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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/web/20081012064034im_/http://www.bmj.com/icons/misc/sectionDOWN.gif)
Community treatment of fractures
- Mr Peter John Kenyon (25 September 2007)
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Immobilisation as Appropriate
- Hussain A Kazi (26 September 2007)
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A total red herring
- peter j mahaffey (28 September 2007)
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dumbing down?
- ben dean (30 September 2007)
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Expertise and evidence must learn to work together
- Paul Glasziou (1 October 2007)
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The case for specialist treatment
- Margaret M McQueen (3 October 2007)
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evidence
- ben dean (8 October 2007)
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The use of Evidence Based Medicine in clinical practice
- Emma Stapleton (8 October 2007)
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Appropriate, no universal, referal please
- Paul P Glasziou (11 October 2007)
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Join the dots
- ben dean (26 October 2007)
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Factures and Immobilization
- Mehdi Tofighi, Elefterios Tsiridis (16 April 2008)
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Mr Peter John Kenyon, Orthopaedic Trainee Wirral University Teaching Hospital
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The author of the article entitled "Do all fractures need full immobilisation?" has successfully highlighted the possible dangers of fracture management in the community. The author describes the assessment of an xray report for a radial head fracture with a possible delay in treatment (not mentioned), however they do not stress the need for further clinical and radiological assessment in these patients. For example, this type of "minor" fracture although initially undisplaced, if treated as was done so without immobilisation, could displace or become unstable creating a possible need for operative intervention. As the author has stated, immobilisation of this type of fracture may lead to some stiffness, however I am sure that the patient would recover much quicker from this than perhaps a radial head repair or replacement. The sensible option in these type of patients is not just a quick literature search but a conscious effort for follow up in specialist fracture clinics, thus avoiding the need for operative intervention and potential litigation. Competing interests: None declared |
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Hussain A Kazi, SpR Trauma and Orthopaedics Leighton Hospital, Crewe CW1 4QJ
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I read the article "Do all fractrues need immobilisation?" with great interest. It did however raise several points which need to be addressed. Firstly, whilst a radiology report is useful it is no substitute for review of the x-rays by someone who is experienced in both the images concerned and the management of the injury. As far as short arm plasters being superior to long arm (above elbow), this depends on the injury concerned. Most orthopeadic surgeons have experience of paediatric forearm fractures which displace and then require remanipulation as a result of a short cast being applied. The author also "coins" the mnemonic MICE (mobilisation, ice, compression, elevation) rather than RICE (rest, ice, compression, elevation). This is essentially the ethos of modern orthopaedic surgery. Whether fractures be managed conservatively or operatively our aim is for mobilisation as soon as applicable (when the fracture is stable and redution satisfactory). In some fractures absolute stability cannot be achieved and therefore relative stability is accepted and the fracture protected until healing, in which case full mobilisation is not encouraged. Unfortunately the subplot of the article is that we use rules of thumb as we are too lazy to review the evidence. I am sure he will find that in most fracture clinics these decisions are made on a case by case basis, taking into consideration the evidence, patient characteristics and availability of follow up. Competing interests: None declared |
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peter j mahaffey, consultant plastic and hand surgeon bedford hospital
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Paul Glasziou article encapsulates much that is wrong with our declining health service. And speaking as he does of fractures, a health service in which not a single high profile Premiership footballer any longer has the confidence to have his treatment in the UK. What does that say of our 'excellence', when 25 years ago the whole world came to Britain for its treatment? Prof Glasziou, apparently a family doctor, sits in his surgery looking up internet information on an arm fracture which he then judges as "minor". By his own admission he has come to his conclusions on management after a search which "took only a few minutes". Of course its marvellous that he can, from the comfort of his surgery armchair, become an instant expert in orthopaedics and even write an "evidence-based" case report on fractures. One hopes that his patient did well, but sadly that is not the outcome with all the cases which government is now encouraging