Orthopaedics
Canadian Orthopaedic Association
Canadian Arthroplasty Society
Arthroscopy Association of Canada
Canadian Orthopaedic Foot and Ankle Society
Canadian Shoulder and Elbow Society
Last updated: May 2024
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Several recent meta-analyses have culminated in clinical practice guidelines recommending against the use of arthroscopic debridement for the treatment of degenerative knee arthritis or degenerative meniscal tears, as it appears there is no maintained benefit of arthroscopic surgery over conservative management (exercise therapy, injections, and drugs). However, this does not preclude the judicious use of arthroscopic surgery when indicated to manage symptomatic co-existing pathology in the presence of osteoarthritis or degeneration.
Sources:
Canadian Arthroplasty Society
Arthroscopy Association of Canada. Position Statement of Arthroscopy Association of Canada (AAC) Concerning Arthroscopy of the Knee Joint [Internet]. September 2017 [cited 2018 Feb].
Brignardello-Petersen R, et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open. 2017 May 11;7(5):e016114. PMID: 28495819.
Khan M,et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ. 2014 Oct 7;186(14):1057-64. PMID: 25157057.
Laupattarakasem W, et al. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005118. PMID: 18254069.
Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015 Jun 16;350:h2747. PMID: 26080045.
Siemieniuk RAC, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 2017 May 10;357:j1982. PMID: 28490431.
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The diagnosis of knee osteoarthritis can be effectively made based upon the patient’s history, physical examination, and plain radiography consisting of weight-bearing posterior-anterior, lateral and skyline views. Ordering MRI scans incurs further waiting times for patients, can cause unnecessary anxiety while waiting for specialist consultation, and can delay MRI imaging for appropriate patients.
Sources:
Arthroscopy Association of Canada
Menashe L, et al. The diagnostic performance of MRI in osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2012 Jan;20(1):13-21. PMID: 22044841.
Sakellariou G, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017 Sep;76(9):1484-1494. PMID: 28389554. https://www.ncbi.nlm.nih.gov/pubmed/28389554
Zhang W, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010 Mar;69(3):483-9. PMID: 19762361. https://www.ncbi.nlm.nih.gov/pubmed/19762361
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The diagnosis of hip osteoarthritis can be effectively made based upon the patient’s history, physical examination and plain radiography. Ordering MRI scans incurs further waiting times for patients, can cause unnecessary anxiety while waiting for specialist consultation, and can delay MRI imaging for appropriate patients.
Sources:
Arthroscopy Association of Canada
Menashe L, et al. The diagnostic performance of MRI in osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2012 Jan;20(1):13-21. PMID: 22044841.
Sakellariou G, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017 Sep;76(9):1484-1494. PMID: 28389554.
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The use of opioids in chronic non-cancer pain is associated with significant risks. Optimization of non-opioid pharmacotherapy and non-pharmacologic therapy is strongly recommended. Treatment with opioids is not superior to treatment with non-opioid medications in improving pain-related function over 12 months in patients with moderate to severe hip, knee or back pain due to osteoarthritis.
Sources:
Arthroscopy Association of Canada
Busse JW, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666. PMID: 28483845.
Krebs EE, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018; 319(9):872–882. PMID: 29509867.
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Several large reviews including thousands of patients have demonstrated that routine pathological examination of operative specimens from uncomplicated primary hip and knee arthroplasty surgeries does not alter patient management or outcome.
Sources:
Campbell ML, et al. Collection of surgical specimens in total joint arthroplasty. Is routine pathology cost effective? J Arthroplasty. J Arthroplasty. 1997 Jan;12(1):60-3. PMID: 9021503.
Kocher MS, et al. Cost and effectiveness of routine pathological examination of operative specimens obtained during primary total hip and knee replacement in patients with osteoarthritis. J Bone Joint Surg Am. 2000 Nov;82-A(11):1531-5. PMID: 11097439.
Lin MM, et al. Histologic examinations of arthroplasty specimens are not cost-effective: a retrospective cohort study. Clin Orthop Relat Res. 2012 May;470(5):1452-60. PMID: 22057818.
Meding JB, et al. Determining the necessity for routine pathologic examinations in uncomplicated total hip and total knee arthroplasties. J Arthroplasty. 2000 Jan;15(1):69-71. PMID: 10654465.
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Since ultrasound is not effective at diagnosing unsuspected deep vein thrombosis (DVT) and appropriate alternative screening tests do not exist, if there is no change in the patient’s clinical status, routine post-operative screening for DVT after hip or knee arthroplasty does not change outcomes or clinical management.
Sources:
Canadian Arthroplasty Society
Abraham P, et al. Does venous microemboli detection add to the interpretation of D-dimer values following orthopedic surgery? Ultrasound Med Biol. 1999 May;25(4):637-40. PMID: 10386740.
American Academy of Orthopaedic Surgeons. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty: Evidence-based guideline and evidence report [Internet]. 2011 Sep [cited 2014 Feb 20].
Bounameaux H, et al. Measurement of plasma D-dimer is not useful in the prediction or diagnosis of postoperative deep vein thrombosis in patients undergoing total knee arthroplasty. Blood Coagul Fibrinolysis. 1998 Nov;9(8):749-52. PMID: 9890718.
Ciccone WJ 2nd, et al. Ultrasound surveillance for asymptomatic deep venous thrombosis after total joint replacement. J Bone Joint Surg Am. 1998 Aug;80(8):1167-74. PMID: 9730126.
Davidson BL, et al. Low accuracy of color Doppler ultrasound in the detection of proximal leg vein thrombosis in asymptomatic high-risk patients. The RD heparin arthroplasty group. Ann Intern Med. 1992 Nov 1;117(9):735-8. PMID: 1416575.
