Short Period Of Immobilization Research Articles

Appropriateness and Timeliness of Initial Thromboprophylaxis in Patients with a Hospital Acquired Venous Thrombosis in a Single Center: A Case Control Study

AbstractAbstract 4359 Introduction:Venous Thromboembolism (VTE) remains the number one preventable cause of hospital acquired morbidity and mortality (1). To mitigate this, guidelines are published for the prevention of VTE (2). Currently, the rate of adherence to guidelines is between 16 and 60% (3). Studies show even short periods of immobilization can increase risk for VTE (4), thus we postulated that delays in prophylaxis may correlate with more VTEs. Methods:Between January 2009 and December 2011, hospital acquired VTEs were identified at a 600 bed teaching hospital. Control cases were selected from consecutive admissions in February 2011 to match the VTE cases by risk category, age and gender. Patients younger than 18 years, or initiated on therapeutic anticoagulation were excluded.VTE was confirmed by imaging, and timing was recorded from time of presentation to time of administration. Prophylaxis appropriateness was determined according to published guidelines (2).Categorical variables were compared using Chi-squared test for independence. Normally distributed continuous variables were compared using 2 tailed T-test. Results:179 cases of hospital acquired VTE were found between 2009 and 2011. 9 cases were excluded due to age or therapeutic anticoagulation. 170 control cases were matched by risk category, age and gender. The patient characteristics are summarized in Table 1. Appropriate prophylaxis rate was lower in the VTE group.(p< 0.0001)(55% vs 80%) There was a higher rate in VTE risk assessment in the VTE group (p=0.021) (90% vs 82%). There was no significant difference (p=0.67) in the timing of initial prophylaxis. (33.4hrs vs 34.8hrs)Table 1Patient CharacteristicsVTE Cases (n=170)Control cases (n=170)p-valueMale66690.64Female104101Age (median)71.5680.89VTE Risk Category0.80Medical Admission, moderate VTE risk5663General Surgery2928Neurosurgery/Spinal Cord Injury1720Elective Spinal Surgery108Orthopedic Surgery1919Thoracic Surgery107Contraindication to chemical prophylaxis2420Low VTE risk55Appropriate prophylaxis given<0.0001Yes93 (55%)136 (80%)No58 (34%)12 (7%)Ordered, not documented19 (11%)22 (13%)VTE Risk Assessed0.021Yes153 (90%)139 (82%)No15 (9%)28 (16%)No opportunity2 (1%)4 (2%)Initial prophylaxis time (hrs)33.434.80.67Prophylaxis choices are summarized in Table 2. The rate of sequential compression devices (SCDs) ordered but undocumented is high in both groups. In many cases, it was the sole prophylaxis ordered, and would have been sufficient (11% VTE, 12% control). Documented contraindications to chemical prophylaxis are shown in table 3. Notably, several cases were listed as “high bleeding risk” but had no identifiable risk. Also among the cases listing thrombocytopenia, only one had less than 50k platelets.Table 2Prophylaxis choiceVTE CasesControl CasesFondaparinux 2.5mg79Undocumented fondaparinux01Enoxaparin 40mg or 30mg3448Heparin 5000U TID or BID2845Documented SCDs4229Undocumented SCDs3023ASA 325mg BID01None2914Table 3Contraindications to chemical prophylaxisVTE CasesControl CasesActive Bleeding2210Bleeding risk184Impeding procedure910Thrombocytopenia61Low risk assessment52Anemia10Same day discharge30Patient Refusal33Heparin antibody testing20None documented3238 Conclusion:Between 2009 to 2011, 170 evaluable cases of VTE were compared against matched controls. There was no difference in the time to prophylaxis in both groups; however the 34 hour delay shows a need for improvement. The statistically lower adherence rate to guidelines in the VTE group is in keeping with other published series (3). This is made more poignant by the higher risk assessment rate in the VTE group, which should increase adherence rates. The low documentation rate of SCDs in both groups stresses the need for standardized documentation. Adherence rates would be higher since SCDs would be sufficient in many cases. Incorrect risk assessment, especially with regard to bleeding risk and thrombocytopenia highlight the need for improved understanding of true chemical prophylaxis contraindications. This study demonstrates the importance of continued adherence to prophylaxis throughout hospitalization. Disclosures:No relevant conflicts of interest to declare.

