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Immobilisation and early motion (protected or unrestricted) are both used following hyperextension injuries to the proximal interphalangeal (PIP) joint of the finger.
Immobilisation and early motion (protected or unrestricted) are both used following hyperextension injuries to the proximal interphalangeal (PIP) joint of the finger.
To assess the effects of conservative interventions (non-surgical management) for treating hyperextension injuries of the proximal interphalangeal joints of the fingers.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2012), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2012, Issue 1), MEDLINE (1946 to January Week 2 2012), EMBASE (1980 to 2012 Week 03), CINAHL (1950 to 24 January 2012), PEDro (1929 to March 2012), trial registers and reference lists of articles.
Randomised and quasi-randomised studies comparing immobilisation/protected mobilisation/unrestricted mobilisation in participants with PIP joint hyperextension injuries managed non-surgically.
Two review authors independently assessed risk of bias and extracted data. There was no pooling of data.
Three trials involving 366 people were identified. All three trials, which were over 15 years old, were methodologically flawed with unclear or high risk of bias. None of the studies reported on self assessment of function. One trial compared unrestricted mobility with immobilisation; one trial compared protected mobilisation with immobilisation; and the remaining trial compared immobilisation for one week versus three weeks. None of these trials found statistically significant differences between their intervention groups in various measures of poor outcome, pain and range of movement at six months follow-up. This lack of difference applied at three years for the comparison between unrestricted mobility with immobilisation.
There is insufficient evidence from trials testing the need for, and the extent and duration of, immobilisation to inform on the key conservative management decisions for treating hyperextension injuries of the proximal interphalangeal joints.
Interventions conservatrices pour le traitement de blessures d'hyperextension des articulations interphalangiennes proximales des doigts
L'immobilisation et le mouvement précoce (avec protection ou sans restriction) sont tous deux utilisés à la suite de blessures d'hyperextension à l'articulation interphalangienne proximale (PIP) du doigt.
Évaluer les effets des interventions conservatrices (prise en charge non chirurgicale) pour le traitement des blessures d'hyperextension des articulations interphalangiennes proximales des doigts.
Nous avons effectué une recherche dans le registre spécialisé du groupe Cochrane sur les traumatismes ostéo-articulaires et musculaires (janvier 2012), le registre Cochrane des essais contrôlés (CENTRAL) (dans The Cochrane Library 2012, numéro 1), MEDLINE (de 1946 à la 2ème semaine de janvier 2012), EMBASE (de 1980 à la 3ème semaine de l'année 2012), CINAHL (de 1950 au 24 janvier 2012), PEDro (de 1929 au mois de mars 2012), les registres d'essais cliniques et les bibliographies d'articles.
Les études randomisées et quasi-randomisés comparant l'immobilisation/la mobilisation avec protection/la mobilisation sans restriction chez des participants présentant des blessures d'hyperextension de l'articulation interphalangienne proximale (PIP) prises en charge de manière non chirurgicale.
Deux auteurs ont, de manière indépendante, évalué les risques de biais et extrait les données. Nous n'avons effectué aucun regroupement de données.
Trois essais impliquant 366 participants ont été identifiés. Les trois essais, datant de plus 15 ans, étaient tous méthodologiquement défectueux avec un risque de biais incertain ou élevé. Aucune des études n'a rapporté la moindre auto-évaluation de la fonction par les participants. Un essai a comparé la mobilité sans restriction à l'immobilisation ; un essai a comparé la mobilisation avec protection à l'immobilisation ; et le dernier essai a comparé l'immobilisation pendant une semaine à trois semaines. Aucun de ces essais n'a identifié de différences statistiquement significatives entre leurs groupes avec intervention dans les différentes mesures de mauvais résultats, de la douleur et de l'amplitude du mouvement au bout de six mois de suivi. Cette absence de différence était observée au bout de trois années de suivi pour la comparaison entre la mobilité sans restriction et l'immobilisation.
Les preuves issues des essais examinant la nécessité, ainsi que l'étendue et la durée, de l'immobilisation sont insuffisantes pour orienter les décisions pour la prise en charge conservatrice essentielle pour le traitement des blessures d'hyperextension des articulations interphalangiennes proximales.
Splints and other non-surgical methods for treating common injuries of the middle joints of the fingers
Injury to the ligaments of the middle joint (proximal interphalangeal joint) of a finger may occur as a result of the finger being forced backwards. This is known as a hyperextension injury. Characteristically, this occurs in sporting accidents, such as where a football strikes an outstretched hand. These injuries are common and typically affect people of working age. Usually, these patients are treated without surgery using a combination of support (splinting/strapping to the adjacent finger) and exercise advice. Use of the hand is commonly encouraged but restricted to some degree by the severity of the injury. By examining the evidence from randomised controlled trials, this review aimed to assess which treatment for hyperextension injuries of the proximal interphalangeal joints of the fingers results in the best outcome for patients. The outcomes examined included function (including return to work), pain and joint movement.
Three small studies including a total of 366 patients met the inclusion criteria for the review. The studies, which were all over 15 years old, were prone to bias. None of the studies reported any self assessment of function by participants. One study compared unrestricted mobility with immobilisation. One trial compared protected mobilisation (using a removable support in combination with exercise) with immobilisation. The remaining study compared immobilisation for one week versus three weeks. None of these trials found important differences between their intervention groups in various measures of poor outcome, pain and range of movement at six months follow-up.
We concluded that there was a lack of robust evidence to inform on the need for, and the extent and duration of, immobilisation for these injuries.
Attelles et autres méthodes non chirurgicales pour le traitement de blessures courantes des articulations moyennes des doigts
Les blessures aux ligaments de l'articulation moyenne (articulation interphalangienne proximale) d'un doigt peuvent survenir en résultat d'un mouvement forcé du doigt vers l'arrière. Ceci est connu sous le nom de blessure d'hyperextension. De façon caractéristique, ceci se produit lors d'accidents de sport, comme lorsqu'un ballon de foot frappe une main en extension. Ces blessures sont courantes et touchent généralement des personnes en âge de travailler. Habituellement, ces patients sont traités sans chirurgie en utilisant une combinaison de support (attelles/sangles au doigt adjacent) et de conseils en faveur de la pratique d'exercices physiques. L'utilisation de la main est couramment encouragée, mais limitée jusqu'à un certain degré par la gravité de la blessure. En examinant les preuves issues d'essais contrôlés randomisés, cette revue avait pour objectif d'établir quel traitement des blessures d'hyperextension des articulations interphalangiennes proximales des doigts aboutit au meilleur résultat pour les patients. Les critères de jugement examinés comprenaient la fonction (incluant la reprise du travail), la douleur et le mouvement de l'articulation.
Trois études de petite taille totalisant 366 patients répondaient aux critères d'inclusion de cette revue. Les études, qui dataient toutes de plus de 15 ans, étaient sujettes aux biais. Aucune des études n'a rapporté la moindre auto-évaluation de la fonction par les participants. Une étude a comparé la mobilité sans restriction à l'immobilisation. Un essai a comparé la mobilisation avec protection (en utilisant un support amovible en combinaison avec des exercices physiques) à l'immobilisation. La dernière étude a comparé l'immobilisation pendant une semaine à trois semaines. Aucun de ces essais n'a identifié de différences importantes entre leurs groupes avec intervention dans les différentes mesures de mauvais résultats, de la douleur et de l'amplitude du mouvement au bout de six mois de suivi.
Nous en avons conclu qu'il manquait des preuves probantes pour orienter la pratique sur la nécessité, ainsi que l'étendue et la durée, de l'immobilisation pour ces blessures.
Notes de traduction
Traduit par: French Cochrane Centre 1st March, 2013
Traduction financée par: Pour la France : Ministère de la Santé. Pour le Canada : Instituts de recherche en santé du Canada, ministère de la Santé du Québec, Fonds de recherche de Québec-Santé et Institut national d'excellence en santé et en services sociaux.