Garino JP, et al. Deep venous thrombosis after total joint arthroplasty. The role of compression ultrasonography and the importance of the experience of the technician. J Bone Joint Surg Am. 1996 Sep;78(9):1359-65. PMID: 8816651.
Larcom PG, et al. Magnetic resonance venography versus contrast venography to diagnose thrombosis after joint surgery. Clin Orthop Relat Res. 1996 Oct;(331)(331):209-15. PMID: 8895640.
Lensing AW, et al. A comparison of compression ultrasound with color Doppler ultrasound for the diagnosis of symptomless postoperative deep vein thrombosis. Arch Intern Med. 1997 Apr 14;157(7):765-8. PMID: 9125008.
Mont MA, et al. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011 Dec;19(12):768-76. PMID: 22134209.
Niimi R, et al. Evaluation of soluble fibrin and D-dimer in the diagnosis of postoperative deep vein thrombosis. Biomarkers. 2010 Mar;15(2):149-57. PMID: 19903012.
Pellegrini VD Jr, et al. The John Charnley Award: Prevention of readmission for venous thromboembolic disease after total hip arthroplasty. Clin Orthop Relat Res. 2005 Dec;441:56-62. PMID: 16330984.
Pellegrini VD Jr, et al. The Mark Coventry Award: Prevention of readmission for venous thromboembolism after total knee arthroplasty. Clin Orthop Relat Res. 2006 Nov;452:21-7. PMID: 16906107.
Robinson KS, et al. Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty: The post-arthroplasty screening study. A randomized, controlled trial. Ann Intern Med. 1997 Sep 15;127(6):439-45. PMID: 9313000.
Schmidt B, et al. Ultrasound screening for distal vein thrombosis is not beneficial after major orthopedic surgery. A randomized controlled trial. Thromb Haemost. 2003 Nov;90(5):949-54. PMID: 14597992.
Westrich GH, et al. The incidence of deep venous thrombosis with color Doppler imaging compared to ascending venography in total joint arthroplasty: A prospective study. Contemp Surg. 1997;51:225-34.
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The use of needle lavage in patients with symptomatic osteoarthritis of the knee does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness or swelling.
Sources:
Canadian Arthroplasty Society
American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (non-arthroplasty): Full guideline [Internet]. 2008 Dec [cited 2014 Feb 20].
Arden NK, et al. A randomised controlled trial of tidal irrigation vs corticosteroid injection in knee osteoarthritis: The KIVIS study. Osteoarthritis Cartilage. 2008 Jun;16(6):733-9. PMID: 18077189.
Bradley JD, et al. Tidal irrigation as treatment for knee osteoarthritis: A sham-controlled, randomized, double-blinded evaluation. Arthritis Rheum. 2002 Jan;46(1):100-8. PMID: 11817581.
Chang RW, et al. A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee. Arthritis Rheum. 1993 Mar;36(3):289-96. PMID: 8452573.
Dawes PT, et al. Saline washout for knee osteoarthritis: Results of a controlled study. Clin Rheumatol. 1987 Mar;6(1):61-3. PMID: 3581699.
Ike RW, et al. Tidal irrigation versus conservative medical management in patients with osteoarthritis of the knee: A prospective randomized study. Tidal Irrigation Cooperating Group. J Rheumatol. 1992 May;19(5):772-9. PMID: 1613709.
Richmond J, et al. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. 2009 Sep;17(9):591-600. PMID: 19726743.
Vad VB, et al. Management of knee osteoarthritis: Knee lavage combined with hylan versus hylan alone. Arch Phys Med Rehabil. 2003 May;84(5):634-7. PMID: 12736873.
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Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic osteoarthritis of the knee.
Sources:
Canadian Arthroplasty Society
American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (non-arthroplasty): Full guideline [Internet]. 2008 Dec [cited 2014 Feb 20].
Altman RD, et al. Effects of a ginger extract on knee pain in patients with osteoarthritis. Arthritis Rheum. 2001 Nov;44(11):2531-8. PMID: 11710709.
Bourgeois P, et al. Efficacy and tolerability of chondroitin sulfate 1200 mg/day vs chondroitin sulfate 3 x 400 mg/day vs placebo. Osteoarthritis Cartilage. 1998 May;6 Suppl A:25-30. PMID: 9743816.
Bucsi L, et al. Efficacy and tolerability of oral chondroitin sulfate as a symptomatic slow-acting drug for osteoarthritis (SYSADOA) in the treatment of knee osteoarthritis. Osteoarthritis Cartilage. 1998 May;6 Suppl A:31-6. PMID: 9743817.
Cibere J, et al. Randomized, double-blind, placebo-controlled glucosamine discontinuation trial in knee osteoarthritis. Arthritis Rheum. 2004 Oct 15;51(5):738-45. PMID: 15478160.
Clegg DO, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006 Feb 23;354(8):795-808. PMID: 16495392.
Das A Jr, et al. Efficacy of a combination of FCHG49 glucosamine hydrochloride, TRH122 low molecular weight sodium chondroitin sulfate and manganese ascorbate in the management of knee osteoarthritis. Osteoarthritis Cartilage. 2000 Sep;8(5):343-50. PMID: 10966840.
Giordano N, et al. The efficacy and tolerability of glucosamine sulfate in the treatment of knee osteoarthritis: A randomized, double-blind, placebo-controlled trial. Curr Ther Res Clin Exper. 2009 Jun;70(3):185-96. PMID: 24683229.