Athletic Cervical Spine Injury in the Setting of Fusion Failure of the Anterior and Posterior Atlas

This article describes a rare congenital abnormality of anterior and posterior C1 fusion failure presenting after an acute athletic injury to the fibrous nonunion. C1 congenital malformations are rare, occurring in approximately 2% of patients; even rarer are combined anterior and posterior arch malformations in the same patient. Posterior ring abnormalities are more common than anterior ring injuries (4.5:1, respectively). To the authors' knowledge, combined anterior and posterior ring congenital malformations with subsequent injury have not been previously described. In the current patient, a congenital failure of fusion of the anterior and posterior arches of C1 was identified. The anterior fibrous nonunion was injured while the patient played football, leading to transient neurologic injury and dysphagia from soft tissue swelling. The patient was initially diagnosed with an acute fracture at another facility; however, given advanced imaging, flexion and extension views, and a normal neurologic examination, the authors diagnosed a traumatized congenital defect. The injury healed with a short period of cervical collar immobilization and supportive measures. Such malformations are usually found incidentally, but they can be symptomatic after trauma. Images to distinguish these deficits can be difficult because the differences between chronic nonunions and congenital malformations are subtle. Surgery is rarely indicated for congenital malformations because they are often stable even after injury; however, they may predispose patients to neurologic injury in the future with high-risk activities. Because the current patient had an increased chance of future injury secondary to the lack of bone formation in the C1 vertebrae, he was restricted from participating in contact sports.

Fracture of the Sesamoid Bone of the Index Finger: A Case Report.

The average adult hand has five sesamoid bones: two at the metacarpophalangeal (MCP) joint of the thumb, one at the interphalangeal joint of the thumb, one at the radial side of the MCP joint of the index finger, and one at the ulnar side of the MCP joint of the little finger. To the best of our knowledge, fracture of the sesamoid bone of the thumb was first reported by Skillern in 19151. In the ninety-six years that have followed, we believe only twenty-one published reports of an additional thirty-six cases of fracture of the thumb sesamoid bones have been reported in the English-language literature2–15. This rare fracture is typically the result of a hyperextension injury to the MCP joint of the thumb and is most often managed conservatively with a short period of immobilization. Full recovery without residual pain is expected2,13,14. Even less common are fractures of other sesamoid bones of the hand. Wood16 described two cases of fracture of the sesamoid bone of the little finger in the only report of which we are aware. To the best of our knowledge, fracture of the sesamoid bone of the index finger has been reported only once17. This injury occurred because of a fall onto an outstretched hand and a resultant hyperextension force to the MCP joint of the index finger. The fracture was treated with six weeks of immobilization, and there was full recovery17. We present a case of fracture of the sesamoid bone of the index finger that resulted from a direct blow to the palm and ultimately required …

Noninfected Atrophic Tibial Pseudoarthrosis Threated With Ilizarov External Fixation And With Autogenous Intramedullary Spongioplasty

We report a case report of a tibial aseptic, atrophic pseudoarthrosis. The patient was treated with immobilization of the lower extremity with a long-leg cast for a period of two and a half months. This treatment was interrupted because the patient developed thrombophlebitis of the affected leg. Possible reasons for the pseudoartrosis were: short period of immobilization, alcoholic malnutrition, and cigarette smoking. When the thrombophlebitis was cured, closed intramedullary fixation of the pseudoarthrosis was planned. The operation was converted later on to external fixation of the pseudoarthrosis according to Ilizarov, because it was not possible to introduce the intramedullary nail to the distal bone fragment with a closed technique, and because the surgical incision had to be made on the place where the pseudoarthrosis was. Second reason for the conversion to Ilizarov external fixation was the bad condition of the skin around the pseudoarthrosis. After the operation was finished, an idea for pseudoarthrosis spongioplasty with spongiosis from crista iliaca, together with fibular resection of one inch length, as a second surgical intervention came into mind. There was a pleasant surprise, because on the following x ray six weeks after the fixation, there was a calus where during the operation the guide wire for the intramedullary nail could not passed to the distal tibial fragment and was going outside. Maybe, during the unsuccessful attempts to pass the intramedullary nail`s guide wire, collateral autogenous intramedullary spongioplasty was made, i.e. spongiosis was brought (transplanted) with the guide wire from the proximal part of the tibia distally to the place of pseudoarthrosis. Three and a half months later the pseudoarthrosis of the tibia was cured and the Ilizarov external fixator was removed. The result of the operation was good. The patient was happy and he could walk normally without subjective difficulties. There was only discrete contracture of the left talocrural joint.

