[Isolated dislocation of the os triquetrum--a rare wrist injury]

The isolated traumatic dislocation of the triquetrum is an extremely rare injury. The clinical signs are unspecific. Roentgenograms of the wrist in posteroanterior and lateral views, possibly complemented by oblique views, will help to provide the diagnosis. The best therapy appears to be the open reduction and fixation with Kirschner wires. With the presented case report, the difficulties in using the classification carpal injuries are discussed. Finally, corresponding to the carpus ring theory, the plausibility of additional injuries to carpal ligaments in such trauma is pointed out.

Combined central slip and volar plate injuries at the PIP joint

PIP joint injuries are common. We describe an unusual injury in which an apparent volar plate avulsion injury was associated with a dorsal, central slip avulsion fracture. We postulate that the mechanism of injury would appear to have been forced flexion with the central slip being avulsed and the volar plate fracture occurring as a secondary impingement fracture. Our two cases were treated with full extension splinting with satisfactory results.

Swan-neck deformity as a complication of the Agee technique

Unstable dorsal fracture dislocations of the PIP joint of a finger commonly result in joint stiffness following immobilization or open reduction and internal fixation (Green and Rowland, 1984). The Agee dynamic external fixator, or force couple splint (Agee, 1978; 1987), was introduced in an attempt to avoid this complication and maintains a concentric reduction whilst allowing a full range of joint movement. The splint is constructed from three Kirschner wires and is activated by a single rubber band. A force couple is created across the proximal interphalangeal joint levering the base of the middle phalanx towards the palm whilst simultaneously lifting the distal end of the proximal phalanx dorsally to restore joint reduction. However, this technique is not without complications (Agee, 1987). We report a swan-neck deformity resulting from this treatment.

Open reduction and internal fixation for displaced intra-articular fractures of the os calcis

Thirty-one patients with displaced intra-articular fracture of the os calcis who were admitted to Queen Mary Hospital, Hong Kong from 1989 to 1991 and who underwent open reduction and internal fixation and bone grafting of the os calcis, were followed up for at least 30 months. Pre- and postoperative X-rays were taken. Functional results were assessed clinically in terms of pain, deformities, activities and motion loss. The majority of the patients had acceptable functional outcome. The results were analysed in an attempt to correlate with the fracture pattern.

Fracture of the cuboid in children. A source of leg symptoms

We report eight cases of fracture of the cuboid in seven children under four years of age, collected during a two-year period. There was no history of trauma in five of the patients. This fracture is rarely diagnosed and has probably been under-reported. Small children are poor historians and difficult to examine, and early radiographs may be normal or have only subtle abnormalities. Cuboid fracture should be considered in the differential diagnosis of limping toddlers, and a bone scan may be needed to confirm the diagnosis earlier than radiography. These fractures heal completely, without sequelae. Treatment in a short-leg walking cast is recommended, primarily for reasons of comfort.

Protected early motion versus cast immobilization in postoperative management of ankle fractures

Sixty-one active-duty military personnel with operatively treated ankle fractures were randomized into two postoperative immobilization regimens: Group I--six weeks short-leg cast, nonweight-bearing; Group II--six weeks removable orthosis, nonweightbearing. Group I began physical therapy at six weeks postoperatively, and Group II began physical therapy within the first postoperative week. Objective measurements of swelling, strength, range of motion, and functional tests were examined. Subjective scores of pain, function, cosmesis, and motion were recorded. Patients in Group II (early mobilization) had significantly better subjective scores at three and six months postoperatively; however, time to return to duty was not significantly different. Objective tests of swelling, strength, range of motion, and functional tests were not significantly different at three months postoperatively for either group. Early mobilization in a removable orthosis, while not objectively altering the postoperative course, provides a safe, preferable method of treatment in the reliable and cooperative patient.

