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Background: Torus (buckle) fractures of the wrist are the most common fractures in children, involving the distal radius and/or ulna. It is unclear if children require rigid immobilisation and follow-up, or would equally recover by being discharged without any immobilisation or a bandage. Given the large number of these injuries, identifying the optimal treatment strategy could have important effects on the child, school absences and NHS costs. Objectives: To establish whether treating children with a distal radius torus fracture with the offer of a soft bandage and immediate discharge (“offer of bandage”), provides the same recovery, in terms of pain, function, complications, acceptability, school absence and resource use, as treatment with rigid immobilisation and follow-up as per usual practice (“rigid immobilisation”). Design: A pragmatic, multicentre, randomised controlled equivalence trial. Setting: 23 UK Emergency Departments. Participants: 965 children (4-15 years) with a distal radius torus fracture were randomised from January 2019 to July 2020 using a secure, centralised, online encrypted randomisation service. Exclusion criteria included presentation >36 hours after injury, multiple injuries and inability to complete follow-up. Interventions: Offer of bandage (n= 489) of whom the bandage was applied in 458, versus rigid immobilisation (n= 476). Participants and clinicians were not blinded to the treatment allocation. Main outcome measures: Pain at 3-days post-randomisation measured using the WongBaker FACES Pain Rating Scale. Secondary outcomes were the PROMIS Upper Extremity score for children, health related quality of life (QoL), complications, school absence, analgesia use and resource use collected up to 6 weeks post-randomisation. Results: 94% of participants provided primary outcome data. Pain was equivalent at the 3 day primary outcome for both groups. With reference to the pre-specified equivalence margin of 1.0, the adjusted difference in the intention-to-treat population was -0.10; 95% CI -0.37 to 0.17 and the per-protocol population was -0.06; 95% CI -0.34 to 0.21. There was equivalence in pain for both age subgroups (4-7 and 8–15 years). There was no difference in the rate of complications, with five (1.0%) in the offer of bandage group and three (0.6%) in the rigid immobilisation group. There were no differences between treatment groups in functional recovery, QoL or school absence at any point during follow-up. Analgesia use was marginally higher at Day 1 in the offer of bandage group (83% vs 78% participants), though was no different at other times. The offer of bandage significantly reduced the cost of treatment, and had a high probability of cost-effectiveness. Limitations: Families had a strong pre-existing preference for rigid immobilisation. Given this, and the inability to blind families to the treatment allocation, observer bias was a concern. However, there was clear evidence of equivalence. Conclusions: The study findings support the offer of bandage in children with a distal radius torus fracture.

Objective To estimate the generalizability of treatment effects observed in a randomized trial of hip fracture surgery implants to a broader population of people undergoing hip surgery in the United Kingdom. Study Design and Setting In 2018, the WHiTE-3 trial (n = 958) demonstrated that a modular hemiarthroplasty implant conferred no additional benefit over the traditional monoblock implant for quality of life and length of hospital stay. We compared and weighted the trial sample against two target populations: WHiTE-cohort (n = 2,457) and UK-National Hip Fracture Database (NHFD, n = 190,894), and re-estimate expected treatment effects for the target populations. Results Despite differences in baseline characteristics of the trial sample and target populations, the re-estimated treatment effects were comparable. For quality of life, the differences between the trial estimate and WHiTE-cohort and NHFD estimates were 0.01 points on the EuroQol (EQ5D). For length of stay, the difference between the trial estimate and WHiTE-cohort was 0.50 days; and the difference between the trial estimate and NHFD estimate was −0.47 days. Conclusion This generalizability analysis of the WHiTE-3 trial found that the inferences from the trial can be generalized to a wider population of individuals in the UK NHFD and the WHiTE-cohort who met the inclusion criteria for WHiTE-3.

Background\ud Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less.\ud Methods\ud This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1–2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing.\ud Findings\ud Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2–14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference −2·1 [95% CI −5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group).\ud Interpretation\ud Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite.\ud Funding\ud National Institute for Health Research Health Technology Assessment Programme.

