Arm and shoulder conditions, active component, U.S. Armed Forces, 2003-2012

This analysis estimated the incidence and health care burden of acute and chronic conditions of the arm and shoulder among active component service members of the Armed Forces from 1 January 2003 through 31 December 2012. There were 196,789 diagnosed incident cases of acute arm and shoulder conditions for a rate of 13.7 cases per 1,000 person-years. The annual incidence rates of sprains, the most common acute condition, nearly doubled during the period. Diagnoses of chronic conditions (overall rate of 28.8 per 1,000 person-years) increased 25 percent during the period, mainly associated with a doubling of the incidence of diagnoses of joint pain. Incidence rates of chronic disorders were progressively higher among successively older age groups of service members. The health care burden of all arm and shoulder conditions together steadily increased during the period, as indicated by numbers of health care encounters, individuals affected, and lost work time. The most commonly documented causes associated with acute and chronic conditions are described.

WITHDRAWN: Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults

BACKGROUND

Acute lateral ankle ligament injuries (ankle sprains) are common problems in acute medical care. The treatment variation observed for the acutely injured lateral ankle ligament complex suggests a lack of evidence-based management strategies for this problem.

OBJECTIVES

The objective of this review was to assess the effectiveness of methods of immobilisation for acute lateral ankle ligament injuries and to compare immobilisation with functional treatment methods.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2001); the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966-May 2000), EMBASE (1988-May 2000), reference lists of articles, and contacted organisations and researchers in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing either different types of immobilisation or immobilisation versus functional treatments for injuries to the lateral ligament complex of the ankle in adults were included. Trials which investigated the treatment of chronic instability or post-surgical treatment were excluded.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two authors. Where appropriate, results of comparable studies were pooled using fixed effects models. Individual and pooled statistics were reported as relative risks with 95% confidence intervals for dichotomous outcomes and weighted (WMD) or standardised (SMD) mean differences and 95% confidence intervals for continuous outcome measures. Heterogeneity between trials was tested using a standard chi-squared test.

MAIN RESULTS

Twenty-one trials involving 2184 participants were included. The mean validity score of the included trials increased from 9.1 (SD 3.0) to 10 (SD 2.9) after retrieving further information (maximum 18 points). Statistically significant differences in favour of functional treatment when compared with immobilisation were found for seven outcome measures: more patients returned to sport in the long term (relative risk (RR) 1.86, 95% confidence interval (CI) 1.22 to 2.86); the time taken to return to sport was shorter (WMD 4.88 (days), 95% CI 1.50 to 8.25); more patients had returned to work at short term follow-up (RR 5.75, 95% CI 1.01 to 32.71); the time taken to return to work was shorter (WMD 8.23 days, 95% CI 6.31 to 10.16); fewer patients suffered from persistent swelling at short term follow-up (RR 1.74, 95% CI 1.17 to 2.59); fewer patients suffered from objective instability as tested by stress X-ray (WMD 2.60, 95% CI 1.24 to 3.96); and patients treated functionally were more satisfied with their treatment (RR 1.83, 95% CI 1.09 to 3.07). A separate analysis of trials that scored 50 per cent or more in quality assessment found a similar result for time to return to work only (WMD (days) 12.89, 95% CI 7.10 to 18.67). No significant differences between varying types of immobilisation, immobilisation and physiotherapy or no treatment were found, apart from one trial where patients returned to work sooner after treatment with a soft cast. In all analyses performed, no results were significantly in favour of immobilisation.

AUTHORS' CONCLUSIONS

Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated.

WITHDRAWN: Different functional treatment strategies for acute lateral ankle ligament injuries in adults

BACKGROUND

Acute lateral ankle ligament ruptures are common problems in present health care. Early mobilisation and functional treatment are advocated as a preferable treatment strategy. However, functional treatment comprises a broad spectrum of treatment strategies and as of yet no optimal strategy has been identified.

OBJECTIVES

The objective of this review is to assess different functional treatment strategies for acute lateral ankle ligament ruptures in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field.

SELECTION CRITERIA

Randomised clinical trials describing skeletally mature individuals with an acute lateral ankle ligament rupture and comparing different functional treatment strategies were evaluated for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of included trials and extracted relevant data on treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcome and (weighted) mean differences (WMD) for continuous outcome measures with 95 per cent confidence intervals (95%CI). Heterogeneity between trials was tested using a standard chi-squared test.

MAIN RESULTS

Nine trials involving 892 participants were included. Lace-up ankle support had significantly better results for persistent swelling at short-term follow up when compared with semi-rigid ankle support (RR 4.19, 95% CI 1.26 to 13.98); elastic bandage (RR 5.48; 95% CI 1.69 to 17.76); and to tape (RR 4.07, 95% CI 1.21 to 13.68). Use of a semi-rigid ankle support resulted in a significantly shorter time to return to work when compared with an elastic bandage (WMD (days) 4.24; 95% CI 2.42 to 6.06); one trial found the use of a semi-rigid ankle support saw a significantly quicker return to sport compared with elastic bandage (RR 9.60; 95% CI 6.34 to 12.86) and another trial found fewer patients reported instability at short-term follow-up when treated with a semi-rigid support than with an elastic bandage (RR 8.00; 95% CI 1.03 to 62.07). Tape treatment resulted in significantly more complications, the majority being skin irritations, when compared with treatment with an elastic bandage (RR 0.11; 95% CI 0.01 to 0.86). No other results showed statistically significant differences.

