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Primary care physicians are often the first to evaluate patients with extremity injuries. Identification of fractures and sprains and their proper management is paramount. After appropriate imaging is obtained, immobilization and determination of definitive management, either nonoperative or operative, is critical. Appropriate immobilization is imperative to injury healing. Nonsurgical management of upper extremity fractures often uses slings, short-term splinting, gutter splints, and/or short or long arm casts. Initial fracture stabilization of the lower extremity is usually accomplished with a posterior splint. Definitive management usually uses controlled ankle movement walker boots, hard-sole shoes, or casting., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Ankle sprains are frequently encountered. They result most of the time in lesions of the lateral ligament complex. Nevertheless, in the context of an ankle sprains, more severe injuries including fracture of the lateral process of the talus, fracture of the base of the 5th metatarsal, tear of the medial ligament complex, lesion of the syndesmosis, sprain of the Chopart joint, and peroneal tendons luxation are potentially overlooked and, if treated inadequately, may be associated with poor functional outcome. The goal of the present paper is to make the emergency practitioner aware of these potential lesions, and to help him making the correct diagnosis in order to initiate the adequate treatment., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Introduction: We describe a new service model, the Orthopaedic Assessment Unit (OAU), designed to provide care for trauma patients during the COVID-19 pandemic. Patients without COVID-19 symptoms and isolated musculoskeletal injuries were redirected to the OAU., Methods: We prospectively reviewed patients throughput during the peak of the global pandemic (7 May 2020 to 7 June 2020) and compared with our historic service provision (7 May 2019 to 7 June 2019). The Mann-Whitney and Fisher Exact tests were used to test the statistical significance of data., Results: A total of 1,147 patients were seen, with peak attendances between 11am and 2pm; 96% of all referrals were seen within 4h. The majority of patients were seen by orthopaedic registrars (52%) and nurse practitioners (44%). The majority of patients suffered from sprains and strains (39%), followed by fractures (22%) and wounds (20%); 73% of patients were discharged on the same day, 15% given follow up, 8% underwent surgery and 3% were admitted but did not undergo surgery. Our volume of trauma admissions and theatre cases decreased by 22% and 17%, respectively ( p =0.058; 0.139). There was a significant reduction of virtual fracture clinic referrals after reconfiguration of services ( p <0.001)., Conclusions: Rapid implementation of a specialist OAU during a pandemic can provide early definitive trauma care while exceeding national waiting time standards. The fall in trauma attendances was lower than anticipated. The retention of orthopaedic staff in the department to staff the unit and maintain a high standard of care is imperative.

Ankle injuries are a common reason for presentation to the pediatric emergency department. An understanding of the anatomy of the ankle joint, the mechanism of injury, and a thorough history and physical examination can help narrow the differential diagnosis. This article will discuss the management of common ankle injuries, including ankle sprains, dislocations, and pediatric fractures, including transitional triplane and Tillaux fractures. A brief review of the literature regarding radiographic evaluation of the ankle and various ankle rules is also discussed.