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The three bones in each finger are called, going from the palm of the hand towards the end of the fingers, the proximal, middle and distal phalanges. The proximal interphalangeal (PIP) joint is the articulation or joint between the proximal and middle phalanges of each finger. The PIP joint is primarily a stable hinge joint. It has a typical range of movement from zero degrees extension (finger is straightened out) up to 110 degrees of flexion (finger is bent) (Glickel 2005). Anatomically, the PIP joint is complex. The contours of the bony surfaces of the proximal and middle phalanges increase the stability of the PIP joint, allowing resistance to lateral (sideways) and rotational stress (Burton 1973; Glickel 2005; Kuczynski 1968). The soft tissue structures surrounding the PIP joint provide further joint stability (Burton 1973; Sprauge 1975). These structures include the volar (palmar) plate, the cord collateral and accessory collateral ligaments and the extensor expansion (Burton 1973; Freiberg 1999; Sprauge 1975). The volar plate, which is a strong soft tissue attachment to the base of the middle phalanx on the palm side, acts as a static ligament and limits hyperextension (thus preventing the finger from being bent backwards) of the PIP joint (Glickel 2005; Sprauge 1975). The other ligamentous structures combine with the volar plate to provide lateral and dorsal (back of the hand) stability (Freiberg 1999).
Injury to the proximal interphalangeal (PIP) joint of the fingers is one of the most common injuries of the hand (Eaton 1976; Sprauge 1975). The spectrum of injury to this joint can range from incomplete soft tissue disruption to unstable fracture-dislocations (Eaton 1976; Incavo 1989). Damage to the PIP joint is frequently the result of a hyperextension force resulting in soft tissue injury, with or without an associated fracture. Hyperextension is defined as a movement of the middle phalanx in a dorsal (backwards) direction beyond neutral, in respect to the proximal phalanx (Sprauge 1975). Any hyperextension injury to the PIP joint will result in some degree of disruption of the ligament complex. Many injuries are incomplete, with only partial damage to ligaments and soft tissue structures. In these cases joint stability is maintained; however, individuals will present with pain, swelling and limited movement (Bowers 1986; Burton 1973). In more severe cases there can be bony disruption and complete rupture of one or more of the supporting structures of the PIP joint (Eaton 1976; Glickel 2005). PIP joint injuries are generally classified into three main types of injury: type I (hyperextension injury); type II (dorsal dislocation); and type III (fracture - dislocation). Table 1 outlines the pathology of these injuries with respect to the damaged structures (Eaton 1976).
|Type I (hyperextension)
|These injuries are characterised by either partial or complete avulsion (pulling away) of the volar plate from the middle phalanx. This may be with or without a bone fragment, and/or minor tears in the collateral ligaments
|Type II (dorsal dislocation)
|With complete dislocation, avulsion of the volar plate occurs, and includes a bilateral split in the collateral ligament system. The middle phalanx tends to adopt a resting position on the condyles of the proximal phalanx, yet there is no contact between the articular surfaces of the PIP joint.
|Type III (fracture - dislocation)
|In this type of injury the force is significant enough to avulse the volar plate from its insertion and create a disruption at the base of the middle phalanx on the volar surface. This result is a fracture dislocation. These injuries can be subdivided into stable and unstable fracture dislocations.
Sporting activities account for the majority of PIP joint hyperextension injuries. For example, Gaine 1998 reported that 92.8% of patients in their study received their injuries during sporting activities; 78% of these injuries being a direct result of ball games. Phair 1989 found that all 74 patients in their study reported a hyperextension mechanism of injury, and 51 patients (69%) had sustained an injury to the PIP joint from a sporting activity.
Type I (hyperextension) or type II (dislocation) injuries of the PIP joint are generally treated by either a period of immobilisation or by protected mobilisation (or a combination of the two) of the finger with range of motion exercises. Dislocated PIP joints without fractures are reduced (put back into place) using gentle manipulation beforehand. Unstable injuries, usually involving bony disruption, are generally managed surgically (Burton 1973; Eaton 1976).
The PIP joint is often immobilised using plaster of Paris or a rigid plastic or metal splint, secured with tape or Velcro to one side of the finger. In most cases only the PIP joint is kept still or supported and the joints above and below are free to move.
Common types of protected mobilisation are buddy strapping, where the injured finger is strapped to a neighbouring finger, and dorsal block splinting. Dorsal block splinting involves securing a metal or plastic splint to the back of the finger and allowing the patient to loosen the tape to bend the PIP joint for exercises whilst preventing unwanted straightening.
Time frames for either of these forms of treatment vary from one to six weeks. It is anticipated that usual function is resumed between six and eight weeks post injury (Eaton 1976; Freiberg 1999; Incavo 1989; Sprauge 1975).
Sprauge 1975 suggested that immobilising the injured PIP joint in a position of flexion for a period of time is favourable for soft tissue healing and for preventing further dorsal or lateral dislocation of the finger. However, other authors report that immobilisation of the PIP joint results in less positive outcomes with individuals taking a greater amount of time to regain range of movement and function of their affected finger (Phair 1989).
Immediate protected mobilisation of the PIP joint, within the individuals' pain tolerance, has been advocated to prevent finger stiffness (Phair 1989). It is considered that mobilisation enhances cartilage and soft tissue healing while movement assists in minimising the formation of tendon adhesions and PIP joint contractures (Freiberg 1999; Kiefhaber 1998). Protective splinting in the form of buddy strapping is considered to prevent lateral and dorsal disruption of the PIP joint and to minimise pain on extension (Bowers 1986; Freiberg 1999; Gaine 1998).
These injuries may result in chronic pain, stiffness, deformity or premature degenerative arthritis (Freiberg 1999). Because the hand is so vital to everyday activities and work, a poor outcome can be disproportionately disabling. Currently there is uncertainty on what is the best approach to take for these injuries in terms of the extent, type and duration of immobilisation. These point to the need for this systematic review in order to inform practice.
To assess the effects (benefits and harms) of conservative interventions for treating hyperextension injuries of the proximal interphalangeal joints of the fingers presenting within one month of injury. Comparisons included:
PIP joint unrestricted mobilisation (e.g. no splint) versus immobilisation
PIP joint protected mobilisation (e.g. dorsal blocking splinting, buddy strapping) versus immobilisation
PIP joint unrestricted mobilisation versus protected mobilisation
We considered any randomised controlled and quasi-randomised (method of allocating participants to a treatment which is not strictly random: e.g. by date of birth, hospital record number, alternation) trials of conservative management for hyperextension injuries of the PIP joint in the hand.
We included trials with participants that had an acute (less than one month), conservatively-managed hyperextension injury to the PIP joint. Injury was defined through: history of dislocation, history of hyperextension injury, diagnosis of volar plate/collateral ligament fracture avulsion via x-ray, joint laxity or pain in the PIP joint following trauma to the finger.
We excluded trials focusing on participants presenting with open hyperextension injuries, concomitant tendon injury, fracture (with the exception of ligamentous avulsion fractures) or hyperextension injuries requiring surgical treatment. Trials focusing on participants with underlying rheumatological, neurological or congenital conditions were also excluded.
Randomised comparisons for the conservative management of PIP joint hyperextension injuries included any two or more of the following interventions: unrestricted movement, buddy strapping, protective splinting, and immobilisation. We also aimed to include trials comparing different time frames for treatment.
We excluded trials that compared management after surgical intervention or different exercise regimens. Comparisons of different exercise regimens were excluded due to the high variation possible between studies, for example, frequency and duration of exercises, as well as active versus passive versus resisted motion.
Self-reported, preferably validated, functional questionnaires such as the Disability of the Arm, Shoulder and Hand (DASH) and the Michigan Hand questionnaires
Poor outcome: finger stiffness, joint laxity, joint deformity (cosmetic or clinically assessed), subsequent surgery
Pain (visual analogue scale, ordinal scale, pain questionnaire)
Range of motion
Return to work/sport/previous activity
Number of follow-up appointments
Our focus is on primary outcomes at final follow-up in the individual studies. Ideally, follow-up should be at least six months for type I injuries and at least 12 months for type II injuries.
We searched the Cochrane Bone, Joint, Muscle Trauma Group Specialised Register (January 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 1), MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Daily Update (1946 to January Week 2 2012), EMBASE (1980 to 2012 Week 03), CINAHL (1950 to 24 January 2012) and PEDro - the Physiotherapy Evidence Database (1929 to March 2012) (see Appendix 1 for details of the search strategies). The subject-specific search has not been combined with a trial filter due to the small number of trials in this area.
We searched the WHO International Clinical Trials Registry Platform (to 8 March 2012) to identify ongoing and recently completed trials, and also Zetoc (1993 to 8 March 2012) to identify additional trials reported in conference proceedings.
