The load applied to the foot in a patellar ligament-bearing cast

The purpose of this study was to determine whether a patellar ligament-bearing cast reduces the load applied to a foot in a cast. In a study of ten people who had no history of gait abnormalities, disease involving the motor system, or deformities of the lower extremities, we compared the load applied to the plantar aspect of a foot in a cast (as detected with F-Scan computer-monitored pedobarographic sensors) with the total load that an extremity in a cast receives relative to the ground (as detected with force-plates). Six trials were completed three times by each person. The trials consisted of walking (1) while wearing regular shoes; (2) with a patellar ligament-bearing cast on one leg; (3) with a patellar ligament-bearing cast and an overlying soft knee brace, locked in full extension, on the leg; (4) with only a below-the-knee cast on the leg; (5) with a below-the-knee cast and an overlying knee brace, locked in full extension, on the leg; and (6) with only a knee brace, locked in full extension, on the leg. The loads at peak heel-strike for all three trials were averaged and normalized to body weight. The load on the plantar aspect of the foot, as compared with the total load, was reduced a mean of 11 percent when the patellar ligament-bearing cast was worn alone, and it was reduced a mean of 26 percent when the patellar ligament-bearing cast was used with an overlying knee brace locked in full extension. This difference was significant (p = 0.007). With the numbers available, we could not detect a significant difference between the reduction in load when a patellar ligament-bearing cast was worn alone compared with that when a below-the-knee cast was worn alone or between the reduction when a below-the-knee cast was worn alone compared with that when a below-the-knee cast was used with a knee brace (p = 0.3). In conclusion, we could not demonstrate a significant reduction in the load on the foot when a patellar ligament-bearing cast was used in a traditional fashion; however, a significant (p = 0.007) reduction in load was found when a knee brace locked in full extension was worn in addition to the patellar ligament-bearing cast.     

Proximal intra-articular tibial fracture in skiers

56 cases of proximal intraarticular tibia fractures over a 4-year period are reviewed. In every case the patients described a preceding valgus-compression trauma of their knee. Clinically we always found a hemarthrosis combined with a tenderness on pressure at the fractured condyle. Roentgenograms should be performed in 4 projections, eventually followed by conventional tomograms or computed tomography. Frequency of the several fracture types is demonstrated following the classification of the AO working group for osteosynthesis. The Eminentia intercondylaris was concerned in 13 cases as avulsion fracture of the anterior cruciate ligament (ACL) with a double peak distribution in the under 20-years- and over 40-years-age group. In the remaining cases we observed split- and/or compression fractures of the lateral tibial plateau of the 40 to 60 year old skier, in 20% communitive fractures. In 85% of the ACL-avulsion fractures we applied a cast brace as a conservative measure, whereas 75% of the tibia plateau fractures were treated operatively by mean of open reconstruction of the articular surface and internal fixation based on the AO-principles as well as bone graft buttressing in two third of the cases.     

Neuroanatomical correlates of the assessment of facial attractiveness

In a randomized prospective trial, closed reduction and plaster application was compared with Kapandji pinning. Closed reduction and plaster cast application was performed in 50 patients, Kapandji pinning in 48 patients. According to the Cooney score, good and excellent results were found in 74% of patients in the closed reduction and plaster cast group compared with 75% of patients in the Kapandji-pinning group. In terms of maintenance of reduction and functional outcome at 1-year follow-up, no statistically significant differences were found between the two groups. We conclude, therefore, that both techniques can be applied to extra-articular fractures of the distal radius according to the characteristics of the forearm and the surgeon's or the patient's need.     

The role of the pulmonary circulation in the regulation of coagulation and fibrinolysis in relation to major surgery

A total of 18 competitive and recreational athletes were enrolled in a randomized, prospective study looking at the effect of pneumatic leg braces on the time to return to full activity after a tibial stress fracture. All patients had positive bone scans and 15 had positive radiographic findings by Week 12. There were two treatment groups. The traditional treatment group was treated with rest and, after 3 pain-free days, a gradual return to activity. The pneumatic leg brace (Aircast) group had the brace applied to the affected leg and then followed the same return to activity guidelines. The guidelines consisted of a detailed functional progression that allowed pain-free return to play. The brace group was able to resume light activity in 7 days (median) and the traditional group began light activity in 21 days (median). The brace group returned to full, unrestricted activity in 21 +/- 2 days, and the traditional group required 77 +/- 7 days to resume full activity. The Aircast pneumatic brace is effective in allowing athletes with tibial stress fractures to return to full, unrestricted, pain-free activity significantly sooner than traditional treatment.     