Houpt JB, et al. Effect of glucosamine hydrochloride in the treatment of pain of osteoarthritis of the knee. J Rheumatol. 1999 Nov;26(11):2423-30. PMID: 10555905.
Hughes R, et al. A randomized, double-blind, placebo-controlled trial of glucosamine sulphate as an analgesic in osteoarthritis of the knee. Rheumatology (Oxford). 2002 Mar;41(3):279-84. PMID: 11934964.
Kahan A, et al. Long-term effects of chondroitins 4 and 6 sulfate on knee osteoarthritis: The study on osteoarthritis progression prevention, a two-year, randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2009 Feb;60(2):524-33. PMID: 19180484.
Mazieres B, et al. Chondroitin sulfate in osteoarthritis of the knee: A prospective, double blind, placebo controlled multicenter clinical study. J Rheumatol. 2001 Jan;28(1):173-81. PMID: 11196521.
Mazieres B, et al. Effect of chondroitin sulphate in symptomatic knee osteoarthritis: A multicentre, randomised, double-blind, placebo-controlled study. Ann Rheum Dis. 2007 May;66(5):639-45. PMID: 17204566.
McAlindon T, et al. Effectiveness of glucosamine for symptoms of knee osteoarthritis: Results from an internet-based randomized double-blind controlled trial. Am J Med. 2004 Nov 1;117(9):643-9. PMID: 15501201.
Moller I, et al. Effectiveness of chondroitin sulphate in patients with concomitant knee osteoarthritis and psoriasis: A randomized, double-blind, placebo-controlled study. Osteoarthritis Cartilage. 2010 Jun;18 Suppl 1:S32-40. PMID: 20399899.
Noack W, et al. Glucosamine sulfate in osteoarthritis of the knee. Osteoarthritis Cartilage. 1994 Mar;2(1):51-9. PMID: 11548224.
Pavelka K Jr, et al. Glycosaminoglycan polysulfuric acid (GAGPS) in osteoarthritis of the knee. Osteoarthritis Cartilage. 1995 Mar;3(1):15-23. PMID: 7536623.
Pavelka K, et al. Efficacy and safety of piascledine 300 versus chondroitin sulfate in a 6 months treatment plus 2 months observation in patients with osteoarthritis of the knee. Clin Rheumatol. 2010 Jun;29(6):659-70. PMID: 20179981.
Rai J, et al. Efficacy of chondroitin sulfate and glucosamine sulfate in the progression of symptomatic knee osteoarthritis: A randomized, placebo-controlled, double blind study [Internet]. 2004 January [cited 2014 Feb 20].
Richmond J, et al. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. 2009 Sep;17(9):591-600. PMID: 19726743.
Rindone JP, et al. Randomized, controlled trial of glucosamine for treating osteoarthritis of the knee. West J Med. 2000 Feb;172(2):91-4. PMID: 10693368.
Samson DJ, et al. Treatment of primary and secondary osteoarthritis of the knee. 2007 Sep 1. Report No.: 157. PMID: 18088162.
Tao QW, et al. Clinical efficacy and safety of gubitong recipe () in treating osteoarthritis of knee joint. Chin J Integr Med. 2009 Dec;15(6):458-61. PMID: 20082253.
Trc T, et al. Efficacy and tolerance of enzymatic hydrolysed collagen (EHC) vs. glucosamine sulphate (GS) in the treatment of knee osteoarthritis (KOA). Int Orthop. 2011 Mar;35(3):341-8. PMID: 20401752.
Uebelhart D, et al. Intermittent treatment of knee osteoarthritis with oral chondroitin sulfate: A one-year, randomized, double-blind, multicenter study versus placebo. Osteoarthritis Cartilage. 2004 Apr;12(4):269-76. PMID: 15023378.
Zakeri Z, et al. Evaluating the effects of ginger extract on knee pain, stiffness and difficulty in patients with knee osteoarthritis [Internet]. 2011 Aug 4 [cited 2014 Feb 20].
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In patients with symptomatic osteoarthritis of the knee, the use of lateral wedge or neutral insoles does not improve pain or functional outcomes. Comparisons between lateral and neutral heel wedges were investigated, as were comparisons between lateral wedged insoles and lateral wedged insoles with subtalar strapping. The systematic review concludes that there is only limited evidence for the effectiveness of lateral heel wedges and related orthoses. In addition, the possibility exists that those who do not use them may experience fewer symptoms from osteoarthritis of the knee.
Sources:
Canadian Arthroplasty Society
American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (non-arthroplasty): Full guideline [Internet]. 2008 Dec [cited 2014 Feb 20].
Baker K, et al. A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis. Arthritis Rheum. 2007 Apr;56(4):1198-203. PMID: 17393448.
Bennell KL, et al. Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial. BMJ. 2011 May 18;342:d2912. PMID: 21593096.
Brouwer RW, et al. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev. 2005 Jan 25;(1)(1):CD004020. PMID: 15674927.
Maillefert JF, et al. Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis: A prospective randomized controlled study. Osteoarthritis Cartilage. 2001 Nov;9(8):738-45. PMID: 11795993.
Nigg BM, et al. Unstable shoe construction and reduction of pain in osteoarthritis patients. Med Sci Sports Exerc. 2006 Oct;38(10):1701-8. PMID: 17019290.
Pham T, et al. Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis. A two-year prospective randomized controlled study. Osteoarthritis Cartilage. 2004 Jan;12(1):46-55. PMID: 14697682.
Richmond J, et al. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. 2009 Sep;17(9):591-600. PMID: 19726743.
Toda Y, et al. Usefulness of an insole with subtalar strapping for analgesia in patients with medial compartment osteoarthritis of the knee. Arthritis Rheum. 2002 Oct 15;47(5):468-73. PMID: 12382293.