AUTHORS' CONCLUSIONS

The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. However, definitive conclusions are hampered by the variety of treatments used, and the inconsistency of reported follow-up times. The most effective treatment, both clinically and in costs, is unclear from currently available randomised trials.

Acupuncture for ankle sprain: systematic review and meta-analysis

BACKGROUND

Ankle sprain is one of the most frequently encountered musculoskeletal injuries; however, the efficacy of acupuncture in treating ankle sprains remains uncertain. We therefore performed a systematic review to evaluate the evidence regarding acupuncture for ankle sprains.

METHODS

We searched 15 data sources and two trial registries up to February 2012. Randomized controlled trials of acupuncture were included if they involved patients with ankle sprains and reported outcomes of symptom improvement, including pain. A Cochrane risk of bias assessment tool was used. Risk ratio (RR) or mean difference (MD) was calculated with 95% confidence intervals (CIs) in a random effects model. Subgroup analyses were performed based on acupuncture type, grade of sprain, and control type. Sensitivity analyses were also performed with respect to risk of bias, sample size, and outcomes reported.

RESULTS

Seventeen trials involving 1820 participants were included. Trial quality was generally poor, with just three reporting adequate methods of randomization and only one a method of allocation concealment. Significantly more participants in acupuncture groups reported global symptom improvement compared with no acupuncture groups (RR of symptoms persisting with acupuncture = 0.56, 95% CI 0.42-0.77). However, this is probably an overestimate due to the heterogeneity (I2 = 51%) and high risk of bias of the included studies. Acupuncture as an add-on treatment also improved global symptoms compared with other treatments only, without significant variability (RR 0.61, 95% CI 0.51-0.73, I2 = 1%). The benefit of acupuncture remained significant when the analysis was limited to two studies with a low risk of bias. Acupuncture was more effective than various controls in relieving pain, facilitating return to normal activity, and promoting quality of life, but these analyses were based on only a small number of studies. Acupuncture did not appear to be associated with adverse events.

CONCLUSIONS

Given methodological shortcomings and the small number of high-quality primary studies, the available evidence is insufficient to recommend acupuncture as an evidence-based treatment option. This calls for further rigorous investigations.

Conservative interventions for treating hyperextension injuries of the proximal interphalangeal joints of the fingers

BACKGROUND

Immobilisation and early motion (protected or unrestricted) are both used following hyperextension injuries to the proximal interphalangeal (PIP) joint of the finger.

OBJECTIVES

To assess the effects of conservative interventions (non-surgical management) for treating hyperextension injuries of the proximal interphalangeal joints of the fingers.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2012), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2012, Issue 1), MEDLINE (1946 to January Week 2 2012), EMBASE (1980 to 2012 Week 03), CINAHL (1950 to 24 January 2012), PEDro (1929 to March 2012), trial registers and reference lists of articles.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing immobilisation/protected mobilisation/unrestricted mobilisation in participants with PIP joint hyperextension injuries managed non-surgically.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. There was no pooling of data.

MAIN RESULTS

Three trials involving 366 people were identified. All three trials, which were over 15 years old, were methodologically flawed with unclear or high risk of bias. None of the studies reported on self assessment of function. One trial compared unrestricted mobility with immobilisation; one trial compared protected mobilisation with immobilisation; and the remaining trial compared immobilisation for one week versus three weeks. None of these trials found statistically significant differences between their intervention groups in various measures of poor outcome, pain and range of movement at six months follow-up. This lack of difference applied at three years for the comparison between unrestricted mobility with immobilisation.

AUTHORS' CONCLUSIONS

There is insufficient evidence from trials testing the need for, and the extent and duration of, immobilisation to inform on the key conservative management decisions for treating hyperextension injuries of the proximal interphalangeal joints.

Sports hip injuries: assessment and management

Over the past 10 years, the understanding, assessment, and management of hip pain and injuries in the athlete have improved. Traditionally, the evaluation of hip pain and injuries was limited to obvious disorders, such as hip arthritis and fractures, or disorders that were previously considered to be simply soft-tissue strains and contusions, such as groin pulls, hip pointers, and bursitis. Two parallel tracks of progress have improved understanding of the complexities of hip joint athletic injuries and the biomechanical basis of early hip disease. In the field of sports medicine, improved diagnostic skills now allow better interpretation of debilitating intra-articular hip disorders and their effects on core performance. In the field of hip preservation, there has been an evolution in understanding the effects of biomechanical mismatches between the femoral head and the acetabulum on the development of early hip damage, injury, and arthritis. The integration of these two parallel fields has accelerated the understanding of the importance of hip biomechanics and early hip injury in human performance and function.

[The avulsion of subclavian artery from brachiocephalic trunk and subclavian vein from right brachiocephalic vein with brachial plexus injury]

The detachment of subclavian artery from brachiocephalic trunk and subclavian vein from right brachiocephalic vein with brachial plexus injury.

INTRODUCTION

Traumas of large vessels of mediastinal and shoulder girdle cause significant life risk and constitute serious diagnostic and therapeutic problems because of lack of time for accurate treatment planning. Particularly difficult to treat are blunt trauma of large arteries in patients under the influence of drugs or with a progressive hypovolemic shock.

AIM

The aim of this dissertation is presenting my own experience in treating a seventeen-year-old motorcyclist who was under the influence of alcohol suffered a detachment of subclavian artery and subclavian vein from mediastinal large vessels following a traffic accident.