Jones fracture. Surgical versus nonsurgical treatment

Sixty-three patients with 66 transverse and short oblique fractures of the proximal shaft of the fifth metatarsal bone (Jones fracture) were evaluated an average of five years (range, one to ten years) after the injury. There were 27 acute fractures and 39 chronic, or stress, fractures. The primary treatment was surgical for one third of the injuries and nonsurgical for the others. Surgical treatment consisted of the insertion of medullary screws. Nonsurgical treatment consisted of the application of either a plaster cast or an elastic bandage. Almost one fourth of the fractures treated nonsurgically later had to be treated surgically because of delayed unions or refractures. Late surgery was required in 12% of acute fractures and in 50% of chronic fractures with sclerosis narrowing the medullary canal. Irrespective of the primary treatment, all the patients had full function at the time of the follow-up evaluation, and no nonunions were diagnosed.     

Effect of the Milwaukee brace on vital and ventilatory capacity of scoliotic patients

The vital capacity (VC) and the maximal voluntary ventilation (MVV) were studied in 29 patients with scoliosis (predominantly idiopathic). The results obtained confirmed earlier observations that scoliotic patients have decreased VC and MVV. The immediate effect of the application of the Milwaukee brace was a slight though statistically significant decrease in MV, whereas there was no significant effect on VC. Treatment with the Milwaukee brace for a mean period of 15 months did not appreciably influence the VC or MVV, as a percentage of the predicted normal values of the patients, when measured without the brace applied.     

Treatment of isolated distal ulnar shaft fractures with below-elbow plaster cast. A prospective study

In a prospective study 52 patients with an isolated fracture of the distal ulna were treated with a below-elbow plaster cast. The histories of 46 patients were reviewed after a mean follow-up of 3.5 years (ranging from 10 months to 7 years). Forty-three fractures united. There were two non-unions. One fracture displaced while in the plaster, so that there was no longer any bone contact between the fragments. The fracture was consequently treated by open reduction and internal fixation. The type of fracture, the initial displacement (all fractures had bone contact) or the initial angulation (maximum 10 deg) was not found to influence the final clinical results. Below-elbow plaster cast appeared to produce satisfactory results in 89% of the patients.     

Long-term results in the treatment of femoral-shaft fractures in young children by immediate spica immobilization

Manual traction reduction without anesthesia and immediate immobilization in a spica cast were used to treat eighty-five children ranging in age from birth to ten years old who had closed femoral-shaft fractures and no associated injuries. Up to two centimeters of overriding, 30 degrees of anterior angulation, and 15 degrees of medial angulation were accepted. Any angulation in excess of these amounts, or lateral or posterior angulation, was corrected by wedging the cast at the fracture site. Further telescoping of the fracture fragments in the case was attributed to the child pressing the foot against the bottom of the cast and was prevented by removing the sole of the cast. Of the seventy-five children examined two to eighteen years after fracture, none had any residual skeletal deformity or joint stiffness. The length discrepancies of the fractured limbs ranged from 1.7 centimeters of shortening to 0.9 centimeter of overgrowth.     

The effects of functional knee braces on speed in collegiate basketball players

Knee braces are worn by many athletes following injury. The purpose of this study was to determine whether two functional knee braces (noncustom design) significantly affected straight line and successive turning trial running times in noninjured collegiate basketball players. Twenty-five coed basketball players completed 2 days of running trials. Subjects ran three full lengths of a basketball court and 10 lengths between the baseline and the foul line first without wearing a brace, then wearing either a DonJoy GoldPoint brace or an Omni OS-5 brace, and finally wearing the other brace. The results indicated no significant difference (p < .05) in straight line or successive turning running times when the two braces were compared with the nonbraced condition and when the two braces were compared with each other. The results implied that speed was not significantly affected by a functional knee brace in noninjured collegiate basketball players.     

Treatment of tibial plateau fractures by limited internal fixation

Seventy-five adults who sustained 76 tibial plateau fractures were treated according to a prospective protocol using instability in extension as the principal indication for operative fixation. Patients showing instability underwent closed manipulative reduction under fluoroscopic guidance. If significant joint depression persisted after reduction, elevation of the fracture was performed either from below using bone punches through a cortical window or via limited arthrotomy. Iliac crest bone graft was used to buttress depressed fractures. Fixation was then secured using 7-mm cannulated screws with washers or buttress plates and screws. Postoperatively, 58 of 76 knees were managed in a hinged knee brace, allowing the patient early range of motion and protected weightbearing for 8 weeks. Patients who were found to have a stable knee were treated with Bledsoe braces according to the postoperative protocol. In the 75 patients, 18 of the 76 knees were unsuitable for percutaneous screw fixation because of fracture complexity requiring plates, severe open injuries, or inadequate reductions with limited fixation had been done. A minimum followup of 12 months was obtained in 55 patients (range, 12-59 months). All fractures had healed at the time of followup. Eighty-seven percent of the patients at followup had a successful outcome using Rasmussen's criteria. Fourteen of these patients had arthroscopic assisted reduction or evaluation. All seven patients who had poor outcomes had AO Type C3 fracture patterns. Severely depressed or comminuted fractures or fractures with significant metaphyseal diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.     