Toda Y, et al. Effect of a novel insole on the subtalar joint of patients with medial compartment osteoarthritis of the knee. J Rheumatol. 2001 Dec;28(12):2705-10. PMID: 11764221.
Toda Y, et al. A 2-year follow-up of a study to compare the efficacy of lateral wedged insoles with subtalar strapping and in-shoe lateral wedged insoles in patients with varus deformity osteoarthritis of the knee. Osteoarthritis Cartilage. 2006 Mar;14(3):231-7. PMID: 16271485.
Toda Y, et al. A comparative study on the effect of the insole materials with subtalar strapping in patients with medial compartment osteoarthritis of the knee. Mod Rheumatol. 2004 Dec;14(6):459-65. PMID: 24387723.
Toda Y, et al. A six-month followup of a randomized trial comparing the efficacy of a lateral-wedge insole with subtalar strapping and an in-shoe lateral-wedge insole in patients with varus deformity osteoarthritis of the knee. Arthritis Rheum. 2004 Oct;50(10):3129-36. PMID: 15476225.
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Routine post-operative splinting of the wrist after the carpal tunnel release procedure showed no benefit in grip or lateral pinch strength or bowstringing. In addition, the research showed no effect in complication rates, subjective outcomes or patient satisfaction. Clinicians may wish to provide protection for the wrist in a working environment or for temporary protection. However, objective criteria for their appropriate use do not exist. Clinicians should be aware of the detrimental effects including adhesion formation, stiffness and prevention of nerve and tendon movement.
Sources:
American Academy of Orthopaedic Surgeons. Clinical practice guideline on the treatment of carpal tunnel syndrome [Internet]. 2008 Sep [cited 2014 Feb 20].
Bury TF, et al. Prospective, randomized trial of splinting after carpal tunnel release. Ann Plast Surg. 1995 Jul;35(1):19-22. PMID: 7574280.
Cook AC, et al. Early mobilization following carpal tunnel release. A prospective randomized study. J Hand Surg Br. 1995 Apr;20(2):228-30. PMID: 7797977.
Fagan DJ, et al. A controlled clinical trial of postoperative hand elevation at home following day-case surgery. J Hand Surg Br. 2004 Oct;29(5):458-60. PMID: 15336749.
Finsen V, et al. No advantage from splinting the wrist after open carpal tunnel release. A randomized study of 82 wrists. Acta Orthop Scand. 1999 Jun;70(3):288-92. PMID: 10429608.
Hochberg J. A randomized prospective study to assess the efficacy of two cold-therapy treatments following carpal tunnel release. J Hand Ther. 2001 Jul-Sep;14(3):208-15. PMID: 11511016.
Jeffrey SL, et al. Use of arnica to relieve pain after carpal-tunnel release surgery. Altern Ther Health Med. 2002 Mar-Apr;8(2):66-8. PMID: 11892685.
Martins RS, et al. Wrist immobilization after carpal tunnel release: A prospective study. Arq Neuropsiquiatr. 2006 Sep;64(3A):596-9. PMID: 17119800.
Provinciali L, et al. Usefulness of hand rehabilitation after carpal tunnel surgery. Muscle Nerve. 2000 Feb;23(2):211-6. PMID: 10639613.
Related Resources:
Patient Decision Aid: Carpal tunnel syndrome – treatment options
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Ankle sprains and Achilles tendon ruptures are diagnosed by a history and physical examination. Further imaging is not necessary when a classic clinical picture is present and do not change management for these injuries. These injuries can often be treated nonoperatively if diagnosed early and further imaging may lead to delayed treatment. In particular for Achilles tendon ruptures, walking on the injury during the wait for further imaging can result in higher risk surgery with less predictable outcomes.
Sources:
Canadian Orthopaedic Foot and Ankle Society
Ivins D. Acute ankle sprain: an update. Am Fam Physician. 2006 Nov 15;74(10):1714-20. PMID: 17137000.
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When neuroma resection is performed by an experienced surgeon and the anatomical appearance of the specimen is not unexpected, pathological examination is not necessary and does not change management. If the surgical findings are atypical, pathological examination may be useful and performed.
Sources:
Canadian Orthopaedic Foot and Ankle Society
Raouf T, Rogero R, McDonald E, Fuchs D et al. Value of Preoperative Imaging and Intraoperative Histopathology in Morton’s Neuroma. Foot Ankle Int. 2019 Sep;40(9):1032-1036. doi: 10.1177/1071100719851121. Epub 2019 May 29. PMID: 31142153.
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When patients are seeking care related to their foot and ankle, weight bearing radiographs should be ordered. Non-weight bearing x-rays underestimate the pathology (arthritis or deformity) and lead to further potentially unnecessary testing and increased unnecessary costs.
Sources:
Canadian Orthopaedic Foot and Ankle Society
Boszczyk, A., Kwapisz, S., Kiciński, M. et al. Non-weightbearing compared with weightbearing x-rays in hallux valgus decision-making. Skeletal Radiol 49, 1441–1447 (2020). PMID: 32318757.
Guo, C., Zhu, Y., Hu, M. et al. Reliability of measurements on lateral ankle radiographs. BMC Musculoskelet Disord 17, 297 (2016). PMID: 27431806.
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Compared to cemented fixation, cementless fixation results in increased revision risk, increased risk of periprosthetic fracture and no reduction in mortality risk. There have been many studies on the outcomes of patients with femoral neck fractures. These studies and subsequent meta analysis in conjunction with international registry data has led to multiple guidelines recommending the use of cemented stems when performing arthroplasty. The use of cemented stems results in a lower risk of revision, lower risk of periprosthetic fracture, and no benefit in mortality risk. These findings are similar to Canadian data demonstrating an increased revision risk with cementless fixation that is independent of individual surgeon volume, and increased mortality with cementless fixation.
