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A systematic review of the literature identified eight trials comparing surgery with cast treatment and found no significant difference in pain, tenderness, cost, functional outcome or patient satisfaction. In the group treated surgically, the rate of non-union was three times less, there was a quicker return to function and grip strength and range of movement was also transiently better. There were, however, more complications among those treated surgically. No significant differences were reported in the two trials that compared above and below elbow casts or the trial that compared scaphoid and Colles' casts.

Ann R Coll Surg Engl 2008; 90: 483-487 483Ankle fractures form a significant part of orthopaedic practice. In a recent population-based epidemiological study, 1 ankle fractures were found to be the most common type of lower extremity fracture, making up to 22.6% of all lower limb fractures. Of these, 'stable' ankle fractures form a separate clinical group comprising 40-75% of all ankle fractures. 2,3 Several studies have shown that these fractures can be managed in a functional brace or Tubigrip, [4][5][6] without the need to repeat radiographs, 7 and produce an insignificant rate of long-term osteoarthritis. 8Despite this evidence there remains a lack of effective guidelines for the management of these fractures resulting in unnecessary cost due to repeat radiographs and outpatient visits. 7,9 The aim of this audit was to assess the current management of stable ankle fractures at the Cumberland Infirmary and measure the change in practice after implementation of evidence-based guidelines. 4 We also calculated the cost of management of these fractures before and after the change in practice and financial savings that can be expected. Studies show that these injuries can be managed successfully in a functional brace, with no need for further radiographs and minimal out-patient follow-up. We aimed to audit current practice and introduce change in order to improve treatment and produce financial savings.

Percutaneous needle fasciotomy treatment of Dupuytren's disease has been used on the continent for over two decades but has only recently gained popularity in the UK. The National Institute for Clinical Excellence published guidance in February 2004 stating that the procedure is safe and effective. We report a case of two complications in the same patient following the use of the technique, on only one occasion, in a patient who was anticoagulated. We believe that it is the first time that a false aneurysm has been reported following the procedure and that this was probably related to the inhibited coagulation cascade. The patient also sustained an injury to flexor digitorum profundus but had an intact superficialis tendon and we find it difficult to explain this occurrence. We report the above complication as we feel this technique may be chosen specifically in patients with co-existing medical problems such as anticoagulation.

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