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Posterior Night Splint

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121. Hand, Rheumatoid Hand

after the procedure, the patient is fitted for a dynamic outrigger splint that maintains extension in an appropriate anatomic position of the fingers while the patient undergoes active flexion exercises. Night splints are manufactured to maintain the fingers in extension. Splinting is required for the next 4-8 weeks. Follow-up radiographs are obtained to confirm the appropriate positioning of the implants. Crossed intrinsic transfer of the extensor tendons from the ulnar side to the radial side (...) this problem should be considered. First, MP joint dislocation produces a fixed deformity with a flexed and ulnarly deviated finger. Second, volar and ulnar subluxation of the extensor tendons into the gutters between the phalanges limits extensor function as the extensors essentially become flexors in this position. In this condition, the patient can sometimes maintain MP extension actively after the finger is passively extended. Finally, paralysis due to posterior interosseous nerve compression can also

2014 eMedicine Surgery

122. Hand, Fracture and Dislocations: Thumb

nonoperative. Continuous undisturbed splinting in extension for 6 weeks should be followed by night splinting in extension for an additional 6-8 weeks. Operative indications include open injury, failed closed treatment, chronic injury and/or mal-union, or a mallet thumb with bony avulsion. Thumb IP Dislocations Thumb IP dislocations generally are easily reduced in a closed manner. Operative indications include an irreducible dislocation or unstable IP joint after relocation, open injury, and chronic (...) by the anterior (volar) and posterior oblique ligaments, anterior and posterior intermetacarpal ligaments, and the dorsal radial ligament. Thumb metacarpal base fractures are classified into extra-articular and intra-articular. Intra-articular fractures are more common and are subdivided into Bennett fractures, Rolando fractures, and comminuted fractures. Extra-articular fractures at the base of the thumb metacarpal are common, are usually transverse or oblique, and occur at the proximal metaphyseal

2014 eMedicine Surgery

123. Hand, Nerve Injury Repair

and regained at different times. Motor fibers are the first lost and the last regained, while pain and sympathetic fibers are the opposite. [ ] Common examples of this kind of injury include pressure palsies such as those that result from a tourniquet or from sleeping with pressure on a nerve, eg, Saturday night palsy. [ ] Axonotmesis (axon cutting), which occasionally is grouped with neurapraxia, describes the situation when axons, myelin, and associated internal nerve structures are disrupted (...) distribution as on the volar surface. [ , ] Motor targets of the ulnar nerve are as follows: Flexor carpi ulnaris Flexor digitorum profundus Hypothenar muscles All interossei Third and fourth lumbricals Adductor pollicis Flexor pollicis brevis - Deep head Radial nerve The radial nerve is a branch off the posterior cord and contains fibers from roots C7-T1. [ ] This nerve wraps around the humerus in the spiral groove as it passes through the upper arm, supplying motor innervation to all 3 heads

2014 eMedicine Surgery

124. Plantar Fasciitis (Treatment)

, NSAID therapy, strapping and taping, and over-the-counter (OTC) orthoses. Counseling as to activity modification, as well as choice of shoe gear, is important. After 6 weeks, recalcitrant cases should be treated additionally with a night splint and, possibly, an injection, along with the initial regimen for another 6 weeks. If pain persists, referral to a foot and ankle specialist should be considered. Injection therapy, immobilization in a cast or walker boot, physical therapy, and custom orthotics (...) in patients with chronic plantar fasciitis that does not respond to conservative management. IPST may be considered before surgery when ESWT devices are not available. A randomized, double-blind, prospective clinical pilot study showed that IPST is safe and effective; however, the exact mechanism is unknown and thus warrants further research. [ ] Previous Next: Splints and Orthoses Night splints Most people naturally sleep with their feet in a plantar-flexed position, which causes the plantar fascia

2014 eMedicine Emergency Medicine

125. Mucopolysaccharidosis (Treatment)

in these patients. Night splinting and occupational aids have also been helpful. Bone marrow transplantation (BMT) has been successful in the treatment of MPS conditions, especially Hurler syndrome. Children treated with BMT generally have an increased lifespan compared to untreated children. Untreated children commonly died of cardiorespiratory compromise in the first decade of life. However, the musculoskeletal condition (dysostosis multiplex) did not improve with BMT. Skeletal radiographs of children treated (...) growth" techniques. Severe deformities may also necessitate corrective osteotomy, usually of the proximal tibia. Ankle valgus can be also be treated with guided growth techniques. Kyphosis is progressive in many of these patients, especially at the thoracolumbar level and sometimes associated with thoracic scoliosis. [ ] Posterior spinal fusion is proved to prevent further progression. In the cervical spine, odontoid hypoplasia can be seen leading to atlantoaxial instability. Fusion from C1 to C3 can

