Diagnosis of tendinitis and bursitis begins with a medical history and physical examination. X-rays do not show tendons or the bursae but may be helpful in ruling out bony abnormalities or arthritis. The doctor may remove and test fluid from the inflamed area to rule out infection.
 Ultrasound scans  are frequently used to confirm a suspected tendinitis or bursitis as well as rule out a tear in the rotator cuff muscles.
Impingement syndrome may be confirmed when injection of a small amount of anesthetic (lidocaine hydrochloride) into the space under the acromion relieves pain. [ citation needed ]


Anti-inflammatory medicines such as  aspirin ,  naproxen  or  ibuprofen  among others can be taken to help with pain. In some cases the physical therapist will use  ultrasound  and electrical stimulation, as well as manipulation. Gentle stretching and strengthening  exercises  are added gradually. If there is no improvement, the doctor may inject a  corticosteroid  medicine into the space under the acromion. However, recent  level one evidence  showed limited efficacy of corticosteroid injections for pain relief. [ 17 ]  While steroid injections are a common treatment, they must be used with caution because they may lead to tendon rupture. If there is still no improvement after six to 12 months, the doctor may perform either arthroscopic or open surgery to repair damage and relieve pressure on the tendons and bursae. [ citation needed ]


In those with  calcific tendinitis  of the shoulder high energy  extracorporeal shock-wave therapy  can be useful. [ 18 ]  It is not useful in other types of tendonitis. [ 18 ]  For a rotator cuff tear, tentative evidence suggests exercise may reduce pain in the short-term. [ 19 ]  Combination of exercise and joint mobilization can result in long term benefits. [ 19 ]  Other evidence demonstrates the use of corticosteroids injections to be more effective. [ 19 ]


A SLAP (superior labrum anterior to posterior) tear occurs when the cartilage of the shoulder (labrum) delaminates from glenoid. This causes an instability of the shoulder, typically in overhead movements. [ citation needed ]


Symptoms include a dull ache deep in the shoulder joint, trouble sleeping due to the instability and discomfort, and extreme weakness in overhead activities. [ citation needed ]


The best diagnosis for a SLAP tear is a clinical exam
followed by an MRI combined with a contrast agent. [ citation needed ]


Very few cases recover to complete mobility without surgical intervention. Some patients are able to strengthen their shoulders to limit the day to day dull ache, but with limited mobility and function. Surgery reattaches the labrum to the glenoid through the use of surgical anchors. [ citation needed ]


Recovery is often a lengthy process. The first four or so weeks the patient is required to wear a sling. Following this, there is a month of physical therapy to regain range of motion. At two months limited strength training occurs. At six months the patient is typically released to full active use, although many patients find that full recovery takes longer than this. [ citation needed ]


As the name implies, movement of the shoulder is severely restricted in people with a " frozen shoulder ". This condition, which doctors call  adhesive capsulitis , is frequently caused by injury that leads to lack of use due to  pain . Rheumatic disease progression and recent shoulder surgery can also cause frozen shoulder. Intermittent periods of use may cause inflammation. Adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a lack of  synovial fluid , which normally lubricates the gap between the arm bone and socket to help the shoulder joint move. It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have been in an accident, are at a higher risk for frozen shoulder. The condition rarely appears in people under the age of 40. [ citation needed ]


A  bone fracture  of the shoulder involves a partial or total crack through one of the three bones in the shoulder, the  clavicle , the  scapula , and the  humerus . The break in a bone usually occurs as a result of an impact injury, such as a fall or blow to the shoulder. Fractures usually involve the  clavicle  or the neck (area below the ball) of the humerus. Fractures of the scapula sometimes occur through the  coracoid process . [ citation needed ]


A shoulder fracture that occurs after a major injury is usually accompanied by severe pain. Within a short time, there may be redness and bruising around the area. Sometimes a fracture is obvious because the bones appear out of position.
(However this occur in non-involved dislocations and separations.) Both diagnosis and severity can be confirmed by X-rays. [ citation needed ]


When a fracture occurs, the doctor tries to bring the bones into a position that will promote healing and restore arm movement. If the clavicle is fractured, the patient must at first wear a strap and sling around the chest to keep the clavicle in place. After removing the strap and sling, the doctor will prescribe exercises to strengthen the shoulder and restore movement. Surgery is occasionally needed for certain clavicle fractures, especially for disunions. [ citation needed ]


Fracture of the neck of the humerus is usually treated with a sling or shoulder immobilizer. If the bones are out of position, surgery may be necessary to reset them. Exercises are also part of restoring shoulder strength and motion. [ citation needed ]


In arthritis of the shoulder, the cartilage of the ball and socket (glenohumeral joint) is lost so that bone rubs on bone.
It may be caused by wear and tear (degenerative joint disease), injury (traumatic arthritis), surgery (secondary degenerative joint disease), inflammation (rheumatoid arthritis) or infection (septic arthritis). [ citation needed ]


Arthritis of the shoulder causes pain and loss of motion and use of the shoulder. X-rays of the shoulder show loss of the normal space between the ball and socket. X-ray can provide  radiographic staging of shoulder osteoarthritis . [ citation needed ]


Early on arthritis of the shoulder can be managed with mild analgesics and gentle exercises. [ 20 ]  Known gentle exercises include warm water therapy pool exercises that are provided by a trained and licensed physical therapist; approved land exercises to assure free movement of the arthritic area; cortisone injections (administered at the minimum of every six months according to orthopedic physicians) to reduce inflammation; ice and hot moist pact application are very effective. Moist heat is preferred over ice whereas ice is preferred if inflammation occurs during the daytime hours.  Local analgesics along with ice or moist heat are adequate treatments for acute pain. [ citation needed ]


In the case of rheumatoid arthritis, specific medications selected by a rheumatologist may offer substantial relief. [ citation needed ]


When exercise and medication are no longer effective, shoulder replacement surgery for arthritis may be considered.  In this operation, a surgeon replaces the shoulder joint with an artificial ball for the top of the humerus and a cap (glenoid) for the scapula. Passive shoulder exercises (where someone else moves the arm to rotate the shoulder joint) are started soon after surgery. Patients begin exercising on their own about three to six weeks after surgery. Eventually, stretching and strengthening exercises become a major part of the rehabilitation programme. The success of the operation often depends on the condition of rotator cuff muscles prior to surgery and the degree to which the patient follows the exercise programme. [ citation needed ]


In young and active patients a partial shoulder replacement with a non-prosthetic glenoid arthroplasty may also be a consideration


The  acromioclavicular articulation  consists of the  acromioclavicular ligament  and a small disk of cartilage located in between the acromion and the clavicle.  This disk can wear down through  injury , extreme joint stress (via  bodybuilding ) or normal wear. [ citation needed ]


Pain is perceived on shoulder motion, especially on certain movements.  Often a crossover arm test is utilized in diagnosis because this compresses the AC joint, exacerbating the symptoms.  X-rays of the shoulder joint may show either  arthritic changes  of the ac joint or  osteolysis .


Conservative treatment for this joint is similar to treatments for other types of arthritis, including restricting activity, anti-inflammatory medications (or supplements), physical therapy, and occasionally cortisone shots.  If the pain is severe, surgery may be an option.  The most common surgical treatment, known as resection arthroplasty, involves cutting a very small portion off the clavicle end and letting scar tissue fill in its place. Some portions of the acromioclavicular ligament may still remain attached. [ citation needed ]


A  mnemonic  for the basic treatment principles of any musculoskeletal problems is  PRICE :  P rotection,  R est,  I ce,  C ompression, and  E levation: [ citation needed ]


If pain and stiffness persist, see a  doctor .


According to the American Academy of Orthopaedic Surgeons (AAOS) visits to orthopedic specialists  for shoulder pain has been rising since 1998 and in 2005 over 13 million patients sought medical care for shoulder pain, of which only 34 percent were related to injury. [ 21 ]


This article contains and extends text from the public domain document "Questions and Answers about Shoulder Problems", NIH Publication No. 01-4865, available from URL  http://www.niams.nih.gov/hi/topics/shoulderprobs/shoulderqa.htm


Spondylitis  is an inflammation of the  vertebrae . It is a form of  spondylopathy . In many cases, spondylitis involves one or more  vertebral joints , as well, which itself is called  spondylarthritis .


Pott disease  is a tuberculous disease of the vertebrae marked by stiffness of the  vertebral column , pain on motion, tenderness on pressure, prominence of certain vertebral spines, and occasionally abdominal pain, abscess formation, and paralysis.


Ankylosing spondylitis  (AS) is a form of arthritis that primarily affects the spine, although other joints can become involved. It causes inflammation of the spinal joints (vertebrae) that can lead to severe, chronic pain and discomfort. In more advanced cases this inflammation can lead to ankylosis—new bone formation in the spine causing sections of the spine to fuse in a fixed, immobile position.


A combination of spondylitis and inflammation of the  intervertebral disc space  is termed a  spondylodiscitis .


Subtalar arthroereisis  is a common treatment for symptomatic  pes planus , also known as flatfoot. There are two forms of pes planus: rigid flatfoot (RFF) and flexible flatfoot (FFF). The symptoms of the former typically necessitate surgical intervention. [ 1 ]  The latter may manifest  fatigue  or pain, but is typically asymptomatic. [ 1 ]


Subtalar arthroereisis is considered as the last resort for treating FFF in cases when conservative measures fail. [ 2 ]  This is accomplished by putting an implant into the  sinus tarsi  to prevent excessive eversion of the  subtalar joint  and improve talus alignment relative to the  calcaneus  and  navicular . This treatment is considered minimally invasive and joint sparing. [ 3 ]


Complications associated with subtalar arthroereisis include undercorrection (due to the use of undersized implants),  sinus tarsi  pain, and implant extrusion. Less common complications include overcorrection caused by oversized implants,  synovitis , infection, and peroneal  spasm .  Nerve injury  can also occur as a complication but can be avoided with careful procedural execution.


Subtalar arthroereisis allows for the removal of the implant in case of postoperative complications while still maintaining the correction achieved for flat feet. The surgery also allows patients to bear weight right after the treatment.


