoing osteosynthesis with acetabular reconstruction. We did not note either mechanical loosening of the acetabular component nor thromboembolic complications. In all, 30% of patients presented acute anemia requiring transfusion, and one death was reported. Conclusion. Post-traumatic periprosthetic acetabular fractures frequently have a transverse component that can destabilize the acetabular implant. The frequency of complications, principally dislocations, led to a high rate of revision surgery. Improvements in preoperative planning should make it possible to codify management to reduce this high rate of complications. The best results were obtained when the surgical strategy combined osteosynthesis with acetabular reconstruction. Cite this article: Bone Jt Open 2024;5(1):28–36

Aims

This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures.

The December 2022 Foot & Ankle Roundup³⁶⁰ looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle.

Aims

Although absorbable sutures for the repair of acute Achilles tendon rupture (ATR) have been attracting attention, the rationale for their use remains insufficient. This study prospectively compared the outcomes of absorbable and nonabsorbable sutures for the repair of acute ATR.

A consensus for the best treatment for acute Achilles tendon ruptures has not yet been reached. Non-operative functional treatment using ankle foot orthosis has shown a reduction in re-rupture rate. This study aims to compare operative, cast immobilisation and functional treatment with cam- walker for acute Achilles tendon ruptures. A retrospective review of medical records of patients with acute Achilles tendon rupture between 1999–2770 was carried out. Open repairs were carried out in the surgical group. In the cam- walker group, patients were immobilised in equines backslab for 2 weeks and then transferred to cam- walker with 3 heel-wedges giving plantar flexion of 20–30 degrees. One wedge was removed weekly after 4 weeks. After 6 weeks, patients removed the cam-walker at night. After 10 weeks, they mobilised in a shoe with a raise. After 12 weeks, the cam-walker was removed. There were 56 patients reviewed of whom 20 were treated operatively, 23 were treated non- operatively in a cast and 13 were treated functionally in a cam-walker. The average age of operative group was 39 years with average post operative immobilisation in a cast of 7.4 weeks. 15% had major complications with 2 DVTs and 1 re-rupture and 45% minor complications with 4 wound infections, 3 sural nerve damage and 2 patients complained of pain. The average age of non-operative group in a cast was 46 years with average immobilisation of 8 weeks. 12% had minor complications with 2 DVTs, 1 re-rupture and 12% healing complications with 1 non- healing and 2 delayed healing. The average age of functional group treated with cam- walker was 44.5 years. They were immobilised in a cast for 2.5 weeks and cam-walker for 9 weeks. There were 35% major complications with 3 DVTs and no re-ruptures. 2 DVTs were treated and 1 DVT spontaneously resolved. Metz et al. (2007) conducted a similar study and found that 34% of surgically treated patients suffered from complications other than rerupture. The main advantage they found with conservative treatment is the elimination of wound complications and intra-operative sural nerve damage. This retrospective review shows that surgical treatment provides a lower re-rupture rate but higher complication rate. A prospective study is currently underway to look at re-rupture rates and functional outcome after non-operative functional treatment with cam-walker

