Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction

Despite widespread use of radiofrequency (RF) shrinkage, there have been no animal studies on the effects of post-operative immobilisation on the histological properties of the shrunken tissue. We have therefore examined the role of post-operative immobilisation after RF shrinkage with special emphasis on the histological properties of collagenous tissue. One patellar tendon of 66 New Zealand White rabbits was shrunk. Six rabbits were killed immediately after the operation. Twenty rabbits were not immobilised, 20 were immobilised for three weeks and 20 for six weeks. Fibroblasts, collagen and vascular quality and density were evaluated on sections, stained by haematoxylin and eosin. Nine weeks after operation the histological properties were inferior to those of the contralateral control tendons. Shrunk tendons did not return to normal at any time after operation irrespective of whether the animals had been immobilised or not. All the parameters improved significantly between zero and three weeks after operation. Immobilised tendons tended to have a better and faster recovery. Careful rehabilitation is imperative after RF shrinkage. Immobilisation aids recovery of the histological properties. Our findings in this animal model support a period of immobilisation of more than three weeks

In a prospective study, 204 consecutive patients with displaced Colles' fractures had closed reduction then plaster immobilisation. Three different positions of the wrist in plaster were randomly allocated: palmar flexion, neutral and dorsiflexion. The results in the three groups were compared. Fractures immobilised with the wrist in dorsiflexion showed the lowest incidence of redisplacement, especially of dorsal tilt, and had the best early functional results. Immobilisation of the wrist in palmar flexion has a detrimental effect on hand function; it is suggested that it is also one of the main causes for redisplacement of the fracture. This is discussed in relation to the functional anatomy of the wrist and the mechanics of plaster fixation

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically.

We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required.

Cite this article: Bone Joint J 2013;95-B:952–9.

While it is not denied that immobilisation of a diseased joint may be essential, there is a growing mass of evidence that immobilisation in recumbency of the whole patient has severe effects both in the neighbourhood of the actual lesion and upon the skeleton as a whole. Further search for measures to counteract the undesirable skeletal effects of recumbency is much needed.

Aim

The purpose of this study was to investigate the effects of plaster/splint immobilisation of the knee/ankle on driving performance in healthy individuals.

Introduction

The incidence of deep venous thrombosis (DVT) in patients with lower limb cast immobilization occurs in up to 20% of patients. This may result from altered calf pump function causing venous stasis. Our aim was to determine the effects of below knee cast on calf pump function.

Purpose of the study: The cervical spine is the most mobile portion of the spinal column. Trauma raises a high risk of bone and ligament injury. Several cervical collars are used in adults with variable efficacy. For children the problem is the availability of adapted collars, although the issue has not been examined in the literature. The purpose of this work was to evaluate the efficacy of paediatric collars widely used for stabilising the cervical spine in children.

Material and method: Thirty asymptomatic patients aged 6 to 12 years participated in this study. Four types of paediatric cervical collars were used (Philadelphia, Miami Jr, Neloc, and the conventional stiff collar). The medium size, proposed for children aged 6 to 12 was used. A standard protocol was applied with the Vicon^® system to analyse movement. Mobility of the neck was recorded with and without collars: flexion, extension, lateral inclination and axial rotation. The mobilities recorded without a collar were compared with the values obtained when the children wore each collar. The degree of mobility reduction was calculated for each collar. Seventeen children participated in a reproducibility study. ANOVA and Student’s t test were used for the statistical analysis.

Results: There was no statistically significant difference between the collars for efficacy in the saggital plane, though apparent stability was better with the Neloc. The degree of reduction was smaller with the Philadelphia than with the other collars in the frontal plane. Miami Jr and Neloc were more effective than the Philadelphia and the conventional collar in the axial plane.

Discussion: This study provide an assessment of the efficacy of paediatric collars to limit mobility of the cervical spine. Although a limited number of collars are proposed, those available on the market appear to ensure optimal stability, particularly the Miami Jr and the Neloc. The stabilisation problem, could be resolved by adapting the collars, particularly the height.

The aim of this study was to assess the use of early ambulatory halo-thoracic immobilisation in paediatric patients with spinal instability.