Platelet-rich plasma (PRP) is a promising treatment for musculoskeletal maladies and clinical data to date have shown that PRP is safe. However, evidence of its efficacy has been mixed and highly variable depending on the specific indication. Additional future high-quality large clinical trials will be critical in shaping our perspective of this treatment option. The heterogeneity of PRP preparations, both presently and historically, leads sweeping recommendations about its utility impossible to make. This heterogeneity has also made interpreting existing literature more complicated., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To investigate the characteristics of hoverboard injuries compared with skateboard injuries in children presenting to US emergency departments (EDs)., Methods: Data regarding hoverboard and skateboard injuries in children <18 years of age were obtained from the National Electronic Injury Surveillance System for calendar years 2015 and 2016. Data included demographics, body regions injured, and ED disposition., Results: There were an estimated 26 854 hoverboard and 121 398 skateboard injuries treated in US EDs between 2015 and 2016. The mean and median ages for hoverboard and skateboard injuries were 11 and 13 years, respectively. In both groups, boys were more commonly injured. The majority of hoverboard injuries occurred at home, whereas skateboard injuries occurred on the street. The wrists were the most common injured body part, and fractures were the most common diagnosis in both groups. The majority of patients in both groups were discharged from the hospital. Approximately 3% of the patients with skateboard injuries and hoverboard injuries were admitted to the hospital., Conclusions: The distribution of injuries among hoverboard riders and skateboarders was similar. Fractures, contusions, and sprains and/or strains were the most common types of injuries in both riders. However, there was a higher number of sprains and/or strains in skateboarders when compared with hoverboard users. This difference may be attributed to the way users ride these boards. Fractures were the most common reason for hospital admission for both toys. By elucidating the characteristics of hoverboard injuries, preventive measures can be implemented to decrease the incidence of these injuries as well as ED visits., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Importance: Lateral ankle injuries without radiographic evidence of a fracture are a common pediatric injury. These children are often presumed to have a Salter-Harris type I fracture of the distal fibula (SH1DF) and managed with immobilization and orthopedic follow-up. However, previous small studies suggest that these injuries may represent ankle sprains rather than growth plate fractures., Objectives: To determine the frequency of SH1DF using magnetic resonance imaging (MRI) and compare the functional recovery of children with fractures identified by MRI vs those with isolated ligament injuries., Design, Setting, and Participants: A prospective cohort study was conducted between September 2012 and August 2014 at 2 tertiary care pediatric emergency departments. We screened 271 skeletally immature children aged 5 to 12 years with a clinically suspected SH1DF; 170 were eligible and 140 consented to participate., Interventions: Children underwent MRI of both ankles within 1 week of injury. Children were managed with a removable brace and allowed to return to activities as tolerated., Main Outcomes and Measures: The proportion with MRI-confirmed SH1DF. A secondary outcome included the Activity Scale for Kids score at 1 month., Results: Of the 135 children who underwent ankle MRI, 4 (3.0%; 95% CI, 0.1%-5.9%) demonstrated MRI-confirmed SH1DF, and 2 of these were partial growth plate injuries. Also, 108 children (80.0%) had ligament injuries and 27 (22.0%) had isolated bone contusions. Of the 108 ligament injuries, 73 (67.6%) were intermediate to high-grade injuries, 38 of which were associated with radiographically occult fibular avulsion fractures. At 1 month, the mean (SD) Activity Scale for Kids score of children with MRI-detected fibular fractures (82.0% [17.2%]) was not significantly different from those without fractures (85.8% [12.5%]) (mean difference, -3.8%; 95% CI, -1.7% to 9.2%)., Conclusions and Relevance: Salter-Harris I fractures of the distal fibula are rare in children with radiograph fracture-negative lateral ankle injuries. These children most commonly have ligament injuries (sprains), sometimes associated with radiographically occult avulsion fractures. Children with fractures detectable only by MRI had a comparable recovery with those with sprains when treated with a removable ankle brace and self-regulated return to activities. This work has the potential to simplify the care of these common injuries, safely minimizing the inconveniences and costs of overtreatment.

Background: Increasing pressure on the emergency department (ED) throughout the world has meant the introduction of innovative ways of working. One such innovation is the advanced practice physical therapist (APP) acting as a primary contact practitioner. There has been little research into the role beyond identifying patient satisfaction with management, cost-effectiveness, and time efficiency. In order to give further support and assist in development of an APP service in the ED, an increased exploration of patient caseload demographics, resource utilization, and management outcomes is needed., Objectives: The purpose of this study was to provide quantitative data regarding patient demographics, time efficiency, resource utilization, and management outcomes to examine the APP role in the ED., Design: This was a prospective observational study of practice., Setting: The study was conducted in a single ED in Melbourne, Australia., Method: Data collection was conducted over a 6-month period. Patient demographics and diagnoses, assessment times, hospital resource utilization, and discharge destinations were recorded., Results: One thousand seventeen patients (45% female; median age=34 years, interquartile range=25-52) were managed by the APPs; 89% had conditions triaged as not serious or life threatening, and 97% had musculoskeletal pathologies, with the most common diagnosis being fracture or dislocation. Four-hour length-of-stay targets were met in 95% of the patients. Forty-six percent of the patients seen were managed independently, without any support from medical colleagues. The most frequent discharge destination was a referral back to the primary care physician or to hospital outpatient clinics. When comparing similar diagnostic groups, the APPs were significantly more time-efficient than ED physicians in their patient management., Conclusions: This study described in detail the caseload managed by the APP in the ED and identified the role as a valuable asset to an ED, managing a great deal of their caseload independently, safely, and time efficiently., (© 2015 American Physical Therapy Association.)