MATERIAL AND METHODS

Seventeen-year-old motorcyclist who was under the influence of alcohol alcohol hit a concrete pole at a speed of 130 km/h. The patient was brought to the hospital in a state of hypovolemic shock, pulse 126/min, blood pressure 80/60 mmHg, without pulse on the right upper limb. The right upper limb was cold, without active movements, pressure and pain sense. The right shoulder was tumid. The right lung without audible murmurs. Pulses on carotid arteries were perceptible. The thoracic plain film x-ray showed a shading on right half of thorax, widening of the upper mediastinum, fracture of right clavicle and the rear right shoulder sprain. Passive movements in the right elbow were correct. The patient was taken to the operating theatre because of progressive hypovolemic shock and was operated in emergency regimen. The transverse thoracotomy was made by both the intercostals spaces between the second and third rib. The thoracotomy showed that subclavian artery from brachiocephalic trunk and subclavian vein from right brachiocephalic vein were detachment. The subclavian vein was ligated and the brachiocephalic vein was sewn (phleborrhaphy). The subclavian artery was connected with brachiocephalic trunk by a synthetic vascular graft so that the received pulse at the periphery of the upper limb. The thyrocervical trunk, costocervical trunk and damaged intercostal vessels at the first, second and third rib were also ligated. The sprained shoulder was set. During the operation, there was no sight that even one of fascicles of brachial plexus was interrupted. The next day pateint was reoperated because of hemorrhage to right pleura. The rest of intercostal vessels at the first, second and third rib were ligated.

RESULTS

The postoperative course was uneventful surgery. After operation was found that ulnar and radial nerve were demaged. The right lung expansion was achieved, upper limb had pulse, wounds healed as needed. The patient was transferred to the neurosurgical treatment.

CONCLUSION

The quick decision to conduct operations without accurate diagnosis was the only factor for patient survival.

Value of MRI in diagnosing injuries after ankle sprains in children

BACKGROUND

To our knowledge, there are only a few prospective studies on the use of magnetic resonance imaging (MRI) to diagnose injuries associated with ankle sprains in children. We hypothesized that MRI examinations of acute ankle sprains in growing children would show relevant injuries that may have been overlooked by conventional clinical, radiological, and ultrasound examinations.

METHODS

Thirty children with acute inversion injury of the ankle were subjected to an MRI examination of the ankle joint, in addition to conventional radiographic procedures. All data were recorded prospectively. Depending on the severity of the clinical symptoms, the children were divided into three different groups. Children with little soft-tissue swelling and who were still able to walk were assigned to Group I (n = 10), Group II consisted of children who were only partially able to walk and had moderate soft-tissue swelling (n = 12), while Group III consisted of the children who were not able to walk and had pronounced soft-tissue swelling (n = 8). Regular followup examinations were carried out. At the final followup examination, on average 8 months after injury, the children in Groups II and III were again examined by MRI. The clinical results were compared and correlated with the results of the MRI examinations.

RESULTS

Altogether, torn ligaments could be verified in 23 out of 30 of the cases; bony avulsions were found in 10% of these. Three of 30 patients had a Salter I injury. Bone bruising was found in 18 out of 30 (60%). Bone bruising was most commonly found near the medial talus. MRI examination of the patients in Group I showed no more ruptures than the clinical examination; here, only four patients were found to have partial ruptures of the ATL. In Group II, torn ligaments were found in six out of 12 (50%) of the cases; similarly, Salter I injuries were found in three out of 12 cases. The patients in Group III also showed serious injuries on the MRI examination. Bone bruising, torn ligaments, or bony avulsions were found in eight out of eight (100%) cases. The recorded clinical results showed only weak correlation to the injury patterns diagnosed using MRI. Only the bone bruises correlated with clinical results. Children with more pronounced swelling and less ability to walk were more commonly diagnosed with bone bruises. No differences were found between groups with regard to pain, instability, or limitations of mobility in the followup examinations or the final MRI examination 8 months after injury.

CONCLUSION

The injury patterns diagnosed through MRI examination did not correlate with clinical findings. With adequate progressive rehabilitation, the pathological changes diagnosed with MRI healed without further complications. MRI examinations of acute ankle distortion injuries in children did not result in any additional therapeutic value. Therefore, we believe conventional clinical, radiological, and ultrasound diagnostic methods are sufficient for the primary diagnosis of ankle fractures and ankle ligament injuries in children.

Canadians' willingness to receive care from physician assistants

OBJECTIVE

To determine the willingness of Canadians to accept treatment from physician assistants (PAs).

DESIGN

Respondents were asked to be surrogate patients or parents under 1 of 3 conditions selected at random. Two scenarios involved injury to themselves, with the third involving injury to their children. The wait time for a physician was assumed to be 4 hours, whereas to explore the sensitivity of patients' preferences for a range of times, PA wait times were 30 minutes, 1 hour, and 2 hours.

SETTING

Vancouver, BC.

PARTICIPANTS

Two hundred twenty-nine mothers attending a hospital with their children.

MAIN OUTCOME MEASURES

The main outcome measure was the proportion of individuals in each scenario who were willing to be treated by PAs for at least one of the time trade-off options offered. A secondary outcome was the proportion of individuals who changed their answers when the waiting time to see the PA varied.

RESULTS

Regardless of the scenarios, 99% of participants opted for PAs under the personal circumstances; 96% opted for PAs when the issue involved their children. The choice favouring the PA persisted, albeit at slightly lower proportions, as the difference in wait time between PAs and physicians decreased (85% and 67% for a difference in PA and physician wait time of 3 and 2 hours, respectively).