Sources:
Canadian Arthroplasty Society
NICE Guideline Hip Fracture: Management. Published 22 June 2011, updated May 2017. Accessed March 1, 2022
American Academy of Orthopaedic Surgeons Management of Hip Fractures in Older Adults Evidence Based Clinical Practice Guideline. Published December 3, 2021.Accessed March 1, 2022
Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group. Australian and New Zealand Guideline for Hip Fracture Care: Improving Outcomes in Hip Fracture Management of Adults. Sydney: Australian and New Zealand Hip Fracture Registry Steering Group; 2014. Accessed 1 March 2022
Lewis SR, Macey R, Parker MJ, Cook JA, Griffin XL. Arthroplasties for hip fracture in adults. Cochrane Database Syst Rev. 2022 Feb 14;2(2):CD013410. PMID: 35156194.
Viberg B, Pedersen AB, Kjærsgaard A, Lauritsen J, Overgaard S. Risk of mortality and reoperation in hip fracture patients undergoing cemented versus uncemented hemiarthroplasty : a population-based study from Danish National Registries. Bone Joint J. 2022 Jan;104-B(1):127-133. PMID: 34969285.
Huddleston JI 3rd, De A, Jaffri H, Barrington JW, Duwelius PJ, Springer BD. Cementless Fixation Is Associated With Increased Risk of Early and All-Time Revision After Hemiarthroplasty But Not After THA for Femoral Neck Fracture: Results From the American Joint Replacement Registry. Clin Orthop Relat Res. 2021 Oct 1;479(10):2194-2202. PMID: 34398846.
Okike K, Chan PH, Prentice HA, Paxton EW, Burri RA. Association Between Uncemented vs Cemented Hemiarthroplasty and Revision Surgery Among Patients With Hip Fracture. JAMA. 2020 Mar 17;323(11):1077-1084. PMID: 32181848.
Nantha Kumar N, Kunutsor SK, Fernandez MA, Dominguez E, Parsons N, Costa ML, Whitehouse MR. Effectiveness and safety of cemented and uncemented hemiarthroplasty in the treatment of intracapsular hip fractures. Bone Joint J. 2020 Sep;102-B(9):1113-1121. PMID: 32862675.
Canadian Institute for Health Information. Hip and Knee Replacements in Canada: CJRR Revision Risk Curves, 2019–2020 — Data Tables. Ottawa, ON: CIHI; 2021; accessed 1 March 2022
Richardson CG, Lethbridge LN, Dunbar MJ. Increased Mortality with the Use of Cementless Fixation for Femoral Neck Fractures: Analysis of 5883 Hip Arthroplasty Cases. J Arthroplasty. 2020 Dec;35(12):3627-3630. Epub 2020 Jul 7. PMID: 32753265.
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Routine imaging is not recommended for patients with non-traumatic shoulder pain. If movement is significantly restricted, symptoms are not improving or if suspecting traumatic pathology, then x-ray is encouraged as the initial investigation. A three-view x-ray series (AP, lateral and axillary views) is recommended. Ultrasound and MRI are not recommended for those with shoulder pain unless malignancy is suspected.
Sources:
Canadian Shoulder and Elbow Society
Cuff A, Parton S, Tyer R, Dikomitis L, Foster N, Littlewood C. Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review. Musculoskeletal Care. 2020 Dec;18(4):546-554. PMID: 32755058.
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The CSES recently completed a Systematic Review and Position Statement on lateral epicondylitis. There is ongoing controversy regarding the non-operative treatment of lateral epicondylitis. All English-language randomized trials comparing non-operative treatment of patient > 18 years of age with lateral epicondylitis were included. The available evidence does not support the use of non-operative treatment options including corticosteroids, PRP, or AB in the treatment of lateral epicondylitis.
Sources:
Canadian Shoulder and Elbow Society
Lapner P, Alfonso A, Hebert-Davies J, Pollock JW, Marsh J, King GJW; Canadian Shoulder and Elbow Society (CSES). Nonoperative treatment of lateral epicondylitis: a systematic review and meta-analysis. JSES Int. 2021 Dec 18;6(2):321-330. doi: 10.1016/j.jseint.2021.11.010. PMID: 35252934.
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Disposal of non-contaminated waste leads to CO2 emissions due to the need for high-temperature incineration. The carbon footprint of disposal of biohazardous clinical waste via high temperature incineration is 1074 kg CO2e/ton compared to regular waste (172–249 kg CO2e/ton) and recycling (21–65 kg CO2e). Various studies have shown that non-contaminated waste generated in the operating room during a primary joint replacement is on average between 5.2 kg and 6.2 kg. Thus, implementing correct waste segregation practices of non-contaminated materials, will aid in reducing the overall impact of emissions on the environment.
Sources:
Rizan, C., Bhutta, M. F., Reed, M., & Lillywhite, R. (2021). The carbon footprint of waste streams in a UK hospital. Journal of Cleaner Production, 286, 125446.
Kooner S, Hewison C, Sridharan S, Lui J, Matthewson G, Johal H, Clark M. Waste and recycling among orthopedic subspecialties. Can J Surg June 01, 2020 63 (3) E278-E283. https://doi.org/10.1503/cjs.018018. PMID: 32437094.