Simulated neural networks to predict outcomes, costs, and length of stay among orthopedic rehabilitation patients

Our purpose was to develop a set of simulated neural networks that would predict functional outcomes, length of stay, and costs among orthopedic patients admitted to an inpatient rehabilitation hospital. We used retrospective data for a sample of 387 patients between the ages of 60 and 89 who had been admitted to a single rehabilitation facility over a period of 12 months. Using age and data on functional capacity at admission from the Functional Independence Measure, we were successful in constructing networks that were 86%, 87%, and 91% accurate in predicting functional outcome, length of stay, and costs to within +/- 15% of the actual value. In each case the accuracy of the network exceeded that of a multiple regression equation using the same variables. Our results show the feasibility of using simulated neural networks to predict rehabilitation outcomes, and the advantages of neural networks over conventional linear models. Networks of this kind may be of significant value to administrators and clinicians in predicting outcomes and resource usage as rehabilitation hospitals are faced with capitation and prospective payment schemes.

Magnetic resonance imaging of bone marrow and osteochondral injury

Posttraumatic occult subcortical fractures represent a heterogeneous group of lesions, with different subgroups associated with a high incidence of osteochondral sequelae. The role of MR imaging must be to determine the significance of the different subgroups of occult fractures in the pathogenesis of posttraumatic osteoarthritis. The ultimate goal is to minimize the eventual effects of impactive forces on the osteochondral complex at the time of detection. Modifications in immediate and rehabilitative management of such patients will ensure maintenance of the best possible chondral integrity.

A prospective study of surgically treated acetabular fractures

Between November 1988 and March 1993, 101 patients with 102 fractures of the acetabulum were referred to the authors' institution. They included 31 both column; 25 transverse associated posterior wall; 16 anterior column associated posterior hemitransverse; 9 posterior wall; 7 posterior column associated posterior wall; 7 anterior column; 5 T shaped; and 2 transverse fractures. Thirteen fractures were excluded, leaving 89 patients with 89 operatively treated fractures available for followup. Postoperative radiographs were evaluated for adequacy of reduction and scored on a scale of 1-9 with 9 being perfect. Perfect or near perfect reduction was achieved in 82% of patients. A minimum of 1 year followup was available for 53 patients. Clinical results were assessed in terms of the patients' activities and included their ability to walk, range of motion and pain. Excellent results were achieved in 27 patients and an additional 16 had satisfactory results, for an overall 81% acceptable outcome. Radiographic evidence of posttraumatic osteoarthrosis was present in 40% of patients: mild in 10, moderate in 5, and severe in 5. Heterotopic ossification was Brooker Grade III and Grade IV in 1 patient each. These results indicate that operative treatment of acetabular fractures provides results that are superior to those achieved with nonoperative treatment.

Fractures in older persons

Fractures in the elderly, especially hip fractures, have increased during recent decades in the west. Due to their large number, and often extended demands on hospital resources, older persons with hip fractures make heavy demands on health care resources. The fractures are the result of both increasing skeletal fragility and increasing falling tendency with age. Preventive measures consist primarily of opposing the sedentary life style of modern society. A continued moderate physical activity since youth, combined with sufficient access to calcium and vitamin D, builds up and retains enough bone stock to resist the decay of 1-2% per year that starts from the fifth decade of life onwards. Falling accidents are probably easier to prevent by training of muscular activity and balance compared to the osteoporosis, which needs a long preventive perspective. The rehabilitation prognosis for the individual patient has greatly improved over recent years.

[Use of a semi-elastic synthetic cast in functional treatment of fresh injuries]

Functional treatment of injured joints is increasing since the introduction of semi-rigid plaster. Injuries to the ligaments of the ankle joint, ruptured Achilles tendon, but also other joints with injured ligaments are suitable for this therapy. We report about our experience of 120 treated ligamental injuries of the ankle joint, treated in a conservative way with semi-rigid plasters.