Subtalar arthroereisis is primarily used for the treatment of flexible  pes planus , a condition characterized by the loss of the  medial longitudinal arch , abduction of the forefoot, and excessive subtalar eversion. [ 4 ]  This surgical procedure is specifically designed to address the biomechanical abnormalities associated with flexible flatfoot. [ 4 ]


When conservative measures such as  physiotherapy ,  orthotics , and anti-inflammatory medications fail to provide sufficient relief, subtalar arthroereisis becomes a valuable option. [ 5 ]  It is particularly indicated for patients who experience persistent pain and functional limitations despite non-surgical interventions. [ 5 ]


The main purpose of subtalar arthroereisis is to correct the excessive subtalar eversion and restore the subtalar joint to a more neutral position. [ 5 ] [ 6 ]  This is achieved by inserting an implant, typically made of materials such as silicone or polyethylene, into the  sinus tarsi  or adjacent to it. The implant serves to provide stability and support to the subtalar joint, helping to improve foot alignment and function. [ 4 ]


Subtalar arthroereisis can alleviate pain, enhance foot functionality, and improve overall quality of life for individuals with flexible pes planus. [ 5 ]


The clinical significance of subtalar arthroereisis can be shown by different measurements and physical conditions. Such as radiological measurements, kinematic measurements, and soreness, function, and alignment.


The radiological assessments have exhibited notable enhancements, converging towards the anticipated normal range. Following the surgical procedure, there have been significant improvements observed in several key measurements, including the post-operative  anteroposterior (AP)  Talar calcaneal angle, which is also known as the kite angle, refers to the angle between lines drawn down the axis of the  talus  and  calcaneus ;  AP Talar first metatarsal angle  which is the angle between the axis of the  1st metatarsal  and the axis of the  proximal phalanx  of the 1st toe;  lateral Talar first metatarsal angle , and calcaneal inclination (or  calcaneal pitch ). [ 5 ] [ 7 ] [ 8 ]


The kinematic measurements have demonstrated notable improvements, characterized by an average reduction of 8.1° in hindfoot valgus. [ 5 ]  Furthermore, enhancements have been observed in  supination ,  dorsiflexion , and Viladot grade, approaching values indicative of a normal function. [ 5 ]


Clinical outcomes were evaluated using standardized surveys, including the Manchester-Oxford Foot Questionnaire and the  American Orthopedic Foot and Ankle Score , which provide quantitative assessments of various parameters such as pain, function, and alignment. [ 5 ]  These outcome scores exhibited significant improvements, indicating favorable treatment effects. For instance, pain levels, as measured by the  Visual Analogue Scale , decreased from an average of 5.5 before the operation to 1.4 after the operation, reflecting a substantial reduction in pain intensity. [ 4 ] [ 9 ] [ 10 ]


Subtalar arthroereisis is primarily used for the correction of flexible flatfoot, while its utilisation as the primary surgical procedure may not be recommended for cases of rigid pes planus. Contraindications to subtalar arthroereisis encompass various factors, including active infection, previous sinus tarsi surgery or trauma, and advanced  arthritis  of the  subtalar joint . [ 4 ] [ 11 ]


Arthroereisis surgery can be performed using a variety of methods and strategies and is usually finished in 20 minutes. [ 12 ]   Anesthesia  might be applied locally, regionally, or generally for the surgery. In the case of children, general  anesthesia  is commonly employed to ensure their stillness during the surgery. A  tourniquet  is not required because the procedure is carried out  percutaneously . During the surgery, the patient lies in a  supine position , and the foot undergoing the operation is internally rotated. An incision of approximately 1 cm is made along the relaxed skin's  tension lines  over the  sinus tarsi . Using a  hemostat , the tissues are spread until reaching the  sinus tarsi . Then,  a guide is inserted percutaneously from the lateral to the medial side across the floor of the  sinus tarsi . The direction of insertion follows from lateral anterior distal to medial posterior proximal, aligning with the  sinus tarsi . To prevent the guidewire from sliding back during trials, the guide pin is pushed towards the medial side and clamped with a  hemostat .


The guiding pin passes beneath the medial  malleolus  and above the posterior  tibial   tendon . Sizing guides are then installed, followed by trial implants. The objective is to restrict excessive outward turning of the foot, allowing for approximately 5 degrees of  eversion  from the neutral position. It is important not to insert a large implant that may overcrowd the  sinus tarsi . The implant is positioned about 1 to 1.5 cm inside the lateral edge of the  calcaneus , towards the medial side, and its position can be confirmed using  anteroposterior  images. On the lateral side, the implant should be observed resting on the floor of the  sinus tarsi . [ 13 ]  In cases where deformities are present in both feet, bilateral arthroereisis can be performed.  Dorsiflexion  of the foot is accomplished with the knee extended post surgical repair. Subcutaneous  Achilles tendon  lengthening is necessary if  dorsiflexion  is restricted until the foot can be dorsiflexed to 10 degrees. [ 14 ]


Subtalar arthroereisis has advantages over other foot pain treatments for primary and secondary flatfoot, as well as for stabilizing the  subtalar joint  into its correct alignment. While this procedure offers certain benefits, it is not without its drawbacks. A systematic review of 76 studies has revealed that complication rates range from 4.8% to 18.6%. Of particular concern is the occurrence of unplanned implant removal, which was reported in 7.1% to 19.3% of cases. [ 15 ]


Various complications can arise with different types of devices used in subtalar arthroereisis. Common issues include undercorrection resulting from the use of undersized implants, pain in the  sinus tarsi , and implant extrusion. Less frequently encountered complications include overcorrection caused by oversized implants,  synovitis , infection, and peroneal spasm. [ 16 ]


Synovitis , a condition characterized by joint inflammation, is often associated with a reaction to  silicone   microparticles  released from  silastic  implants. [ 17 ]  Over time,  silicone  implants can fragment due to the forces exerted on them within the joint. The use of metal implants instead of  silastic  may potentially reduce implant degradation rates and the corresponding  inflammatory response . [ 18 ]


Nerve injury  is another complication that can be prevented through careful procedural execution.  Sinus tarsi  pain, a common complication, can usually be resolved by removing the implant. [ 19 ]  However, a rare but serious complication is the occurrence of a talar neck  fracture , which can significantly impact mobility and recovery potential. [ 20 ]


Treatment options for these complications vary depending on their severity. Possible remedies include replacing an incorrectly-sized implant with a larger or smaller one, complete removal of the implant in cases of persistent pain, or the appropriate use of  anti-inflammatory  or  antibiotic  treatments. It is important to note that all surgical interventions carry inherent risks. It is crucial to consider all available treatment options, starting with the least invasive approaches, in order to achieve the best possible outcomes.


Post-operative care is essential for patients who have undergone  Achilles tendon  lengthening and medial  soft tissue  tightening, while those without  soft tissue  surgery or  gastrocnemius  release may not require plaster fixation. For patients requiring plaster fixation, it is typically maintained for a duration of 4 weeks. During this time, they wear walking braces during the night and engage in passive  plantar  and  dorsal flexion  exercises starting from the first day after surgery. On the second day after surgery, active flexion exercises of the  ankle  are initiated. Suture removal takes place approximately 12-14 days after the operation.


Around 3 weeks after surgery, patients are usually advised to engage in non-weight-bearing exercises such as swimming and bicycling. After 6 weeks, partial weight-bearing functional exercises can be commenced. To monitor the progress of the correction of deformities and the positioning of the implant, AP, lateral, and oblique  radiographs  are performed immediately after surgery, at 6 weeks, and at 12 weeks. Subsequently,  X-rays  are taken every 3 months. During the last follow-up, measurements of the Meary angle and the talus-first metatarsal angle are recorded and compared with pre-operative data. The evaluation of functionality is conducted using the AOFAS ankle-hind foot score and the VAS score. [ 21 ]  Remarkably, all patients are able to resume sports activities within a period of 12 months.


The concept of surgically modifying the tarsi and subtalar joint to address flatfoot conditions emerged in 1946 through the proposal made by Chambers. [ 6 ]  He suggested using a wedge placed on the superior surface of the calcaneus to restrict the anterior displacement of the talus from the calcaneus. [ 4 ]  The first surgeon to introduce a cortical bone wedge graft into the sinus tarsi was Stefán Haraldsson in 1962. [ 4 ]  This technique aimed to limit subtalar eversion and treat patients with pes planus. [ 4 ]  In 1970, LeLièvre from France coined the term "arthroereisis" while describing the insertion of a bone graft into the sinus tarsi, secured with a staple. [ 4 ]  Subotnick, in 1974, proposed the use of a synthetic silicone implant placed in the sinus tarsi to enhance the proper positioning of the talus with the calcaneus. [ 4 ]  These developments laid the foundation for the modern-day arthroereisis procedure.


A  compression fracture  is a collapse of a  vertebra . It may be due to trauma or due to a weakening of the vertebra (compare with  burst fracture ). This weakening is seen in patients with  osteoporosis  or  osteogenesis imperfecta ,  lytic  lesions from  metastatic  or  primary tumors , [ 1 ]  or infection. [ 2 ]  In healthy patients, it is most often seen in individuals suffering extreme vertical shocks, such as ejecting from an  ejection seat . Seen in lateral views in plain  x-ray  films, compression fractures of the spine characteristically appear as  wedge deformities , with greater loss of height anteriorly than posteriorly and intact  pedicles  in the anteroposterior view. [ 3 ]


Acute fractures will cause severe  back pain . Compression fractures which develop gradually, such as in osteoporosis, may initially not cause any symptoms, but will later often lead to back pain and loss of height. [ citation needed ]


Compression fractures are usually diagnosed on  spinal radiographs , where a wedge-shaped vertebra may be visible or there may be loss of height of the vertebra. In addition,  bone density measurement  may be performed to evaluate for osteoporosis. When a tumor is suspected as the underlying cause, or the fracture was caused by severe trauma,  CT  or  MRI  scans may be performed. [ citation needed ]


Volkmann's contracture  is a permanent  flexion   contracture  of the  hand  at the  wrist , resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful. [ 1 ]


The most important signs and symptoms of  compartment syndrome  are observable before actual contracture. What is known as the five Ps of compartment syndrome include:  pain , generally the initial symptom, accompanied by pulselessness,  pallor ,  paralysis , and  paraesthesias . Pain will likely also increase upon extension of the affected limbs hands and fingers, which is one of the earliest signs of compartment syndrome and should urgently be followed up by an exam to look for potential development of Volkmann contracture itself. Palpating for tissue firmness in the forearm, and the pulse volume and character of the  radial artery , also reflects the degree of compartment syndrome. [ 2 ]


Any fracture in the elbow region or upper arm may lead to Volkmann's ischemic contracture, but it is especially associated with  supracondylar fracture  of the  humerus . It is also caused by fractures of the forearm bones if they cause bleeding from the major blood vessels of the forearm. [ citation needed ]


The condition may be caused by obstruction on the  brachial artery  near the elbow, possibly from improper use of a  tourniquet , improper use of a  plaster cast , or  compartment syndrome . [ citation needed ]


Volkmann's contracture results from acute  ischaemia  and  necrosis  of the muscle fibres of the flexor group of  muscles of the forearm , especially the  flexor digitorum profundus  and  flexor pollicis longus . The muscles become fibrotic and shortened. [ citation needed ]


Prevention of the condition requires restoration of blood flow after injury and reduction of compartmental pressure on the muscles. Any splints, bandages, or other devices that might be obstructing circulation must be removed. [ citation needed ]


A  fasciotomy  may be required to reduce pressure in the muscle compartment. [ 3 ]


If contracture occurs, surgery to release the fixed tissues may help with the deformity and function of the hand. In established stage reconstructive surgery may be needed.  [ citation needed ]


It is named after  Richard von Volkmann  (1830–1889), the 19th century German doctor who first described it, [ 4 ]  in a paper on  "non-Infective Ischemic conditions of various fascial compartments in the extremities" . [ 5 ]  Because the contracture occurred at the same time as the paralysis, he considered a nerve cause to be unlikely. [ 6 ]


A  Gigli saw  is a flexible  wire saw  used by  surgeons  for  bone cutting . [ 1 ]  A Gigli saw is used mainly for  amputation , where the bones have to be smoothly cut at the level of amputation. [ 2 ]  It is also used in  veterinary medicine  for cutting  antler ,  horn , and  tusks , as well as bone.