GPs to retain in the community rather than have the benefit of secondary care services which have taken 50 years to build up and are now being emasculated. My own hospital has been turned into a ghost ship by the dramatic downturn in GP referrals as practitioners manage conditions in the surgery because to refer onwards means that money leaches away from the primary care service. But there is a sad pay-off. Whereas I may have seen a complication in my outpatient clinic from ill-advised primary care management a couple of times a year in the past, I now see 2 -3 per week out of a total of 15 new referrals. GPs simply cannot become instant experts in all the fields of medicine or surgery by scanning the internet for a few minutes, any more than a hospital specialist can learn the skills and judgment involved in general practice in a similar manner. There is a very pernicious process at work indeed when a family specialist feels able to write an article in the BMJ about fracture immobilisation. That process involves, along with generic referrals, practice-based commissioning, exceptional treatment panels and much more, the total dumbing down of British medicine. Competing interests: None declared |
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ben dean, sho oxford
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I read the article with great interest and this segment stood out for me: "Of course, I could have called the local orthopaedic registrar, and that is often the wise thing to do. But once I had seen the patient I was sure that this was just a "minor" fracture that could be dealt with in primary care." If a junior doctor, for example, elected to make clinical decisions in areas in which they were not adequately trained by conducting a quick ad hoc internet search instead of consulting the specialist for an opinion, then I think the junior doctor may find themselves in hot water. Why is it acceptable for a GP to do the same? I think the same principles apply. As Mr Mahaffey eloquently points out, this kind of attitude is rather symptomatic of the dumbing down present in our declining health service. Many undertrained workers are now being given roles beyond their means, and most worryingly they are starting to believe they are up to the task. Whether it be HCAs doing the job of nurses, or paramedics having a crack at diagnosis, GPSIs doing the work of fully trained specialists or nurse practitioners carrying out the work of fully trained doctors; it seems that this dumbing down is rather dangerous and this is ironically demonstrated by Professor Glasziou's piece. Competing interests: None declared |
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Paul Glasziou, General Practitioner OX3 7LF
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Expertise and evidence from research are both needed for best medical practice, but how to integrate these is an ongoing evolution. Like Dr Dean, I too would be concerned if clinicians at any level - junior doctor, experienced GP, or consultant - did "a quick ad hoc internet search" rather than finding high quality research relevant to the patients problems. And clinicians at all levels have information needs in most consultations, but usually ignore these or use readily available or out of date resources to get answers. I would also resist the "dumbing down": expertise is essential. But with over 1,500 new research articles entering MEDLINE each day, finding and applying the best research is an additional expertise for any medical graduate who does not want their "use-by" date to be yesterday. Expertise is essential for all stages of managing a patient. But expertise can go wrong, and needs continual checking against good research. Mr Kazi is correct that experienced clinicians will find that remanipulation is sometimes needed when paediatric forearm fractures are immobilized with short arm plasters. But experience cannot teach us everything, and hence the recent randomised trial[1] that showed such remanipulation was needed just as frequently with long arm plasters was something of a surprise. Expertise and evidence need to learn to work hand in hand, without either claiming to know all. I was disappointed that some of the respondents chose to denigrate the expertise of general practitioners and made assumptions about their, or my, clinical experience. I was intrigued to notice the difference in the management of simple fractures in the UK and Australia. In Australia GPs routinely manage a number of minor fractures which avoids unnecessarily clogging the specialty system with injuries that can be readily handled in the community, and reserve precious expertise for cases were it is really needed. My patient was clearly one who could be well managed in the community, and made an uneventful recovery. 1. Bohm ER, Bubbar V, Yong-Hing K, et al. Above and below-the-elbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Joint Surg Am 2006;88:1–8. Competing interests: (Author's Response) |
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Margaret M McQueen, Consultant Orthopaedic Trauma Surgeon Edinburgh Orthopaedic Trauma Unit, EH16 4SU