A computer-aided walking rehabilitation robot

Even with recent techniques, a significant number of patients with multiple injuries cannot be mobilized at an early stage despite the fixation of all fractures. Conventional mobilization aids are not able to provide the prescribed weight bearing needed in fractures, especially those involving both the lower limbs. Robotics is a current technology aimed at improving the quality of medical care. To this end, Takatoshi Ide developed the mobility rehabilitation robot, the REHABOT. This apparatus facilitates rehabilitation by providing secure postural support and prescribed weight bearing during ambulation. The REHABOT has been used for early mobilization and gait training of severely disabled patients at different hospitals in Japan during the last 6 years. In most of the cases, this training has resulted in earlier improvement of ambulatory capability. In this paper we report the use of this device for early ambulation in two patients with multiple fractures involving the extremities and the spine. Early mobilization was achieved by initially reducing the weight bearing to 30% of body weight followed by a gradual increase governed by patient tolerance. The average length of training for these two patients was 18 days. The average total distance was 5.5 km and total walking duration was 4.5 h. After the completion of the training both patients were able to walk independently.

The therapist's management of intra-articular fractures

Fabrication of the dynamic traction splint is described in step-by-step fashion in order to aid surgeons to understand the principles of application of the method and to assist hand therapists to make the splint. The new 6-inch diameter arcuate hoop and the radial or ulnar gutter base splint are detailed. Modification of continuous passive motion machines is described for use in conjunction with dynamic traction. Alternative splint applications and post-dynamic traction splinting therapy methods are outlined.

Extension block splinting

Extension block splinting (EBS) at the proximal interphalangeal joints of the fingers is a common technique for both primary treatment of reduced dorsal dislocations/fracture-dislocations at that joint and as a rehabilitation method following open reduction of such injuries. It is seldom realized that the method is a classic example of two orthopedic principles: stable arc splinting and early protected motion. As a primary treatment technique, following reduction of the dislocation, EBS is exemplary for an ideal group of cases, competitive for a marginal group of cases, and often unsatisfactory for a questionable group of cases. Demarcation between the groups is made, and the technique of EBS is reviewed.

A new method of training for the lower extremity using unloading

Rehabilitation of the patient with lower extremity dysfunction is frequently limited to open kinetic chain exercise due to pain and weakness in weight-bearing positions. Although hydrotherapy has been used in the past as a method of reducing body weight forces, task-specific training is not possible due to the resistance offered by water and the inability to regulate load. This clinical commentary describes a new form of lower extremity rehabilitation through the use of Unloading, a controlled reduction in body weight during task-specific activities. Two case reports of professional basketball players with foot injuries are presented in order to describe this method of therapy, which, in the authors' opinion, has the potential for broad applications in physical rehabilitation and deserves further research.

Early postoperative ankle exercise. A study of postoperative lateral malleolar fractures

Fifty-three patients with dislocated lateral malleolar fractures were randomly selected after operation for either active ankle movement and weight bearing in an orthosis or no ankle movement but weight bearing in a walking cast. At follow-up examinations after three, six, and 18 months, no differences were found between the groups except for a better linear analogue scale result at three months for the orthosis group. Active ankle movements do not improve the rehabilitation of surgically treated lateral malleolar fractures.

[Markedly varying physiotherapeutic treatment following carpal injuries]

OBJECTIVE

To inventory long-term symptomatic and physiotherapeutic results in patients treated conservatively for a carpal injury.

DESIGN

Follow-up investigation and case control study.

SETTING

University Medical Centre, Amsterdam.

METHOD

A follow-up investigation was conducted in a group of 100 patients with carpal injury. In this group clinical parameters of patients treated conservatively and with physiotherapy (PT) (n = 16) were compared with 16 case controls without PT, selected for age, sex, diagnosis and duration of immobilisation.

RESULTS

After removal of the plaster cast, 16 patients had been referred to a physiotherapist because pain was a major complaint. PT was given 2-3 times a week for an average of 11 days after a period of immobilisation of about 9.5 weeks. Treatment varied strongly among the physiotherapists. Follow-up took place 13-50 months after injury. Patients treated with PT had significantly more complaints concerning the traumatised hand than patients without PT. In the long run only 2 patients benefited from PT.

CONCLUSION

Physiotherapy after carpal injury lacks method. Applications were arbitrary added or omitted. Patients with carpal injury who were treated with physiotherapy after immobilisation had more complaints in the long run. This difference may be due to selectivity in the policy of referring for physiotherapy.