Trials were included regardless of language and publication status.
We also searched reference lists of articles, reviews and relevant textbooks.
Two review authors (MB and ZA) independently screened the titles, abstracts and descriptors of identified studies for possible inclusion. We obtained full text versions of all studies that were considered potentially eligible by either author, and independently assessed these for inclusion. Any disagreement was resolved by discussion with a third author (JC). Where uncertainty remained about eligibility, we contacted trial authors for clarification. Translations for potential studies published in languages other than English were obtained where possible.
Two review authors (JC and ZA) independently extracted trial details and data using a standardised data collection form. The form was tested for consistency on two studies prior to the commencement of the review. Any disagreement was resolved by discussion with a third review author (MB).
Two review authors (JC and ZA) independently assessed the risk of bias in each included study using The Cochrane Collaboration's 'Risk of bias' tool. We assessed generation of allocation sequence, allocation concealment, blinding (of trial participants, care providers and assessors), incomplete outcome data, selective outcome reporting, and other sources of bias. The risk of bias was rated for each domain and was expressed as 'Yes', implying a low risk of bias; 'No', implying a high risk of bias; or 'Unclear', implying the risk of bias is unclear. Any disagreement was resolved by discussion with a third review author (MB) when required. Journal titles, authors and supporting institutions were not be masked at any time.
Risk ratios and 95% confidence intervals were calculated for dichotomous data. We planned to calculate mean differences or, where different scales or tools were used to measure the same outcome, standardised mean differences and 95% confidence intervals for continuous data.
A possible unit of analysis issue may arise if an individual had more than one injured finger and the individual (or both or more digits) is randomised rather than the individual digits. When such an issue arose and appropriate corrections were not made, we presented the data for such trials where the disparity between the units of analysis and randomisation is small. Should data pooling be possible, we planned to perform a sensitivity analysis to examine the effects of excluding incorrectly reported trials from the analysis.
We contacted authors of individual studies for missing data and clarification. Where possible, we performed intention-to-treat analyses. We stated beforehand that we would not impute missing standard deviations.
We planned the following approach for assessing study heterogeneity, which we determined from both clinical and statistical perspectives. Clinical heterogeneity was assessed in terms of important differences between trials in the study populations, interventions and outcome measures. Statistical heterogeneity between pooled trials was to be assessed using a combination of visual inspection of the graphs along with consideration of the chi² test (with statistical significance set at P < 0.10), and the I² statistic.
We attempted to reduce reporting biases, particularly publication bias, through our comprehensive search of the literature. This extended across multiple databases using a sensitive search strategy, include clinical trial registers, and a search of Zetoc that identified trials reported at conferences but never published in full. Thus, searches were not constrained by language or publication status.
Where considered appropriate from a clinical perspective, we planned to pool data from comparable trials. Initially we planned to use the fixed-effect model and 95% confidence intervals. We also would have considered using the random-effects model, especially where there was unexplained heterogeneity.
Should sufficient data become available in future versions of this review, our planned subgroup analyses are based on age (those younger than 16, those aged between 17 and 64 and those aged older than 65), the type of injury (see Table 1), and time elapsed between injury and medical intervention (treatment started within two weeks versus after two weeks) where possible and appropriate.
We planned to perform sensitivity analyses to examine the effects of missing data and of the inclusion of trials at high risk of bias (such as from lack of allocation concealment). However, it was not possible to perform these analyses in this version of the review.
See: Characteristics of included studies; Characteristics of excluded studies.
The search strategy found 520 references, of which 480 were excluded through initial screening of reference titles and abstracts. Of those excluded, 155 were duplicates and 325 were not considered relevant. Of the 40 remaining potentially relevant studies, for which full reports were obtained, 35 were excluded as they were clearly not randomised or quasi-randomised controlled trials. Three studies were included (Norregaard 1987 (3 reports of study); Thomsen 1979; Thomsen 1995) and one (Arora 2004) was excluded. No ongoing trials were identified.
All three included studies were reported in medical journals. Norregaard 1987 was reported in a conference abstract (Norregaard 1986), an English language report (Norregaard 1987) and a Danish language report (Norregaard 1988). A translation from Danish were obtained for Thomsen 1979.
Details of the three individual trials can be found in the Characteristics of included studies. A summary of these is presented below.
Norregaard 1987 was a quasi-randomised trial with two intervention groups. Thomsen 1979 and Thomsen 1995 were randomised trials with four and two intervention groups respectively.
In total, there were 366 participants with proximal interphalangeal joint hyperextension injuries randomised into the three trials. Norregaard 1987 included 126 participants (as reported in Norregaard 1986 and Norregaard 1988). However, we based our analysis of this trial on the English language report that reported on 112 participants only, 87 of whom were followed up at six months. Thomsen 1979 randomised 200 patients of which 181 were followed up. This study included participants with multiple finger injuries and follow-up analysis was based on the number of treated fingers (191) rather than participants. Thomsen 1995 included 40 participants of whom 39 were followed up at six months. Overall, 307 participants and 317 fingers were included in the six months follow-up results for the three trials.
All three trials were conducted in Denmark with participants presenting to hospital emergency departments or orthopaedic clinics. All trials are over 15 years old: Norregaard 1987 was completed in 1983; Thomsen 1979 in 1978; and Thomsen 1995 in 1993.
All participants in the three trials had sustained a hyperextension injury to the proximal interphalangeal joint. Diagnostic criteria varied across the studies and were reported to various levels. Norregaard 1987 included participants with hyperextension trauma presenting with four signs of injury (volar tenderness, pain at maximal flexion, relief from pain in the intermediate position and recurrence of pain at maximal extension). In contrast, Thomsen 1995 did not describe inclusion criteria beyond that of lesions to the volar plate of the proximal interphalangeal joint. Thomsen 1979 admitted participants who sustained hyperextension trauma and volar pain at maximal flexion, pain relief in semi-flexion and pain increasing at maximal extension. Participant demographics of gender and age were not reported in Norregaard 1987. The participants of Thomsen 1979 were aged between 7 and 76 years, and 41% were male. Thomsen 1995 reported an age range of 18 to 79 years and that 49% of participants were male.
The three trials evaluated four different comparisons in all.
Norregaard 1987 compared unrestricted mobilisation of the affected PIP joint versus immobilisation of the affected PIP joint in 15 degrees of flexion, the metacarpophalangeal joint in 80 to 90 degrees flexion and the wrist in 30 degrees of extension for three weeks using an aluminium splint.
Thomsen 1995 investigated limitation of PIP joint protected motion through the application of a double finger elastic bandage (motion ranging between neutral and 25 to 30 degrees of flexion) versus immobilisation with an aluminium splint applied to the dorsum of the finger prohibiting PIP joint movement. The splint was designed to position the finger in 15 degrees of flexion at the PIP joint. These interventions were instituted for an initial two week period, after which the elastic bandage or aluminium splint was removed and normal hand movement was encouraged.
In Thomsen 1979, patients were randomised into four groups: group one, aluminium splint for one week; group two, aluminium splint for three weeks; group three, plaster of Paris cast for one week; group four, plaster of Paris cast for three weeks. The authors describe positioning the PIP joint in semi-flexion but do not report the angle of measurement. Active range of motion was commenced for all groups once the aluminium splint or plaster of Paris had been removed, at either one or three weeks. Thomsen 1979 made two comparisons: immobilisation of the affected PIP joint for one week versus three weeks; and aluminium splint versus plaster of Paris cast. However, results were provided for the first comparison only.
Two trials (Norregaard 1987; Thomsen 1995) reported outcomes by participant, while Thomsen 1979 reported on outcome by injured finger.
Follow-up assessment ranged from two weeks (Thomsen 1995) to three years (Norregaard 1987); however, all three trials investigated outcome at six months.
Norregaard 1987 reviewed joint stiffness, laxity and deformity at both six months and three years post injury. However, the authors do not clearly report the methods by which they determined and measured these sequelae. Secondary outcomes of pain and range of movement were acknowledged. Pain was rated using the Moller scale (Moller 1974). The origin, method, validity and reliability of this scale is not reported in the literature. Range of movement was described in terms of an extension or flexion deficit. It is not clear if goniometry was used to assess for deficit or what parameters the authors use to define a range of movement deficit.