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Recommendations 1-5
The Canadian Orthopaedic Association (COA) developed recommendations 1-5 in early 2018 in collaboration with the Canadian Arthroplasty Society (CAS) and the Arthroscopy Association of Canada (AAC). Recommendation 1 arises from the position statement from the AAC concerning arthroscopy of the knee joint. Recommendations 2, 3 and 5 were brought forth by members of the CAS at their Annual Meeting in 2017. Recommendation 4 was brought forth by members of the COA Standards Committee following the COA Annual Meeting in June 2017.
Recommendations 6-10
Recommendations 6-10 were published before 1-5 in April 2014. COA established its first list Choosing Wisely Canada Top 5 recommendations by asking its National Standards Committee to review the evidence base associated with the five treatments and procedures chosen by the American Academy of Orthopaedic Surgeons for the Choosing Wisely® campaign in the United States. Satisfied that the list was relevant to the Canadian clinical context, the Committee recommended its adoption to the COA’s Executive Committee, and the motion was then unanimously approved by the Board of Directors. Therefore, all five items were adopted with permission from the Five Things Physicians and Patients Should Question, © 2013 American Academy of Orthopaedic Surgeons.
Recommendations 11-16
The COA recently formed a Subspecialty Society Council, in which all affiliated Subspecialty Societies are represented by their President or a member of the Executive. This Council encouraged the Subspecialty Society members to forward their recommendations and references for review. As clinical and practical experts in their field, the COA has endorsed these recommendations based on past position statements and publications.
Sources:
Canadian Arthroplasty Society
Arthroscopy Association of Canada. Position Statement of Arthroscopy Association of Canada (AAC) Concerning Arthroscopy of the Knee Joint [Internet]. September 2017 [cited 2018 Feb].
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Arthroscopy Association of Canada
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Arthroscopy Association of Canada
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Arthroscopy Association of Canada
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Canadian Arthroplasty Society
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Canadian Arthroplasty Society
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Canadian Arthroplasty Society
American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (non-arthroplasty): Full guideline [Internet]. 2008 Dec [cited 2014 Feb 20].
Altman RD, et al. Effects of a ginger extract on knee pain in patients with osteoarthritis. Arthritis Rheum. 2001 Nov;44(11):2531-8. PMID: 11710709.
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Richmond J, et al. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. 2009 Sep;17(9):591-600. PMID: 19726743.
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Trc T, et al. Efficacy and tolerance of enzymatic hydrolysed collagen (EHC) vs. glucosamine sulphate (GS) in the treatment of knee osteoarthritis (KOA). Int Orthop. 2011 Mar;35(3):341-8. PMID: 20401752.
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Canadian Arthroplasty Society
American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee (non-arthroplasty): Full guideline [Internet]. 2008 Dec [cited 2014 Feb 20].
Baker K, et al. A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis. Arthritis Rheum. 2007 Apr;56(4):1198-203. PMID: 17393448.
Bennell KL, et al. Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial. BMJ. 2011 May 18;342:d2912. PMID: 21593096.
Brouwer RW, et al. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev. 2005 Jan 25;(1)(1):CD004020. PMID: 15674927.
Maillefert JF, et al. Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis: A prospective randomized controlled study. Osteoarthritis Cartilage. 2001 Nov;9(8):738-45. PMID: 11795993.
Nigg BM, et al. Unstable shoe construction and reduction of pain in osteoarthritis patients. Med Sci Sports Exerc. 2006 Oct;38(10):1701-8. PMID: 17019290.
Pham T, et al. Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis. A two-year prospective randomized controlled study. Osteoarthritis Cartilage. 2004 Jan;12(1):46-55. PMID: 14697682.
Richmond J, et al. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. 2009 Sep;17(9):591-600. PMID: 19726743.
Toda Y, et al. Usefulness of an insole with subtalar strapping for analgesia in patients with medial compartment osteoarthritis of the knee. Arthritis Rheum. 2002 Oct 15;47(5):468-73. PMID: 12382293.
Toda Y, et al. Effect of a novel insole on the subtalar joint of patients with medial compartment osteoarthritis of the knee. J Rheumatol. 2001 Dec;28(12):2705-10. PMID: 11764221.
Toda Y, et al. A 2-year follow-up of a study to compare the efficacy of lateral wedged insoles with subtalar strapping and in-shoe lateral wedged insoles in patients with varus deformity osteoarthritis of the knee. Osteoarthritis Cartilage. 2006 Mar;14(3):231-7. PMID: 16271485.
Toda Y, et al. A comparative study on the effect of the insole materials with subtalar strapping in patients with medial compartment osteoarthritis of the knee. Mod Rheumatol. 2004 Dec;14(6):459-65. PMID: 24387723.
Toda Y, et al. A six-month followup of a randomized trial comparing the efficacy of a lateral-wedge insole with subtalar strapping and an in-shoe lateral-wedge insole in patients with varus deformity osteoarthritis of the knee. Arthritis Rheum. 2004 Oct;50(10):3129-36. PMID: 15476225.
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Related Resources:
Patient Decision Aid: Carpal tunnel syndrome – treatment options
Canadian Orthopaedic Foot and Ankle Society
Ivins D. Acute ankle sprain: an update. Am Fam Physician. 2006 Nov 15;74(10):1714-20. PMID: 17137000.
Canadian Orthopaedic Foot and Ankle Society
Raouf T, Rogero R, McDonald E, Fuchs D et al. Value of Preoperative Imaging and Intraoperative Histopathology in Morton’s Neuroma. Foot Ankle Int. 2019 Sep;40(9):1032-1036. doi: 10.1177/1071100719851121. Epub 2019 May 29. PMID: 31142153.