Noninfected Atrophic Tibial Pseudoarthrosis Threated With Ilizarov External Fixation And With Autogenous Intramedullary Spongioplasty

We report a case report of a tibial aseptic, atrophic pseudoarthrosis. The patient was treated with immobilization of the lower extremity with a long-leg cast for a period of two and a half months. This treatment was interrupted because the patient developed thrombophlebitis of the affected leg. Possible reasons for the pseudoartrosis were: short period of immobilization, alcoholic malnutrition, and cigarette smoking. When the thrombophlebitis was cured, closed intramedullary fixation of the pseudoarthrosis was planned. The operation was converted later on to external fixation of the pseudoarthrosis according to Ilizarov, because it was not possible to introduce the intramedullary nail to the distal bone fragment with a closed technique, and because the surgical incision had to be made on the place where the pseudoarthrosis was. Second reason for the conversion to Ilizarov external fixation was the bad condition of the skin around the pseudoarthrosis. After the operation was finished, an idea for pseudoarthrosis spongioplasty with spongiosis from crista iliaca, together with fibular resection of one inch length, as a second surgical intervention came into mind. There was a pleasant surprise, because on the following x ray six weeks after the fixation, there was a calus where during the operation the guide wire for the intramedullary nail could not passed to the distal tibial fragment and was going outside. Maybe, during the unsuccessful attempts to pass the intramedullary nail`s guide wire, collateral autogenous intramedullary spongioplasty was made, i.e. spongiosis was brought (transplanted) with the guide wire from the proximal part of the tibia distally to the place of pseudoarthrosis. Three and a half months later the pseudoarthrosis of the tibia was cured and the Ilizarov external fixator was removed. The result of the operation was good. The patient was happy and he could walk normally without subjective difficulties. There was only discrete contracture of the left talocrural joint.

Short‐term cast immobilisation is effective in reducing lesion propagation in a surgical model of equine superficial digital flexor tendon injury

Larger superficial digital flexor tendon (SDFT) injuries have a poorer prognosis than smaller lesions. During the inflammatory phase enlargement of the initial lesion is frequently noted, with biomechanical loading being recently proposed to play an important role. To evaluate the effect of lower limb cast immobilisation on tendon lesion propagation in an equine model of surgically induced SDFT injury. Core lesions were surgically induced in both front SDFTs of 6 young mature horses. At the end of surgery, one leg was randomly placed in a lower limb cast and the other leg (control) was bandaged for 10 days. Computerised ultrasonographic tissue characterisation performed at Days 10, 15, 21, 28, 35 and 42 allowed measurement of lesion length (cm) and width (expressed as a percentage of whole tendon cross-section). On Day 42 horses were subjected to euthanasia and both SDFTs were sectioned every centimetre to assess the lesion length macroscopically. Statistics were performed to compare cast vs. control legs with significance set at P<0.05. When all time points were combined, lesion length was 19% shorter (P<0.0001) and lesion width 57% smaller (P = 0.0002) in the cast legs (6.13 ± 0.12 cm; 6.90 ± 0.64%) than in the control legs (7.30 ± 0.21 cm; 10.85 ± 1.22%). On Day 42 the lesion length on macroscopic evaluation was 19% shorter (P = 0.04) in the cast (7.00 ± 0.36 cm) than in the control legs (8.33 ± 0.33 cm). Cast immobilisation for 10 days effectively reduced lesion propagation (length and width) compared to bandaging in an in vivo model of artificially-induced tendon lesions. A short period of cast immobilisation during the early phase of tendon healing may be an easy and cost-effective way to reduce the initial enlargement of lesion size and hence to improve prognosis.