Thomsen 1979 presented pooled results for the two groups immobilised for one week and the two groups immobilised for three weeks. They commented on stiffness and deformity but did not report the methods by which they measured these outcomes. Secondary outcomes of pain and deficits in extension and flexion were reported. This trial also monitored discomfort from use of a splint or plaster and recorded sick leave. As with Norregaard 1987, pain was rated using the Moller scale (Moller 1974). The parameters of defining an extension/flexion deficit were not described.
Norregaard 1987 and Thomsen 1979 both appeared to use the same assessment tool that considered pain (during movement, work and hobby activities), volar plate tenderness, stiffness and coldness, thickened joint, extension and flexion deficits, swan neck deformity and button-hole deformity. This assessment tool is not referenced by either study.
Thomsen 1995 assessed range of motion, volar stability and return to work at two weeks. The authors also used an assessment of results scale originally developed by Benke 1979 that is based on movement, symptoms, stability and function. Outcome was rated as excellent, good or poor. The authors used this scale to comment on the primary outcome measure of 'poor outcome'. The only secondary outcome reported in this study is range of movement. This is discussed in terms of achieving PIP joint range of motion 0 to 90 degrees. There was no information provided on how these deficits were measured and if goniometry was used.
One study (Arora 2004) was excluded after contact with the authors established that participants were not randomised to treatment group (see the Characteristics of excluded studies).
See Figure 1 and Figure 2. All three trials included in this review were methodologically flawed. Many items described in the 'Risk of bias' tool were judged to be at high risk of bias. Others were judged as being unclear because of insufficient information. More details about the sources of bias in each study can be found in the Characteristics of included studies.
Norregaard 1987, which was a quasi-randomised trial, based on the date of patient trauma, was at a high risk of selection bias. Thomsen 1979 used a random numbers table for sequence generation but Thomsen 1995 did not describe their method of sequence generation. There was no details to determine whether allocation was concealed in either trial.
The nature of these trials make it impossible for participants to be blinded to their treatment. It is also not possible to blind those delivering treatment. However, it is unclear if there was any blinding of assessors at follow-up in any of the included studies.
Participants were lost to follow-up in all three trials. The reporting of loss to follow-up was inconsistent in Norregaard 1987, which was judged at high risk of attrition bias based on the inconsistent reporting and the high loss to follow-up (22% at six months using data from Table 1 of the trial report; see the Characteristics of included studies). Nine per cent of patients randomised to treatment with immobilisation for one week were lost compared with 10% immobilised for three weeks in Thomsen 1979. One participant was lost to follow-up in Thomsen 1995 from the protection motion group.
It is difficult to determine the presence of selective reporting as protocols are not available for any of the trials.
All three studies failed to provide sufficient information regarding the baseline characteristics of their treatment groups. Two of the three studies (Thomsen 1979; Thomsen 1995) reported an inadequate length of follow-up (six months). Although outcome measures reported in each of the studies are appropriate to these injuries, the methods of assessment vary and it is not clear if these were undertaken in a validated and reliable fashion, if these are subjective or objective measures, nor the parameters for determining the presence of a particular outcome. For example, Thomsen 1979 and Norregaard 1987 both report pain using the Moller scale, but do not describe the nature of this scale. Similarly, all three trials report range of movement as an outcome without reporting how this was assessed (e.g. goniometry). Further bias may have been introduced in the assessment process by the involvement of multiple assessors. Thomsen 1995 reports the involvement of three assessors whilst the other two studies do not provide any information as to the number of assessors.
Norregaard 1987 found no statistically significant differences between the no immobilisation (unrestricted motion) group and the splint immobilisation group in the reported outcomes at either six months or three years. The risk of attrition bias, in particular relating to the high loss to follow-up and inconsistencies in the reporting of the losses to follow-up raises some questions over the reliability of the results from this quasi-randomised trial. The following analyses use the data from the main publication of this study only. At six months after injury there were no statistically significant differences between the two groups for poor outcome, a primary outcome measure, particularly joint stiffness and coldness (6/43 versus 11/44; RR 0.56, 95% CI 0.23 to 1.37) or thickened joints (8/43 versus 7/44; RR 1.17, 95% CI 0.46 to 2.94) (see Analysis 1.1). One participant in the splint group developed a swan neck deformity. Similar findings applied at three years (see Analysis 1.2): stiffness and coldness (3/34 versus 5/34; RR 0.60, 95% CI 0.16 to 2.31) and thickened joint (8/34 versus 4/34; RR 2.00, 95% CI 0.66 to 6.02). No participant had swan neck or button hole deformity at this time. Similar numbers in each group had 'sequelae', which were mainly 'mild' involving 'minor pain': 9/34 versus 7/34; RR 1.29, 95% CI 0.54 to 3.06). While there were some differences across the three papers for this trial, none of these changed the overall findings: the results for 'sequelae' at two to three years are given in Analysis 1.2.
There was also no difference between the two groups for secondary outcomes of pain and tenderness at six months (see Analysis 1.3): pain during movement (7/43 versus 5/44; RR 1.43, 95% CI 0.49 to 4.17); pain during work (5/43 versus 5/44; RR 1.02, 95% CI 0.32 to 3.28); pain during hobby activities (4/43 versus 4/44; RR 1.02, 95% CI 0.27 to 3.83); and volar plate tenderness (5/43 versus 8/44; RR 0.64, 95% CI 0.23 to 1.80). Similar findings applied at three years for pain and tenderness (see Analysis 1.4): pain during movement (3/34 versus 2/34; RR 1.50, 95% CI 0.27 to 8.42); pain during work (5/34 versus 2/34; RR 2.50, 95% CI 0.52 to 12.01); pain during hobby activities (4/34 versus 1/34; RR 4.00, 95% CI 0.47 to 33.97); and volar plate tenderness (6/34 versus 6/34; RR 1.00, 95% CI 0.36 to 2.79). There were no differences between groups at six months for extension deficit (5/43 versus 3/44; RR 1.71, 95% CI 0.43 to 6.70) or flexion deficit (7/43 versus 8/44; RR 0.90, 95% CI 0.36 to 2.25) (see Analysis 1.5). The same lack of statistically significant differences between two groups applied at three years in both extension deficit (1/34 versus 2/34; RR 0.50, 95% CI 0.05 to 5.26) or flexion deficit (2/34 versus 3/34; RR 0.67, 95% CI 0.12 to 3.74) (see Analysis 1.6).
Thomsen 1995 found no statistically significant differences in reported outcomes between protected mobilisation versus immobilisation in an aluminium splint at two weeks following injury, nor at six months. There was no formal measure of functional outcome. At two weeks, fewer participants in the protection mobilisation group had instability (3/19 versus 7/20; RR 0.45, 95% CI 0.14 to 1.49; see Analysis 2.1) and more were able to bend their finger (11/19 versus 6/20; RR 1.93, 95% CI 0.89 to 4.17; see Analysis 2.2); neither result reached statistical significance.
At six months, there was no difference between groups in the number of participants who were considered to have had an excellent outcome (16/19 versus 16/20; RR 1.05, 95% CI 0.79 to 1.41; see Analysis 2.3). The remaining participants (3 versus 4) had a good outcome and thus none of the participants were considered to have had a poor outcome.
The authors reported that all participants were able to return to their normal job within two to three weeks post injury.
Thomsen 1979 used two methods of immobilisation (plaster cast and aluminium splint) to restrict movement for one week or for three weeks. They presented "complaints and findings" results for 191 fingers (181 participants) split according to the period of immobilisation: one week versus three weeks. Thomsen 1979 did not provide details of the distribution of the participants with multiple injuries to their PIP joints: but these were equally distributed with five extra fingers in each duration-of-immobilisation group. There were no statistically significant differences in the reported outcomes between the two duration of immobilisation groups at six month follow-up. Similar results were found for poor outcome (see Analysis 3.1) as represented by complaints of joint stiffness and coldness (23/96 versus 28/95 fingers; RR 0.81, 95% CI 0.51 to 1.30) and joint thickening (19/96 versus 15/95 fingers; RR 1.25, 95% CI 0.68 to 2.32). Likewise, there was little difference between the two groups in pain or tenderness (see Analysis 3.2): pain during movement (20/96 versus 16/95 fingers; RR 1.24, 95% CI 0.68 to 2.24; pain during work (17/96 versus 13/95 fingers; RR 1.29, 95% CI 0.67 to 2.51); pain during hobby activities (19/96 versus 15/95 fingers; RR 1.25, 95% CI 0.68 to 2.32); and volar plate tenderness (1/96 versus 3/95; RR 0.33, 95% CI 0.03 to 3.12). Few people in each group had decreased range of motion at six months (decreased extension: 3/96 versus 1/95 fingers; RR 2.97, 95% CI 0.31 to 28.04; decreased flexion: 3/96 versus 3/95 fingers; RR 0.99, 95% CI 0.20 to 4.78) (see Analysis 3.3). The authors reviewed the number of sick days taken by participants, regardless of immobilisation method, and concluded that number of sick days increased when the PIP joint was immobilised for a longer period of time.