Ankle sprains are a common musculoskeletal injury in sport. Older people are increasingly participating in sports such as running. The specificities of musculoskeletal injuries in older people pose a different diagnostic challenge from that in young people participating in the same activities. A clinical case is presented of a 64-year-old patient diagnosed with a grade 1, plantar flexion/inversion ankle sprain that was later diagnosed as a quite different and rare injury. Fractures of the fibular malleolus, talar neck and dome are possible differential diagnoses for an ankle sprain, as are talar dome chondral defects. Response to treatment may help to guide the diagnostic procedure when pain persists after appropriate treatment., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Posterior injuries to the sternoclavicular (SC) joint are uncommon. In the skeletally immature (SI) population, these injuries have been described as either dislocations of the SC joint or fractures of the medial clavicular physis. The current literature and standardized test questions state that a posterior SC injury, in a SI patient, is more likely a physeal fracture than a SC joint dislocation. However, this injury characterization is based on case reports or small case series. The purpose of this study is to characterize posterior SC injuries in SI patients in terms of the prevalence of dislocation versus medial clavicle physeal fracture., Methods: A retrospective review was performed of 48 SI patients treated for posterior SC joint injuries over a 20-year period with a mean age of 15.4 years (range, 13 to 18 y). Forty patients underwent open reduction and internal fixation as their definitive treatment and 8 patients were treated exclusively with closed reduction. Patients treated operatively were utilized in determining the prevalence of SC joint dislocation versus physeal fracture., Results: All patients treated operatively underwent primary repair without reconstruction. Twenty (50%), of the 40 patients treated operatively had a true SC joint dislocation and 20 patients (50%) had a medial clavicle physeal fracture. Twenty-two (46%) of the 48 total patients had an attempted closed reduction of which only 8 (36%) were successful. Among the 14 unsuccessful closed reductions, 12 (86%) were true dislocations (P<0.001). All successful closed reductions occurred in patients within 24 hours from injury. Eleven of the 48 (23%) patients' injuries were missed on initial presentation., Conclusions: Posterior SC joint dislocation and medial clavicular physeal fracture both occur with roughly equivalent prevalence in patients with an open medial physis. An attempted closed reduction may be more successful if performed within 24 hours after injury. Patients who fail attempts at closed reduction are more likely to have a posterior SC joint dislocation than a physeal fracture. Posterior SC joint injury may be missed in nearly 25% of patients on initial presentation., Level of Evidence: Level IV-retrospective case series.

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.

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.

Background: Avulsion fractures of the lateral malleoli in ankle inversion injuries are often undetected on routine radiographs. Undetected avulsion fractures have been managed as ankle sprain, which may affect the outcome of the treatment of the ankle sprain. The purposes of this study are to compare the outcomes of functional treatment between the first-time severe ligament injury and avulsion fracture of the lateral ankle, and to investigate how the anterior talofibular ligament (ATFL) view or the calcaneofibular ligament (CFL) view affects the diagnosis of the avulsion fracture and outcome of functional treatment of the ankle inversion injury., Methods: A total of 276 consecutive patients with a first-time severe ankle inversion injury were classified into a ligament injury group (group I) or an avulsion fracture group (group II) on the basis of physical examination and radiographs. The patients with a negative finding on routine radiographs and a positive finding on the ATFL or CFL view derived from group II (group IIA). Age, sex, and activity level were analyzed. Patients were treated by stirrup splint., Results: A total of 202 (73.2%) patients were in group I and 74 (26.8%) were in group II. In all, 50 patients in group II showed negative standard radiographs and a positive ATFL or CFL view. Altogether, 240 patients were followed up for at least 1 year and assessed clinically and radiographically. Differences in age, sex, and activity level before injury between groups were not statistically significant. Clinical and radiographic results of group II were inferior to those of group I. The outcome of group IIA was comparable to that of group I., Conclusions: The outcome of functional treatment of avulsion fracture was inferior to that of ligament injury. The ATFL and CFL views provide a more precise diagnosis but do not affect the outcome of the functional treatment.

The orthopaedic nurse will undoubtedly care for patients with ankle injuries. Ankle sprains and fractures are common injuries seen in orthopaedic practices in the United States. To provide comprehensive nursing care of these injuries, nurses should understand ankle biomechanics as well as anatomy. Knowledge of fracture classification schemes, pathology of injury, and treatment modalities is also important. Fracture classification schemes vary as do treatment modalities. Ankle sprains and fractures can be treated operatively or nonoperatively, and orthopaedic nurses play an important role in the care of patients with such ankle injuries.