The case notes, radiographs and clinical findings at follow-up of 12 patients treated this way were reviewed. The mean age was 8.6 years (4 to 16). The aetiology was trauma in six, os odontoidium in one, tuberculosis in three, and Morquios syndrome and chronic granulomatous osteitis in one each. The instabilities were atlanto-axial rotatory subluxation in one patient, transverse ligament rupture in six, dens anomalies in two, anterior destruction by tuberculosis in two, and a dens fracture. The halo jackets were applied under general anaesthetic. In addition, posterior C1/2 fusions were performed in seven patients, posterior occipitocervical decompression and fusions in two, and posterolateral thoracotomies in two. No surgery was done on the patient with the dens fracture. Autograft was used in all cases except one posterior C1/2 fusion. This patient, who was HIV-positive, was the only one in whom union did not occur. There was one case of minor pin-tract sepsis. All patients mobilised in the halo jacket and, where possible, were managed as outpatients. Despite radiological nonunion in one patient, spinal stability was achieved in all.

Early ambulatory halo jacket immobilisation is a useful, safe and well-tolerated technique in the paediatric patient group.

The purpose of this study was to investigate the effects of right leg restriction at the knee, ankle or both, on a driver’s braking times. Previous studies have not investigated the effects of knee restriction on braking performance. A total of 23 healthy drivers performed a series of emergency braking tests in a driving simulator in either an above-knee plaster cast, a below-knee cast, or in a knee brace with an increasing range of restriction. The study showed that total braking reaction time was significantly longer when wearing an above-knee plaster cast, a below-knee plaster cast or a knee brace fixed at 0°, compared with braking normally (p < 0.001). Increases in the time taken to move the foot from the accelerator to the brake accounted for some of the increase in the total braking reaction time. Unexpectedly, thinking time also increased with the level of restriction (p < 0.001). The increase in braking time with an above-knee plaster cast in this study would increase the stopping distance at 30 miles per hour by almost 3 m.

These results suggest that all patients wearing any lower-limb plaster cast or knee brace are significantly impaired in their ability to perform an emergency stop. We suggest changes to the legislation to prevent patients from driving with lower-limb plaster casts or knee braces.

1. The effect of immobilisation on bone formation has been investigated in the rat. As chlortetracycline has the property of being deposited preferentially in areas of newly deposited bone, its uptake can be used as a reflection of osseous formation.

2. One hind limb of albino rats was immobilised either by section of the second, third and fourth lumbar nerve trunks or by section of tendo calcaneus and ligamentum patellae. The incorporation of chlortetracycline was determined quantitatively in the femur and tibia of both hind limbs at intervals after immobilisation.

3. Tetracycline uptake is expressed in terms of bone weight, this being most important in order to obtain correct values.

4. A comparison between the tetracycline uptake and the weight of the bones gives information about the rate of bone destruction.

5. In animals immobilised by nerve section three phases can be distinguished: a first phase with diminished bone formation, a second with increased formation and increased destruction and a third phase with diminished bone formation. Both mechanisms, decreased formation and increased destruction, are therefore important in the production of immobilisation osteoporosis; their relative importance depending upon the duration of the immobilisation.

6. In animals immobilised by tendon section the mechanical function becomes restored in the second week as a result of healing: this explains the rapid compensation for the initial loss of weight of the bones accompanied by a marked increase in tetracycline uptake.

7. These results are discussed and compared with information in the literature. Variations in bone formation and destruction rates with time could explain the varied results reported by other authors.

1. Between 1936 and 1945, 525 patients with sciatic pain were treated at the Princess Elizabeth Orthopaedic Hospital, Exeter. Of these, 225 had neurological signs and they were selected for review; 147 were traced.

2. Of these, 123 were treated by means of plaster jackets and twenty-four were treated by other methods. The late results of treatment in the two groups were about the same, roughly one-third being "cured," one-third "relieved," and one-third "not relieved."

3. Nevertheless examination of the immediate results suggests that protection by means of a plaster jacket had at least a palliative effect, relieving acute symptoms and allowing early rehabilitation. Moreover it should be emphasised that in limiting the investigation to cases of sciatica with evidence of nerve root pressure only the more severe cases have been included.