CONCLUSION

These findings suggest that British Columbians are willing to be treated by PAs under most circumstances, whether this includes themselves or their children. The high level of willingness to be treated by PAs demonstrates public confidence in PA care, and suggests that the use of PAs in Canadian emergency departments or clinics is a viable policy response to decreasing primary care capacity.

What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?

CONTEXT

Ankle sprains are common problems in acute medical care. The variation in treatment observed for the acutely injured lateral ankle ligament complex in the first week after the injury suggests a lack of evidence-based management strategies for this problem.

OBJECTIVE

To analyze the effectiveness of applying rest, ice, compression, and elevation (RICE) therapy begun within 72 hours after trauma for patients in the initial period after ankle sprain.

STUDY SELECTION

Eligible studies were published original randomized or quasi-randomized controlled trials concerning at least 1 of the 4 subtreatments of RICE therapy in the treatment of acute ankle sprains in adults.

DATA SOURCES

MEDLINE, Cochrane Clinical Trial Register, CINAHL, and EMBASE. The lists of references of retrieved publications also were checked manually.

DATA EXTRACTION

We extracted relevant data on treatment outcome (pain, swelling, ankle mobility or range of motion, return to sports, return to work, complications, and patient satisfaction) and assessed the quality of included studies. If feasible, the results of comparable studies were pooled using fixed- or random-effects models.

DATA SYNTHESIS

After deduction of the overlaps among the different databases, evaluation of the abstracts, and contact with some authors, 24 potentially eligible trials remained. The full texts of these articles were retrieved and thoroughly assessed as described. This resulted in the inclusion of 11 trials involving 868 patients. The main reason for exclusion was that the authors did not describe a well-defined control group without the intervention of interest.

CONCLUSIONS

Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines.

Update on acute ankle sprains

Ankle sprains are a common problem seen by primary care physicians, especially among teenagers and young adults. Most ankle sprains are inversion injuries to the lateral ankle ligaments, although high sprains representing damage to the tibiofibular syndesmosis are becoming increasingly recognized. Physicians should apply the Ottawa ankle rules to determine whether radiography is needed. According to the Ottawa criteria, radiography is indicated if there is pain in the malleolar or midfoot zone, and either bone tenderness over an area of potential fracture (i.e., lateral malleolus, medial malleolus, base of fifth metatarsal, or navicular bone) or an inability to bear weight for four steps immediately after the injury and in the emergency department or physician's office. Patients with ankle sprain should use cryotherapy for the first three to seven days to reduce pain and improve recovery time. Patients should wear a lace-up ankle support or an air stirrup brace combined with an elastic compression wrap to reduce swelling and pain, speed recovery, and protect the injured ligaments as they become more mobile. Early mobilization speeds healing and reduces pain more effectively than prolonged rest. Pain control options for patients with ankle sprain include nonsteroidal anti-inflammatory drugs, acetaminophen, and mild opioids. Because a previous ankle sprain is the greatest risk factor for an acute ankle sprain, recovering patients should be counseled on prevention strategies. Ankle braces and supports, ankle taping, a focused neuromuscular training program, and regular sport-specific warm-up exercises can protect against ankle injuries, and should be considered for patients returning to sports or other high-risk activities.

[Efficacy observation on rear thigh muscles strain of athletes treated with surrounding needling of electroacupuncture and hot compress of Chinese medicine]

OBJECTIVE

To verify the clinical efficacy on rear thigh muscles strain of athletes treated with surrounding needling of electroacupuncture and hot compress of Chinese medicine.

METHODS

Eighty-six cases were randomly divided into an observation group and a control group, 43 cases in each one. In the observation group, surrounding needling of electroacupuncture and hot compress of Chinese medicine were used at Ashi points around the local affected area of rear thigh muscles. In the control group, conventional needling method and local cupping were applied at Chengfu (BL 36), Yinmen (BL 37), Weizhong (BL 40), etc. The treatment was given once a day. Ten treatments made one session. Two sessions were required. The score of rear thigh muscles pain, swelling and tenderness, walking function recovery and the total score were compared before and after treatment between two groups. The efficacy was compared between two groups.

RESULTS

The score of pain, swelling and tenderness, walking function recovery and the total score were reduced obviously after treatmeat in two groups (all P < 0.01), and the improvements in the observation group were superior to those in the control group (P < 0.01, P < 0.05). The cured and remarkably effective rate was 83.7% (36/43) in the observation group, which was better than 60.5% (26/43) in the control group (P < 0.05).

CONCLUSION

The efficacy of the surrounding needling of electroacupuncture and the hot compress of Chinese medicine is significant on rear thigh muscles strain for the athletes, which is superior to that of the conventional needling method and cupping in terms of the improvements in the symptoms and physical signs as well as the recovery of the walking function.

[Case-control study on therapeutic effects between bone-setting and herbal fumigation for the treatment of the obsolete malleolus joint sprains]

OBJECTIVE

To compare the clinical effects of bone-setting technique and herbal fumigation for the treatment of the obsolete malleolus joint sprains.