A comparative study of modified tension brand wiring and cerclage wiring in management of transverse fractures of patella

Management of patellar fractures is controversial. This study compares the results of two commonly used methods of internal fixation for transverse fractures of patella namely cerclage wiring and modified tension band wiring. Outcome of treatment of twenty (20) cases of transverse fractures of patella from the 2 hospitals attached to the MRMC Medical college, Gulbarga, India were studied between March 2003 to February 2005. Group -A consist of 10 cases which were treated with modified tension band wiring and group-B consist of 10 cases treated with cerclage wiring. Union was achieved in all 20 cases results were compared by using modified Bostman scale. Nine out of 10 patients treated with modified tension band (Group-A) has excellent to good results, 7 patients had knee flexion more than 120°, 8 patients had near normal quadriceps power and 1 patient had extensor lag. In group-B which were treated with cerclage 8 out of 10 patients had excellent to good results, 6 of them had knee flexion of more than 120°, 7 of them had near normal quadriceps power and 2 of them developed extensor lag. Out of 20 cases, 3 cases were compound Grade-I. All 3 cases healed satisfactory, one developed infection leading to stiffness. The results were comparable to closed group. Quadriceps wasting were seen in all 20 cases but it was minimal in group-A treated with modified tension band wiring may because of shorter period of immobilization. It was found that the results of all the cases were comparable but cases treated with modified tension band wiring showed better results as compared to cerclage wiring as the stability of implant is better and post operative rehabilitation is faster. Compound grade-I fractures of patella shows good results when treated by internal fixation.

Low-profile plate fixation in arthrodesis of the first metacarpophalangeal joint

Fifty-one consecutive arthrodeses (46 patients) of the first metacarpophalangeal joint were retrospectively reviewed, after fixation with a Leibinger low-profile titanium plate, using a cup-and-cone technique. Primary bone union was achieved in 98%. Three cases required removal of the plate and one case a tenolysis. Follow-up time was 13-92 months (mean 52). There was no correlation between patient satisfaction and position of fusion. We conclude that this technique gives a high rate of union, a short period of immobilization and rehabilitation, and a reliable position at the site of fusion.

Lack of muscle recovery after immobilization in old rats does not result from a defect in normalization of the ubiquitin–proteasome and the caspase‐dependent apoptotic pathways

Immobilization periods increase with age because of decreased mobility and/or because of increased pathological episodes that require bed-rest. Then, sarcopaenia might be partially explained by an impaired recovery of skeletal muscle mass after a catabolic state due to an imbalance of muscle protein metabolism, apoptosis and cellular regeneration. Mechanisms involved during muscle recovery have been little studied and in elderly they remain almost unknown. We show, in rats, that a short immobilization period during ageing initiated muscle atrophy that was indeed not recovered after 40 days. Immobilization was associated with an activation of both the ubiquitin-proteasome and the mitochondria-associated apoptotic pathways and the inflammatory and redox processes, and a decrease of cellular regeneration. We show that the lack of muscle recovery during ageing is not due to a defect in proteolysis or apoptosis down-regulation. These observations lead us to hypothesize that muscle protein synthesis activation after immobilization was altered during ageing.

WITHDRAWN: Rehabilitation after surgery for flexor tendon injuries in the hand.