The saw was invented by  Leonardo Gigli , an Italian  obstetrician , to simplify the performance of a lateral  pubiotomy  in  obstructed labour . [ 3 ]


It is featured in the 2023 American  horror film   Saw X . [ 4 ]


In medicine, the  Ilizarov apparatus  is a type of  external fixation  apparatus used in  orthopedic surgery  to lengthen or to reshape the damaged bones of an arm or a leg; used as a  limb-sparing technique  for treating complex fractures and open  bone fractures ; and used to treat an infected non-union of bones, which cannot be surgically resolved. The Ilizarov apparatus corrects angular deformity in a leg, corrects differences in the lengths of the legs of the patient, and resolves osteopathic non-unions; [ 1 ]  further developments of the Ilizarov apparatus progressed to the development of the  Taylor Spatial Frame .


Gavriil Abramovich Ilizarov  developed the Ilizarov apparatus as a limb-sparing surgical remedy for the treatment of the  osteopathic non-unions  of patients with unhealed broken limbs. [ 1 ]  Consequent to a patient lengthening, rather than shortening, the adjustable-rod frame of his external-fixation apparatus, Ilizarov observed the formation of a  fibrocartilage callus  at and around the site of the bone fracture, and so discovered the phenomenon of  distraction osteogenesis , the regeneration of bone and soft tissues that culminates in the creation of new bone. [ 1 ]


In 1987, the Ilizarov apparatus and Ilizarov's surgical techniques for repairing the broken bones of damaged limbs were introduced to U.S. medicine. [ 2 ]  The mechanical functions of the Ilizarov apparatus derive from the mechanics of the  shaft bow  harness for a horse. [ 3 ]


The Ilizarov apparatus is a specialized  external fixator  of modular construction, composed of rings ( stainless steel ,  titanium ) that are transfixed to healthy bone with  Kirschner wires  and pins of heavy-gauge stainless steel, and immobilised in place with additional rings and threaded rods that are attached with and through adjustable nuts. The circular construction of the apparatus, the rods, and the controlled tautness of the Kirschner wires immobilises the damaged limb to allow healing. [ 4 ]


The mechanical functions of the Ilizarov apparatus are based upon the principles of  tension  (pulling force), wherein the controlled application of mechanical tension to the damaged limb immobilises the broken bones, and so facilitates the biological process of  distraction osteogenesis  (the regeneration of bone and soft tissue) in a reliable and reproducible manner. Moreover, external fixation with the apparatus allows the damaged limb to bear weight early in the medical treatment. [ 5 ]


Once emplaced onto the limb, the top rings of the apparatus transfer mechanical force to the bottom ring through the rods, and so by-pass the site of the fractured bone, thus the Ilizarov apparatus immobilizes the damaged limb and relieves mechanical stresses from the wound, which then allows the patient to move the entire limb. The middle rings stiffen the support rods and hold the bone fragments in place, whilst supporting the immobilised limb. In by-passing the site of the bone fracture, the top and bottom rings bear the critical load by transferring mechanical force from the area of healthy bone above the fracture to the area of healthy bone below the fracture. [ 6 ]


The Ilizarov surgical method of  distraction osteogenesis  (regeneration of bone and soft tissues) for repairing complex fractures of the bones of the limbs is the preferred treatment for cases featuring a high risk of bacterial  infection ; and for cases wherein the extent and severity of the fracture precludes using  internal fixators  to immobilise the damaged bone for proper repair. [ 7 ]


In 1968, Ilizarov successfully treated the  non-union osteopathy  of  Valeriy Brumel , a Soviet athlete, who suffered a broken ankle and a broken shinbone (tibia) of the right leg, [ 1 ]  had undergone more than twenty failed bone-repair surgeries in three years, and yet his broken leg-bones had not healed and the leg was shorter than before the motorcycle accident in 1965. [ 3 ]  By way of distraction osteogenesis and an external-fixation apparatus, Ilizarov resolved Brumel's osteopathic non-union, by growing new leg bone, which extended the athlete's leg 3.5 cm (1.4 in) to its normal length. [ 3 ]


In 1980, Ilizarov successfully treated the osteopathic non-union of  Carlo Mauri , a journalist and an explorer, who, ten years earlier, had broken the distal end of a tibia in an Alpine accident, yet his broken leg-bone had yet to heal. [ 1 ] [ 2 ]  During an expedition in the Atlantic Ocean, Mauri's leg wound reopened; a concerned teammate, a Russian doctor, recommended that Mauri consult with Ilizarov for proper diagnosis, surgical repair, and treatment in the city of  Kurgan , Russia. [ 1 ] [ 2 ]


In 2013, consequent to a PTSD-induced fall that broke his left leg, the British war correspondent  Ed Vulliamy  underwent limb-sparing medical treatment that featured surgeries and an Ilizarov apparatus to repair and heal the severely fractured bones in his left leg. [ 8 ]


The photographs and  radiographs  illustrate the application and emplacement of an external fixator, an Ilizarov apparatus, to repair the  open fracture  of the lower left leg of a man. The photographs were taken four weeks after the patient fractured the shinbone ( tibia ) and the calfbone ( fibula ) of his left leg, and two weeks after the surgical emplacement of the Ilizarov apparatus to immobilise the leg and isolate the wound and fracture site to facilitate healing.


The Ilizarov apparatus corrects deformed bones by way of the process of  distraction osteogenesis , which reproduces bone tissues. After an initial surgery during which the bone to repair is fractured, and the apparatus is attached to the limb of the patient; once the fracture has been immobilised, the bone tissues begin to grow and eventually bridge the fracture with new bone. [ 9 ]  In the course of the osteogenesis process, the bone grows and the physician extends the rods of the Ilizarov apparatus to increase the space between the rings at each end of the apparatus. As the rings are installed at and connected to the opposite ends of the fracture site, the adjustment, done four times a day, separates the healing fracture by approximately one millimetre per day; in due course, the millimetric adjustments lengthen the bone of the damaged limb. Upon completing the bone-lengthening phase of treatment, the Ilizarov apparatus remains emplace for a period of osteopathic consolidation, the ossification of the regenerated bone tissues. Using crutches, the patient is able to bear weight on the damaged limb; once healed, the patient undergoes a second surgery to remove the Ilizarov apparatus from the repaired limb. The result of the Ilizarov surgical treatment is a limb that is much longer than before the medical treatment.


In the case of lengthening a leg bone, an additional surgery will lengthen the  Achilles tendon  to accommodate the longer length of the treated bone. The therapeutic advantage of the Ilizarov treatment is that the patient can be physically active whilst awaiting the bone to repair. The Ilizarov apparatus also is used to treat and resolve a structural defect in a long bone, by transporting a segment of bone whilst simultaneously lengthening and regenerating the bone to reduce the defect, and so produce a single bone. Installing the Ilizarov apparatus requires minimally invasive surgery, and is not free of medical complications, such as inflammation, muscle transfixion, and  contracture  of the affected joint.


An  osteotome  is an instrument used for cutting or preparing bone. [ 1 ]  Osteotomes are similar to a  chisel  but bevelled on both sides. [ 2 ]  They are used today in  plastic surgery ,  orthopedic surgery  and  dental implantation . [ 3 ]


The  chain osteotome , originally referred to simply as the osteotome, was invented by the German physician  Bernhard Heine  in 1830. [ 4 ] [ 5 ]   This device is essentially a small  chainsaw . [ 6 ] [ 7 ]


The  Taylor Spatial Frame  (TSF) is an  external fixator  used by  podiatric  and  orthopaedic surgeons  to treat  complex fractures [ 1 ]  and  bone deformities . The medical device shares a number of components and features of the  Ilizarov apparatus . The Taylor Spatial Frame is a  hexapod  device based on a  Stewart platform , and was invented by orthopaedic surgeon Charles Taylor. The device consists of two or more  aluminum  or  carbon fibre  rings connected by six  struts . Each strut can be independently lengthened or shortened to achieve the desired result, e.g. compression at the fracture site, lengthening, etc. Connected to a bone by tensioned wires or half pins, the attached bone can be manipulated in three dimensions and 9 degrees of freedom. Angular, translational, rotational, and length deformities can all be corrected simultaneously with the TSF.


The TSF is used in both adults and children. It is used for the treatment of acute  fractures , mal-unions, non-unions and  congenital  deformities. It can be used on both the upper and lower limbs. Specialised foot rings (which are not seen in the picture) are also available for the treatment of complex foot deformities. [ citation needed ]


Once the fixator is attached to the bone, the deformity is characterised by studying the postoperative  x-rays , or  CT scans . The angular,  translational ,  rotational , and length deformity values are then entered into specialised software, along with mounting parameters and hardware parameters such as the ring size and initial strut lengths. The software then produces a "prescription" of strut changes that the patient follows. The struts are adjusted daily by the patient until the correct alignment is achieved. [ citation needed ]


Correction of the bone deformity can typically take 3–4 weeks. For simpler fractures where no deformity is present the struts may still be adjusted post-surgery to achieve better bone alignment, but the correction takes less time. For individuals performing strut adjustment. a hand mirror may be useful to aid in reading the strut settings.