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I accept that all systems are inherited and that at present 'simple' fractures are seen by a range of staff with varying degrees of expertise. However would Professor Glasziou not agree that in a modern system which should be becoming more sophisticated all conditions should ideally be reviewed by specialists. If GPs treat 'simple' fractures such as the radial head fracture in question then probably about 80% will do well. However a non-specialist will not be able to identify those who are unlikely to do well and for whom early intervention gives better outcomes. Politically 80% success may be considered acceptable but does Professor Glasziou not agree that as clinicians we should be striving for 100% success? Competing interests: None declared |
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ben dean, sho oxford
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There are several questions that remain unanswered concerning this case. There is a great difference between being able to competently search the literature and being able to put the results of that literature search into practice safely and competently. Judging from the opinion of several consultant orthopods who have responded and several I have spoken to, Professor Glasziou is treading on thin ice. Arguably there are several problems with his argument, for one the radiology report is assumed to be correct, virtually all orthopods will look at the Xray in person as well as the report, risk can only be increased by not viewing the film. Secondly the interpretation of specialist evidence requires clinical experience in that area, and by this I mean clinical experience out of primary care in a more specialist setting. I am sure that Professor Glasziou would get things right most of the time, but as another respondent points out, what would happen if a fracture was mismanaged, whether down to a dodgy radiology report or down to a misinterpretation of the evidence, or even down to a lack of specialist orthopaedic skills? I wonder how far a GP could go in managing fractures before they reached a point beyond which their actions would be indefensible if something went wrong? Certainly in today's litiginous landscape GPs would be very brave or stupid to move too far away from their areas of expertise. One thing that certainly should be encouraged, is for GPs to just ring the local orthopod to double check things, even if they are 99% sure. Prof Glasziou's original article intimated an attitude of not double checking things, am I the only one who thinks that this is probably not the best attitude to encourage? Competing interests: None declared |
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Emma Stapleton, ST3 otolaryngology Institute of Neurosciences, Southern General Hospital, Glasgow G51 4TF
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I was slightly concerned by Glasziou's admission that he read only abstracts (not full papers) and that his search took only a few minutes, yet he used this information to make a clinical decision regarding a patient about whom he had insufficient information, and who had a condition he was unqualified and inexperienced in managing. None of us can deny that there's a valid basis for the judicious use of EBM in policy-making and safe protocol-construction, but I'm not sure Glasziou's method was a safe or professional way to do it. As a Professor of Evidence Based Medicine, surely he's aware that making a safe clinical judgement on the basis of published data requires meticulous critical appraisal and a comprehensive systematic review of all data available, and that this cannot safely be carried out as he describes? I'm relieved to hear that his patient recovered uneventfully, and I think Miss McQueen's rapid response hit the nail on the head. These 'simple' cases may be safely managed by GPs in 80% of cases, but what about the other 20%? A two-minute Pubmed search (and a skim through the online abstracts of published trials) are no substitute for comprehensive specialist review, nor are they a substitute for non-specialist treatment under strict, safe departmental protocols constructed using Evidence Based Medicine in the form of a comprehensive, critical literature review. Competing interests: None declared |
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Paul P Glasziou, general practitioner Oxford, OX3 7LF
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I am pleased that no one has questioned the validity of the Liow trial or its applicability to the patient: the trial enrolled Mason 1 and 2 radial head fractures, and my patient had a "suspected" Mason 1 undisplaced fracture. The issues raised appear to concern which patients require referral from primary care, a goal of 100% "success", and the appropriate information resources doctors should use. I would like to discuss these in turn.
How should we decide who is managed in primary care and who in secondary care? One extreme that Dr McQueen seems to suggest is that "all conditions should ideally be reviewed by specialists" and GPs would simply decide which specialist every patient should see. An immediate problem would be the swamping of secondary care, and delays in treatment that would degrade rather than improve care. But even if we could massively increase secondary care capacity to allow referal of all patients, the resulting fragmented care would have undesirable consequences, particularly for patients with multiple conditions and for preventive care. This may partly explain why stronger primary care is related to better health outcomes[1]. Rather than every patient been seen by consultants, we would be best off with appropriate referal guidance. As a junior doctor, though I studied Apley's texts, I liked Patrick Browne's "Basic Facts