Background Hip fracture is common, affecting 20% of women and 10% of men during their lifetime. The trajectory of patients’ recovery as they transition from the acute hospital setting to their usual residence is poorly understood. Recently, the use of activity trackers to monitor physical activity during recovery has been investigated as a way to explore this trajectory. Methods This prospective observational cohort study followed patients from hospital to home as they recovered from a hip fracture. Participants were recruited from a single centre and provided with a 3-axis logging accelerometer worn as a pendant, for 16 weeks from recruitment. Participants received monthly follow-up visits which included questions about wearing the monitor. Monthly activity monitor data were also downloaded. Participant activity was estimated from the monitor data using the calibrated “Euclidean Norm Minus One” (ENMO) metric. Polynomial mixed-effects modelling was used to evaluate the difference between the weekly activity trends of 2 groups of participants: those with and without independent mobility at 16 weeks (defined by whether aids or personal assistance were required to mobilise). Results Twenty-nine participants from 125 eligible patients were recruited. Of these, 19 (66%) reported being aware of wearing the monitor at least some of the time. Fourteen (48%) participants withdrew before study completion. Data for thirteen (45%) participants were of sufficient quantity to be included in the activity modelling procedure. Of these, 8 reported independent mobility at 16 weeks post-surgery, and 5 did not. By week 7, the weekly predicted mean ENMO ($$ {\overline{ENMO}}_W $$ENMO¯W) values were significantly different between the two participant groups, demonstrating feasibility of the model’s ability to predict which patients will report independent mobility at 16 weeks. Conclusions This is the first study to our knowledge to investigate acceptability and feasibility of a pendant-worn activity monitor in this patient cohort. Acceptability of wearing the monitor and feasibility of recruitment and retention of participants were limited. Future research into the use of activity monitors in this population should use minimally intrusive devices which are acceptable to this population. Study registration MoHIP is a sub-study of the World Hip Trauma Evaluation (WHiTE) Study (ISRCTN 63982700).

The Fragility Fracture Network is coordinating international initiatives to promote collaborative research, multidisciplinary care, and the secondary prevention of fragility fractures. This review discusses the use of national audit processes and the collection of common outcomes to facilitate research, as well as the key role played by patient and public involvement, and strategies to overcome research barriers.

Open fractures of the tibia are potentially life-changing injuries with huge costs to both patients and healthcare systems. These injuries require early coordinated interventions by senior orthopaedic and plastic surgical teams (orthoplastic) to reduce the risk of long-term complications and improve outcomes. Here we review clinical guidelines and developments in the evidence base to highlight key aspects of the coordinated care of open fractures of the tibia.

Hip fracture is a global problem both for patients and healthcare systems. Patients with a hip fracture have complex health and social needs which present challenges to measuring outcomes. In this review we discuss how knowledge of what patients consider important in their recovery has increased our understanding of how to measure outcomes in this patient population, the work towards establishing a core set of outcomes, and how exploiting existing infrastructure in the UK has provided a powerful framework within which to undertake research.

The purpose of this study was to assess the intra-rater and inter-rater reliability of electronic and manual dynamometry and goniometry in healthy volunteers, and the inter-instrument reliability in the assessment of healthy volunteers and patients recovering after a fracture of the distal radius. Grip strength, grip fatigue, pinch strength and range of motion were assessed in all participants with both the manual and electronic instruments by two physiotherapists and orthopaedic specialist trainee. The measures of dynamometry demonstrated excellent reliability (intra-class correlation coefficient >0.90), with the instruments found to be interchangeable with the exception of the grip fatigue. Variable intra-rater and inter-rater reliability was demonstrated with all planes of movement for the goniometry measures regardless of the instrument used. The results of this study support the continued use of dynamometry in the clinical setting, but raise questions regarding the use of goniometry measurements. Level of evidence Diagnostic level III

Objectives Rupture of the Achilles tendon is a debilitating injury. Advances have led to the development of immediate weight bearing rehabilitation. A range of early rehabilitation methods exist, but further research is required into this new area. The first stage in the investigation of a complex intervention is to identify its defining components. The aim of this review was to systemically identify and summarise, from clinical studies, the individual components that define immediate weight bearing rehabilitation protocols for the treatment of acute Achilles tendon rupture's. Data sources The electronic databases MEDLINE, EMBASE, CINAHL, AMED and the register of current controlled trials were searched up to March 2010. Review methods All study designs and languages were included. Two independent reviewers used pre-defined inclusion and exclusion criteria to identify all eligible articles. Eligible articles were summarised and critically reviewed, using the extension of the CONSORT statement for non-pharmacological interventions. Results Two hundred and fifteen articles were screened, nine were included. These studies, presented the results of 424 patients; 236 who had surgery and 188 who were managed non-operatively. There were a range of rehabilitation protocols that were defined by four components. These components consisted of the degree of maintained plantarflexion, whether daily range of movement exercises were permitted, the type of orthotic and for how long it was worn. Conclusions The efficacy of different immediate weight bearing rehabilitation protocols following an acute rupture of the Achilles tendon remains unclear. Further research is required to evaluate the identified components to optimise rehabilitation.