2014 eMedicine Surgery

126. Supracondylar Humerus Fractures (Treatment)

of the plates, it is clear that contoured locking plate designs perform far better than traditional nonlocking plates. The ultimate decision regarding plate orientations should be made by the surgeon after careful consideration of the specific requirements of the patient, the characteristics of the fracture, and the availability of equipment. Previous Next: Postoperative Care A posterior long-arm splint is applied with the elbow at 60-90° of flexion, depending on the amount of swelling. The arm is elevated (...) , and early motion, acceptable results can be achieved. Next: Surgical Therapy Optimally, surgery should be performed within the first 72 hours following the injury. Further delay may be necessary in patients with multiple traumatic injuries or in patients who are unable to undergo anesthesia for other medical reasons. In these cases, splint the limb in as nearly normal an anatomic position as possible and elevate it or keep it in sidearm olecranon traction. Generally, unless an open injury, vascular

2014 eMedicine Surgery

127. Swan-Neck Deformity (Treatment)

after the procedure, the patient is fitted for a dynamic outrigger splint that maintains extension in an appropriate anatomic position of the fingers while the patient undergoes active flexion exercises. Night splints are manufactured to maintain the fingers in extension. Splinting is required for the next 4-8 weeks. Follow-up radiographs are obtained to confirm the appropriate positioning of the implants. Crossed intrinsic transfer of the extensor tendons from the ulnar side to the radial side (...) this problem should be considered. First, MP joint dislocation produces a fixed deformity with a flexed and ulnarly deviated finger. Second, volar and ulnar subluxation of the extensor tendons into the gutters between the phalanges limits extensor function as the extensors essentially become flexors in this position. In this condition, the patient can sometimes maintain MP extension actively after the finger is passively extended. Finally, paralysis due to posterior interosseous nerve compression can also

2014 eMedicine Surgery

128. Spinal Tumors (Treatment)

. Osteoid osteoma usually present in children aged 10-20 years, with a male predominance. They involve the axial skeleton only 10% of the time. In the spine, 59% of osteoid osteomas are found in the lumbar region, 27% in the cervical region, 12% in the thoracic region, and 2% in the sacral region. [ , ] Osteoid osteomas are usually stage 2 lesions and are actively symptomatic. They can result in painful scoliosis, radicular pain, gait disturbances secondary to pain and splinting, and muscular atrophy (...) . Symptoms usually are relieved or ameliorated by administration of nonsteroidal anti-inflammatory drugs (NSAIDs) or salicylates. In the spine, osteoid osteomas occur 75% of the time in the posterior elements (pedicles, facets, or laminae). Osteoid osteomas occur 7% of the time in the vertebral body and 18% of the time in the transverse and spinous processes. On plain radiography, osteoid osteomas appear as a round or oval radiolucent nidus, with a surrounding rim of sclerotic bone. An area of central

2014 eMedicine Surgery

129. Ulnar-Sided Wrist Pain (Follow-up)

by an average of 11°. The distal radius has a biconcave articular surface with two articular facets that are separated by an anterior and a posterior ridge. The lateral scaphoid facet is triangular, whereas the medial lunate facet is quadrilateral. The ulnar aspect of the radius has a concavity: the sigmoid notch, which articulates with the convex semicircular head of the distal ulna. The distal radioulnar joint (DRUJ) is the articulation of the distal radius and ulnar head. [ ] When the DRUJ is considered (...) palpable over the ECU sheath. An injection of lidocaine and cortisone into the sheath can be both diagnostic and therapeutic. As with subluxation, MRI can be used to confirm the diagnosis. Conservative treatment includes activity modification, ice, splinting, steroid injections, and nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical release is often necessary with progressive fibrosis of the sixth compartment. With partial rupture or , the ECU may be tender, red, and tense. A radiograph

2014 eMedicine Surgery

130. Ulnar Nerve Entrapment (Follow-up)

symptoms. The ulnar nerve should be protected from prolonged elbow flexion during sleep and protected during the day through avoidance of direct pressure or trauma. For initial conservative treatment of cubital tunnel syndrome, use of an elbow pad or night splinting for a 3-month trial period is recommended. [ , ] If symptoms do not improve with splinting, daytime immobilization for 3 weeks should be considered. Surgical release may be warranted if the symptoms do not improve with conservative (...) option is to apply a commercial soft elbow splint, with a thermoplastic insert, for persistent symptoms. For constant pain and paresthesia, one should consider using a rigid thermoplastic splint positioned in 45° of flexion to decrease pressure on the ulnar nerve. Initially, patients should wear this splint at all times; as symptoms subside, they can wear it only at night. Patient education and insight are important. Resting on elbows at work, using elbows to lift the body from bed, and resting

