Therapeutic Level I.

Forty-seven patients over the age of 55 years with a displaced fracture of the ankle were entered into a prospective, randomised study in order to compare open reduction and internal fixation with closed treatment in a plaster cast; 36 were reviewed after a mean of 27 months. The outcome was assessed clinically, radiologically and functionally using the Olerud score. The results showed that anatomical reduction was significantly less reliable (p = 0.03) and loss of reduction significantly more common (p = 0.001) in the group with closed treatment. Those managed by open reduction and internal fixation had a significantly higher functional outcome score (p = 0.03) and a significantly better range of movement of the ankle (p = 0.044) at review.

We report the outcome at a mean of 93 months (73 to 110) of 71 patients with an acute fracture of the scaphoid who were randomised to Herbert screw fixation (35) or below-elbow plaster cast immobilisation (36). These 71 patients represent the majority of a randomised series of 88 patients whose short-term outcome has previously been reported. Those patients available for later review were similar in age, gender and hand dominance. There was no statistical difference in symptoms and disability as assessed by the mean Patient Evaluation Measure (p = 0.4), or mean Patient-Rated Wrist Evaluation (p = 0.9), the mean range of movement of the wrist (p = 0.4), mean grip strength (p = 0.8), or mean pinch strength (p = 0.4). Radiographs were available from the final review for 59 patients. Osteoarthritic changes were seen in the scaphotrapezial and radioscaphoid joints in eight (13.5%) and six patients (10.2%), respectively. Three patients had asymptomatic lucency surrounding the screw. One non-operatively treated patient developed nonunion with avascular necrosis. In five patients who were treated non-operatively (16%) there was an abnormal scapholunate angle ( > 60 degrees ), but in four of these patients this finding was asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups.

BackgroundScaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased, in spite of insufficient evidence of improved outcomes over non-surgical management. We compared the clinical effectiveness of surgical fixation with cast immobilization and early fixation of those that fail to unite, for ≤2 mm displaced scaphoid waist fractures in adults. MethodsThis pragmatic, multicentre, open-label, parallel-group, two-arm randomised clinical trial included adults who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear, bicortical fracture of the scaphoid waist on radiographs. Participants were randomly assigned to early surgical fixation or below-elbow cast immobilization followed by immediate fixation of confirmed non-union. The primary outcome was the Patient Rated Wrist Evaluation (PRWE) total score at 52 weeks post-randomisation. Registration ISRCTN67901257. FindingsOf 439 randomised patients (mean age 33 years, 363 [83%] men), 408 (93%) were included in the primary analyses. There was no difference in PRWE score at 52 weeks (adjusted mean difference -2•1 points, 95% CI -5•8 to 1•6, p=0•27). There were no differences at 52 weeks for the PRWE pain or function subscales. More participants in the surgery group experienced a surgery-related potentially serious complication than in the cast group (n=31, 14% vs n=3, 1%), but fewer had cast-related complications (n=5, 2% vs n=40, 18%). The number experiencing a medical complication (n=4, 2% vs n=5, 2%) was similar in the two groups." InterpretationAdult patients with ≤2 mm displaced scaphoid waist fracture should have initial cast immobilization and suspected non-unions confirmed and immediately fixed. This will help avoid risks of surgery and mostly limit its use to fixing non-union.

O ur aim was to determine whether children with buckle fractures of the distal radius could be managed at home after initial hospital treatment. There were 87 patients in the trial: 40 had their short-arm backslab removed at home three weeks after the initial injury, and 47 followed normal practice by attending the fracture clinic after three weeks for removal of the backslab.Clinical examination six weeks after the injury showed no significant difference in deformity of the wrist, tenderness, range of movement and satisfaction between the two groups. Fourteen (33%) of the hospital group compared with five (14%) (p = 0.04) of those managed in the community stated that they had problems with the care of their child's fracture. It was found that both groups, given a choice, would prefer to remove their child's backslab at home (p < 0.001). Our findings show that it is clinically safe to manage children with buckle fractures within the community. The inherent stability of many fractures of the distal radius has encouraged the use of various methods of management. A recent report 1 audited the treatment of greenstick fractures of the distal radius using a soft cast which was removed by patients at home. This showed effective reduction in the numbers attending the clinic and that the patients involved were satisfied with the treatment. However, without formal follow-up, the clinical effectiveness of such treatment remains in doubt. Our study aimed to show that home management of buckle fractures of the distal radius is clinically safe and satisfactory. Patients and MethodsThe study was approved by the local Ethics Committee. Between September 1997 and May 1998, 154 children were diagnosed as having buckle fractures of the distal radius on presentation to the Accident and Emergency Department of Leicester Royal Infirmary. Of these, 101 were referred to the study team. We excluded patients who had pathological fractures, previous problems with the wrist on the side of the fracture, bicortical fractures and those who did not understand or were unwilling to enter the study. Patients and their parents were seen on the day of presentation. Three were diagnosed as having bicortical fractures, one had had previous abnormality of the wrist on the side of the fracture, four attended without their parents, one spoke no English, two wished to be followed up in another city and in three the parents refused consent. This left 87 patients for whom parental consent for entry into the trial was obtained. These were subsequently randomised either to home (study) or hospital (control) groups using a computer-generated random-number sheet. In each group the fracture was treated in a below-elbow backslab. Patients in the hospital group followed our usual management for buckle fractures of the distal radius; they returned to the fracture clinic three weeks after injury for removal of the backslab by nursing staff and for medical review.Those randomised to the home group did not return to the hospital, but had their backslab removed by the...