Canadian Orthopaedic Foot and Ankle Society
Boszczyk, A., Kwapisz, S., Kiciński, M. et al. Non-weightbearing compared with weightbearing x-rays in hallux valgus decision-making. Skeletal Radiol 49, 1441–1447 (2020). PMID: 32318757.
Guo, C., Zhu, Y., Hu, M. et al. Reliability of measurements on lateral ankle radiographs. BMC Musculoskelet Disord 17, 297 (2016). PMID: 27431806.
Canadian Arthroplasty Society
NICE Guideline Hip Fracture: Management. Published 22 June 2011, updated May 2017. Accessed March 1, 2022
American Academy of Orthopaedic Surgeons Management of Hip Fractures in Older Adults Evidence Based Clinical Practice Guideline. Published December 3, 2021.Accessed March 1, 2022
Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group. Australian and New Zealand Guideline for Hip Fracture Care: Improving Outcomes in Hip Fracture Management of Adults. Sydney: Australian and New Zealand Hip Fracture Registry Steering Group; 2014. Accessed 1 March 2022
Lewis SR, Macey R, Parker MJ, Cook JA, Griffin XL. Arthroplasties for hip fracture in adults. Cochrane Database Syst Rev. 2022 Feb 14;2(2):CD013410. PMID: 35156194.
Viberg B, Pedersen AB, Kjærsgaard A, Lauritsen J, Overgaard S. Risk of mortality and reoperation in hip fracture patients undergoing cemented versus uncemented hemiarthroplasty : a population-based study from Danish National Registries. Bone Joint J. 2022 Jan;104-B(1):127-133. PMID: 34969285.
Huddleston JI 3rd, De A, Jaffri H, Barrington JW, Duwelius PJ, Springer BD. Cementless Fixation Is Associated With Increased Risk of Early and All-Time Revision After Hemiarthroplasty But Not After THA for Femoral Neck Fracture: Results From the American Joint Replacement Registry. Clin Orthop Relat Res. 2021 Oct 1;479(10):2194-2202. PMID: 34398846.
Okike K, Chan PH, Prentice HA, Paxton EW, Burri RA. Association Between Uncemented vs Cemented Hemiarthroplasty and Revision Surgery Among Patients With Hip Fracture. JAMA. 2020 Mar 17;323(11):1077-1084. PMID: 32181848.
Nantha Kumar N, Kunutsor SK, Fernandez MA, Dominguez E, Parsons N, Costa ML, Whitehouse MR. Effectiveness and safety of cemented and uncemented hemiarthroplasty in the treatment of intracapsular hip fractures. Bone Joint J. 2020 Sep;102-B(9):1113-1121. PMID: 32862675.
Canadian Institute for Health Information. Hip and Knee Replacements in Canada: CJRR Revision Risk Curves, 2019–2020 — Data Tables. Ottawa, ON: CIHI; 2021; accessed 1 March 2022
Richardson CG, Lethbridge LN, Dunbar MJ. Increased Mortality with the Use of Cementless Fixation for Femoral Neck Fractures: Analysis of 5883 Hip Arthroplasty Cases. J Arthroplasty. 2020 Dec;35(12):3627-3630. Epub 2020 Jul 7. PMID: 32753265.
Canadian Shoulder and Elbow Society
Cuff A, Parton S, Tyer R, Dikomitis L, Foster N, Littlewood C. Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review. Musculoskeletal Care. 2020 Dec;18(4):546-554. PMID: 32755058.
Canadian Shoulder and Elbow Society
Lapner P, Alfonso A, Hebert-Davies J, Pollock JW, Marsh J, King GJW; Canadian Shoulder and Elbow Society (CSES). Nonoperative treatment of lateral epicondylitis: a systematic review and meta-analysis. JSES Int. 2021 Dec 18;6(2):321-330. doi: 10.1016/j.jseint.2021.11.010. PMID: 35252934.
Rizan, C., Bhutta, M. F., Reed, M., & Lillywhite, R. (2021). The carbon footprint of waste streams in a UK hospital. Journal of Cleaner Production, 286, 125446.
Kooner S, Hewison C, Sridharan S, Lui J, Matthewson G, Johal H, Clark M. Waste and recycling among orthopedic subspecialties. Can J Surg June 01, 2020 63 (3) E278-E283. https://doi.org/10.1503/cjs.018018. PMID: 32437094.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
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Canadian Orthopaedic Association
Canadian Paediatric Orthopaedic Group
Last updated: February 2023
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Hip dysplasia/dislocation is relatively rare, with incidence of approximately 7 per 1,000 births. Studies have shown that universal screening programs for developmental hip instability using ultrasounds to assess otherwise normal appearing hips have a nearly negligible positive yield. There is a substantial false positive rate. When there are no physical findings or underlying risk factors for hip dysplasia/dislocation in a newborn, a hip ultrasound is costly, time-intensive and the findings may be misleading to parents and physicians.
Sources:
Mahan ST, Katz JN, Kim YJ. To screen or not to screen? A decision analysis of the utility of screening for developmental dysplasia of the hip. J Bone Joint Surg Am. 2009 Jul:91(7):1705-1719. PMID: 19571094.
Laborie LB, Markestad TH, Davidsen H. Bruras KR, Aukland SM, Bjorlykke JA, Reigstad H. Indrekvam K, Lehmann TG, Engesaeter IO, Engesaeter LB, Rosendahl K. Selective ultrasound screening for developmental hip dysplasia: effect on management and late detected cases. A prospective study during 1991-2006. Pediatri Radiol. 2014 Apr;44 (4): 410-424. PMID: 24337789.