Thomsen 1979 restricted movement for one or three weeks using either an aluminium splint or a plaster cast. The authors reported there was no difference between two methods of splinting and presented pooled data according to the duration of immobilisation. However, they reported the cost of application of an aluminium splint to be less than the cost of a plaster cast (9.53 Danish kroner versus 33.73 Danish kroner), mainly reflecting differences in staffing time involved.
Despite a comprehensive search for appropriate trials, we were only able to identify three trials that adequately met our selection criteria for inclusion in this review.
Three trials of 366 participants with hyperextension injuries to the proximal interphalangeal joints of the hand managed with conservative interventions were identified.
Norregaard 1987, which compared unrestricted mobility with splint immobilisation, found no statistically significant differences in outcome between the two groups at six months or three years post injury. Reported outcomes included finger movement, pain, joint tenderness and stiffness.
Thomsen 1995 found no statistically significant differences in reported outcomes between protected mobilisation versus immobilisation in an aluminium splint at two weeks following injury, nor at six months. Reported outcomes included finger movement, instability, and overall outcome.
Thomsen 1979 found no statistically significant differences between immobilisation for one week versus three weeks in the reported outcomes, relating to poor outcome, pain and tenderness and range of motion at six months follow-up. Thomsen 1979 reported, without providing data, no difference in outcome at six months post intervention between aluminium splint versus plaster of Paris aside from greater application (mainly staffing) costs for plaster of Paris.
There was no statistically significant difference in outcomes reported by any of the three studies included in this review and it is therefore not possible to determine if one form of treatment (unrestricted mobilisation, protected mobilisation, immobilisation) is better than any other when deciding how to conservatively manage PIP joint hyperextension injuries.
All studies report on one of this review's primary outcome measures: 'poor outcome', including finger stiffness, joint laxity and joint deformity. The other primary outcome measure, self-reported functional outcomes, was not acknowledged in any of the three studies.
All three studies adequately reported the inclusion and exclusion criteria. While it is likely that these trial populations are representative, the lack of detailed information on the baseline characteristics of the trial participants on all three trials reduces the confidence on the applicability of their findings.
Despite the age of these trials, being more than 15 years since publication, these methods of conservative management continue to be applicable in clinical practice. Trials report participants presenting to emergency departments and orthopaedic clinics, as is commonly the case. However none of the three trials describe the methods used to evaluate the outcome measures on which the authors base their results. Additionally, the studies did not report information on exercise prescription. It is therefore difficult to extrapolate these outcomes to clinical practice and makes it almost impossible to replicate the studies in order to compare results.
The quality of evidence available for the purpose of this review is very low. As well as being quasi-randomised, Norregaard 1987 was inconsistently reported and was at high risk of attrition bias. Thomsen 1979 was the only study to report an adequate method of sequence generation, but neither this trial nor Thomsen 1995 provided information on allocation concealment. Whilst we recognise that for the three included trials it was not possible to blind treatment providers or the patients to the interventions included, blinded assessors could have been used to review and record clinical outcomes.
In an attempt to reduce the possibility of bias in the review process, we undertook a comprehensive search of electronic databases. We acknowledge that all three studies are more than 15 years old. Although we found more recent publications on management of PIP joint hyperextension injuries, none were randomised controlled trials. There may be unpublished trials that have been reported in abstracts only. For future updates, we will attempt to identify non-published studies by liaising with content area specialists and search conference proceedings. As part of this review, contact was made with two authors to establish both the suitability of the trial for inclusion in the review and for clarification on the randomisation process.
We did not find any other reviews that looked at conservative management of hyperextension injuries.
There is insufficient evidence from trials testing the need for, and the extent and duration of, immobilisation to inform on the key conservative management decisions for treating hyperextension injuries of the proximal interphalangeal joints.
Hyperextension injuries of the proximal interphalangeal joints are a common presentation in hand clinics (Eaton 1976; Sprauge 1975). Currently, there is no consensus on optimum management. Further randomised trials comparing intervention options, exercise prescription and outcomes would be useful in determining the appropriate level of intervention for these injuries. Outcomes should include self-reported functional ability and pain, and objective measures of deformity, motion, grip strength.
A randomised controlled trial comparing thermoplastic splinting and early active mobilisation versus buddy strapping and early active mobilisation is recommended. As well as short term follow-up at three and six months to monitor recovery and capture time to return to function and employment, longer term follow-up at 12 and 24 months post injury is needed. Direct and indirect costs should also be included in the study to determine the cost-effectiveness of each intervention. Such trials should meet the CONSORT criteria for design and reporting of non-pharmacological studies (Boutron 2008).
The authors would like to thank Roma Bhopal, Lesley Gillespie, Nigel Hanchard, Helen Handoll and Adam Watts for helpful comments about the protocol and the review, as well as acknowledging the assistance of Lindsey Elstub and Amy Kavanagh of the Cochrane Bone, Joint and Muscle Trauma Group in preparing drafts of both the protocol and the review.
We would like to thank Anne Moseley at The George Institute for Public Health for running searches through PEDro.
We would like to thank Steve Powell, Clinical Effectiveness Department, St George's Healthcare NHS Trust for his assistance in obtaining full text articles.
We would also like to thank Dr Annette Bluemle and Jeppe Schroll for their assistance in translating articles.
We thank Mr John Jakobsen for providing further details of his trial.
Our thanks also to the Therapies Department, St George's Healthcare NHS Trust and to the staff of St George's University Library for their support and assistance.