Once the deformity has been corrected, the frame is then left on the limb until the bone fully heals. This often takes 3–6 months, depending on the nature and degree of deformity.


When the bone has sufficiently healed, the frame can be dynamised. This is a process of gradually reducing the supportive role of the frame by reducing the length stability. This causes force that was previously transmitted around the fracture site and through the struts to be transmitted through the bone. [ citation needed ]


After a period of dynamisation, the frame can be removed. This is a relatively simple procedure often performed under  gas and air  analgesic.


The rings are removed by cutting the olive wires using wire cutters.


The wires are then removed by first sterilising them and then pulling them through the leg using pliers. The threaded half pins are simply unscrewed.


External fixation via TSFs tends to be less invasive than  internal fixation  and therefore has lower risks of infection associated with it. This is particularly relevant for  open fractures .


For open  comminuted  fractures of the  tibial plateau  the use of circular frames (like TSF) has markedly reduced infection rates. [ 2 ]


The time taken for bones to heal (time to union) varies depending on a number of factors.  Open fractures  take longer to heal, and infection will delay union. For tibial fractures union is generally achieved after between 3 and 6 months, [ 3 ]  though time to union can be rather subjective, [ 4 ]  and the dynamistion process combined with irregular appointments may interfere with these measures.


Infection of the pin sites (points where wires enter the skin) of the TSF is a common complication (estimates are that it affects 20% percent of patients). In extreme cases this can result in  osteomylitis  which is difficult to treat. However, pin site infections are normally successfully treated with a combination of oral antibiotics,  intravenous  antibiotics, or removal of the affected pin. [ citation needed ]


Pin sites are classified as  percutaneous  wounds


Best practice for maintenance of pin sites is unclear and requires more study. [ 5 ]  Common practice involves the regular cleaning of the pin sites with  chlorhexidine gluconate  solution (advice varies from every day to every week), regular showering, and dressing of sites that exude liquid with non-woven gauze soaked in chlorhexidine gluconate. This dressing can be held in place with bungs or makeshift clips or by twisting around the wire.


Advice varies as to whether scab tissue or any "crust" surrounding a pin site should be maintained. With some literature arguing that this acts as a barrier to entry, while other literature argues this may increase the risk of infection.


Arthroscopic lavage  is the washing out or cleaning out the contents (blood, fluid or loose debris) inside a joint space.  Lavage  is a general term referring to the therapeutic washing, cleaning or rinsing. [ 1 ]


Excessive growth of irritated  synovial membrane  causes it to increase its surface area by buckling into fronds, and the fronds may become inflamed and pour destructive enzymes into the joint space, causing joint swelling and joint surface destruction. Removing this excess material via lavage frequently resolves arthritic knee inflammation or pain. [ 2 ]


Arthroscopic lavage is one of many procedures available to help reverse the damage of early  arthritis .  There is, however, controversy about the value of simple lavage and debridement for the older patient with established  osteoarthritis . [ 3 ]


Needle lavage should not be used in an attempt to treat persons seeking long-term relief for symptomatic osteoarthritis of the knee. [ 4 ]  The use of this treatment in this case has not been shown to decrease pain, stiffness, tenderness, or swelling, or to increase 50-foot walking time or body function. [ 4 ]


A   cast saw  is an  oscillating   saw  used to remove  orthopedic casts . Instead of a rotating blade, cast saws use a sharp, small-toothed blade rapidly oscillating or vibrating back and forth over a minimal angle to cut material and are therefore not  circular saws . [ 1 ]  This device is often used with a cast spreader. [ 2 ]


The patient's skin frequently comes into contact with the cast saw blade without cutting although it can cause lacerations when used over bony prominences. [ 3 ]  The design enables the saw to cut rigid materials such as plaster or fiberglass. In contrast, soft tissues such as skin move back and forth with the blade, dissipating the shear forces, and preventing injury. [ 4 ]


Modern cast saws date back to the plaster cast cutting saw which was submitted for a patent on April 2, 1945, by  Homer H. Stryker , an orthopedic surgeon from  Kalamazoo ,  Michigan . [ 5 ]


Cast removal procedures result in complications in less than 1% of patients. These complications include skin abrasions or thermal injuries from friction between the saw and cast. Temperatures exceeding 101 °C (214 °F) have been recorded during the removal of fiberglass casts. The proper use of the saw is to perforate (instead of cutting) the cast, which can then be separated using a cast spreader. [ 4 ]


Alternatives include cast cutting shears which were patented in 1950 by Neil McKay. [ 6 ]


Cunningham shoulder reduction  was originally published in 2003  [ 1 ]  and is an anatomically based method of  shoulder reduction  that utilizes positioning (analgesic position), voluntary scapular retraction, and  bicipital   massage . It is designed for true  anterior /subcoracoid  glenohumeral dislocations  in patients who can fully adduct their  humerus . [ 2 ]  This is distinct from anteroinferior/subglenoid glenohumeral dislocations for which alternative techniques should be used. [ 3 ]
The method is one of several techniques used for  shoulder reduction . [ 4 ] [ 5 ] [ 6 ]


Shoulder dislocation is a common complication of  upper limb trauma  (arm pulled while in  abduction  or direct impact to shoulder) resulting with the humeral head sitting anteriorly out of the  glenoid  fossa.


Technique is as follows: [ 2 ]


Step 1  Sit patient up (without slouching, towel or pillow down spine) and place into analgesic position. ‘Hold’- take control of the affected limb with a 'hold.' This is a firm steady downward hold (not a pull) designed to move the humeral head towards where it needs to be, taking off some of the stretch from the  capsule  (reducing pain), and providing confidence to the patient that you have taken control of the limb. Once you are in this position, it can be useful to ask the patient their  pain level , and explain again what you are going to do. It’s important to note that the elbow is not being supported from below, but is being placed in a downwards ‘hold’. The affected arm is  adducted  (next to the body) and the elbow fully  flexed  (optimally shortens the biceps muscle, allowing full relaxation) The humerus points directly down and should be in a neutral position (no forward flexion or external rotation). Ask the patient to “shoulders back, chest out.” (reducing scapular  anteversion  and so reducing the static obstruction of the glenoid rim). Kneel next to your patient and place your wrist onto their forearm, with their hand resting on your shoulder.


Step 2  Massage the  biceps . Ask your patient to again put “shoulders back, chest out” and relax. Massage the biceps (gently) at mid humeral level. Wait for your patient to fully relax and the  humeral head  slips back into place. Tell your patient that they will feel “strange” as the joint slips back in and not to fight this movement. Continue to gently move the humerus forwards and back in order to find the perfect angle, and provide a small amount of momentum to allow the head to slide across the glenoid.


Step 3  anterior/posterior humeral movements. The humerus can then be gently moved forwards and back in order to find the perfect angle, and provide a small amount of momentum to allow the head to slide across the glenoid. This combines the principle of overcoming the movement inertia with the apposition of the slippery  articular surfaces  of the  glenoid rim  and the  humeral head .


If performed correctly most patients do not require  analgesia  for the performance of this technique. [ 7 ]  Inappropriate use of  traction  will result in pain for the patient with subsequent  spasm  and failure to reduce. If the patient is unable to adduct the humerus, or unable to cooperate with positioning, the technique should not be attempted. The patient may require analgesia or  sedation  if they are in pain or unable to relax spasming muscles. [ citation needed ]


Friedrich Hessing , after 1913  von Hessing  (19 June 1838,  Buch am Wald  - 16 March 1918,  Göggingen ) was an  organ builder  and a pioneer in the field of  orthopedic  technology.


He was the thirteenth and youngest child born to Johann Georg Hessing (1793-1858), a farmer, and his wife Maria Barbara, née Klee (1796-1861), a  midwife . An impoverished upbringing may have led to his small stature of only 4' 8". [ 1 ]


After completing his primary education in 1852, he began training as a gardener for the  Hohenlohe  family. After two years, he quit to take an apprenticeship in carpentry; obtaining his  journeyman 's license in 1857. He then found employment at the organ building firm of  G. F. Steinmeyer & Co.  [ de ]  in  Oettingen , where he learned how to build organs and  harmoniums . After some further training in  Stuttgart , he moved to  Augsburg  to work with the piano manufacturer, Max Joseph Schramm (1838-1916).


In 1866, he received a business license to make organs. That same year, he made an artificial foot for an amputee. The following year, he asked the city of Augsburg for financial support, so he could make artificial limbs a regular part of his business. His request was denied. In 1868, his application to open an orthopedic sanatorium was also denied. He was not discouraged and, later that year, received permission from the  Regierung von Schwaben  [ de ] . His clinic opened within a few weeks and he took out a newspaper advertisement, assuring everyone that his therapies would not include surgery.


The response was positive and he treated thousands of people there; including the writer  Max Brod , who was fitted with what came to be known as a  Hessingkorsett  [ de ] , for a  spinal curvature . Later, Brod would describe his stay there in his memoirs. In addition to the corset, he was also known for a " schienenhülsenapparat  [ de ] ", for treating the effects of  polio , the basic design of which is still in use today. Despite this, for many years, the sale of organs and pianos remained his primary source of income and provided most of the funds needed for establishing the sanatorium.


In 1886, he added an entertainment facility, the  Kurhaus Göggingen  [ de ] , designed by the architect,  Jean Keller  [ de ] . In the 1890s, he opened a spa complex at  Rothenburg ob der Tauber . His true breakthrough came in 1899, when he successfully treated  Augusta Victoria of Schleswig-Holstein , German Empress and Queen of Prussia, for an ankle fracture. [ 2 ]  As a result, he became acceptable to the aristocracy and the international public. In 1904, he was appointed a "Royal Bavarian Councilor" and, in 1913, was named a Knight in the  Order of Merit of the Bavarian Crown , which gave him the right to use the noble prefix "von".


His legacy was passed to the Hessing Foundation which still exists today and operates, among things, the  Hessing-Klinik  [ de ] , a geriatric rehabilitation center. The private Hessingpark Clinic operates a  rheumatism  center as well as an orthopedic shoe company. [ 3 ]  A street in  Bad Reichenhall  is named after him.