Postoperative rehabilitation of the flexor tendons in the hand consists of a short period of immobilisation while pain and swelling diminish, followed by progressive mobilisation to maximize the range of motion of the affected fingers. By altering the time of immobilisation and the manner of subsequent mobilisation different rehabilitation regimes are created. To determine, with evidence from randomised controlled trials, the optimal rehabilitation strategy after surgery for flexor tendon injuries in the hand. We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (November 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 4, 2002), MEDLINE (1966 to November 2002), EMBASE (1988 to November 2002), CINAHL (1982 to October 2002), CURRENT CONTENTS (1993 to October 2002), PEDro - The Physiotherapy Evidence Database (http://ptwww.cchs.usyd.edu.au/pedro/ accessed 30/10/2002) and reference lists of articles. All randomised and quasi-randomised controlled trials of interventions for rehabilitation after surgery of flexor tendon injuries in the hand after surgery. Two reviewers independently assessed trial quality, using a 10 item scale, and extracted data where possible. Additional information was sought from trialists when required. Due to the lack of extractable data and the variety of interventions used, pooling was not attempted. Where possible relative risks and 95 per cent confidence intervals were calculated for dichotomous outcomes, and mean differences and 95 per cent confidence intervals calculated for continuous outcomes. Six trials, including three reported only in abstracts, with a total of 464 participants were included. Data were not pooled. One trial compared continuous passive motion (CPM) with controlled intermittent passive motion (CIPM) and found a significant difference in mean active motion favouring CPM (WMD 19.00 degrees, 95% CI 15.11 to 22.89). One trial compared a shortened passive flexion/active extension programme with a normal passive flexion/active extension mobilisation programme, and reported (without data) a significant reduction in absence from work of 2.1 weeks in favour of the shortened programme. Other trials compared active flexion with rubber band traction, early controlled active mobilisation with early controlled passive mobilisation and dynamic splintage versus static splintage. No trials found significant differences in overall functioning or complication rate. Controlled mobilisation regimens are widely employed in rehabilitation after flexor tendon repair in the hand. This review found insufficient evidence from randomised controlled trials to define the best mobilisation strategy.

Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence

To summarize the best available evidence in the last decade for managing ankle sprains in the community, data were collected using MEDLINE database from January 2000 to December 2009. Terms utilized: 'ankle injury primary care' (102 articles were found), 'ankle sprain primary care' (34 articles), 'ankle guidelines primary care' (25 articles), 'ankle pathways primary care' (2 articles), 'ankle sprain community' (18 articles), 'ankle sprain general practice' (22 articles), 'Cochrane review ankle' (58 articles). Of these, only 33 satisfied the inclusion criteria. The search terms identified many of the same studies. Two independent reviewers reviewed the articles. The study results and generated conclusions were extracted, discussed and finally agreed on. Ankle sprains occur commonly but their management is not always readily agreed. The Ottawa Ankle Rules are ubiquitous in the clinical pathway and can be reliably applied by emergency care physicians, primary care physicians and triage nurses. For mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. For severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. Lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. Semi-rigid orthoses and pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. Supervised rehabilitation training in combination with conventional treatment for acute lateral ankle sprains can be beneficial, although some of the studies reviewed gave conflicting outcomes. Therapeutic hyaluronic acid injections in the ankle are a relatively novel non-surgical treatment but may have a role in expediting return to sport after ankle sprain. There is a role for surgical intervention in severe acute and chronic ankle injuries, but the evidence is limited.

Prolonged immobilization compromises up‐regulation of repair genes after tendon rupture in a rat model

It was hypothesized that mobilization vs immobilization after injury would promote tissue healing by regulating gene expression for molecules associated with repair. Cast immobilization vs free mobilization was studied after rat Achilles tendon rupture. Reverse transcriptase-polymerase chain reaction was performed at 8 and 17 days post-rupture to assess different growth factors [brain-derived neurotrophic factor (BDNF), basic fibroblast growth factor (bFGF), nerve growth factor (NGF) and insulin-like growth factor-1 (IGF-1)] and inflammatory mediators [cyclooxygenase 1 and 2 (COX 1 and COX 2), inducible nitric oxide synthase and hypoxia-inducible factor-1alpha (HIF-1alpha)] in the healing region. At 8 days post-injury, tendon mRNA levels were comparable in both groups. However, by day 17, the mRNA levels for BDNF, bFGF, COX 1 and HIF-1alpha in the mobilized group had increased significantly. Corresponding mRNA levels in the immobilized group decreased during the same period. There were no significant differences in the expression of NGF, IGF-1 or COX 2 between the different groups, indicating that injury-associated expression of these molecules is not overtly influenced by loading. This study supports the notion that prolonged immobilization post-rupture hampers the healing process by compromising the up-regulation of repair gene expression in the healing tendon. It might be speculated that a shorter period of immobilization, i.e. 1 week, would not impair the healing process significantly. The findings support the current development of earlier and more active rehabilitation programs after tendon injuries.