|Outcome or subgroup title
|No. of studies
|No. of participants
|Statistical method
|Effect size
|1 Poor outcome (6 months)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|1.1 Stiffness and coldness
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|1.2 Thickened joint
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|1.3 Swan neck deformity
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|1.4 Button hole deformity
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2 Poor outcome (3 years)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|2.1 Stiffness and coldness
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2.2 Thickened joint
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2.3 Swan neck deformity
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2.4 Button hole deformity
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2.5 "Sequelae" (mainly mild pain)
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2.6 "Sequelae" (mainly mild pain) - alternative report data
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|3 Pain and tenderness (6 months)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|3.1 Pain during movement
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|3.2 Pain during work
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|3.3 Pain during hobby-activities
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|3.4 Volar-plate tenderness
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|4 Pain and tenderness (3 years)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|4.1 Pain during movement
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|4.2 Pain during work
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|4.3 Pain during hobby-activities
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|4.4 Volar-plate tenderness
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|5 Range of motion defect (6 months)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|5.1 Extension defect
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|5.2 Flexion defect
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|6 Range of motion defect (3 years)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|6.1 Extension defect
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|6.2 Flexion defect
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|Outcome or subgroup title
|No. of studies
|No. of participants
|Statistical method
|Effect size
|1 Instability (2 weeks: post intervention)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|2 Range of movement 0 to 90 degrees (2 weeks: post intervention)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|3 Excellent outcome (6 months)
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|Outcome or subgroup title
|No. of studies
|No. of participants
|Statistical method
|Effect size
|1 Poor outcome
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|1.1 Stiffness and coldness
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|1.2 Thickened joint
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2 Pain and tenderness
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|2.1 Pain at movement
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2.2 Pain at work
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2.3 Pain at hobbywork
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|2.4 Volar plate tenderness
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|3 Decreased range of motion
|Risk Ratio (M-H, Fixed, 95% CI)
|Totals not selected
|3.1 Decreased extension
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
|3.2 Decreased flexion
|Risk Ratio (M-H, Fixed, 95% CI)
|0.0 [0.0, 0.0]
#1 (proximal interphalangeal):ti,ab (77)
#2 (PIPs OR PIPj* OR PIP joint*):ti,ab (307)
#4 MeSH descriptor Dislocations, this term only (179)
#5 MeSH descriptor Fractures, Bone, this term only (976)
#6 MeSH descriptor Finger Injuries, this term only (82)
#7 (fracture* OR dislocat* OR injur*):ti (8773)
#8 ((injur* OR fracture* OR dislocat*) NEAR/3 (ligament* OR volar plate OR interphalangeal OR proximal)):ti,ab (431)
#9 (hyperexten* OR sublux*):ti,ab (175)
1 "proximal interphalangeal".ti,ab. (1910)
2 (PIPs or PIPj* or "PIP joint*").ti,ab. (1323)
3 VOLAR PLATE/in (11)
4 1 or 2 or 3 (2796)
5 DISLOCATIONS/th (3101)
6 FRACTURES, BONE/th (6275)
7 FINGER INJURIES/th (812)
8 (fracture* or dislocat* or injur*).ti. (277899)
9 ((injur* or fracture* or dislocat*) adj3 (ligament* or "volar plate" or interphalangeal or proximal)).ti,ab. (10489)
10 (hyperexten* or sublux*).ti,ab. (9309)
11 5 or 6 or 7 or 8 or 9 or 10 (290636)
12 4 and 11 (579)
14 ("early motion" or "early active motion" or mobili*).ti,ab. (135541)
15 exp EXERCISE THERAPY/ (24123)
16 exercis*.ti,ab. (170086)
17 ((buddy or neighbour* or adjacent) adj2 (strap* or tape* or taping or wrap*)).ti,ab. (46)
20 splint*.ti,ab. (9851)
21 14 or 15 or 16 or 17 or 18 or 19 or 20 (337734)
22 12 and 21 (202)
2 "proximal interphalangeal joint*".ti,ab. (1517)
3 (PIPs or PIPj* or "PIP joint*").ti,ab. (1493)
4 1 or 2 or 3 (3189)
5 DISLOCATION/th or FINGER DISLOCATION/ (1706)
7 JOINT INJURY/th or JOINT FRACTURE/th (130)
8 FINGER INJURY/th (471)
9 ((injur* or fracture* or dislocat*) adj3 (ligament* or "volar plate" or interphalangeal or proximal)).ti,ab. (11783)
10 (fracture* or dislocat* or injur*).ti. (306032)
11 (hyperexten* or sublux*).ti,ab. (9870)
12 5 or 6 or 7 or 8 or 9 or 10 or 11 (318155)
13 4 and 12 (603)
15 ("early motion" or "early active motion" or mobili*).ti,ab. (148937)
16 exp EXERCISE/ or MOVEMENT THERAPY/ (164981)
17 exercis*.ti,ab. (199501)
18 ((buddy or neighbour* or adjacent) adj2 (strap* or tape* or taping or wrap*)).ti,ab. (49)
19 SPLINTS/ or SPLINTING/ or BANDAGE/ (17806)
20 splint*.ti,ab. (10286)
21 14 or 15 or 16 or 17 or 18 or 19 or 20 (434718)
22 13 and 21 (206)
1. TX (proximal N3 interphalangeal N3 joint*) (220)
2. TX (PIP or PIPj*) (315)
3. TX (PIP N3 joint*) (82)
4. TX (volar N1 plate*) (81)
5. S1 or S2 or S3 or S4 (544)
6. (MH "Finger Dislocation") (240)
7. (MH "Finger Injuries") (26)
8. MH "Hand Fractures") (29)
9. TI (fractur* or dislocat* or injur*) (62074)
10. TX (injur* or fracture* or dislocat*) N3 (ligament* or interphalanageal or proximal) (6336)
11. TX (hyperexten* OR sublux*) (2823)
12. S6 or S7 or S8 or S9 or S10 or S11 (68529)
13. S5 and S12 (164)
14. (MH "Joint Mobilization") (1)
15. TX ("early motion"or "early active motion" or mobili*) (21335)
16. (MH "Therapeutic Exercise+") (30452)
17. TX (exercis*) (89288)
18. TX (buddy or neighbour or adjacent) N2 (strap* or tape* or taping or wrap*) (13)
19. (MH "Splints") (429)
20. (MH "Taping and Strapping") (1539)
21. S14 or S15 or S16 or S17 or S18 or S19 or S20 (138485)
22. S13 and S21 (32)
/in: injuries subheading
/th: therapy subheading
.ti: textword in title
.ti,ab: textword in title and abstract
All authors were involved in the preparation of the protocol, the conception of which was based on previous work undertaken by MB. All authors contributed to the work and writing involved in the review. Data entry and analysis were completed by SM. JC, MB and ZA completed the first draft of the review with feedback from SM.
None known.
St George's NHS Healthcare Trust, UK.
No sources of support supplied
In our risk of bias assessment, we did not assess patient reported and clinician rated outcome measures separately in our assessment of assessor blinding and completeness of outcome data. Another difference was that we also assessed risk of performance bias associated with blinding of participants and care providers.
|Quasi-randomised trial. Patients randomised to group 1 on even dates of trauma and to group 2 on odd dates of trauma
126 patients with hyperextension injuries to the PIP joint (mean age at time of injury: 24 years) were randomised (stated in two reports of the trial). However, 112 were reported in the 1987 English language publication, which is treated as the main publication in this review.
Participants were recruited on presentation to an Emergency Department in Denmark between 1 November 1982 and 1 November 1983.
Analgesics and commencement of unrestricted motion within days of the initial trauma (56 patients)
3 weeks of immobilisation with 15 to 20 cm foam rubber covered aluminium splint applied to volar surface with the injured joint flexed to 15 degrees, the MP joint 80 to 90 degrees, and the wrist extended 30 degrees (56 patients)
Pain (during movement, during work, during hobby activities), volar plate tenderness, stiffness and coldness, thickened joint, extension deficit, flexion deficit, swan neck deformity, button-hold deformity, other.
Pain was graded according to the Moller 1974 scale.
Follow-up at six months and three years.
Diagnostic inclusion criteria was the presence of a volar plate lesion, indicated by the presence of all of:
1. local volar tenderness
2. pain at maximal flexion
3. relief from pain in intermediate position
4. recurrence of pain at maximal extension.
Six months after injury: In the text of the report: 78 patients (34 in group 1 and 44 in group 2) were re-examined. In table 1 of the main report, it is 87 (44 versus 43).
A further follow-up of 77 (text: 34 in group 1 and 43 in group 2; table 1 68 in all: 34 versus 34) patients was performed about 3 years after the injury. Given the pattern of the loss to follow-up was similar in the other reports of the trial to that given in table 1, we have used these data in the results.
Sequelae were graded according to Moller (1974):
+ mild pain from forceful loading or cold water
++ moderate pain from tapping or performing normal work
+++ considerable daily pain, symptomatic restriction of movement, dystrophic appearance
|Risk of bias
|Authors' judgement
|Support for judgement
|Random sequence generation (selection bias)
|High risk
|Date of trauma
|Allocation concealment (selection bias)
|High risk
|Quasi-randomised by date of trauma
|Blinding of participants and personnel (performance bias)
All outcomes
|High risk
|Author contacted - unable to recall relevant details of assessment procedure and blinding of personnel is not reported. Not possible to blind participants
|Blinding of outcome assessment (detection bias)
All outcomes
|High risk
|As above.
|Incomplete outcome data (attrition bias)
All outcomes
|High risk
|Irregularities in reported loss to follow-up both within trial report (results in the text vary from the results table) and between trial reports. In the text of the main report: 39% were lost from the no immobilisation group and 21% from the immobilisation group at 6 months; but table 1 of the report shows more similar losses in the two groups 23% versus 21%. There is no indication as to how the incomplete outcome data was managed
|Selective reporting (reporting bias)
|Unclear risk
|Unable to assess this as no protocol for the trial was located
|Other bias
|Unclear risk
|No indication of baseline demographics of groups. Assessment procedures for outcome measures is unclear nor is the number of assessors reported. There are inconsistencies in the results text and the table of results
|Parallel group randomised controlled trial
|200 patients (181 patients followed up; 191 fingers) with hyperextension lesions of the volar fibrocartilage in the PIP joint (age range 7 to 76 years; 75 males and 106 females) were randomised. Participants were recruited on presentation to an Emergency Department in Denmark between 1 September 1977 to 1 September 1978.