A  hip protector  is a specialized form of pants or underwear containing pads (either hard or soft) along the outside of each hip/leg, designed to prevent  hip fractures  following a fall. Recent developments include the use of double-sided adhesive films that are breathable and more comfortable to wear than specialised pants. The adhesive films are safer because they can be worn in the bath or shower, or when toileting. Hip protectors are most commonly used in elderly individuals who have a high risk of falls and hip fractures (for example, due to history of a previous fall and underlying  osteoporosis ). [ 1 ]


Most hip fractures follow an impact due to a  lateral  fall. [ 2 ]  The pads are located over the  trochanters , the bony extrusions of the hip region.


A 2014  Cochrane review  found that hip protectors decrease the number of  hip fractures  among the elderly. [ 3 ]


A number of reviews have found that hip protectors are cost-effective, particularly among residents of care homes and for long-stay patients in hospital [ 4 ]


A previous review found that the effect for preventing hip fracture among nursing home residents was small and not effective among community dwelling elderly individuals. [ 5 ]   A 2007 review found a decreased risk of hip fractures in elderly nursing home residents. [ 6 ]


However,  acceptance  and long-term compliance towards them has historically been quite low, [ 5 ]  mainly because of discomfort, dislike of their appearance by the person wearing it, and disagreement about fracture risk. [ 7 ]  More modern hip protectors do not suffer from these disadvantages because they are slimmer with a low profile, so less noticeable, have ventilation holes and ducting to keep the skin cool under the pad and are soft and pliable conforming to the contours of the hip. Better independent testing procedures developed by Professor Julian Minns have established a reliable baseline for impact absorption performance. [ 8 ]


Research which has found hip protectors to be beneficial found that hard, energy-shunting hip protectors to be superior to soft, energy-absorbing ones. [ 9 ]  However this research predates the introduction of hip protector pads in 2011/2012 using modern non-Newtonian materials, such as  D3o  that absorb around 75% of the impact, typically twice that of previous devices that used soft materials such as textiles or foam pads in an airtight bag, but comparable to the best of the energy-shunting devices, which have now largely disappeared from the market because of a slight tendency to cause pelvic fractures when the energy is transferred [ 10 ]  Another study showed that hip protectors' design and mechanical properties vary drastically among commercially available hip protectors. [ 11 ]


Hip protectors are either of the "crash helmet type" or "energy-absorbing type". The "crash helmet type" distributes impacts into the surrounding soft tissue, while the "energy-absorbing type" is made of a compressible material and diminishes the force of impact. Both of these systems aim to reduce the focused force beneath an estimated fracture threshold. [ 1 ] [ 12 ]  Several different commercially available hip protectors exist. [ 1 ] [ 9 ]


Orthopaedic nursing  (or  orthopedic nursing ) is a  nursing  specialty focused on the prevention and treatment of  musculoskeletal disorders .   Orthopaedic  issues range from acute problems such as  fractures  or hospitalization for  joint replacement  to chronic systemic disorders such as loss of  bone density  or  lupus erythematosus .


Orthopaedic nurses have specialized skills such as neurovascular status monitoring, traction,  continuous passive motion  therapy,  casting , and care of patients with  external fixation .


Certification in general orthopaedic nursing results in the designation " Orthopaedic Nurse Certified " (ONC).


Orthopedic templating  is a process wherein  surgeons  use either  acetate  templates or digital templates to estimate the correct size of the  prosthesis  to be used in surgery.  The biggest educator on the subject has been AO/ASIF.  In a study published in the Injury journal published in 1998, 94% of consultants and 100% of trainees felt that planning was important but half, respectively, routinely planned fracture treatment. [ 1 ]


Since 1999, companies have developed software to computerize the process. In 1999, mediCAD® was the first commercially available software [ 2 ]  focused mainly on the German market. The orthopedic templating software market began in the United States in 2000 [ 3 ]  when Medstrat, bootstrapped by Mike Cowden and company, introduced their Workflow Engine (WFE), the industry’s first orthopedic-specific PACS. The market grew in 2003 when UK-based OrthoView was founded by Albany Ventures and the Israeli-based Orthocrat-TraumaCad was bootstrapped by an Orthopedic Surgeon Doron Norman MD and a software entrepreneur Zeev Glozman. Other later work includes that of the orthopedic pediatric surgeon Peter Stevens MD from the University Of Utah.


The main driver of software-based orthopedic templating was the introduction of computed radiography (CR) and  digital radiography  (DR) systems on a mass scale, which in essence eliminated film from the hospital environment, creating the need for digital templating. Unfortunately, eliminating film creates a major flaw when viewing digital images in a variety of viewing formats. Therefore, a value of known size must be present within the image much like a legend on a map. The first calibration device has been introduced into the market by Zimmer corporation which consisted of an acrylic bar with two embedded steel balls. OrthoMark and J2 Medicals Akucal were the first devices to use a spherical marker on an articulating and adjustable arm attached to a base that could be placed next to or under a patient. Subsequently, several different OrthoMark models became available with a variety of bases. Some companies copied these devices, among them was Orthocrat-TraumaCad (subsequently Voyant Health, then Brainlab) with what they called VoyantMark. Another adaptation was the development by Mr Richard King of the University of Coventry & Warwickshire of a dual marker calibration device dubbed KingMark.


Several PACS ( picture archiving and communication system ) providers such as Medstrat, Sectra, and Cedara developed templating in-house as part of their PACS solution, making them orthopedic-specific PACS. Many non-orthopedic PACS providers have partnered with Voyant Health (previously Orthocrat-TraumaCad, now Brainlab, purchased in 2012) or OrthoView.
While none of the software packages necessarily address the entire aspect of the surgical tactic, instead focusing on pre-operative implant size selection, the tools prove to be quite usable, convenient, and efficient.


The next step of this technology was making it available on mobile devices such as iPad as well as Android platforms. Medstrat introduced its echoes iPad application in January of 2011. BrainLab demonstrated its iPad application for Orthopaedic templating at AAOS 2014.


Medstrat envisioned digital templating helping pre-plan cases as a result of the relationship between a Stryker joint rep and his brother-in-law. Orthocrats TraumaCad was founded as a result of  patient-doctor relationship  between a young rock climber and an orthopedic surgeon. OrthoView was founded in 2003 by Adrian Dwyer, Peter Quinn, and John Chambers as well as an orthopaedic surgeon Grant Shaw of Southampton. It was acquired by Materialise NV in 2014. [ 4 ]


As technology moves forward,  Artificial Intelligence (AI) made its way to orthopedic templating .  PeekMed  launched in 2015 an AI-based system, that speeds and automatizes several time-consuming and cumbersome steps by performing automatic bone segmentation, automatic landmark detection, and the automatic planning of the procedure, using the best surgical practices and quick selection of the correction and implants needed. Furthermore, PeekMed allows the surgeon to edit the planning and to simulate different outcomes of the procedure. One of the features of this ultimate technology, automatic  orthopedic templating  helps the surgeon by automatically placing the most suitable template in the correct position with extreme accuracy.


A variety of  orthopedic boots  are used for the treatment of injuries of the foot or ankle. Along with  orthopedic casts ,  leg braces ,  splints  and  orthotics , they can immobilize and shift weight bearing to help treat injuries to the foot area. [ 1 ] [ 2 ]


A  controlled ankle motion walking boot , also referred to as a  controlled ankle movement walking boot ,  below knee walking boot ,  CAM boot ,  CAM walker , or  moon boot , is an  orthopedic  device prescribed for the treatment and stabilization of severe  sprains , [ 3 ]   fractures , and  tendon  or  ligament  tears in the ankle or foot. In situations where ankle motion but not weight is to be limited, it may be used in place of a  cast . [ 4 ]


A walking boot consists of:


CAM walkers may range in height from mid-calf to nearly knee-length, depending on the condition they are meant to treat. Some contain inflatable compartments that can be adjusted by the patient for maximum support and comfort. For further protection of the injured ankle and leg, CAM walkers may also utilize a more extensive plastic shell that also encloses the back and sides of the walker, with detachable plastic plates for the front. [ 5 ]


While CAM walkers do not provide the same degree of immobility that an orthopedic cast offers, they have some advantages. [ 6 ]  Unlike casts, they are adjustable and reusable, and fully removable, permitting the patient to bathe the foot and ankle and remove the walker at night, if they so desire; [ 7 ]  and a CAM walker requires no special modifications for the patient to bear weight and walk. With some fractures, however, removal may result in worse outcomes and thus this may be a negative; also, with some fractures, the person should be non-weight bearing. Additionally, there is greater cost.


For more severe fractures, a traditional cast may still be preferable.


Orthopedic casts  or just  casts  are a form of medical treatment used to immobilize and support bones and soft tissues during the healing process after fractures, surgeries, or severe injuries. By restricting movement, casts provide stability to the affected area, enabling proper alignment and healing of bones, ligaments, and tendons. They are commonly applied to the limbs but can also be used for the trunk, neck, or other parts of the body in specific cases. Orthopedic casts come in various types and designs, tailored to the nature and severity of the injury, as well as the patient's needs. Advances in medical techniques have made casts more comfortable, effective, and versatile, allowing for both weight-bearing and non-weight-bearing options.


Upper extremity casts are frequently utilized to immobilize the arm, wrist, or hand for the treatment of fractures, soft tissue injuries, or during post-surgical recovery. They offer stabilization and support, aiding in proper healing while minimizing the risk of further injury. Common types include  long arm casts ,  short arm casts , and specialized versions such as  thumb spica casts . [ 1 ]


A long arm cast extends from the upper arm to the wrist or hand, immobilizing the elbow joint in addition to the forearm. It is typically used for injuries requiring stabilization across multiple joints, such as forearm fractures, certain elbow injuries, and complex soft-tissue damage. It is usually insured that the elbow remains immobilized in a slightly flexed position, usually around 90 degrees, to promote healing while maintaining comfort. Patients with long arm casts often require close monitoring for swelling and circulation issues, given the cast’s extensive coverage.


A short arm cast is designed to immobilize the wrist and part of the forearm, extending from below the elbow to the hand, often leaving the fingers free for limited mobility. It is used to treat less severe injuries, such as wrist fractures, sprains, or carpal bone issues. The cast restricts wrist movement while allowing elbow mobility, providing a balance between immobilization and functionality. In some cases, a  thumb spica  variant is added to include the thumb in immobilization, such as for scaphoid fractures or severe thumb sprains. Proper fit and careful alignment are critical to ensure effective healing and prevent complications.