METHODS

From March 2008 to May 2011, 76 patients were divided into treatment group (39 cases) and control group (37 cases). In the treatment group: 15 males and 24 females; the age ranged from 20 to 59 years with an average of (42.97 +/- 9.21) years; the course of disease ranged from 1 to 60 months; the average score of ankle joint function was (71.27 +/- 4.50). In the control group: 11 males and 26 females; the age ranged from 25 to 57 years with an average of (41.29 +/- 8.77) years; the course of disease ranged from 1 to 36 months with an average of (8.47 +/- 7.37) months; the average score of ankle joint function was (71.45 +/- 4.61). The patients in the treatment group were treated with bone-setting technique two times a week, and the patients in the control group were treated with herbal fumigation once a day. The ankle joint function scores and treatment effects of the two groups were compared after 3 weeks by using Baird-Jackson ankle function score.

RESULTS

After 3 weeks of the treatment, the average score of ankle joint function of the treatment group was (93.44 +/- 4.91), and in the control group was (85.8 +/- 16.57), the difference has statistical significance. The treatment group score was better than that of the control group. Before and after treatment,the average ankle score of the treatment group was (71.27 +/- 4.50) and (93.44 +/- 4.91), the difference has statistical significance. Before and after treatment, the average ankle score of the control group was (71.45 +/- 4.61) and (85.81 +/- 6.57), the difference has statistical significance. In the treatment group, 16 cases got an excellent result, 18 good, 3 fair, 2 poor; in the control group, 9 cases got an excellent result, 14 good, 5 fair,9 poor. The difference has statistical significance.

CONCLUSION

The bone-setting techniques and herbal fumigation treatment of obsolete malleolus joint sprains both have a certain effect, and the former is better than the latter.

Manipulative interventions for reducing pulled elbow in young children

BACKGROUND

Pulled elbow (nursemaid's elbow) is a common injury in young children. It results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial dislocation) of the radial head. The child experiences sudden acute pain and loss of function in the affected arm. Pulled elbow is usually treated by manual reduction of the subluxed radial head. Various manoeuvres can be applied. Most textbooks recommend supination of the forearm, as opposed to pronation and other approaches. It is unclear which manoeuvre is most successful. This is an update of a Cochrane review first published in 2009.

OBJECTIVES

The objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, LILACS, PEDro, clinical trial registers and reference lists of articles. Date of last search: July 2011.

SELECTION CRITERIA

Any randomised or quasi-randomised controlled clinical trials evaluating manipulative interventions for pulled elbow were included. Our primary outcome was failure at the first attempt, necessitating further treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data.

MAIN RESULTS

One trial with 66 children was newly included in this update. Overall, four trials with 379 children, all younger than seven years old, were included. All four trials compared pronation versus supination. One trial was at high risk of selection bias because allocation was not concealed and all four trials were at high risk of detection bias due to the lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (21/177 versus 47/181, risk ratio 0.45; 95% confidence interval 0.28 to 0.73). Pain perception was reported by two trials but data were unavailable for pooling. Both studies concluded that the pronation technique was less painful than the supination technique.

AUTHORS' CONCLUSIONS

There is limited evidence from four small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. We recommend that a high quality randomised trial be performed to strengthen the evidence.

Hamstring injuries

Hamstring injuries are a frequent injury in athletes. Proximal injuries are common, ranging from strain to complete tear. Strains are managed nonoperatively, with rest followed by progressive stretching and strengthening. Reinjury is a concern. High grade complete tears are better managed surgically, with reattachment to the injured tendon or ischial tuberosity. Distal hamstring injury is usually associated with other knee injuries, and isolated injury is rare.

[Clinical observation on warming-promotion acupuncture for lumbar muscle strain]

OBJECTIVE

To observe the theraputic effect of warming-promotion acupuncture for lumbar muscle strain.

METHODS

Sixty-four cases were randomly divided into a warming-promotion acupuncture group(group A) and a routine acupuncture group (group B), 32 cases in each group. The group A was treated with acupuncture at Shenshu (BL 23) and Guanyuanshu (BL 26) with warming-promotion acupuncture method, (Guanyuanshu (BL 26), Yaoyangguan (GV 3), Weizhong (BL 40) with twirling uniform reinforcing-reducing method. The group B was treated with acupuncture at same acupoints only with twirling uniform reinforcing-reducing method. After four-session treatment, the theraputic effect of two groups was compared.

RESULTS

The cured and markedly effective rate of 65.6% (21/32) in the group A, which was superior to that of 40.6% (13/32)in the group B (P < 0.05).

CONCLUSION

The efficiency on lumbar muscle strain treated with warming-promotion acupuncture is superior to that with routine acupuncture, means a suitable manipulation can enhance the therapeutic effect.

Therapeutic ultrasound for acute ankle sprains

BACKGROUND

Ultrasound is used in the treatment of a wide variety of musculoskeletal disorders, which include acute ankle sprains. This is an update of a Cochrane review first published in 1999, and previously updated in 2004.

OBJECTIVES

To evaluate the effects of ultrasound therapy in the treatment of acute ankle sprains.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (1966 to September 2010), EMBASE (1983 to September 2010), CINAHL (1982 to 2004), and PEDro - the Physiotherapy Evidence Database (accessed 01/06/09). We also searched the Cochrane Rehabilitation and Related Therapies Field database, reference lists of articles, and contacted colleagues.The WHO International Clinical Trials Registry Platform was searched for ongoing trials.

SELECTION CRITERIA

Randomised or quasi-randomised trials were included if the following conditions were met: at least one study group was treated with therapeutic ultrasound; participants had acute lateral ankle sprains; and outcome measures included general improvement, pain, swelling, functional disability, or range of motion.