4. Permanent relief after immobilisation in plaster was greatest when the duration of symptoms was short, and when the patient was treated during his first attack. It was least in patients who showed all three signs of nerve root pressure—diminished ankle jerks, hypo-aesthesia, and muscle hypotonicity.

5. Absence of tendon reflexes due to nerve root pressure, and areas of hypo-aesthesia, tend to remain permanently; but diminution of reflexes and loss of muscle power may recover.

Introduction: In orthopaedic surgery, tendon transfers are used routinely. Examples are the correction of deformities due to spasticity in infantile cerebral palsy or clump foot surgery. Aftertreatment is not evidence based but depends mostly on the surgeons personal preferences. This is especially true for the duration of postoperative immobilization. Adhesions between tendon and surrounding tissue are supposedly a key factor for reduced functionality after immobilisation and it appears to be common sense that the amount of scarring depends on the duration of immobilisation.

The purpose of this study was to determine the optimal (im)mobilisation schema, protecting the suture as well as avoiding impairment of the capability of the transferred tendon to slide properly.

Methods: A tendon transfer of the m. flexor digitorum longus to the dorsal talus was performed in 32 New-Zealand rabbits. The tendon was passed through a drill hole and sutured to itself. Animals were randomised into 6 groups. Groups 1 to 3 experienced mobilisation of varying duration (none, 2 and 4 weeks) after two weeks of immobilisation. Groups 4 to 6 received the same time of mobilisation (4 weeks) but after different periods of immobilisation (4, 6, 8 weeks).

Histomorphological examinations including synovial cell coating, appearance of tendon and tissue interface, inflammation and scarring of the site of surgery were done. The results were analyzed statistically (Kruskal-Wallis-test; Jonckheere Terpstra-test).

Results: Except a difference in development of a synovial cell coating of questionable clinical significance there were no significant findings regarding the histomorphology between the different groups.

Conclusion: In opposition to traditional believes, our results suggest that the influence of postoperative mobilisation or immobilisation towards the formation of scarring and adhesions in tendon transfers may by widely overestimated. This implies that the decision for the duration of postoperative immobilisation should be mainly based on safe ingrowths, without the imminent risk of loss of function.

Operative and non-operative treatment regimens for Achilles tendon ruptures vary greatly but commonly involve rigid casting or functional bracing. The aim of our study was to investigate the extent of tendon apposition following such treatments.

Twelve fresh-frozen, adult below knee lower-extremity cadaveric specimens with intact proximal tibiofibular joints were used. Each was prepared by excising a 10cm × 5cm skin and soft tissue window exposing the Achilles tendon. With the ankle in neutral position, the tendon was transfixed with a 2mm k-wire into the tibia, 8cm from its calcaneal insertion. A typical post-rupture gap was created by excising a 2.5cm portion of tendon between 3.5cm and 6cm from its calcaneal insertion.

The specimens were then placed into a low profile walker boot (SideKICK^TM, Procare) without wedges and a window cut into the back. The distance between the proximal and distal Achilles tendon cut edges was measured and repeated with 1, 2 and 3 (10mm) wedges. Subsequently the specimens were placed into a complete below knee cast in full equinus which was also windowed.

The Achilles tendon gap (mean +/− SD) measured: 2.7cm (0.5) with no wedge, 2.3cm (0.4) with 1, 2.0cm (0.4) with 2, 1.5cm (0.4) with 3 wedges and 0.4cm (0.3) in full equinus cast.

The choice of treatment had a significant effect on tendon gap (p< 0.0001 – repeated measures ANOVA), and all pairwise comparisons were significantly different (Bonferroni), with all p< 0.001, apart from 0 wedge vs. 1 wedge (p< 0.01) and 1 wedge vs. 2 wedges (p< 0.05).

Our results showed that each wedge apposed the tendon edges by approximately 0.5cm with the equinus cast achieving the best apposition. Surgeons should consider this when planning appropriate immobilisation regimes for Achilles tendon ruptures.