Exercise following a short immobilization period is detrimental to tendon properties and joint mechanics in a rat rotator cuff injury model

Rotator cuff tears are a common clinical problem that can result in pain and disability. Previous studies in a rat model showed enhanced tendon to bone healing with postoperative immobilization. The objective of this study was to determine the effect of postimmobilization activity level on insertion site properties and joint mechanics in a rat model. Our hypothesis was that exercise following a short period of immobilization will cause detrimental changes in insertion site properties compared to cage activity following the same period of immobilization, but that passive shoulder mechanics will not be affected. We detached and repaired the supraspinatus tendon of 22 Sprague-Dawley rats, and the injured shoulder was immobilized postoperatively for 2 weeks. Following immobilization, rats were prescribed cage activity or exercise for 12 weeks. Passive shoulder mechanics were determined, and following euthanasia, tendon cross-sectional area and mechanical properties were measured. Exercise following immobilization resulted in significant decreases compared to cage activity in range of motion, tendon stiffness, modulus, percent relaxation, and several parameters from both a structurally based elastic model and a quasi-linear viscoelastic model. Therefore, we conclude that after a short period of immobilization, increased activity is detrimental to both tendon mechanical properties and shoulder joint mechanics, presumably due to increased scar production.

Clinical and radiological evaluation of minimally displaced proximal humeral fractures

The purpose of this prospective study was to assess the Constant score and radiographic outcome in 66 patients (mean age 58.7 years/mean follow-up 51 months) with a minimally displaced and/or impacted fracture of the proximal humerus treated with early mobilization. Special attention was paid to analyze the specific intrinsic parameters (age, gender, ASA grade and length of physiotherapy), injury-related parameters (classification, osteoporosis) and therapy-related parameters (initial fracture displacement, residual bony-deformity after healing, secondary fracture displacement during healing period, non-union, humeral head necrosis and omarthrosis) that may influence the final score. There were 31 A (47%), 22 B (33%) and 13 C-fractures (19%). The median Constant score for the fractured shoulder was 89 points. All fractures healed without non-union. The radiological assessment showed in 80% a fracture-displacement with <15 degrees angulation and/or <5-mm displacement of the greater tuberosity. At time of follow-up, the residual bony-deformity was perfect and good in 88% of cases. There was a significant association between the final Constant score and the age, ASA classification, AO (ABC) classification and initial fracture displacement. Early physiotherapy, with a short period of immobilization is a sufficient therapy for management of minimally displaced and/or impacted fractures of the proximal humerus.

Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial

Severe ankle sprains are a common presentation in emergency departments in the UK. We aimed to assess the effectiveness of three different mechanical supports (Aircast brace, Bledsoe boot, or 10-day below-knee cast) compared with that of a double-layer tubular compression bandage in promoting recovery after severe ankle sprains. We did a pragmatic, multicentre randomised trial with blinded assessment of outcome. 584 participants with severe ankle sprain were recruited between April, 2003, and July, 2005, from eight emergency departments across the UK. Participants were provided with a mechanical support within the first 3 days of attendance by a trained health-care professional, and given advice on reducing swelling and pain. Functional outcomes were measured over 9 months. The primary outcome was quality of ankle function at 3 months, measured using the Foot and Ankle Score; analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN37807450. Patients who received the below-knee cast had a more rapid recovery than those given the tubular compression bandage. We noted clinically important benefits at 3 months in quality of ankle function with the cast compared with tubular compression bandage (mean difference 9%; 95% CI 2.4-15.0), as well as in pain, symptoms, and activity. The mean difference in quality of ankle function between Aircast brace and tubular compression bandage was 8%; 95% CI 1.8-14.2, but there were little differences for pain, symptoms, and activity. Bledsoe boots offered no benefit over tubular compression bandage, which was the least effective treatment throughout the recovery period. There were no significant differences between tubular compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences between treatments. Reported events (all treatments combined) were cellulitis (two cases), pulmonary embolus (two cases), and deep-vein thrombosis (three cases). A short period of immobilisation in a below-knee cast or Aircast results in faster recovery than if the patient is only given tubular compression bandage. We recommend below-knee casts because they show the widest range of benefit. National Co-ordinating Centre for Health Technology Assessment.