Leg casts are designed to immobilize the lower limb, facilitating the healing process for fractures, ligament injuries, or post-surgical repairs. They provide stability to the affected area, helping to alleviate pain and prevent additional damage. The design of leg casts can vary to cater to specific injuries, from simple foot fractures to more complicated multi-joint issues. The most common types of lower extremity casts include,  long leg casts ,  Short leg casts . Different varieties exist between the two main types.


A long leg cast extends from the upper thigh to the toes, immobilizing the knee joint as well as the lower leg and ankle. It is typically used for injuries requiring stabilization across multiple joints, such as tibial or fibular fractures, severe knee injuries, or post-surgical recovery. It is ensured that the knee remains immobilized in a slightly flexed position, typically around 20-35 degrees, [ 2 ]  to promote healing while maintaining comfort. Patients with long leg casts often require close monitoring for swelling, circulation issues, and mobility challenges due to the cast’s extensive coverage.


The short leg cast is designed to immobilize the lower leg and ankle, extending from just below the knee to the toes. It is used to treat less severe injuries, such as ankle fractures, foot fractures, or severe sprains. The cast restricts ankle movement while allowing knee mobility. In some cases, a toe plate is added to a short leg cast to provide additional protection for toe injuries or fractures. The toe plate is an extension of the cast that covers the toes, shielding them from external forces and reducing the risk of further injury during recovery. It also helps maintain proper alignment of the toes, preventing displacement of fractured bones or soft tissue damage. Toe plates are particularly useful for injuries where direct impact or accidental movement could hinder healing, such as complex fractures or severe soft tissue injuries in the toes.


When a patient is advised not to put weight on an injured limb, mobility aids like  crutches ,  walkers , or  wheelchairs  can be used to help with movement during the recovery process. These aids protect the injured area while allowing the patient to move around safely. For those who cannot use crutches due to balance or strength challenges, a wheelchair or knee scooter might be suggested as a more stable mobility option. In certain situations, partial weight-bearing may be permitted, and specialized footwear can be fitted over the cast for added support. For leg casts that allow weight-bearing, the under-sole is usually reinforced to evenly distribute pressure and minimize strain on the injury. Walking casts, as they are called, come with a hard, flat sole to aid in walking while ensuring proper alignment and stability. Other  alternative for ambulation with an injured leg include using an


Cylinder casts are orthopedic devices used to immobilize the arm or leg while leaving the surrounding joints free, providing focused stabilization to specific regions. In the arm, a cylinder cast typically extends from the upper arm to just above the wrist, stabilizing injuries like isolated humeral fractures or post-surgical repairs that do not require elbow immobilization. For the leg, the cast extends from the thigh to just above the ankle, often used to manage patellar fractures, some types of tibial plateau injuries, or post-operative care following knee surgeries. The application involves precise alignment to maintain proper positioning of the affected area while ensuring adjacent joints remain mobile, allowing for some functional movement and reducing stiffness during recovery.


Body casts, also known as full-body casts are devices designed to immobilize the trunk of the body, sometimes extending to the neck, head, or extremities. They are less commonly used today due to advances in less restrictive bracing systems and surgical techniques but remain crucial in specific cases where maximum immobilization is essential. Body casts are often used in pediatric patients, particularly young children, who may struggle to comply with wearing a back brace consistently. They are also employed after radical surgeries to repair spinal injuries, congenital deformities, or significant trauma to the spine, pelvis, or upper thigh.


A common variant, the body jacket, encases the trunk and includes shoulder straps to provide added stabilization, particularly for injuries involving the thoracic or lumbar spine. These casts are meticulously shaped to maintain spinal alignment and prevent movement that could disrupt healing. Despite their efficacy, body casts can be extremely uncomfortable due to their restrictive nature and the challenges they pose for hygiene and mobility. In some cases, openings or windows are incorporated into the cast to allow access for wound care or medical monitoring.


An EDF (elongation, derotation, flexion) cast is a specialized orthopedic device used in the treatment of Infantile Idiopathic Scoliosis. This method of correction was pioneered by UK scoliosis specialist Min Mehta and is a non-surgical approach designed to guide spinal growth and alignment during a critical developmental period. [ 3 ]  Scoliosis is a three-dimensional spinal deformity requiring correction in all planes—coronal, sagittal, and axial—and EDF casting addresses these complex needs. By employing traction, the EDF method elongates the spine, derotates the vertebrae and pelvis, and improves lordosis and overall body alignment, significantly enhancing the patient’s posture and physical function.


The EDF casting technique is distinct from  Risser casting  in its design and application. EDF casts are tailored to each child’s anatomy, with configurations either over or under the shoulder, depending on the curve pattern and severity. A key feature is the large mushroom-shaped opening on the front, which facilitates proper chest expansion and breathing. On the back, a small cutout is strategically placed on the concave side of the curve, stopping at the midline. This cutout has been shown to improve rotational correction and enhance spinal alignment compared to casts without it. The combination of elongation, derotation, and flexion in this casting method offers an effective early intervention to correct scoliosis and guide proper spinal development.


A spica cast encases the trunk of the body and one or more limbs, providing immobilization for injuries or conditions requiring stabilization across multiple joints. Spica casts can be used for both upper and lower extremities. For instance, a shoulder spica covers the trunk of the body and one arm, typically extending to the wrist or hand. These casts were once common for severe shoulder injuries but are rarely used today, as specialized splints and slings have largely replaced them, promoting early mobility to prevent joint stiffness during recovery.


A hip spica cast, by contrast, is used to immobilize the trunk and one or more legs. Variants include the single hip spica, which covers the trunk and one leg down to the ankle or foot; the double hip spica, which covers the trunk and both legs; and the one-and-a-half hip spica, which encases one leg fully and the other only to above the knee. The extent of trunk coverage depends on the specific injury or condition and the surgeon’s preference, ranging from the navel for spinal mobility to as high as the rib cage or armpits in rare cases. Hip spicas are commonly used to maintain reduction of femoral fractures, treat congenital hip dislocations in infants, and stabilize the hips and pelvis after surgery.


In some cases, a spica cast may not fully encase the legs, extending only to above the knee. These casts, known as pantaloon casts, are occasionally used to immobilize the lumbar spine or pelvis. When applied for such injuries, the trunk portion of the cast typically extends to the armpits to ensure adequate stabilization.


Maintaining proper hygiene while wearing a cast is crucial to ensure patient comfort, prevent skin irritation, and reduce the risk of infection. Since casts are often made of non-breathable materials and remain in place for weeks, they can create an environment prone to moisture buildup, which can lead to odors, skin irritation, or fungal growth. Patients are advised to keep the cast completely dry, as moisture can weaken the cast material and compromise its integrity. Waterproof covers or plastic bags secured with elastic can be used during bathing to protect the cast, but immersing the cast in water should always be avoided unless it is specifically designed to be waterproof.


To maintain hygiene around the cast, patients should clean and moisturize the exposed skin near the cast edges, being cautious not to let any liquids seep inside. A damp cloth with mild soap can be used for cleaning, followed by gentle drying. Avoid inserting objects, such as sticks or sharp items, into the cast to alleviate itching, as this can cause skin abrasions or damage the cast lining. If itching becomes unbearable or if there is persistent discomfort, a healthcare provider should be consulted rather than attempting to adjust the cast.


For long-term casts, regular inspections by a medical professional are recommended to ensure the skin underneath remains healthy and the cast fits properly. Unpleasant odors, excessive itching, or discharge from the cast are potential signs of an infection or skin breakdown, requiring immediate medical attention. Maintaining proper cast hygiene not only contributes to physical comfort but also supports a safe and successful healing process.


Casts typically come in two main types of material, fiberglass, and plaster, though it is less common. Plaster casts have several limitations, including weight, which restricts movement, and skin complications such as dryness, itching, rashes, and infections, particularly in hot weather. Plaster can also break down if exposed to moisture. The cast removal process, which involves a noisy oscillating saw, can cause distress, especially in children, though it is generally painless. Due to these drawbacks, fiberglass casts were developed in the 1970s, offering a lighter, more durable, and water-resistant alternative, though they still have limitations in terms of skin irritation and moisture management.


Plaster casts consist of a cotton bandage that has been combined with  plaster of paris , which hardens after it has been made wet. Plaster of Paris is  calcined   gypsum  (roasted gypsum), ground to a fine powder by milling. When water is added, the more soluble form of  calcium sulfate  returns to the relatively insoluble form, and heat is produced.


The setting of unmodified plaster starts about 10 minutes after mixing and is complete in about 45 minutes; however, the cast is not fully dry for 72 hours. [ 5 ]


Bandages of synthetic materials are also used—often knitted  fiberglass  bandages impregnated with  polyurethane , sometimes bandages of  thermoplastic . These are lighter and dry much faster than plaster bandages. However, plaster can be more easily moulded to make a snug and therefore more comfortable fit. In addition, plaster is much smoother and does not snag clothing or abrade the skin. [ 6 ]


Traditional cast liners are made from cotton or synthetic materials, which help absorb sweat and keep the skin dry. However, in modern casting, fiberglass or polyester liners are often used, offering greater durability and comfort. Some liners are specifically designed to be waterproof, allowing patients to bathe or swim while wearing their casts. These waterproof liners are typically made from materials like polyurethane or special synthetic fibers that prevent water from seeping into the cast. While waterproof liners offer significant convenience, they may increase the application time and cost of the cast


There are some washable casts like FlexiOH which provide good ventilation and maintain good skin hygiene. With this cast, patients are able to bathe and go out in the rain. These types of casts have advantages that deliver patients a better treatment than conventional casts made of plaster of Paris or Fiberglass. They are the next generation of orthopedic immobilization photo-curing specialty-resin technology that enables a waterproof, washable, lightweight, strong and comfortable way of recovering from fractures . [ citation needed ]


Alternative immobilization techniques offer non-cast methods for stabilizing injuries, providing options that may be more comfortable, adjustable, or suitable for specific conditions. While traditional casts are commonly used for fractures and soft tissue injuries, alternatives are increasingly being utilized to address various patient needs and preferences.


One prominent alternative is the  splint , which is often used for fractures that are not as severe or when a temporary immobilization method is required. Splints are typically made from materials like fiberglass, aluminum, or plastic and are easier to apply and adjust than casts. They can be used for injuries like sprains, minor fractures, or post-surgical stabilization. Unlike casts, splints are generally open on one or both sides, allowing for adjustments as swelling fluctuates during the healing process. They also provide more flexibility and can be removed for hygiene or rehabilitation purposes.