2014 eMedicine Surgery

131. Tendon Transfers (Follow-up)

is performed in an end-to-side manner so that if reinnervation occurs, the continuity of the reinnervated ECRB is not lost. Low-profile dynamic splints can be worn during the day, with night splints maintaining the digits and wrist in extension. [ ] All joints must maintain full passive range of motion, including the first web space. During World War I, Sir Robert Jones developed a set of tendon transfers for radial nerve paralysis, which formed the basis for reconstructive tendon transfer surgery (...) , tenodesis, capsulodesis, and pulley release Protect the tendon transfer postoperatively, with no tension on the transfer; for example, if a tendon passes volarly, the wrist is splinted in palmar flexion The first three steps in the above list are also referred to as the three-column theory or principle for tendon transfers. Drawing out these steps in three columns facilitates the decision-making process. Previous Next: Radial Nerve Paralysis Tendon transfers for radial nerve paralysis have the best

2014 eMedicine Surgery

132. Tarsal Tunnel Syndrome (Follow-up)

on the orthotic for both the hindfoot and forefoot. The use of night splints with the foot in plantar flexion and varus may be considered in patients with a valgus foot. This modality has not been shown to have long-term efficacy in well-controlled comparison studies with outcome measures, but it is commonly used in clinical practice. [ ] Previous Next: Surgical Therapy When conservative therapy fails to alleviate the patient's symptoms, surgical intervention may be warranted. Space-occupying masses require (...) , whereas six had very good results, four good, and two poor. Protective sensation recovered in all patients. Preparation for surgery The patient may be placed in either the supine or the lateral recumbent position to facilitate exposure of the medial aspect of the operative foot. Use of a pneumatic tourniquet is recommended. Operative details A curved incision should be made approximately 1 cm posterior to the distal tibia and carried in the plantar direction, paralleling the shaft and malleolus

2014 eMedicine Surgery

133. Ulnar Clubhand (Follow-up)

With an early presentation, the anlage should be excised before the occurrence of radial bowing or radial head dislocation, around age 6 months. The procedure is performed through an ulnar incision along the wrist. Care is taken to protect the ulnar artery and nerve. Excision of the entire anlage is not necessary; however, at least 50% should be excised. The wrist is placed in maximal radial deviation in a long-arm cast for a month. Night splints are worn for up to 6 months to maintain the correction (...) position. Radial head dislocation Treatment involves observation, resection only, or resection with the creation of a single-bone forearm. Ulnar osteotomy has been performed with or without shortening, [ ] with open reduction and stabilization of the radial head and plus/minus early radial head prosthetic replacement. [ , ] A single-bone forearm is created through a posterior approach, with the posterior interosseous nerve protected. A sufficient amount of proximal radius is excised to achieve proper

2014 eMedicine Surgery

134. Cubital Tunnel Syndrome (Overview)

Author: Charles F Guardia, III, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE Share Email Print Feedback Close Sections Sections Ulnar Neuropathy Overview Background The ulnar nerve is an extension of the medial cord of the brachial plexus. It is a mixed nerve that supplies innervation to muscles in the forearm and hand and provides sensation over the medial half of the fourth digit and the entire fifth digit (the ulnar aspect of the palm) and the ulnar portion of the posterior aspect of the hand (...) to be satisfactory. Next: Anatomy Course of ulnar nerve The ulnar nerve is the terminal branch of the medial cord of the brachial plexus and contains fibers from C8, T1, and, occasionally, C7. [ , ] It enters the arm with the axillary artery and passes posterior and medial to the brachial artery, traveling between the brachial artery and the brachial vein. At the level of the insertion of the coracobrachialis in the middle third of the arm, the ulnar nerve pierces the medial intermuscular septum to enter

2014 eMedicine Surgery

135. Ulnar Clubhand (Treatment)

With an early presentation, the anlage should be excised before the occurrence of radial bowing or radial head dislocation, around age 6 months. The procedure is performed through an ulnar incision along the wrist. Care is taken to protect the ulnar artery and nerve. Excision of the entire anlage is not necessary; however, at least 50% should be excised. The wrist is placed in maximal radial deviation in a long-arm cast for a month. Night splints are worn for up to 6 months to maintain the correction (...) position. Radial head dislocation Treatment involves observation, resection only, or resection with the creation of a single-bone forearm. Ulnar osteotomy has been performed with or without shortening, [ ] with open reduction and stabilization of the radial head and plus/minus early radial head prosthetic replacement. [ , ] A single-bone forearm is created through a posterior approach, with the posterior interosseous nerve protected. A sufficient amount of proximal radius is excised to achieve proper