1 week of immobilisation with an aluminium splint (46 participants)
3 weeks of immobilisation with an aluminium splint (39 participants)
1 week of immobilisation with plaster of Paris cast (45 participants)
3 weeks of immobilisation with plaster of Paris cast (51 participants).
Pain, decreased flexion or extension, stiffness and coldness, tenderness and thickened joint at 6 months. Any sick leave. Discomfort from splint or plaster at week 1 or week 3.
Application costs of aluminium splint versus plaster of Paris.
Follow-up at 6 months (3 patients with severe complications were seen again at 12 months).
Inclusion criteria: hyperextension trauma and
1. volar pain at maximal flexion of the PIP joint
2. pain relief at semiflexion
3. pain increase at maximal extension.
Exclusion criteria: larger fractures, abnormal hyperextension and lateral laxity
The authors report no difference between immobilisation method therefore they pooled all subjects immobilised for one week and all subjects immobilised for three weeks.
Results are presented in terms of injured fingers rather than participants.
|Risk of bias
|Authors' judgement
|Support for judgement
|Random sequence generation (selection bias)
|Low risk
|Used randomised table
|Allocation concealment (selection bias)
|Unclear risk
|Not specified
|Blinding of participants and personnel (performance bias)
All outcomes
|High risk
|Not possible to blind participants and no report of personnel blinding
|Blinding of outcome assessment (detection bias)
All outcomes
|High risk
|As above
|Incomplete outcome data (attrition bias)
All outcomes
|Unclear risk
|No indication of how lost data was managed. Nine per cent of participants immobilised for one week and 10% of participants immobilised for three weeks were lost to follow-up or excluded. Exclusion criteria were applied after randomisation
|Selective reporting (reporting bias)
|Unclear risk
|Unable to assess this as no protocol for the trial was located
|Other bias
|Unclear risk
|Unclear homogeneity of groups and unclear procedures of assessment. Inadequate follow-up period (6 months except for 3 patients) and no comment as to the number of assessors involved
|Randomised controlled trial
|40 patients with hyperextension injuries to the PIP joint (age range 18 to 79; 19 males and 20 females). One patient (gender unknown) withdrew after removal of bandage, not wishing to participate in trial. The study was conducted in Denmark, between August 1992 and September 1993 (setting unclear).
2 weeks of elastic double finger bandage allowing the PIP joint to be flexed 25 to 30 degrees (19 patients)
2 weeks of aluminium splint applied to dorsal surface of finger holding PIP joint in 15 degrees of flexion (20 patients)
Two weeks: range of movement, volar instability, return to work.
Six months: Assessment of outcome using the Benke and Stableforth (1979) criteria based on movement, symptoms, stability and function, rated as excellent / good / poor.
Inclusion criteria: type 1 lesions of the volar plate - volar plate avulsion or minor avulsion fracture and minor split in collateral ligaments (Eaton 1976)
Exclusion criteria: patients with previous injuries to the joint
Two weeks and six months after injury 39 patients were re-examined (20 in group 1 and 19 in group).
Outcome was graded according to Benke and Stableforth (1979):
Excellent: Movement 0 to 90°+, no symptoms, stable, normal function
Good: Fixed flexion of 20 or less, flexion of 90°+, minimal symptoms, stable, good function
Poor: Fixed flexion > 20, flexion < 90, significant symptoms, instability, poor function
|Risk of bias
|Authors' judgement
|Support for judgement
|Random sequence generation (selection bias)
|Unclear risk
|Prospective randomised trial - sequence generation not reported
|Allocation concealment (selection bias)
|Unclear risk
|Not reported
|Blinding of participants and personnel (performance bias)
All outcomes
|High risk
|Not possible for participants to be blinded and no report of personnel blinding
|Blinding of outcome assessment (detection bias)
All outcomes
|High risk
|Not reported. However, it was reported that authors performed all assessments at follow-up
|Incomplete outcome data (attrition bias)
All outcomes
|Unclear risk
|No indication of incomplete outcome data. However, one patient withdrew after removal of the elastic bandage
|Selective reporting (reporting bias)
|Unclear risk
|Unable to assess this as no protocol for the trial was located
|Other bias
|Unclear risk
|No report on homogeneity of the two groups. Outcomes were assessed by three examiners, who were the authors. Unclear assessment procedures and inadequate length of follow-up (3 months)
|Reason for exclusion
|Arora 2004
|This trial reported two different types of management options for hyperextension injuries. Communication with the author confirmed this study was not a randomised or a quasi-randomised controlled trial.


text:
Eastern Michigan University News
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A Darkly Hidden Truth (The Monastery Murders) Paperback – December 1, 2011
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A loving couple, grieving the loss of their son, finds their marriage in free fall when a beautiful, long-lost acquaintance inserts herself into their lives. Learn More
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Antony was by far my favorite character. He's kind, chivalrous and unassuming, but certainly not boring. His humble demeanor was balanced out with noticeable charm and I found myself smiling each and every time he winked or grinned at Felicity. Our heroine, Felicity was an enigma in the first third of the book. I couldn't decide if I liked her or was just putting up with her. As the story progressed, Felicity proved to be a worthy heroine - a modern personality warring with the search for some higher purpose. She found her footing halfway through and began to show her strength and determination. Her personality seemed to shine through more as the story progressed and I became immersed in both the intellectual and romantic relationship between her and Antony.
Then there's the murder and mystery - well plotted, well developed and not entirely predictable. I'll admit that one of the culprits was a complete surprise to me. I had gone along thinking I knew everyone who did it and where I figured out most, I appreciated that the author could twist enough to keep me on my mental toes.Read more ›
Author: Donna Fletcher Crow
Publisher: Monarch
Pages: 365
Year: 2011
Note: I received a complimentary copy from Kregel. Follow future reviews and read past reviews on my Blog, Seeking Him with all Yur Heart: [...]
Have you ever watched a movie, TV series or read a book looking forward to the upcoming action? How about starting a sequel of the original be it a movie, television or a book only to not finish it because you were disappointed? Let me tell you, this series written by Donna Fletcher Crow seems to only get better with each book. Mrs. Crow is a writer who not only researches for her stories from various sources; she actually travels to where her stories take place.
In this second book, Antony and Felicity are back on the track of another murder? Not in this well written, highly intriguing story. Each of the characters is battling his own thoughts and fears, all the while looking for where they belong, a question real people ask all the time. What keeps the reader from putting the book down is that the path each main character takes is not the same one, yet they are intertwined in a way the reader seeks to grasp.
While most authors put the height of the story in the middle, Donna does a masterful job of placing action right near the latter portion of these novels. She takes care to lay the groundwork from a historical perspective for the story, and then she brings characters her readers can identify with into the story. There seem to be multiple stories happening simultaneously with the characters, though it isn't hard for the audience to follow at all. There are many themes woven in the tapestry of the story.Read more ›
This read begins with Felicity embarking on a journey to become a nun. Felicity reminded me of Maria in the movie, The Sound of Music. Felicity loves life and likes change. Sometimes Felicity changes her way of life, like wanting to become a nun, just because the notion overtakes her at the time or going off to another convent just because of the adventure. Even though, at the time, Felicity is totally convinced that it is the right thing to do, never thinking of consequences or life results. One cannot help but love Felicity!
Being Protestant I was slightly confused at the being of this read...I thought this was about the Catholic church but then I realized that Felicity and Anthony are Anglican (like the Episcopal church). A Catholic priest takes a vow not to marry; whereas, an Anglican priest can marry. From a protestants view point, I found all of the church history very enlightening and informative.
This is one read that won't leave you hanging! The mystery of sacred icons being stolen and murders abounding makes for a grand gothic read! Ms. Crow writes with a dynamic mix of intellect and realism! The reader can "feel" the chill of the monastery or the blandness of the dreary sky.
Then there is the emotion of family dynamics between Felicity and her mother which is so true to life or the sweet hint of romance whenever Anthony is around Felicity. Loved the ending to this story!
This stand.alone.read is not to be missed! And will make you wanting more...waiting impatiently for The Unholy Communion book #3 in the Monastery Murders.