Orthopedic brace  are another alternative, commonly used for joint injuries or soft tissue sprains and strains. Braces provide support and stabilize joints like the knee, ankle, or wrist. They are often used for conditions such as ligament sprains, tendinitis, or as post-operative support. Braces are usually made of fabric, neoprene, or metal components, allowing for greater mobility and easier removal compared to casts. They can be particularly useful for injuries that require gradual rehabilitation and controlled movement.


For certain types of fractures or injuries,  Traction (orthopedics)  is an effective immobilization method. Traction involves using a pulling force to align bones and reduce fractures, particularly in cases involving the spine, pelvis, or long bones. It can be achieved through a variety of mechanisms, including skin traction (using adhesive materials attached to the skin) or skeletal traction (which involves pins or wires placed directly into the bone). Traction helps maintain the correct alignment and promotes healing without the need for a cast, especially in more complex fractures.


In cases where the injury requires complete immobilization but not the rigidity of a cast, an  orthopedic boot , also known as a CAM boot (controlled ankle motion) may be used, especially for foot or ankle injuries. These options are designed to protect the injured area while still allowing limited mobility. Orthopedic boots are often preferred in weight-bearing fractures, as they provide stability while allowing the patient to walk with  crutches  or other mobility aids. [ citation needed ] [ example needed ]


Casts are typically removed by perforation using a cast saw, an  oscillating saw  designed to cut rigid material such as plaster or fiberglass while not harming soft tissue. [ 7 ]  Manually operated shears, patented in 1950 by  Neil McKay , [ 8 ]  may be used on pediatric  or other patients who may be affected by the noise of the saw. [ 9 ]


The earliest methods of holding a   reduced  fracture involved using  splints .  These are rigid strips laid parallel to each other alongside the bone. The  Ancient Egyptians  used wooden splints made of bark wrapped in linen. They also used stiff bandages for support that were probably derived from  embalming  techniques. The use of plaster of Paris to cover walls is evident, but it seems it was never used for bandages.   Ancient Hindus treated fractures with  bamboo  splints, and the writings of  Hippocrates  discuss management of fractures in some detail, recommending wooden splints plus exercise to prevent muscle  atrophy  during the immobilization.   The  ancient Greeks  also used waxes and resins to create stiffened bandages and the Roman  Celsus , writing in AD 30, describes how to use splints and bandages stiffened with starch.  Arabian  doctors used lime derived from sea shells and albumen from egg whites to stiffen bandages. The Italian School of  Salerno  in the twelfth century recommended bandages hardened with a flour and egg mixture as did  medieval  European bonesetters, who used casts made of egg white, flour, and animal fat. By the sixteenth century the famous French surgeon  Ambroise Paré  (1517–1590), who championed more humane treatments in medicine and promoted the use of artificial limbs, made casts of wax, cardboard, cloth, and parchment that hardened as they dried.


These methods all had merit, but the standard method for the healing of fractures was  bed rest  and restriction of activity. The search for a simpler, less-time-consuming, method led to the development of the first modern occlusive dressings, stiffened at first with starch and later with plaster-of-paris. The ambulatory treatment of fractures was the direct result of these innovations. The innovation of the modern cast can be traced to, among others, four military surgeons,  Dominique Jean Larrey ,  Louis Seutin ,  Antonius Mathijsen , and  Nikolai Ivanovich Pirogov . [ 10 ]


Dominique Jean Larrey  (1768–1842) was born in a small town in southern France. He first studied medicine with his uncle, a surgeon in Toulouse. After a short tour of duty as a naval surgeon, he returned to Paris, where he became caught up in the turmoil of the  French Revolution , being present at the  Storming of the Bastille . From then on, he made his career as a surgeon in France's revolutionary and  Napoleonic armies , which he accompanied throughout Europe and the Middle East. As a result, Larrey accumulated a vast experience of military medicine and surgery.
One of his patients after the  Battle of Borodino  in 1812 was an infantry officer whose arm was amputated at the shoulder. The patient was evacuated immediately following the operation and passed from Russia, through Poland and Germany. When the dressing was removed on his arrival home in France, the wound had healed. Larrey concluded that the fact that the wound had been undisturbed had facilitated healing. After the war, Larrey began stiffening bandages using  camphorated  alcohol,  lead acetate  and egg whites beaten in water.


An improved method was introduced by  Louis Seutin , (1793–1865) of Brussels. In 1815 Seutin had served in the allied armies in the war against Napoleon and was on the field of  Waterloo . At the time of the development of his bandage he was chief surgeon in the Belgium army. Seutin's "bandage amidonnee" consisted of cardboard splints and bandages soaked in a solution of starch and applied wet. These dressings required 2 to 3 days to dry, depending on the temperature and humidity of the surroundings. The substitution of  Dextrin  for starch, advocated by Velpeau, the man widely regarded as the leading French surgeon at the beginning of the 19th century, reduced the drying time to 6 hours. Although this was a vast improvement, it was still a long time, especially in the harsh environment of the battlefield.


A good description of Seutin's technique was provided by  Sampson Gamgee  who learned it from Seutin in France during the winter of 1851–52 and went on to promote its use in Britain. The limb was initially wrapped in wool, especially over any bony prominences. Pasteboard was then cut into shape to provide a splint, and dampened so it could be molded to the limb. The limb was then wrapped in bandages before a starch coating was applied to the outer surface. Seutin's technique for the application of the starch apparatus formed the basis of the technique used with plaster of Paris dressings today. The use of this method led to the early mobilization of patients with fractures and a marked reduction in hospital time required.


Although these bandages were an improvement over Larrey's method, they were far from ideal. They required a long time to apply and dry and there was often shrinkage and distortion. A great deal of interest had been aroused in Europe around 1800 by a British diplomat, consul  William Eton , who described a method of treating fractures that he had observed in Turkey. He noted that  gypsum plaster  (plaster of Paris) was moulded around the patient's leg to cause immobilization. If the cast became loose due to atrophy or a reduction in swelling, then additional gypsum plaster was added to fill the space. Adapting the use of plaster of Paris for use in hospitals, however, took some time. In 1828, doctors in Berlin were treating leg fractures by aligning the bones in a long narrow box, which they filled with moist sand. Substitution of plaster of Paris for the sand was the next logical step. Such plaster casts did not succeed however as the patient was confined to bed due to the casts being heavy and cumbersome.


Plaster of Paris bandages were introduced in different forms by two army surgeons, one at a peacetime home station and another on active service at the front.   Antonius Mathijsen  (1805–1878) was born in  Budel , the Netherlands, where his father was the village doctor. He was educated in Brussels, Maastricht and Utrecht obtaining the degree of doctor of medicine at Gissen in 1837. He spent his entire career as a medical officer in the Dutch Army. While he was stationed at Haarlem in 1851, he developed a method of applying plaster of Paris bandages. A brief note describing his method was published on January 30, 1852; it was followed shortly by more complete accounts. In these accounts Mathijsen emphasised that only simple materials were required and the bandage could be quickly applied without assistance. The bandages hardened rapidly, provided an exact fit and could be windowed or bivalved (cut to provide strain relief) easily. Mathijsen used coarsely woven materials, usually linen, into which dry plaster of Paris had been rubbed thoroughly. The bandages were then moistened with a wet sponge or brush as they were applied and rubbed by hand until they hardened.


Plaster of Paris dressings were first employed in the treatment of mass casualties in the 1850s during the  Crimean War  by  Nikolai Ivanovich Pirogov  (1810–1881). Pirogov was born in Moscow and received his early education there. After obtaining a medical degree at  Dorpat  (now Tartu,  Estonia ) he studied at  Berlin  and  Göttingen  before returning to Dorpat as a professor of Surgery. In 1840, he became the professor of surgery at the academy of military medicine in St. Petersburg. Pirogov introduced the use of  ether  anaesthesia to Russia and made important contributions to the study of cross-sectional human anatomy. With the help of his patron, the grand duchess  Helene Pavlovna , he introduced female nurses into the military hospitals at the same time that  Florence Nightingale  was beginning a similar program in British military hospitals.


Seutin had travelled through Russia demonstrating his 'starched bandage', and his technique had been adopted by both the Russian army and navy by 1837. Pirogov had observed the use of plaster of Paris bandages in the studio of a sculptor who used strips of linen soaked in liquid plaster of Paris for making models (this technique, called " modroc ," is still popular). Pirogov went on to develop his own methods, although he was aware of Mathijsen's work. Pirogov's method involved soaking coarse cloth in a plaster of Paris mixture immediately before application to the limbs, which were protected either by stockings or cotton pads. Large dressings were reinforced with pieces of wood.


As time passed and the method moved more into the mainstream some disagreement arose as to the problems associated with cutting off air to skin contact, and also some improvements were made. Eventually Pirogov's method gave way to Mathijsen's. Among the improvements suggested as early as 1860 was that of making the dressing resistant to water by painting the dried plaster of Paris with a mixture of  shellac  dissolved in alcohol. The first commercial bandages were not produced until 1931 in Germany, and were called Cellona. Before that the bandages were made by hand at the hospitals.


As a plaster cast is applied, it expands by approximately 0.5%. The less water used, the more linear expansion occurs.   Potassium sulfate  can be used as an accelerator and  sodium borate  as a retarder to control setting time. [ citation needed ]


An orthopedic  implant  is a medical device manufactured to replace a missing joint or bone, or to support a damaged bone. [ 1 ]  The medical implant is mainly fabricated using  stainless steel  and  titanium alloys  for strength and the plastic coating that is done on it acts as an  artificial cartilage . [ 2 ]  The biodegradable metals in this category are magnesium-based  [ 3 ]  and iron-based alloys, though recently zinc has also been investigated. [ 4 ]  Currently, the uses of  bioresorbable metals  are as fracture fixation implants [ 5 ] [ 6 ] [ 7 ] [ 8 ]   Internal fixation  is an operation in  orthopedics  that involves the surgical implementation of implants to repair a bone. [ 9 ] [ 10 ]  During the surgery of broken bones through internal fixation the bone fragments are first reduced into their normal alignment then they are held together with the help of internal fixators such as plates,  screws , nails, pins, and wires. [ 11 ] [ 12 ]


Bipolar


Thompson


Accolade


Endo-Model


Attune


Scorpio


Legion


Genesis II


VanguardXP


Persona


PFNA


TFN


PFNA II


Clamp


Trocar


Ilizarov
JET-X


Galaxy


2.7mm Locking


3.5mm Locking


4.5/5.0mm Locking


Condylat Plate


DHC, DCS


Jewett Nail Plate


Monoaxial Screws


Polyaxial Screws


Cages


Mesh


The discipline of orthopedic implants is constantly evolving as new biomaterials become available. An important consideration in this respect is that the health status of the patient influences the optimal choice of the material to be implanten. For instance it was shown that patients with steatotic liver disease benefit from nanohydroxyapatite-coated (nHA) titanium surfaces, whereas this is not necessary for patients without fatty liver disease. [ 39 ]  A  surface engineering  method was developed for biodegradable magnesium alloys to enhance orthopedic implants. [ 40 ]


An  orthopedic plate  is a form of  internal fixation  used in  orthopaedic surgery  to hold  fractures  in place to allow  bone healing [ 1 ]  and to reduce the possibility of  nonunion . Most modern plates include bone screws to help the orthopedic plate stay in place.