Treatment of Painful Accessory Navicular: A Modification to Simple Excision

An accessory tarsal navicular ossicle may produce pain and tenderness despite conservative treatment modalities. This condition causes pain along the medial arch and limitations of activities. This described modification of the Kidner procedure and simple excision technique keeps the tendon insertion intact while restoring some of the normal biomechanical relationships. In addition, this modification has the theoretical advantage of enhancing dynamic support of the longitudinal arch, and by maintaining the continuity of the posterior tibial tendon, a shorter period of immobilization is required. All patients at the most recent follow-up showed improvement, with 11 of 13 patients having excellent results with long-term follow-up.

Snapping Popliteal Tendon in a 21-Year-Old Female

Case report. Determining the cause of painful snapping on the lateral aspect of the knee can be a challenge. The differential diagnosis includes iliotibial band friction syndrome, lateral meniscus tear, intra-articular loose body, discoid lateral meniscus, snapping biceps femoris tendon, degenerative joint disease, proximal tibiofibular joint instability, and snapping popliteus tendon. A 21-year-old female presented with a 7-year history of a painful snapping on the lateral aspect of her left knee. She reported the snapping occurred with all activities involving knee flexion and extension, including running and walking. With a diagnosis of snapping iliotibial band, she had received a variety of physical therapy interventions, including various lower extremity stretching and strengthening exercises. Nonsteroidal anti-inflammatory medications were also prescribed by her physician. Conservative and pharmoclogical interventions were unsuccessful in improving her symptoms. Similarly, our attempt with conservative treatment consisting of ice, taping, and a short period of immobilization was not successful. The patient underwent a surgical procedure consisting of removal of a prominent tubercle on the lateral femoral condyle and tenodesis of the popliteus tendon to the proximal aspect of the fibular (lateral) collateral ligament, followed by a postoperative program of physical therapy including range-of-motion and progressive strengthening exercises. At 6 weeks following surgery, the patient had returned to all activities with complete resolution of her symptoms. Painful snapping at the lateral aspect of the knee may be caused by a variety of disorders, including the popliteus tendon. Clinical diagnosis is challenging. Clinical suspicion of a snapping popliteus tendon as a source of the signs and symptoms of the condition is important for inclusion in the differential diagnosis. Differential diagnosis, level 4.

Funktionelle Therapie und ihre Grenzen bei akuten Ellenbogenluxationen

Dislocation of the elbow joint is the second most common dislocation, the shoulder being the most common. Non-surgical therapy is done by repositioning and early active motion after a short period of immobilization. There are, however, certain principles which must be followed in order to obtain a favorable result with functional therapy. On the basis of case reports the constraints of early active motion are discussed. Knowing the mechanism or kinematics of an elbow dislocation, it is possible to determine a staging of the injury. Using detailed x-rays and an exact stability test, the degree of instability must be checked after repositioning. It is important to determine the grade of instability and to operatively correct a major instability.

Fractures in the child's hand

Summary Most children's hand fractures can be successfully treated by either simple protective splinting or closed reduction and a short period of immobilisation. However, failure to correct rotational deformities can produce long-term problems. Certain injuries that may require early operative treatment are frequently missed. These include fractures of the neck and condyles of the proximal phalanx and dislocation of the nail combined with an epiphyseal fracture of the distal phalanx.

Sakrumfraktur als seltene Frühkomplikation nach lumbosakraler Spondylodese

A 57 year old patient with secondary cortisone induced osteoporosis war surgically treated by means of posterior lumbar interbody fusion with internal fixation from L4-S1 for symptomatic instability in the level L4/5 after previous dorsal stabilisation L5/S1. After an unapparent initial postoperative phase, the patient complained of severe pain in the low back and gluteal region 9 day after surgery. Radiographs as well as CT-scans showed a horizontal fracture of the sacrum. After a short period of immobilisation the patient was carefully remobilised with an orthesis and the pain gradually subsided. Conventional radiographs one year later showed complete consolidation of the fracture and a good clinical result. There are only two literature reports with together 3 cases of patients attaining an early sacral fracture after spondylodesis. The main cause seems to be the unphysiological biomechanical stress placed on the osteoporotic sacrum after moresegmental spondylodesis. Further risk factors seem to be adipositas, female gender and age. Despite the rarity of sacral fractures after lumbosacral fusion, this complication should at least be considered in the differential diagnosis in patients who complain of persisting or sudden-onset pain after surgery.