DATA COLLECTION AND ANALYSIS

Two authors independently performed study selection, and assessed the risk of bias and extracted data. Risk ratios and risk differences together with 95% confidence intervals were calculated for dichotomous outcomes and mean differences together with 95% confidence intervals for continuous outcome measures. Limited pooling of data was undertaken where there was clinical homogeneity in terms of participants, treatments, outcomes, and follow-up time points.

MAIN RESULTS

Six trials were included, involving 606 participants. Five trials included comparisons of ultrasound therapy with sham ultrasound; and three trials included single comparisons of ultrasound with three other treatments. The assessment of risk of bias was hampered by poor reporting of trial methods and results. None of the five placebo-controlled trials (sham ultrasound) demonstrated statistically significant differences between true and sham ultrasound therapy for any outcome measure at one to four weeks of follow-up. The pooled risk ratio for general improvement at one week was 1.04 (random-effects model, 95% confidence interval 0.92 to 1.17) for active versus sham ultrasound. The differences between intervention groups were generally small, between zero and six per cent, for most dichotomous outcomes.

AUTHORS' CONCLUSIONS

The evidence from the five small placebo-controlled trials included in this review does not support the use of ultrasound in the treatment of acute ankle sprains. The potential treatment effects of ultrasound appear to be generally small and of probably of limited clinical importance, especially in the context of the usually short-term recovery period for these injuries. However, the available evidence is insufficient to rule out the possibility that there is an optimal dosage schedule for ultrasound therapy that may be of benefit.

The impact of adherence on sports injury prevention effect estimates in randomised controlled trials: looking beyond the CONSORT statement

OBJECTIVE

To investigate estimated outcome effects of a sports injury prevention intervention when analysed by means of a per protocol (PP) analysis approach.

DESIGN

Randomised controlled trial (RCT) involving 522 athletes who sustained a lateral ankle sprain allocated to either an intervention (received a preventive programme in addition to usual care) or control group who were followed prospectively for one year.

METHODS

Secondary analysis of data relating to registered ankle sprain recurrences, exposure and adherence to the allocated intervention using a PP analysis approach.

RESULTS

Twenty-three percent of the RCT intervention group indicated to have fully adhered with the neuromuscular training programme. A per protocol analysis only considering fully adherent athletes and control athletes, showed a Hazard Ratio of 0.18 (95% CI: 0.07-0.43). Significantly fewer recurrent ankle sprains were found in the fully adherent group compared to the group that was not adherent (relative risk = 0.63; 95% CI: 0.43-0.99).

CONCLUSIONS

A PP analysis on fully adherent athletes versus control group athletes showed that the established intervention effect was over threefold higher compared to an earlier intention-to-treat based analysis approach. This shows that outcomes of intervention studies are heavily biased by adherence to the allocated intervention.

[Treatment of musculoskeletal injuries in children and adolescents during the Bone and Joint Decade 2000-2010]

Treatment of musculoskeletal injuries in children and adolescents during the Bone and Joint Decade 2000-2010 has changed substantially. This is connected both with the increasingly accurate and rapid diagnostics, as well as the emergence of specialized centers. The experiences gained from various centers to help choose the best and most effective method of supplying injuries. To review a set of patterns of conduct in individual locomotor injuries in children and adolescents, from the scene by emergency departments, to establish guidelines for specialist units. A more radical approach to the treatment of fractures can be justified in getting faster and better function, greater comfort without use of plaster casts and a short stay in hospital, which is extremely important for young patients.

[Guideline for diagnosis and treatment of acute inversion trauma of the ankle in athletes]

This multidisciplinary guideline has been developed as an aid to diagnosis and treatment of patients, especially athletes, with an acute inversion trauma of the ankle. Diagnosis of an acute inversion trauma is by means of a combination of location of the swelling, palpation and executing an anterior drawer test. X-rays are only indicated if weight-bearing is not possible and palpation of specific areas according to the 'Ottawa ankle rules' causes pain. Physical diagnostic examination 4-5 days post-trauma is a reliable method for discriminating between ankle sprain and lateral ligament rupture.- Rest, application of ice, compression and elevation (RICE) during the first days post-trauma is recommended. Analgesic therapy, with paracetamol as medication of choice, should be restricted to 2-7 days post-trauma. Conservative treatment is preferential to surgical treatment. A semi-rigid brace protection should become a standard treatment procedure. Exercise therapy results in a faster recovery and a faster resumption of work and sporting activities. Exercises to improve proprioception, coordination and muscle strength are indicated.

Effectiveness of additional supervised exercises compared with conventional treatment alone in patients with acute lateral ankle sprains: systematic review

OBJECTIVE

To summarise the effectiveness of adding supervised exercises to conventional treatment compared with conventional treatment alone in patients with acute lateral ankle sprains.

DESIGN

Systematic review. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, Cinahl, and reference screening.

STUDY SELECTION

Included studies were randomised controlled trials, quasi-randomised controlled trials, or clinical trials. Patients were adolescents or adults with an acute lateral ankle sprain. The treatment options were conventional treatment alone or conventional treatment combined with supervised exercises. Two reviewers independently assessed the risk of bias, and one reviewer extracted data. Because of clinical heterogeneity we analysed the data using a best evidence synthesis. Follow-up was classified as short term (up to two weeks), intermediate (two weeks to three months), and long term (more than three months).