of Fractures" because of its clear guidance about expertise needed to handle different injuries and fractures (using a * to **** system). Undisplaced radial head fractures, along with undisplaced clavilcular fracture, contused elbow, isolated fibula fracture, etc are one "*" and "... can be managed quite adequately by any doctor at his office with the minimum of equipment". While I admire the sentiment of 100% success, this is an impossible "target". Primary and secondary care should work together to continually reduce error and poor outcomes, but we will never reach 100%. As the various reports on quality and safety suggest, secondary care is not error free either[2,3], and an overworked and overcrowded secondary care would be more prone to error. Wise use of our medical workforces’ diverse skills is necessary to give us the time to manage well. Finally, the respondents appear not to be aware of how we currently answer, and don't answer, information needs in practice. Several studies suggest that most doctors information needs go unanswered, and when they are answered it is generally with readily available rather than the best information[4]. And searching clinicians poorly skilled in searching and appraisal can degrade rather than improve decisions[5]. Patients would be better served if clinicians better recognised their own information needs, and had the skills to identify and use the best available research evidence, and discuss this with colleagues in both primary and secondary care. References 1. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res 2003: 831-65. 2. Experience of wrong site surgery and surgical marking practices among clinicians in the UK. Qual Saf Health Care. 2006 Oct;15(5):363-8. 3. Shaw R, Drever F, Hughes H, Osborn S, Williams S. Adverse events and near miss reporting in the NHS. Qual Saf Health Care. 2005 Aug;14(4):279-83. 4. Green ML, Ciampi MA, Ellis PJ. Residents' medical information needs in clinic: are they being met? Am J Med. 2000 Aug 15;109(3):218-23. 5. McKibbon KA, Fridsma DB. Effectiveness of clinician-selected electronic information resources for answering primary care physicians' information needs. J Am Med Inform Assoc. 2006 Nov-Dec;13(6):653-9. Competing interests: None declared |
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ben dean, sho oxford
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The author stated in the original article: "I went to the Clinical Queries section of PubMed Central (which is bookmarked on my Firefox toolbar) and used the narrow version of the "therapy" filter (which filters for randomised trials). I entered search terms to describe the condition "fracture and radial and head," which brought up seven studies. Two of these studies were not trials and three were not relevant (two looked at different types of internal fixation, and one looked at different methods of reduction), which left two that were relevant. I used the most recent study (2002)1 because it was more relevant to this patient's problem and I had access to the full text. I had access only to the abstract of the second trial,2 but this seemed to be consistent with the findings of the first trial. My search took only a few minutes." Therefore it seems fair to assert that the author only read one full text on this topic. He also states in his rapid response: "And searching clinicians poorly skilled in searching and appraisal can degrade rather than improve decisions" Can anyone else join the dots? Competing interests: None declared |
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Mehdi Tofighi, Clinical fellow Leeds General Infirmary, LS1 3EX, Elefterios Tsiridis
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Sir, we read with interest your article entitled “Do all fractures need full immobilization”? By Paul Glasziou published in September 2007 and found it very informative, we would like to contribute some additional information for your readers. In majority of intraarticular fractures, patients are encouraged for early passive and active motions, but weight bearing (in lower limbs fractures) or weight lifting (in upper limb fractures) are introduced gradually, depending on the type of fractures and mode of fixations, if any. In contrary to the standard postoperative management advised by the Association for the Study of Internal Fixation (Müller et al 1969) after the internal fixation of ankle fractures which advised on the use of crutches without weight-bearing, there are no functional differences between weight bearing and non weight bearing , nor early versus delayed active ankle movement.1 2 3 Cuboid, Majority of 5th metatarsal and undisplaced fractures of the second to fourth metatarsal and with displacement in the horizontal plane can be treated conservatively either by soft dressing followed by a firm, supportive shoe or with protected weight bearing in a cast shoe for 4-6 weeks.4 5 Isolated fibular shaft fracture, provided ankle mortise is intact and there is no common proneal nerve compromise, can be treated without immobilization and full weight bearing. Regarding tibial shaft fractures, Weight bearing is permitted in nailing procedures, depending on the fracture configuration. In a simple low-energy fracture, immediate weight bearing is permissible (Court-Brown et al). Otherwise, instituting non–weight-bearing or partial weight- bearing schedules is preferred. Patients undergoing plating and external fixation should not be allowed to bear weight until signs of