Shorter D, Hong T, Osborn DA. Cochrane Review: Screening programs for developmental dysplasia of the hip in newborn infants. Evid Based Child Health. 2013; 8(1): 11-54. PMID: 23878122.
Shaw BA, Segal LS, Section on Orthopaedics. Evaluation and referral for developmental dysplasia of the hip in infants. Pediatrics 2016; 138(6). PMID: 27940740.
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Mild in-toeing is usually a physiologic phenomenon reflecting ongoing maturation of the skeleton. Metatarsus adductus, femoral anteversion, and tibial torsion all contribute to in-toeing and tend to improve with growth. Simply monitoring gait for continued improvement at normal well child examination intervals is adequate until the age of 7–8 unless there is severe tripping and falling or asymmetry. It is not possible to alter the natural evolution using physical therapy, bracing or shoe inserts.
Sources:
Fabry G, Cheng LX, Molenaers G. Normal and abnormal torsional development in children. Clinical Orthopaedics and Related Research. May 1994; (301):22-26. PMID: 8168306.
Fabry G, MacEwen GD, Sharnds AR, Jr. Torsion of the femur: A follow up study in normal and abnormal conditions. J Bone Joint Surg. Am. Dec 1973;55(8):1726-1738. PMID: 4804993.
Lincoln TL. Suen PW. Common rotational variations in children. The Journal of the American Academy of Orthopaedic Surgeons. Sep-Oct 2003; 11(5):312-320. PMID: 14565753.
Staheli LT. Corbett M. Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. Jan 1985;67(1):39-47. PMID: 3968103.
Svenningsen S. Apalset K. Terjesen T, Anda S. Regression of femoral anteversion. A prospective study of in-toeing of children. Acta Orthopaedica Scandinavica. Apr 1989;60(2):170-173. PMID: 2728876.
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Flexible flat feet are normal physiologic variants commonly found in children and adults. Unlike a painful or rigid flatfoot that requires further workup, if an arch is present when standing on tiptoe, the foot can be managed with observation or over-the-counter orthotics. The use of custom orthotic devices to provide support for the foot does not aid in the development of the arch.
Sources:
Wenger DR, Mauldin D, Speck G. Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am. 1989 Jul;71(6):800-810. PMID: 2663868.
Staheli LT, Chew DE, Corbett M. The longitudinal arch: A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am. 1987 Mar;69(3):426-428. PMID: 3818704.
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History, physical examination, and appropriate radiographs remain the primary diagnostic modalities in pediatric orthopaedics, as they are both diagnostic and prognostic for the great majority of pediatric musculoskeletal conditions. Examples of such conditions would include the work up of injury or pain (spine, knees and ankles), possible infection, and deformity. MRI examinations and other advanced imaging studies are costly and frequently require sedation in the young child (under 5 years old) Additionally, a significant dose of radiation is delivered to the patient during a CT scan.
Sources:
Piccolo CL, Galluzzo M, Ianniello S, Trinci M, Russo A, Rossi E, Zecconlini M, Laporta A, Guglielmi G, Muiele V. Pediatric musculosketetal injuries: role of ultrasound and magnetic resonance imaging. Mesculoskelet Surg. 2017 Mar; 101(Supple 1):85-102. PMID: 28155066.
LaBella CR, Hennrikus W, Hewett TE. Anterior cruciate ligament Injuries: Diagnosis, Treatment, and Prevention. Pediatrics 2014;133(5):e1437-e1450. PMID: 24777218.
Tuite MJ, Kransdort MJ, Beaman FD, Adler RS, Amini B, Appel M, Bernard SA, Dempsey ME, Fries IB, Greenspan BS, Khurana B, Mosher TJ, Walker EA, Ward RJ, Wessell DE, Weissman BN. ACR. Appropriateness Criteria® Acute Trauma to the Knee. American College of Radiology. Revised 2014.
Deyle GD. The role of MRI in musculoskeletal practice: a clinical perspective. J Man Manip Ther. 2011 Aug;19(3):152-161 PMID: 22851878.
Bateni C, Bindra J, Haus B. MRI of sports injuries in children and adolescents: what’s different from adults. Current Radiology Reports. 2014;2:45.
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Buckle (torus) fractures are very common injuries in young children, especially in the distal radius These fractures are inherently stable and do not necessarily require a formal cast, unless severe pain or fracture instability necessitates a cast for 4 weeks. Instead immobilization with a simple wrist brace or removable splint is often preferable. If the fracture is non-tender to palpation at 4 weeks post-injury, no follow-up radiograph is required, and full activities may be resumed.
Sources:
Symons S. Rowsell M, Bhowal B, Diass JJ. Hospital versus home management of children with buckle factures of the distal radius: A prospective randomized trial. J Bone Joint Surg Br. 2001;83:556-560. PMID: 11380131.
Van Bosse HJ, Patel RJ, Thacker M, Sala DA. Minimalistic approach to treating wrist torus fractures. J Pediatric Orthop. 2005 Jul-Aug;25(4):495-500. PMID: 15958903.
Williams KG, Smith G, Luhmann SJ, Mao J, Gunn JD 3rd, Luhmann JD. A randomized controlled trial of cast versus splint for distal radial buckle fracture: an evaluation of satisfaction, convenience, and preference. Pediatr Emerg Care. 2013 May;29(5):555-9. doi: 10.1097/PEC.0b013e31828e56fb. PMID: 23603644.
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The COA recently formed a Subspecialty Society Council, in which all affiliated Subspecialty Societies are represented by their President or a member of the Executive. This Council encouraged the Subspecialty Society members to forward their recommendations and references for review. As clinical and practical experts in their field, the COA has endorsed these recommendations based on past position statements and publications.
Sources:
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