RESULTS

11 studies were included. There was limited to moderate evidence to suggest that the addition of supervised exercises to conventional treatment leads to faster and better recovery and a faster return to sport at short term follow-up than conventional treatment alone. In specific populations (athletes, soldiers, and patients with severe injuries) this evidence was restricted to a faster return to work and sport only. There was no strong evidence of effectiveness for any of the outcome measures. Most of the included studies had a high risk of bias, with few having adequate statistical power to detect clinically relevant differences.

CONCLUSION

Additional supervised exercises compared with conventional treatment alone have some benefit for recovery and return to sport in patients with ankle sprain, though the evidence is limited or moderate and many studies are subject to bias.

Platelet enriched plasma for acute muscle injury

Hamstring muscle strains are among the most common injuries in sport, but despite increasing research into the epidemiology, aetiology and management the rates of both injury and re-injury remain high. Typically, hamstring injury management is conservative, but recently the use of autologous platelet enriched plasma (PEP), has been proposed as a treatment tool which may optimise muscle regeneration and enhance clinical outcomes. Unfortunately however, there remains little scientific evidence for the clinical use of these techniques in muscle injuries. This report outlines the current clinical evidence for the use of PEP in muscle injuries. A case report of a patient with a grade II semi-membranosus muscle strain, injected with PEP while concurrently using platelet inhibitors will illustrate the clinical, radiological and theoretical challenges of this new technique. Further clinical research into the clinical utility of PEP in muscle injury is required and it is incumbent on Sports Physicians and researchers to address this research deficit, if PEP is to live up to its high public profile.

Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy

OBJECTIVES

Acute back and neck strains are very common. In addition to administering analgesics, these strains are often treated with either heat or cold packs. The objective of this study was to compare the analgesic efficacy of heat and cold in relieving pain from back and neck strains. The authors hypothesized that pain relief would not differ between hot and cold packs.

METHODS

This was a randomized, controlled trial conducted at a university-based emergency department (ED) with an annual census of 90,000 visits. ED patients >18 years old with acute back or neck strains were eligible for inclusion. All patients received 400 mg of ibuprofen orally and then were randomized to 30 minutes of heating pad or cold pack applied to the strained area. Outcomes of interest were pain severity before and after pack application on a validated 100-mm visual analog scale (VAS) from 0 (no pain) to 100 (worst pain), percentage of patients requiring rescue analgesia, subjective report of pain relief on a verbal rating scale (VRS), and future desire for similar packs. Outcomes were compared with t-tests and chi-square tests. A sample of 60 patients had 80% power to detect a 15-mm difference in pain scores.

RESULTS

Sixty patients were randomized to heat (n = 31) or cold (n = 29) therapy. Mean (+/-standard deviation [SD]) age was 37.8 (+/-14.7) years, 51.6% were female, and 66.7% were white. Groups were similar in baseline patient and pain characteristics. There were no differences between the heat and cold groups in the severity of pain before (75 mm [95% CI = 66 to 83] vs. 72 mm [95% CI = 65 to 78]; p = 0.56) or after (66 mm [95% CI = 57 to 75] vs. 64 mm [95% CI = 56 to 73]; p = 0.75) therapy. Pain was rated better or much better in 16/31 (51.6%) and 18/29 (62.1%) patients in the heat and cold groups, respectively (p = 0.27). There were no between-group differences in the desire for and administration of additional analgesia. Twenty-five of 31 (80.6%) patients in the heat group and 22 of 29 (75.9%) patients in the cold group would use the same therapy if injured in the future (p = 0.65).

CONCLUSIONS

The addition of a 30-minute topical application of a heating pad or cold pack to ibuprofen therapy for the treatment of acute neck or back strain results in a mild yet similar improvement in the pain severity. However, it is possible that pain relief is mainly the result of ibuprofen therapy. Choice of heat or cold therapy should be based on patient and practitioner preferences and availability.

New therapeutic approaches for management of sport-induced muscle strains

Muscle strains are one of the most common sports-induced injuries. Depending on the severity and location of the muscle strain, different treatment approaches can be taken. This review highlights recent trends in conservative, pharmacologic, and surgical approaches to the management of sports-induced muscle injuries as presented at a symposium held during the 93rd Annual Congress of the Italian Society of Orthopedics and Traumatology (SIOT) in Rome, Italy in November 2008. Conservative approaches now include growth factor therapy and administration of autologous platelet-rich plasma during the early postinjury period; however, its use is currently considered a doping violation under the World Anti-Doping Agency code, therefore restricting its use to nonelite sports people only. Topical anti-inflammatory therapy is a promising therapeutic strategy, since it allows local analgesic and anti-inflammatory effects while minimizing systemic adverse events. As the drug delivery system is critical to clinical effectiveness, the advent of a new delivery system for ketoprofen via a new-generation plaster with a marked increase in tissue penetration and a clinical efficacy comparable with that of oral administration, provides a viable option in the treatment of single sport lesions. Surgical treatment of muscle lesions is less common than conservative and topical therapies and indications are limited to more serious injuries. Presentations from SIOT 2008 show that advances in our understanding of the healing process and in conservative, pharmacologic, and surgical treatment approaches to the management of sports-induced muscle strains contribute to better clinical outcomes, faster healing, and a swifter return to normal training and activity levels.

[Clinical study of the infra-patellar fat pad strain treated by galvanism penetration of traditional Chinese medicine combined with ultrasonic wave and manipulation]

OBJECTIVE

To evaluate the therapeutic effects of galvanism penetration of traditional Chinese medicine combined with ultrasonic wave and manipulation in the treatment of strain of the infrapatellar fat pad, to study an effective approach in the treatment of this diseas.