healing are evident radiologically, this regime applies for fractures of knee, femur, acetabulum and pelvic. In regards to fractures involving knee joint, tireless work of Salter RB et al (1970 to 2004), showed continuous passive motion enhances healing of articular cartilage postoperative pain, improve local circulation (both arterial and venous), reduce swelling and accelerate return of joint motion. Immediate weight bearing with early strengthening activities following open reduction- internal fixation of midshaft of femur fracture may result in early resolution of impairments and functional limitations and decreased disability.6 7 Stable pelvic and acetabulum fractures are treated with immediate full weight bearing (FWB). Unstable ones, whether treated operatively or non-operatively, varies from touch weight bearing to FWB, depending on the stage of healing, however, passive and active movements of hip are being encouraged.8 9 Ribs and sternal fracture don not need more than analgesia, having said that, however, possible associate life threatening injuries like pneumothorax, haemothorax, lung contusion, etc. must be ruled out.10 Most clavicle and scapular fractures, without involvement of the glenoid, are successfully treated with a sling and early passive and active motion.11 12 Simple humerus and head & neck of radius fractures are mainly managed with sling or collar and cuff with mobilization as early as one week post injury. 13-16 The earliest and least expensive techniques for management of hand (Metacarpal and phalangeal fractures) fractures involve immobilization followed by protected motion with splinting and/or casting. The specific method of immobilization varies from buddy taping to plaster casting and splinting to custom-molded orthoplast splints. For many fractures today, even when more advanced techniques are available, this is the preferred method of treatment, and it is particularly suited to non-displaced fractures and to fractures that can be stably reduced.17 18 Mr Mehdi Tofighi, MBBS, MSc, MD, MRCS, clinical fellow, Department of Trauma & Orthopaedics, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX. Mr Elefterios Tsiridis, MBBS, MSc, MD, PHD, FRCS Ortho, Consultant Orthopaedic Surgeon, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX all correspondence should be sent to:
References: 1.van Laarhoven CJ, Meeuwis JD, van der Werken C. Postoperative treatment of Internally Fixed Ankle Fractures: A Prospective Randomized study. J Bone Joint Surg Br 1996; 78(3): 395-9. 2. Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle: A prospective, randomized comparison of management in a cast or a functional brace. J Bone Joint Surg Br 2000; 82: 246-249. 3. Finsen V, Saetermo R, Kibsgaard L, Farran K, Engebretsen L, Bolz KD, et al. Early postoperative weight-bearing and muscle activity in patients who have a fracture of the ankle. J Bone Joint Surg Am 1989; 71(1): 23-27. 4. Rammelt J, Heineck H, Zwipp. Metatarsal fractures. Injury 2004; 35(2): 77-86. 5. Lawrence SJ, Botte MJ, Jones' fractures and related fractures of the proximal fifth metatarsal. Foot & Ankle 1993; 14(6): 358-65. 6. Brumback RJ, Toal TR Jr, Murphy-Zane MS, Novak VP, Belkoff SM. Immediate Weight-Bearing after Treatment of a Comminuted Fracture of the Femoral Shaft with a Statically Locked Intramedullary Nail. J Bone Joint Surg Am 1999; 81(11): 1538-44. 7. Paterno MV, Archdeacon MT, Ford KR, Galvin D, Hewett TE. Early Rehabilitation Following Surgical Fixation of a Femoral Shaft Fracture. Physical Therapy 2006; 86(4): 558-572. 8. Tornetta P. Non-operative management of acetabular fractures. J Bone Joint Surg Br 1999; 81(1): 67-70. 9. AO Foundation [homepage on the Internet]. Davos: The Association; c 2006-2008. post operative care of Acetabulum fracture; Available from: http://www.aofoundation.org/portal/wps/portal/!ut/p/_s.7_0_A/7_0_96E?method=&redfix;_url=&treatment;=&showPage;=rehabilitation&classification;=&segment;=Acetabulum&implantstype;=&bone;=Pelvis&approach.; 10. Thoracic Trauma. Advanced Trauma Life Support. Chicago: American College of Surgeons; 2005. p. 103-130. 11. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg. 2007; 15(4): 239-48. 12. Wilber MC, Evans EB. Fractures of the scapula: An analysis of forty cases and a review of the literature. J Bone Joint Surg Am.1977; 59(3): 358-62. 13. Quintero J. Olecranon/radial head/complex elbow injuries. In: Ruedi M, Murphy WM, editors. AO Principles of Fracture Management. New York: Thieme Medical Publishers Inc; 2000. p. 323-338. 14. Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA Jr, Green DP, editors. Fractures in Adults. Philadelphia: Lippincott-Raven; 1996. p. 929-1024. 15. Sarmiento A, Zagorski JB, Zych GA, Latta IL, Capps CA. Functional Bracing for the Treatment of Fractures of the Humeral Diaphysis.J Bone Joint Surg Am 2000; 82(4): 478-9. 16. Lefevre-Colau MM, Babinet A, Fayad F, Fermanian J, Anract P, Roren A, et al. Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture: A randomized controlled trial. J Bone Joint Surg Am. 2007; 89: 2582-2590. 17. Pun WK, Chow SP, So YC, Luk KD, Ip FK, Chan KC, et al. A prospective study on 284 digital fractures of the hand. J Hand Surg Am 1989; 14(3): 474-81. 18. Stern PJ, Fractures of the metacarpals and phalanges. In: Green DP, Hotchkiss RN and W.C. Pederson, editors. Green's operative hand surgery. Philadelphia: Churchill Livingstone; 1999. Competing interests: None declared |
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