[Functional treatment of basal joint fractures of three-joint fingers]

Phalangeal fractures have up to now always been treated using a conservative static form of splint. Open reduction and stabilisation is preferred in the case of injuries with severe displacement, shortening, open fractures and joint involvement. In this study, we have shown the results of 86 proximal phalangeal fractures that were treated with "dynamic splinting". In the "intrinsic plus" position a dorsopalmar plaster splint is affixed in combination with a Bedford double finger stall, splinting the injured finger securely to its neighbour. Clinical and X-ray results were evaluated. Oblique, rotational and transverse fractures can be reduced and treated showing good results with dynamic splinting. Bending fractures cannot always be treated with this method. Especially basal fractures with dorsal comminution can be problematic. Comminuted fractures can only be treated with dynamic splinting if they have been primarily adequately reduced. Intraarticular condylar fractures have to be treated surgically. Our results have also shown that the fingers still are freely mobile even when the bone has not healed in an anatomical position.

Rehabilitation of fractures in the elderly

Rehabilitation is the most important aspect of care after a fracture in an older person. Epidemiology, contributing factors, general principles of management are discussed in this article. Proper management requires knowledge of various mechanisms of injury, different forms of orthopedic treatments, interpretation of radiographs, and familiarity with available therapeutic modalities.

[The structure of distracting-compressing stabilizers Dynastab DK intended for functional treatment of articular fractures]

The structure of the distracting-compressing stabilizers Dynastab DK intended for functional treatment of transarticular fractures is described. The stabilizers realize the idea of functional treatment of fractures outside the hospital bed making possible free moving around of the patient during the treatment. This has been made possible owing to building-in of a mechanical articulation imitating the physiological movement in the injured joint. The articulation in the stabilizer reduces also the load on the joint. In the stabilizers for the treatment of such fractures of the elbow joint and ankle joint the articulations are monoaxial (hinge-like). In the stabilizer for the treatment of the radiocarpal joint this is a hinge articulation making possible flexion in sagittal plane. In the stabilizer for knee fractures the movements in the injured joint are taken over by a mechanical articulation of special structure. The distracting-compressing action of the Dynastab DK stabilizers for the treatment of transarticular fractures is realized by the tension screw mechanism e.g. in the stabilizer for the treatment of knee joint fractures. In the case of stabilizers for ankle joint, radiocarpal joint and elbow joint this tension is provided by calibrated compressing springs.

Outpatient percutaneous screw fixation of the acute Jones fracture

Nine patients (8 men and 1 woman, ranging in age from 17 to 22 years) who sustained a Jones fracture were treated with percutaneous intramedullary screw fixation as outpatients. All of the patients were varsity athletes. Seven were Division I scholarship athletes. Beginning at 7 to 10 days after surgery, all patients were allowed weightbearing as tolerated with a CAM walker. Stationary bicycling, swimming, and Stairmaster were allowed at 2 to 3 weeks. The average return to running was 5.5 weeks (range, 3 to 10). The average return to full competition was 8.5 weeks (range, 7 to 12). No perioperative or postoperative complications occurred. Average followup was 2.5 years. All fractures attained clinical and radiographic union. We believe that outpatient percutaneous intramedullary screw fixation of the acute Jones fracture is a reasonable alternative for those active patients who would have difficulty with a non-weightbearing cast and crutches or who desire an expeditious return to activities. Time restraints are particularly critical for in-season or preseason athletes. With the outpatient screw fixation method, our patient population had predictable healing, and they returned to full sports participation within 12 weeks.

[Follow-up care of surgically-treated fractures and evaluation of healing process in the roentgen picture]

The aim of surgical therapy of a fracture is the restoration of the original integrity of the limb. X-rays are the only means by which the surgeon can observe fracture healing over time. This includes direct bone healing without major radiological changes and indirect bone healing which shows callus formation. The two requirements needed for rapid bone remodelling and early mobilization after operation are an exact repositioning of the fracture fragments, if possible, and the maintenance of soft tissue and joints. Postoperative findings, complications and aftertreatment are discussed. X-ray series are presented, and the differences in fracture healing are shown.