Injuries of the tarsometatarsal, or Lisfranc, joint are rarely seen. Lisfranc fractures and fracture dislocations are among the most frequently misdiagnosed foot injuries in the emergency department. A misdiagnosed injury may have severe consequences including chronic pain and loss of foot biomechanics. Evaluation of a foot injury should include a high level of suspicion of a Lisfranc injury, and a thorough work-up is needed for correct diagnosis.

The first ray differs from the other rays in its position and its importance with weight bearing. Because it is a critical structure in the formation of the tripod of the foot, injuries to this ray can cause critical alterations in the biomechanics of the foot. This allows for pathologic weight-bearing points of contact and deformity that lead to a disabling gait. Physicians who are involved in the care of the foot and ankle should be familiar with the spectrum of injuries that concern the first ray. These injuries, their management, and sequelae are reviewed.

Fractures in children are common, but the plasticity of children's bones means that they may be incomplete. If a child has deformity, swelling or bony point tenderness in a limb after a fall, it is likely to be fractured. A fractured limb that appears deformed will most probably need to be reduced. Effective splinting, using whatever means is readily available, and early, adequate analgesia, can ameliorate the severe pain associated with a fracture. In young children with open growth plates, Salter-Harris type I injuries of the distal fibula are more common than ligament injuries of the ankle. After an ankle ligament injury, functional treatment--brace or tapes, with active physiotherapy--results in a better outcome than immobilisation. A child with a head injury, who does not lose consciousness, has only one or no episodes of vomiting, and is stable, alert and interactive, and neurologically normal, is extremely unlikely to have sustained an intracranial injury.

This study was designed to determine the efficacy of waterproof cast-lining materials in children with short-arm, long-arm, and short-leg casts. Eligible patients had healing fractures 2 weeks after reduction, stable fractures requiring no reduction, or sprains. A total of 165 waterproof-lined casts were applied and 124 children and parents completed a survey (76.9%) upon cast removal. Results revealed 79% very satisfied, 21% satisfied, and 0% dissatisfied. There were 16 (12.9%) minor skin integrity issues. Waterproof casts in stable fractures and sprains allow acceptable immobilization with no significant associated unusual risk and allow children to resume their usual recreational water activities and hygiene regimen without risk of adverse results.

As one of the most commonly injured areas in the immature athlete, the foot and ankle has many disorders. Knowledge of congenital and developmental abnormalities and possible injury patterns enables the clinician to correctly diagnose these disorders. Physical examination and appropriate use of imaging technology provide confirmation of the initial impression. As children and adolescents participate in sports with greater intensity, there is a higher incidence of overuse injuries that may have long-term implications.

Purpose: The understanding of the os subfibulare in childhood., Material and Methods: A retrospective study of radiographs following for indirect ankle injury in childhood over a period of two years., Results: The daily use of an oblique view during the exploration of ankle sprains in emergency has allowed us to image 12 small and linear chiplike fractures of the fibula by avulsion of the antero-medial part of the malleolar's tip where the talo-fibular collateral ligament is attached. Two children were reviewed one year after for a recurrent sprain: a larger and rounder fragment of bone has taken the place of the first piece of bone., Conclusion: Symptomatic ossicles of the lateral malleolus in children is frequently if not always the consequence of an avulsion of the tip of the fibula. The outcome of these children may be a localised tenderness and recurrent episodes of sprains for minimal injury due to the weakness of the lateral ligament.

This report describes five male rodeo bull riders, aged 18 to 32 years, who sustained syndesmotic ankle injuries during competition. The mechanism of injury was identical in each case. As the rider attempted to escape after being thrown, the bull stepped on his lateral ankle, resulting in forced external rotation. All patients delayed seeking medical care, the interval between the injury and presentation ranging from 2 days to 4 weeks. All five patients sustained significant syndesmotic tears, two with associated fibular fractures. Three patients underwent surgical stabilization, and all riders returned to competitive rodeo events, often prior to medical clearance. To the authors' knowledge, this is the first reported association between injuries caused by livestock stepping and syndesmotic disruptions.

Lisfranc injuries still remain a problematic situation in many clinical cases. Although thought to be an uncommon problem, they are actually a common injury. This article serves to make the clinician aware of the many recent changes in diagnosis and treatment. Emphasis is placed on the precise diagnosis of this condition and subsequent follow-up.