Treatment routines of flexor tendon injuries. Results of a questionnaire study

A questionnaire was distributed to the surgical departments of all Norwegian hospitals, asking about the routines for treating flexor tendon injuries in 1990. The response rate was 95.5%. Some of the smaller hospitals did their own flexor tendon surgery, but referred patients with a complex injury to a hospital with better trained hand surgeons. In 1990, a total of 573 flexor tendon repairs were carried out in Norwegian hospitals. After surgery, all patients had a cast or a brace for a period ranging from three to six weeks. Most of the hospitals used dynamic traction and had a programme for training the patient, which was supervised by a hand therapist. Active flexion was allowed from two to eight weeks after the operation. We recommend referral of all flexor tendon injuries in zone II to a surgical unit with trained hand surgeons. After surgery, a programme including dynamic traction and training supervised by the surgeon and a hand therapist should be compulsory.     

Injury of the dens axis in early childhood. Clinical case report and discussion

Because of the special features of the subdental synchondrosis, fractures of the odontoid process in childhood can be seen as a separate entity. The subdental synchondrosis must be regarded as sort of an intervertebral disc and not as a growth plate. Among the generally rare fractures of the cervical spine in children this type ist the most common. Usually conservative treatment with a cast-fixation like the halo fixateur or the minerva jacket leads to consolidation. We report on the case of a 2-year-old girl with a fracture of the odontoid process who developed a unilateral syndrome hours after the accident. The treatment was conservative with a halo-like cast fixation. Nine weeks after the fixation bony consolidation was achieved and the cast could be removed. In the first days after fixation full neurological recovery had occurred. In early childhood (till the 7th year of life) according to the literature, patterns of neurologic dysfunction are incomplete injuries of the spinal cord and have the potential for recovery [4, 5, 7, 9, 10, 12].     

A comparison of the relative costs of cast treatment and intramedullary nailing for tibial diaphyseal fractures in the UK

A retrospective study was undertaken to compare the costs of treating tibial diaphyseal fractures non-operatively in a cast or operatively with locked intramedullary nailing. In total 39 patients with isolated closed or grade I open, two-part, displaced tibial diaphyseal fractures were studied. Of these, 18 were treated by manipulation under anaesthesia and cast immobilization, and 21 by closed, reamed, locked intramedullary nailing. A detailed analysis of the cost of treatment of each patient was performed and analysed in terms of the in-hospital costs and the overall costs, taking into account time off work. The mean hospital costs were 2226 pounds for plaster treatment and 3727 pounds for intramedullary nailing (significantly different, p < 0.05). The mean time off work was 9 weeks longer in the plaster group and when the cost of lost production through time off work was added to the hospital costs, the overall costs of plaster treatment and intramedullary nailing were 6810 Pounds and 6592 Pounds (difference not significant). This study suggests that the cost to the hospital of treating these fractures is less with plaster treatment but that the overall cost to the community is no different.     

Biomechanical effect and clinical application of the hip joint moment reduction brace

A new brace, the hip joint moment reduction brace, has been designed and constructed. The basic construct of the brace incorporates only the thigh, and it minimally restricts one's activities of daily living. The concept of the brace is to reduce the frontal plane moment of the applied force against which the abductor muscle must contract to balance, and this reduction of the frontal plane moment results in reduction of the abductor muscle force. The brace uses the mechanism of the ischial weightbearing and lessens the abductor moment by transmitting load from the ischium through the condyle of the femur. In gait testing, the maximum ischial load taken up by the brace was 36.9% of the ground reaction force in the late stance phase, and the integrated electromyogram of the abductor muscle was reduced by 32.6% during the whole stance phase using this brace. These findings confirmed a reduction in the frontal plane moment of the hip joint and the potential for reduction in the load on the hip joint. The hip joint moment reduction brace is recommended as effective conservative management of hip disorders, such as coxarthrosis, that are caused or worsened by biomechanical insufficiency.     