2014 eMedicine Surgery

136. Ulnar-Sided Wrist Pain (Treatment)

by an average of 11°. The distal radius has a biconcave articular surface with two articular facets that are separated by an anterior and a posterior ridge. The lateral scaphoid facet is triangular, whereas the medial lunate facet is quadrilateral. The ulnar aspect of the radius has a concavity: the sigmoid notch, which articulates with the convex semicircular head of the distal ulna. The distal radioulnar joint (DRUJ) is the articulation of the distal radius and ulnar head. [ ] When the DRUJ is considered (...) palpable over the ECU sheath. An injection of lidocaine and cortisone into the sheath can be both diagnostic and therapeutic. As with subluxation, MRI can be used to confirm the diagnosis. Conservative treatment includes activity modification, ice, splinting, steroid injections, and nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical release is often necessary with progressive fibrosis of the sixth compartment. With partial rupture or , the ECU may be tender, red, and tense. A radiograph

2014 eMedicine Surgery

137. Plantar Heel Pain (Overview)

. J Bone Joint Surg Am . 2010 Nov 3. 92 (15):2514-22. . Berlet GC, Anderson RB, Davis H, Kiebzak GM. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics . 2002 Nov. 25 (11):1273-5. . Attard J, Singh D. A comparison of two night ankle-foot orthoses used in the treatment of inferior heel pain: a preliminary investigation. Foot Ankle Surg . 2012 Jun. 18 (2):108-10. . Tisdel CL, Harper MC. Chronic plantar heel pain (...) Soft heel cushion to absorb shock. Soft heel cushion and a cup. Custom-molded orthotic. Stretching exercise. Lean against the wall with the knee kept straight and the heel touching the floor. Stretching the back of the leg at the edge of a stair. Massaging and stretching the plantar fascia using a can. A night splint applied on back of the leg and foot. A night splint applied on the front of the leg. Lateral radiograph of the hindfoot showing a cyst in the anterior aspect of the calcaneus in a 19

2014 eMedicine Surgery

138. Plantar Fasciitis (Overview)

effort to maintain a heel-cord stretching program or to wear a night splint. They should also be taught proper performance of a home exercise program involving stretching the plantar fascia. The following recommendations are appropriate: Wear shoes with adequate arch support and cushioned heels; discard old running shoes and wear new ones; rotate work shoes daily Avoid long periods of standing Lose weight Stretch the plantar fascia and warm up the lower extremity before participating in exercise (...) Podiatr Med Assoc . 2001 Feb. 91(2):55-62. . Batt ME, Tanji JL, Skattum N. Plantar fasciitis: a prospective randomized clinical trial of the tension night splint. Clin J Sport Med . 1996 Jul. 6(3):158-62. . Wapner KL, Sharkey PF. The use of night splints for treatment of recalcitrant plantar fasciitis. Foot Ankle . 1991 Dec. 12(3):135-7. . Powell M, Post WR, Keener J, Wearden S. Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome

2014 eMedicine Surgery

139. Ulnar Nerve Entrapment (Treatment)

symptoms. The ulnar nerve should be protected from prolonged elbow flexion during sleep and protected during the day through avoidance of direct pressure or trauma. For initial conservative treatment of cubital tunnel syndrome, use of an elbow pad or night splinting for a 3-month trial period is recommended. [ , ] If symptoms do not improve with splinting, daytime immobilization for 3 weeks should be considered. Surgical release may be warranted if the symptoms do not improve with conservative (...) option is to apply a commercial soft elbow splint, with a thermoplastic insert, for persistent symptoms. For constant pain and paresthesia, one should consider using a rigid thermoplastic splint positioned in 45° of flexion to decrease pressure on the ulnar nerve. Initially, patients should wear this splint at all times; as symptoms subside, they can wear it only at night. Patient education and insight are important. Resting on elbows at work, using elbows to lift the body from bed, and resting

2014 eMedicine Surgery

140. Tendon Transfers (Treatment)

is performed in an end-to-side manner so that if reinnervation occurs, the continuity of the reinnervated ECRB is not lost. Low-profile dynamic splints can be worn during the day, with night splints maintaining the digits and wrist in extension. [ ] All joints must maintain full passive range of motion, including the first web space. During World War I, Sir Robert Jones developed a set of tendon transfers for radial nerve paralysis, which formed the basis for reconstructive tendon transfer surgery (...) , tenodesis, capsulodesis, and pulley release Protect the tendon transfer postoperatively, with no tension on the transfer; for example, if a tendon passes volarly, the wrist is splinted in palmar flexion The first three steps in the above list are also referred to as the three-column theory or principle for tendon transfers. Drawing out these steps in three columns facilitates the decision-making process. Previous Next: Radial Nerve Paralysis Tendon transfers for radial nerve paralysis have the best

2014 eMedicine Surgery

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