Prior to the invention of the orthopedic plate, metal wiring was used to solve the issue of bone fractures until about 1850. It was debated when the first use of this technique was actually made. Supposedly, the first use of this metal wiring was by the ancient Greeks. [ 2 ]  The first recorded use of metal wiring was in 1755 in a French journal. [ 2 ]   It was not until 1870, a Frenchman by the name of Laurent Berenger-Feraud began writing a book on internal fixation and bone fractures called " Traité de l'immobilisation directe des fragments osseux dans les fractures "  (a book on direct immobilization of bone fragments of fractures). [ 2 ]  All the information proved to be beneficial in medical procedures, however one thing lacked, the antiseptic treatments needed to properly administer these techniques. Joseph Lister, a British assistant surgeon who in 1877 tried his techniques on a patient and showed huge success. Carl Hausmann is credited with making the first successful plate using both nickel sheets and screws and creating a method of removal without reopening the wound site in 1886. [ 2 ]  The years following focused on better surgical techniques and experimentation with other materials. Metals were the most common material for orthopedic plates, until cytotoxic tests were used to determine biocompatibility of metals put into the patients body post operation. [ citation needed ]


Modern orthopedic plating did not start until the 1950s where Maurice Muller formed AO/ASIF (Association for the study of internal fixation) along with other surgeons to better improve plating techniques. [ 3 ]  The  purpose of the AO were to better understand bone repair, fracture formation and surgical techniques to gain better results in medical applications. [ 1 ]


Orthopedic plates are designed based on the bone fracture. While the general design is similar, each plate must be manufactured to not only to reduce the fracture but also fit the contour of the patient's bone. [ 5 ]


Protection


Locking plates can be used either to support a locking head screw, or to force bone together at the fracture. Locking head screws can be applied at the fracture, with the orthopedic plate in place to reduce applied force on the bone fracture.


Tension and Compression


Compression plates can be implanted in such a way that it is in tension, forcing the bone together at the fracture. The use of an articulated tension device can also be used to compress the bone together by pulling the compression plate.


Bridging


For fragmentary bone fractures, bridging plates can be used to hold the bone in place when there are no anchor points at the fracture point. Bridging can allow for relative stability along the bone, while not disturbing the bone fragments. [ 6 ]


Buttress


Buttress plates, or concave plates, are useful for fractures along concave surfaces. Due to the angle of the bone,  the contour of the concave plate aligns with the bone, providing even compressive force along the fracture. [ 6 ]


A  splint  is defined as "a rigid or flexible device that maintains in position a displaced or movable part; also used to keep in place and protect an injured part" or as "a rigid or flexible material used to protect, immobilize, or restrict motion in a part". [ 1 ]  Splints can be used for injuries that are not severe enough to immobilize the entire injured structure of the body. For instance, a splint can be used for certain fractures, soft tissue sprains, tendon injuries, or injuries awaiting  orthopedic  treatment. A splint may be static, not allowing motion, or dynamic, allowing controlled motion. Splints can also be used to relieve pain in damaged  joints . Splints are quick and easy to apply and do not require a plastering technique. Splints are often made out of some kind of flexible material and a firm pole-like structure for stability. They often buckle or  Velcro  together.


Splinting has been used since ancient times. Evidence suggests that splint usage dates back to 1500 B.C. that could treat not only fractures but burns as well. [ citation needed ]  These splints were made from materials like, "leaves, reeds, bamboo, and bark padded with linen … [and] copper."  Mummies  from  Egypt  have been uncovered wearing splints from previous injuries that were obtained in their lifetime. Hippocrates, alive from 460 to 377 B.C., was very well known for his discoveries and techniques for splinting. He created a "distraction splint" that was advanced for his time. The splint, made up of leather cuffs that were separated by slim wooden slats, worked to repair the fracture and realign the bones. Around 1000 A.D. the use of  Hippocrates ' splinting technique using plants, like palm branches and cane halves, continued to be practiced. Flour dust, egg whites, and vegetable mixtures were created to form plaster for creating splints. Most splints in ancient times were cast-like and made to immobilize an area of the body. This is illustrated by the  Aztecs  around 1400 A.D. They made splints with leaves, leather, and paste. [ 9 ]


In the early 1500s  gunpowder  was introduced to Europe which caused a serious decline in the market of armor making. Armor makers had to figure out how to make a living with the skills they had already acquired. This led to the creation of braces due to the common use of metal in braces.  Armor makers  were knowledgeable in areas of the exterior  anatomy  and joint alignment, making braces the obvious replacement for their armor making. In 1517, after the evolution of the armor trade, injuries were being treated by metal  braces  secured by screws. Jumping to 1592, the first written piece on splints by surgeon  Hieronymus Fabricius , shows various drawings of armor-like splints for the entire body. [ 9 ]


In the mid-1700s, doctors and mechanics worked with each other to create splints for certain injuries. Surgeons need these mechanics to design and build the splints for them. Most splints were made of metal.  Plaster of Paris , a white powdery substance used mostly for casts and molds in the form of a quick-setting paste with water, began to be used for immobilizing splints. [ 10 ]  This method was not a popular way of splinting as it took too long to dry and suitable fabric was sparse.


In the 1800s it was beginning to be recognized that rehabilitation after an injury was important. Orthopedics started to become a separate field from general surgery. A famous British Surgeon,  Hugh Owen Thomas , created specialty splints that were cheap and best for injuries that were being rehabilitated. By 1883, mechanics and surgeons separated due to class issues. This created two different areas that shaped the way braces were being created and distributed. Around 1888, F. Gustav Ernst, a dedicated mechanic, released a book illustrating upper body splints. In 1899, orthopedic surgeon  Alessandro Codivilla  followed suit and published a book explaining the importance of using surgical procedures to set up better results using splints. [ 9 ]


The  American Joint Replacement Registry  (AJRR) is a non-profit organization established to foster the creation of a national center for data collection, and is dedicated to the improvement in arthroplasty patient care.


In partnership with the  American Academy of Orthopaedic Surgeons  (AAOS), the AJRR was founded in 2009 with the goal to optimize patient outcomes through collection of data on all primary and revision total joint replacement procedures in the U.S., while enhancing patient safety, improving quality of care, and reducing the cost for patients. Since then, the AJRR has grown to over 620 participating hospitals with over 400,000 procedures in their database. [ 1 ]  Both figures are expected to increase by year's end, and will continue to do so as more participants join the registry.


In February 2010, The AAOS ratified the AJRR Board of Directors. In November 2010, AJRR received 501(c)(3) status, and in December 2010, their Business Plan was finalized and approved by the AJRR Board of Directors.


In March 2011, the Pilot Program was initiated, with successful Level I data transmission and collection from pilot sites completed in July of the same year.


In 2012, the national registry software was launched. In August 2012, Jeffrey P. Knezovich, CAE, was hired as AJRR's first Executive Director.


In November 2013, AJRR launched a pilot program of Level II, Level III, and Level IV data collection systems. That pilot study is expected to be concluded by the end of the third quarter 2014.


In February 2014, the AJRR was named to the National Quality Registry Network (NQRN) [1]  Council, an initiative of the  American Medical Association ; and, in May, 2014, the AJRR was named a Qualified Clinical Data Registry (QCDR) by the  Centers for Medicare and Medicaid Services  (CMS).


On January 1, 2015, the AJRR officially became a freestanding association. 2015 also marked the formation of the AJRR User Group Network, the merger of the California Joint Replacement Registry (CJRR) into AJRR, and the enrolling of the 600th hospital. [ 2 ]


(CMS)  [5]   Archived  2018-10-03 at the  Wayback Machine


A  joint replacement registry  is a system of collecting information of  arthroplasty  outcomes at a population (often national) level, in order to provide an evidence-base for safe and effective treatment options.


The UK registry, the NJR, was set up as recommendation of a  Royal College of Surgeons of England  review into the high-profile failure of the  3M  Capital Hip. [ 1 ]


Registers collect information on a combination of  hip replacements ,  knee replacements  (both total and  unicompartmental ),  shoulder replacements ,  ankle replacements  and  elbow  replacements.  Some countries exclude  hemiarthroplasties  done for traumatic  hip fractures .


Initially designed only to record  surgeon  and  implant  performance, the main outcome collected was  implant failure , however recently  patient-reported outcome  measures are being added.


Given the amount of information stored, the data from many of the registries is used as the basis of scientific papers, for example on the  metal-on-metal hip controversy . [ 2 ]


There are currently 31 national members of the International Society of Arthroplasty Registers (ISAR). [ 3 ]   In addition, in the United States, there are 10 regional or private registries collecting data.


The  National Hip Fracture Database  (NHFD) is a nationwide audit within the  NHS  concerning the management and outcomes of patients with  hip fractures .


It was initially set up by the  British Orthopaedic Association  and the  British Geriatrics Society , however it is now commissioned by the  Healthcare Quality Improvement Partnership  (HQIP), a consortium of the  Academy of Medical Royal Colleges  and the  Royal College of Nursing  which holds the contract to manage and develop the  National Clinical Audit and Patient Outcomes Programme  (NCAPOP), as part of the  Falls and Fragility Fracture Audit Programme  (FFFAP) of the  Royal College of Physicians , in association with the  BOA , BGS,  Royal College of Surgeons of England  and the  Falls and Fractures Alliance  (composed of  Age UK  and the  National Osteoporosis Society ).


The NHFD aims to improve the quality and effectiveness of  hip fracture  care by enabling clinical teams to monitor their performance against agreed clinical standards from the  BOA  and BGS 'Blue Book' publication, [ 1 ]  in addition to compliance with  NICE  Guidance 124 - ‘The Management of Hip Fracture in Adults’. [ 2 ]