Complete neurological recovery following prolonged cardiac arrest. Description of a clinical case

The therapy of fibular ligament ruptures is still a controversial subject. Reports on healing processes following operative or conservative treatment have been verified hitherto by means of clinical examinations and stress tests. The MRT, as a highly sensitive non-invasive method, allows exact documentation of the ligament structures in the ankle joints. This technique was used in a randomized clinical trial over a 6-month period. The 29 patients (ages 17-51 years) had recent ligament rupture [admission criteria: clinical signs of trauma, talar tilt in anteroposterior stress radiographs (15 kp) > or = 10 degrees, talar shift > or = 10 mm] were examined with regard to ligament healing during functional therapy with AIRCAST pneumatic leg braces. Within the first week an MRT was done for verification of ligament injury. Treatment was conservative and functional: lower leg cast for 2 weeks and subsequent mobilization with protection provided by an AIRCAST brace. Follow-up examination was 3 months after injury, taking the form of clinical examination, a-p-radiographs with stress tests, and MRT. In all patients both clinical and radiological examination confirmed that ligament structures had healed, as was also verified by MRT.     

Results of 193 conservatively treated acute fractures of the carpal navicular--indications for operative treatment (author's transl)

The results of 193 conservatively treated acute fractures of the carpal navicular are presented. Ninety-eight (50.7%) had horizontal oblique fractures, 82 (42.5%) transverse, and 13 (6.8%) vertical oblique fractures. In 23 (11.9%) cases the fracture was located in the proximal third, in 125 (64.7%) in the middle third, and in 45 (23.4%) in the distal third. An unpadded cast extending from the elbow to the metacarpophalangeal joints including the thumb was used generally. On the following day the cast was always completed by addition of a volar plaster splint and a circular plaster bandage. Duration of immobilization lasted from 6 to 16 weeks (mean: 10 weeks). On average, 4.5 years after injury 190 (98.4%) fractures had healed by osseous union and 3 (1.6%) had a pseudarthrosis. The reasons for non-union were too short time of immobilization, and former diastasis between the fragments. The number of arthrosis in the radiocarpal joint in our patients amounted to less than 1%. Primary operative treatment (open reduction and screwing) is preferred for vertical oblique fractures and for fractures with a large diastasis between the fragments. Secondary operative treatment is performed if there are no signs of osseous consolidation.     

The SURF-6 protein is a component of the nucleolar matrix and has a high binding capacity for nucleic acids in vitro

We reviewed the literature to determine the clinical outcomes of the treatment of closed fractures of the tibial shaft with immobilization in a cast, open reduction with internal fixation, or fixation with an intramedullary rod. We reviewed 2372 reports of comparative trials and uncontrolled studies of series of patients published between 1966 and 1993. Nineteen reports, involving six controlled trials and twenty-seven groups of patients, met our inclusion criteria. A structured questionnaire was used to assess the quality of the literature in terms of the experimental design and the method of assessment of outcome. Outcomes from controlled trials were summarized with odds ratios and risk differences, and outcomes from case series were summarized by the medians of the reported results. The studies that were reviewed generally had few subjects and were poorly designed. The comparative trials showed treatment with a cast to be associated with a lower rate of superficial infection than open reduction and internal fixation (mean difference, -5.81 per cent; p = 0.02) and open reduction and internal fixation to be associated with a higher rate of union by twenty weeks than treatment with a cast (mean difference, -18.07 per cent; p = 0.008). There were no other significant associations. There were insufficient data for us to evaluate any aspect of functional status, level of pain, or other patient-reported outcomes of any of the methods of treatment. The results of the present review suggest that the data from the published literature are inadequate for decision-making with regard to the treatment of closed fractures of the tibia.     

Percutaneous reduction of fractures of the neck of the radium in children by means of a steinmann nail (author's transl)

Percutaneous reduction of fractures of the neck of the radius or of epiphysiolysis with displacement can be achieved in children by means of a Steinmann nail. No additional means of fragment fixation seems to be necessary. Fracture healing is ensured by cast immobilization. Functional results are equivalent to those after conservative treatment.     

The non-operative management of collateral ligament injuries of the knee joint

Severe knee ligament injuries are frequently underestimated, and this results in later problems of chronic instability. A history of an appropriate mechanism coupled with immediate reduction in function should arouse suspicion of a major disruption. Examination with the patient under anesthesia may be required to assess the extent of the injury. If the lesion is an isolated collateral tear, the intact cruciate ligaments prevent wide displacement. Such an injury can be managed non-operatively. A long leg plaster at 90 degrees for 2 weeks followed by 4 weeks in a cast brace with motion from 45 degrees to 100 degrees is recommended. The knee is then protected in a brace during athletic activities for approximately 6 months. Thirty collateral ligament tears have been managed in this fashion. Only one has significant residual complaints. It is emphasized that an isolated collateral ligament tear is a positive diagnosis, and associated cruciate lesions must be ruled out. The recovery is faster in those patients managed non-operatively than in those who have surgical repair. There has not been a problem with late instability.