Platelet-rich plasma has been shown in several in vitro and animal studies to play a role in promoting new bone formation. A systematic literature review was conducted to identify the current relevant evidence base, searching across multiple sources including Medline, Embase and the Cochrane Library, and finding five clinically relevant articles. Only one was a randomised controlled trial, but this was underpowered for the outcome measure defined. Three studies exclusively concerned children, and included those with congenital limb deformities. Two other reports were case series. Early clinical results suggest that the use of platelet-rich plasma is safe and feasible, but that at present there is no clinical evidence of benefit in either acute or delayed fracture healing.

The widely used proportional odds model is developed for correlated repeated ordinal score data, using a modified version of the generalized estimating equation (GEE) method for model fitting for a range of working correlation models. The algorithm developed estimates the correlation parameter, by minimizing the generalized variance of the regression parameters at each step of the fitting algorithm. Methods for parameter estimation are described for the widely used uniform and first-order autoregressive correlation models, for data potentially recorded at irregularly spaced time intervals. A full implementation of the algorithm (repolr) in the R statistical software package, that both tests the assumption of proportional odds and accommodates missing data, is described and applied to a clinical trial of post-operative treatment, after rupture of the Achilles tendon and a study of patient pain response after hip joint resurfacing.

Summary Background Non-union following long bone fractures is a cause of significant morbidity to the patient. The management of this condition has proved difficult for the orthopaedic surgeon. Much research has been carried out on the use of electromagnetic stimulation in the healing of non-union. Objectives The objective of this review is to determine what evidence exists to support electromagnetic stimulation in the management of established non-union of long bone fractures. Methods A systematic search was carried out of the peer-reviewed English language literature to identify all studies investigating electromagnetic stimulation in the treatment of non-union of fractures of long bones. Results Three of the articles reviewed were randomised clinical trials. Forty-six other studies were also included in the review. Conclusions There is a consensus that electromagnetic stimulation is an effective adjunct to conventional therapy when used in the management of non-union of long bone fractures.

Classification systems for fractures of the femur with a prosthetic hip in situ are diverse and complex. Most of them are based on the site of the fracture, which is not the most important differentiating factor in treatment planning. The Coventry classification system groups the periprosthetic fractures into 'happy hips' and 'unhappy hips' based on whether or not the stem is loose. In 'happy' hips, treatment only needs to address the fracture itself, unless the fixation has been compromised by the fracture. In the 'unhappy hips', revision of the prosthesis is recommended.

The timing of tourniquet release is a potential confounding factor in the use of retransfusion drains in total knee arthroplasty. A pilot randomised trial was performed using retransfusion drains to determine whether releasing the tourniquet after wound closure reduced the overall blood loss and allogenic transfusion rate. Forty eight patients undergoing total knee arthroplasty were randomly allocated to receive either a retransfusion drain or no drain. Within each group the tourniquet was released before or after wound closure at the discretion of the surgeon. The peri-operative fall in haemoglobin, allogenic blood transfusion rate and complication rate were measured. There was an overall transfusion rate of 16%. There was no difference in the peri-operative fall in haemoglobin or the allogenic transfusion rates between the No Drain and Retransfusion Drain groups for patients undergoing total knee arthroplasty. Furthermore, the timing of the tourniquet release did not alter these findings. The results of this study suggest that the timing of the tourniquet release does not impact upon the ability of retransfusion drains to reduce the peri-operative fall in haemoglobin or the requirement for allogenic blood transfusion in total knee arthroplasty.

A rise in plantar pressure has been observed in pregnant women with foot pain. The current literature on plantar pressure in pregnancy is sparse. It has been postulated that changes in plantar pressure result from the physiological effects of pregnancy. In this study we aim to quantify the plantar pressure of women in late pregnancy. Methods Twenty-two pregnant women undergoing a caesarean section and twenty non-pregnant women were recruited from University Hospital Coventry and Warwickshire between May to June 2007. Plantar pressure measurements were performed using an in-shoe measurement system. The control group was compared with the pregnant group at 38 weeks gestation. A selection of the pregnant group had repeat measurements at 4 months post-partum. The pre and post-partum measurements were also compared. Results The pregnant group (PG) exerted a significantly higher mean midfoot pressure compared to the non-pregnant control group (CG) (PG=115.5kPa, CG=95.4kPa; p=0.001). Post-partum (PP), there was a significant reduction in the mean and maximum midfoot pressure (mean; PG=111.9kPa, PP=66.2kPa; p