Radial head fractures are common and mainly require a functional conservative treatment. About 20% of patients will present an unsatisfactory final functional result. There is, however, little data allowing us to predict which patients are at risk of bad evolve. This makes it difficult to optimize our therapeutic strategies in these patients. The aim of this study is to determine the personal and environmental factors that influence the functional prognosis of patients with a radial head fracture. We realized over a 1-year period a prospective observational longitudinal cohort study including 125 consecutive patients referred for a fracture of the radial head in a tertiary trauma center. We originally collected the factors believed to be prognostic indicators: age, sex, socioeconomic status, factors related to trauma or fracture, alcohol, tobacco, detection of depression scale, and financial compensation. A clinical and radiological follow-up took place at 6 weeks, 3 months, 6 months, and 1 year. The main functional measurement tool is the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH). 123 patients were included in the study. 114 patients required nonsurgical management. 102 patients completed the 1-year follow-up for the main outcome (89 for the DASH score). Two patients required an unplanned surgery and were excluded from analyses. At 1 year, the average MEPS was 96.5 (range, 65–100) and 81% of subjects had an excellent result (MEPS ≥90). The most constant factor to predict an unsatisfactory functional outcome (MEPS <90 or DASH >17) is the presence of depressive symptoms at the initial time of the study (P = 0.03 and P = 0.0009, respectively). This factor is present throughout the follow-up. Other observed factors include a higher socioeconomic status (P = 0.009), the presence of financial compensation (P = 0.027), and a high-velocity trauma (P = 0.04). The severity of the fracture, advanced age, female sex, and the nature of the treatment does not influence the result at 1 year. No factor has been associated with a reduction in range of motion. Most of the radial head fractures heal successfully. We identified for the first time, with a valid tool, the presence of depressive symptoms at the time of the fracture as a significant factor for an unsatisfactory functional result. Early detection is simple and fast and would allow patients at risk to adopt complementary strategies to optimize the result

Introduction. Isolated Weber B fractures usually heal uneventfully but traditionally require regular review due to the possibility of medial ligament injury allowing displacement. Following recent studies suggesting delayed talar shift is uncommon we introduced a functional treatment protocol and present the early results. Methods. 141 consecutive patients presenting acutely with Weber B fractures without talar shift between January and December 2015 were included. Patients were splinted in a removable boot and allowed to weight bear. ED notes and radiographs were reviewed by an Orthopaedic consultant. Patients without signs of medial injury were discharged with an information leaflet and advice. If signs of medial ligament injury were noted or the medial findings were not documented the patient was reviewed in fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. Olerud and Molander scores were collected between 6 and 12 months post-injury. Results. 65 of 89 patients with signs of medial ligament injury or no documented medial findings attended fracture clinic. Of 51 patients without signs of medial ligament injury 23 were discharged according to protocol and 28 patients attended fracture clinic. One discharged patient re-accessed care. Of 93 patients reviewed in the fracture clinic none developed delayed talar shift. One underwent delayed ORIF for ongoing fibula discomfort and the remainder continued with non-operative treatment. 99 (70%) patients provided outcome scores. The mean score at a minimum of 6 months follow-up was 87 and the median score was 100. No significant difference was found between treatment arms. The scores were comparable to those in the published literature. Conclusion. We conclude the risk of delayed talar shift is low and satisfactory outcomes can be safely achieved with our functional protocol. Additional tests/imaging to establish the integrity of the medial ligament may be unnecessary

Introduction. Many common fractures are inherently stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable fractures are advised that they need a cast, despite the potential for stiffness, skin problems and thromboembolism. Attempts to challenge this practice often meet the argument that patients prefer a cast for pain relief. We analysed five years of a single consultant's fracture clinic to see how many patients with stable foot and ankle fractures chose a cast after evidence-based counselling. Materials and methods. All patients with stable fractures of the ankle or metatarsals seen between 1st June 2005 and 31st May 2010 were included. Displaced or potentially unstable ankle fractures, Jones fractures and fractures involving the Lisfranc joint were excluded. Patients were advised functional treatment but offered a cast if they wished. Patients were documented prospectively as part of a larger audit, including demographics, diagnosis and treatment in the emergency department and fracture clinic. Results. 93 patients had stable ankle fractures. One (1%) chose a cast, 77 an ankle brace and 14 the RICE regime. One was advised a cast for neurological deformity. 105 patients had fifth metatarsal fractures outside the “non-” zone. 19 (18%) chose casts and 86 followed the RICE regime. 50 patients had other stable metatarsal fractures 15 (30%) chose casts. 86% of patients had casts applied in the emergency department. Discussion. The majority of patients with stable foot and ankle fractures do not wish to wear a cast once they understand it will not affect their outcome. In many cases this decision could have been reached in the emergency department with appropriate guidelines and education, preventing patient inconvenience and possible adverse events. Conclusion. Most patients are happy with evidence-based functional treatment of stable fractures