METHODS

Eighty patients were divided randomly into treatment group and control group, there were 40 cases in each group. In treatment group 40 cases were treated by galvanism penetration of traditional Chinese medicine, ultrasonic wave and manipulation, included 22 males and 18 females with an average age of (63.15 +/- 8.10) years old and a mean disease course of (6.84 +/- 3.50) years. In control group, 40 cases were treated with ultrasonic wave and manipulation, included 23 males and 17 females with an average age of (62.63 +/- 8.20) years old and the course was (6.59 +/-3.70) years. visual analogue scale (VAS) and the scales for pain with finger press were evaluated before and after treatment in two groups. The clinical effects were researched and analysed statistically.

RESULTS

In treatment group,12 patients were in remarkable effects, 17 in good effective, 9 in effective and 2 in ineffective. As well in control group, above data were 8,15, 8 and 9 respectively. There was a significant difference in the rate of general effective between treatment group and control group (P < 0.05). In treatment group, the scales for VAS before and after treatment were (7.92 +/- 2.21) and (2.16 +/- 1.87) and the scales for pain with finger press before and after treatment were (3.01 +/- 0.63) and (0.86 <-- 0.46). As well in control group, above data were (7.71 +/2.65), (3.83 +/- 2.45), (2.98 +/- 0.61) and (1.32 +/- 0.52) respectively. The comparison of the scales for VAS and pain with finger press before and after treatment in two groups had significant difference (P < O.01).

CONCLUSION

Ultrasonic wave and manipulation have a good effect in the treatment of stain of the infrapatellar fat pad, when the galvanism penetration of traditional Chinese medicine is applied at the same time, the therapeutic efficiency can be improved significantly. Three therapies are used in treatment at the same, it can improve the therapeutic effect, and it is an easy, economic, practical and effective comprehensive approach.

Obturator internus strain in the hip of an adolescent athlete

A male 13-year-old presented with acute onset of right hip pain as he prepared to kick a soccer ball. A case of acute strain of the obturator internus is reported. The strain resolved completely after a period of activity modification and physical therapy.

Manipulative interventions for reducing pulled elbow in young children

BACKGROUND

Pulled elbow (nursemaid's elbow) is a common injury in young children. It results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial dislocation) of the radial head. The child experiences sudden acute pain and loss of function in the affected arm. Pulled elbow is usually treated by manual reduction of the subluxed radial head. Various manoeuvres can be applied. Most textbooks recommend supination of the forearm, as opposed to pronation and other approaches. It is unclear which manoeuvre is most successful.

OBJECTIVES

The objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, LILACS, PEDro, clinical trial registers and reference lists of articles. Date of last search: January 2009.

SELECTION CRITERIA

Any randomised or quasi-randomised controlled clinical trials evaluating manipulative interventions for pulled elbow were included. Our primary outcome was failure at the first attempt, necessitating further treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data.

MAIN RESULTS

Three trials with 313 participants, all younger than seven years old, were included. All three trials compared pronation versus supination. The methodological quality of all three trials was low because of incomplete reporting and high risk of bias resulting from lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (risk ratio 0.53, 95% confidence interval 0.32 to 0.87). Pain perception was reported by two trials but data were unavailable for pooling. Both studies concluded that the pronation technique was less painful than the supination technique.

AUTHORS' CONCLUSIONS

There is limited evidence from three small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. However, only a small difference in effectiveness was found. We recommend that a high quality randomised trial be performed to strengthen the evidence.

[Acute ankle sprain: which immobilization?]

Acute ankle sprain is the most frequent orthopaedic injury. Up to 4% of patients admitted to the emergency room will present with an acute ankle sprain. The lateral ligaments are involved at various degrees (anterior talo-fibular and calcaneo-fibular ligaments). Grade I acute ankle sprains are well treated with a compression bandage or an Aircast brace. Grade II and III acute ankle sprains are best treated with a below-knee cast. The Aircast brace is the next best treatment for such lesions (grades II and III) and will provide satisfactory support, but has been shown to be not as effective as the below-knee cast in terms of short to mid-term patients outcome (pain and function).

[Observation on therapeutic effect of bee needle therapy on chronic lumbar muscle strain]

OBJECTIVE

To explore a new method for treatment of chronic lumbar muscle strain.

METHODS

One hundred and fifty cases were randomly divided into 2 groups, an observation group of 78 cases and a control group of 72 cases. The observation group was treated with bee-needle therapy, with Jiaji (EX-B 2) on the loin and Shenshu (BL 23), Zhishi (BL 47), Ciliao (BL 32), Weizhong (BL 40), Ashi points selected as main; and the control group was treated with routine acupuncture at the same points as those in the observation group, in combination with fire-cupping or warm needle moxibustion. They were treated once daily, 10 sessions constituting one course. After 3 courses and a half year later, therapeutic effects were observed and followed up.

RESULTS

In the observation group, 49 cases were cured, 27 improved, 2 ineffective, with a cured rate of 62.8%, and in the control group, the corresponding figures were 29, 40, 3 and 40.3%, with a significant difference between the two groups in the cured rate (P < 0.01).

CONCLUSION

The therapeutic effect of the bee-needle therapy on chronic lumbar muscle strain is better than that of the routine acupuncture, which provides a better method for treatment of chronic lumbar muscle strain.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

INTERPRETATION

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.

FUNDING

National Co-ordinating Centre for Health Technology Assessment.