Background There is strong evidence that severely injured patients are optimally treated within inclusive trauma networks. One feature of such networks is prehospital triage of the most injured patients to designated trauma hospitals. In April, 2012, major trauma services across England were reconfigured into regional trauma networks based around designated major trauma centres (MTCs). This study explored the early effects of the regionalisation of major trauma services in England. Methods The Trauma & Audit Research Network (TARN) identified severely injured patients treated in the 9 months before and after each MTC became fully operational. Outcomes included quality indicators (eg, time to CT scanning for head injured patients) and clinical outcomes (eg, in-hospital mortality). Completeness of the TARN dataset was quantified with Hospital Episode Statistics. Death registrations were used to identify any change in the overall number of traumatic deaths in England. Findings The number of severely injured patients treated in MTCs increased from 7705 to 12 476. All care quality indicators improved: treatment by a consultant (30·4% before MTC vs 54·3 after MTC, p vs 58·5, p=0·006), and time to CT scanning for head injured patients (49·2 min vs 31·2, p vs 25·9, p vs 64·5, p Interpretation There is early evidence of improved care associated with trauma service regionalisation, including some process measures, enhanced case reporting for national audit, and reduced need for secondary transfer of patients between hospitals. However, in this early post-implementation analysis, significant reductions in patient mortality were not observed. Funding Royal College of Surgeons of England Fulbright Scholarship.

We present the case of a 28-year-old competitive runner with iliotibial band (ITB) friction syndrome associated with a synovial cyst. Magnetic resonance imaging (MRI) did not demonstrate a fluid collection. However, open exploration revealed a large cyst beneath the ITB arising from the capsule of the knee proximal to the lateral meniscus. The cyst disappeared on extension. The pre-operative MRI scan may have revealed the cyst, if it had been taken with the knee flexed.

Resume Prepare par Mark Elkins, membre du comite de redaction Question Apres un traitement chirurgical ou conservateur d’une rupture du tendon d’Achille, une mobilisation immediate avec appui dans une orthese ameliore-t-elle le resultat fonctionnel par rapport a une mobilisation sans appui ? Methodologie Deux essais randomises controles avec allocation par tirage au sort, evaluation en double aveugle et analyse en intention de traiter des patients de trois centres orthopediques britanniques. Patients Dans un premier essai de 48 patients presentant une rupture du tendon d’Achille de moins de 7 jours, l’allocation par tirage au sort etait de 23 patients dans le groupe d’appui postoperatoire immediat et de 25 patients dans le groupe sans appui postoperatoire immediat. Dans le deuxieme essai, l’allocation etait de 22 patients dans le groupe avec appui et de 26 dans le groupe sans appui apres un traitement non chirurgical. Interventions Pour les deux essais, la mobilisation dans le groupe avec appui se faisait avec une orthese commerciale en fibre de carbone et une talonnette de 1,5 cm. Le groupe sans appui portait un plâtre conventionnel. Les patients chirurgicaux etaient revus toutes les deux semaines avec une reduction progressive de l’amplitude de la flexion plantaire de l’orthese/plâtre jusqu’a l’appui plantigrade complet. L’orthese/plâtre etait retiree a la huitieme semaine. Les patients non chirurgicaux avaient une reduction progressive de la flexion plantaire a partir de 6 semaines puis par intervalles de 2 semaines jusqu’a 12 semaines. Evaluation Les patients etaient revus a 3, 6 et 12 mois. Le critere principal d’evaluation etait le delai necessaire pour recuperer une performance normale aux activites suivantes : l’activite sportive, la marche, la montee des escaliers, l’activite professionnelle. Des criteres d’evaluation secondaires etaient la qualite de vie en rapport avec l’etat de sante, le diametre du mollet, l’amplitude des mobilites articulaires et les resultats dynamometriques. Les effets secondaires etaient notes. Resultats Chez les patients chirurgicaux, le temps de recuperation d’une marche normale etait plus court dans le groupe avec appui. La difference etait significative avec une difference de 5,5 semaines (IC 95 % : 0 a 11). Pour la montee des escaliers, le retour a la normale etait significativement plus precoce dans le groupe a appui avec une difference mediane de 9semaines (IC 95 % : 5,3 a 12,7). L’appui n’a pas eu d’effet sur le retour aux activites sportives ou professionnelles, ni sur aucun des criteres d’evaluation secondaires. Chez les patients traites sans chirurgie, il n’y avait pas eu de difference significative entre le groupe avec appui et le groupe sans appui, quel que soit le critere d’evaluation. Dans les deux essais, il y avait peu d’effets secondaires, sans difference entre les groupes avec et sans appui, y compris pour la rupture iterative. Conclusion Les patients dont le traitement de la rupture du tendon d’Achille etait chirurgical ont recupere une capacite normale de marche et de monter des escaliers plus rapidement apres une mobilisation precoce avec appui postoperatoire. Chez les patients traites par une technique non chirurgicale, la recuperation fonctionnelle etait similaire avec et sans appui postoperatoire. Les avantages pratiques d’un appui immediat font de cette methode therapeutique l’option de preference apres un traitement chirurgical ou non chirurgical d’une rupture du tendon d’Achille.