Aim

To assess if Osteoset (CaSO4) improves graft incorporation after shelf procedure and whether spica immobilisation is necessary

Introduction:

NICE guidelines state that every patient should be assessed for their VTE risk on admission to hospital. The aim of this study was to determine whether currently recommended risk assessment tools (Nygaard, Caprini, NICE and Plymouth) can correctly identify the patients at risk.

1. Three cases of premature epiphysial closure at the knee complicating prolonged immobilisation for congenital dislocation of the hip are described.

2. The etiology of this complication is briefly discussed, and it is suggested that relative ischaemia of the epiphysial plates is the most likely cause.

The traditional treatment for a primary anterior shoulder dislocation has been immobilisation in a sling with the arm in adduction and internal rotation. The recurrence rates after the initial traumatic event range from 20% to 94%. However, recent results have suggested that recurrent instability after primary shoulder dislocation may be reduced with immobilisation in external rotation. Since then, controversy exists regarding the position of immobilisation following these injuries. The objective of the present study was to compare immobilisation in internal and external rotation after a primary anterior shoulder dislocation.

Fifty patients presenting to our fracture clinic with a primary traumatic anterior dislocation of the shoulder were randomly assigned to treatment with immobilisation in either internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. In addition of a two-years clinical follow-up, patients underwent a magnetic resonance imaging (MRI) of the shoulder with intra-articular contrast within four days following the traumatic event, and then at three months of follow-up. The primary outcome was a recurrent dislocation within 24 months of follow-up. The secondary outcome was the healing rate of the labral lesion seen on MRI (if present) within each immobilisation group.

The follow-up rate after two years was 92% (23 of 25) in the IR group and 96% (24 of 25) in the ER group. The recurrence rate in the IR group (11 of 23; 47.8%) was higher than that in the ER group (7 of 24; 29.2%) but the difference did not reach statistical significance (p=0.188). However, in the subgroup of patients aged 20–40 years, the recurrence rate was significantly lower in the ER group (3 of 17; 6.4%) than that in the IR group (9 of 18; 50%, p<0,01). In the subgroup of patients with a labral lesion present on the initial MRI, the healing rate of the lesion was 46.2% (6 of 13) in the IR group and 60% (6 of 10) in the ER group (p=0.680). Overall, the recurrence rate among those who showed healing of the labrum (regardless of the immobilisation group) was 8.3% (1 of 12), but patients who did not healed their labrum had a recurrence rate of 45.5% (5 of 11; p=0.069).

This study suggests that immobilisation in ER reduces the risk of recurrence after a primary anterior shoulder dislocation in patients aged between 20 and 40 years. At two years follow-up, the recurrence rate is lower in patients who demonstrated a healed labrum at three months, regardless of the position of immobilisation. Future studies are required in order to identify factors that can improve healing of the damaged labrum following a traumatic dislocation of the shoulder.

Introduction: Arthrodesis of 1st MTPJ is performed using various fixation techniques including lag screws, dorsal plate and screws, K-wiring. We evaluated the strength of fixation using two staples placed at right angles.

Methods: Ten pairs of cadaveric feet were dissected to harvest the hallux MTPJ. Planar cut of articular surfaces using a micro-saggital saw. The bony ends were then approximated with an intervening blade and fixed using 2 staples placed at right angles. The specimen was supported on either ends and subjected to 3 point loading using a materials testing machine (Instron). The load at which the joint opened up sufficiently to let the blade fall was recorded. The load at which the construct failed was then recorded

Results: The joint opened up at an average of 41 Newtons. The load to failure was 130 Newtons. The corresponding average values in kilograms were 4.19 kilograms for the opening of the joint and 12.61 kilograms for the failure of the construct. On full weight bearing using the heel weight bearing shoes that we normally use post-operatively, the forces going through the forefoot were 0 newtons/kilograms, calculated using a TEK SCAN (measures the foot pressure on walking)

Conclusion: It is safe to walk patients using a heel weight bearing shoe (Benefoot post op wedge shoe) following 1st MTPJ fusion using staples (uniclip-NewDeal). This is a major advantage compared to other methods of fixation that require plaster cast immobilisation thus reducing inconvenience, plaster expenses and possible complications like DVT.