The ankle is often a neglected joint by the athlete because of an inadequate understanding of the injury. Sprains and fractures are common injuries in the athlete because of the force of impact on the ankle during activity. Appropriate management of ankle injuries promotes healing and prompt return to sports activities.

Many PIP joint injuries which appear to be innocuous are actually very severe injuries to this small hinged joint and carry a high percentage of disability for the hand as well as the individual digit. A flexion contracture of the PIP joint of one digit may significantly reduce the functional capacity of the entire hand. To prevent such physical impairment, the type of PIP joint injury must be defined and the proper treatment for the particular injury must be initiated. Second, it is paramount that prolonged immobilization of this joint be prevented. It has been found, through clinical experience and experimental projects, that the early healing process is complete by 3 weeks and active motion may then be initiated without any detrimental effects. Extensor and flexor contractures of this joint are apt to occur in digits which have been immobilized for significantly longer than 3 weeks. Finally, the well-publicized "position of function" for the hand is not necessarily the ideal position for the rehabilitation of the hand. The "intrinsic plus position" is the position of choice for immobilization of the MP and PIP joints to prevent contractures. This concept has been confirmed by our clinical experience and the biomechanical studies performed in the laboratory.

In a prospective study, 38 patients with so-called "wrist sprains" and a clinical nonradiological diagnosis of scaphoid fracture were immobilized in a plaster cast for 2 weeks. At 2 weeks, six patients were found to have a complete fracture of the scaphoid through the waist. In view of this high incidence (15.8%) of occult scaphoid fracture, it is once again suggested that all cases of wrist sprains where scaphoid fracture is suspected be immobilized for a 2-week period.

Six athletic injuries commonly misdiagnosed as a sprained finger are three types of closed tendon injuries, two types of intra-articular fractures involving the middle joint and a volar plate avulsion of the middle joint. The proper diagnosis can usually be made with a good history, a thorough examination and anteroposterior, lateral and oblique x-rays of the finger. Reconstructive procedures can be performed for missed injuries, but the results are inferior to those obtained with early treatment.

Injuries involving the midtarsal joint, which are frequently misdiagnosed, have been studied to clarify the mechanism, classification and treatment. The necessity for routine antero-posterior, lateral and oblique radiographs is emphasised. Seventy-one injuries have been classified according to the direction of the deforming force:medial, longitudinal compression, lateral, plantar and crush types are described. Included in the medial and lateral types is a hitherto undescribed tarsal rotation or "swivel" injury. The mechanism whereby longitudinal compression causes fractures of the body of the navicular is described, and two varieties having different prognoses are defined: one due to purely longitudinal compression and the other due to longitudinal compression with a medial component. The results of treatment have been assessed clinically and radiologically. Reduction, open if necessary, with internal fixation, is recommended for displace fractures: primary arthrodesis is not indicated. For severe persistent symptoms from medial and longitudinal force injuries triple arthrodesis is recommended, and from lateral force injuries, calcaneo-cuboid arthrodesis.

The following case is presented as one of unusual foot and leg lesions encountered in an adolescent long-distance runner. The associated problems of a first metatarsal Salter Harris type II epiphyseal stress fracture, and an accessory calf muscle with "shin splints" in the contralateral leg are discussed. Treatment of these conditions is outlined with eventual return to full function by the athlete.

A 40-year-old woman with a history of injury to the left foot was initially treated for an ankle sprain. When the initial roentgenograms were reassessed, os peroneum fracture with diastasis was diagnosed. This may be the second case of fracture of the uncommon anomaly to be reported in the literature. A fracture of the os peroneum may be confused with ankle sprain. Only careful examination of serial roentgenograms may avoid an incorrect diagnosis and further complications.

Injuries to the clavicle and articulations have been reviewed. Attention has been drawn to the more common symptoms, signs, and treatment associated with these injuries.

Everyone knows that some fractures in children have a great capacity for remodeling and require minimal care. Likewise, everyone knows that some growth-plate injuries have great potential for disaster. The skill comes in knowing which is which.

Both plaster of Paris and fiberglass can be used for temporary or definitive treatment of acute extremity fractures, sprains, and strains. Longitudinal slab splints are appropriate for immobilizing inflamed tendons or joints of the wrist, elbow, and knee. "Sugar-tong" splints work well for humerus, forearm, and ankle fractures or sprains.