*This book was provided for review by Kregel Publications*
Most Recent Customer Reviews
my religious connection with monasteries.......just loved the settings visited most places ...intriguing to the end. would recommend to anyone who likes a good old fashion murder.Published on July 15, 2013 by pamela a barlow
I've just been reading excerpts from Julian of Norwich's writing. How enormously satisfying to open a novel that begins with a reminder of the woman (and daughter of a woman)... Read morePublished on August 14, 2012 by Sheila Deeth
A DARKLY HIDDEN TRUTH by Donna Fletcher Crow is a fast paced historical mystery. This is book 2 in "The Monastery Murders",but can be read as a stand alone. Read morePublished on May 10, 2012 by My Book Addiction and More
Julian of Norwich must have had a mother, and so does our heroine Felicity. Julian's mother may have mourned when her daughter shut herself away in a fourteenth-century anchorage,... Read morePublished on May 10, 2012 by LeAnne Hardy
A great read, keeps you guessing right up to the end! Good mix of history and human relationships. The characters are easy to relate to and the story both informative and... Read morePublished on April 20, 2012 by Juliekevandrew
There are two groups of people in the world: Those who've read A Very Private Grave (the first installment of the Monastery Murders by Donna Fletcher Crow) and those who haven't. Read morePublished on March 31, 2012 by Jeffrey C. Reynolds
"A Darkly Hidden Truth," the second of Donna Fletcher Crow's "Monastery Murders" series, follows the progress of young headstrong Felicity, our heroine. Read morePublished on March 22, 2012 by Carol-Lynn
From start to finish this novel is a thoroughly enjoyable and gripping read, Fletcher Crow is a master storyteller. Read morePublished on March 12, 2012 by Amazon Customer
"Felicity has decided to become a nun. She departs to visits convents in spite of ther mother's imminent arrival and Fr. Anselm's request that she and Fr. Read morePublished on March 10, 2012 by Sam


text:
To JFF 2016
Back for our eighth year! This year's Festival is a continuation of the highly successful collaboration between the Embassy of Japan and access>CINEMA, with support from the Ireland Japan Association and the Japan Foundation.
Featured Films
Miss Hokusai
Keiichi Hara, 2015
The new film by the director of Colorful (which screened in the 2011 Festival) focuses on the untold story of O-Ei, daughter of the renowned Edo period Japanese artist Katsushika Hokusai. O-Ei is an independent, headstrong young woman and a talented
The Empire of Corpses
Ryotaro Makihara, 2015
In 19th century London, the development of a technology called "corpse reanimation" allows for the creation of dead servants who perform basic physical labour for humans. Young medical student John Watson has become obsessed with replicating Dr
Sion Sono, 2015
Two buses full of schoolgirls are travelling to a summer camp when a freak, bloody accident leaves Mitsuko (Reina Triendl) the only survivor. Seemingly pursued by a malicious, invisible force, a terrified Mitsuko finds sanctuary at a nearby high scho
Love and Peace
Sion Sono, 2015
Kyo is an office worker living his life in constant fear of rejection and mockery. An adopted turtle named Pikadon is his only friend and confidante. After being flushed down a toilet, the turtle winds up in a mysterious sewer lair, where an old man
The Case of Hana & Alice
Shunji Iwai, 2015
When Alice moves to a new town, she discovers her classmates are obsessed with a bizarre mystery. The 'Judas murder' apparently saw one boy disappear, with the other students believing there was a supernatural cause behind everything. Unable to g
100 Yen Love
Masaharu Take, 2014
Lazy Ichiko lives at home above her family's takeaway restaurant, rarely motivated to leave the house at all. A family dispute forces her to eventually leave home and find her own place. She takes a night shift at the local '100 Yen' convenienc
To JFF 2016
Back for our eighth year! This year's Festival is a continuation of the highly successful collaboration between the Embassy of Japan and access>CINEMA, with support from the Ireland Japan Association and the Japan Foundation.
The 2016 Festival features a diverse and packed programme of 22 films, which includes work of the most acclaimed filmmakers from contemporary Japanese cinema, and covers a variety of themes, genres and topics.
This year we will host 45 screenings at venues in Dublin, Cork, Limerick, Sligo, Galway, Dundalk and Waterford.
We hope that you will be able to join us.
Enjoy & Arigato!


text:
antitheft alarm goes off at times by itself. i just want to dissable it. the owners manual shows fuse 7 to be for anittheft module. can i pull the fuse to dissable it. if not, what do i do to dissable it. i no longer want it to work. the car is 20 years old and i just want it to run fine and it does.1993 lincoln mark viii
do i pull fuse 7 in the dash fuse box to dissable my antitheft system? on 1993 Lincoln Mark VIII
The nation's largest network of independent repair shops certified for expert training, quality work and fair pricing
2 answers
yes, you could pull the fuse and disable the anti-theft system...but with it disabled, you won't be able to start your car.
try it and see not sure. the module may be connected to others which will prevent this from working. i rec you seek help at an electrical shop and poss get it by passed


text:
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Samsung mobile 1GB DRAM
Dennis Hissink : January 3th 2007 - 15:00 CET
Samsung mobile 1GB DRAM :
Samsung announced that it has developed the industry's first one gigabit (Gb) Mobile DRAM (dynamic random access memory) for mobile products, using 80nm process technology. The new chip, also known as low-power DDR (double data rate) or synchronous DRAM, will be more cost effective than other high density mobile solutions and used for a wide range of advanced handset applications as well as for digital still cameras, portable media players and portable gaming products. The monolithic 1Gb Mobile DRAM is a highly competitive choice for mobile applications over the double-die stack, 1Gb memory solution widely used today, as the electric current in the new chip drops a full 30 percent.
Samsung 1GB mobile DRAM
The new 1Gb Mobile DRAM chip uses the same packaging technique as the 512Mb double-die stack 1Gb package, however it introduces a new temperature-sensing feature. This new temperature-compensated, self-refresh feature maximizes the self-refresh cycle to reduce power drain in standby mode by 30 percent over conventional memory chip designs. Also offering a more compact form factor, the new 1Gb Mobile DRAM chip is at least 20 percent thinner than a multi-stack package of 512Mb dies, allowing a single high-density package solution of 1.5Gb or even 2Gb Mobile DRAM memory, for which market demand is expected to grow in 2007.
1GB mobile DRAM - Samsung memory
One 1Gb mobile DRAM also can be combined with Flash memory in multi-chip packaging including package-on-package designs. Samsung plans to mass produce the new device beginning in the second quarter of 2007 at a time when demand for high-density 1Gb mobile DRAM is expected to be very high.
About Samsung Electronics
Samsung Electronics Co., Ltd. is a global leader in semiconductor, telecommunication, digital media and digital convergence technologies with 2005 parent company sales of US$56.7 billion and net income of US$7.5 billion. Employing approximately 128,000 people in over 120 offices in 57 countries, the company consists of five main business units: Digital Appliance Business, Digital Media Business, LCD Business, Semiconductor Business and Telecommunication Network Business. Recognized as one of the fastest growing global brands, Samsung Electronics is a leading producer of digital TVs, memory chips, mobile phones and TFT-LCDs.
Samsung DRAM Memory
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text:
3 Reviews
I absolutely don't mind using something like Calvados in a recipe when I know that the alcohol will burn off leaving a great fruity flavor behind! Made this recipe exactly as given & we had an absolutely wonderful new way for me to make this kind of chicken soup! Definitely a winner & a keeper of a recipe! [Tagged & made in Please Review My Recipe]
Love leeks, love apple in savoury dishes and just LOVED this soup. I couldn't find calvados (but I shall continue looking for next time I make this) so I simply added some white wine. I used a low-sodium chicken stock and low fat cream but otherwise made this exactly to the recipe. Apart from having used three leeks and being determined to track down that calvados, I wouldn't want to change a thing in this recipe: a great balance of flavours and textures. Thank you so much for sharing this recipe. Made for PRMR.
This is a beautiful and tasty twist on an old favorite soup. The addition of apples and cider gives it a delicate sweet under-tone and the cream and cheese goes nicely with that. We'll definitely have it again, thanks for sharing. Made for Photo Tag game.


text:
Fleece Friday: Take 15% off 1+ yards of Fleece Fabric Through 11:59 PM EDT July 29th.
Preview scale: 21.0 x 18.0 inches

Change DPI Base size is 150
Collection: Christmas Time
geometric (57250),
green (25786),
festive (867),
hakea (7)
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to add a comment.
cjldesigns says:
Thanks Donna and Victoria.
Posted over 3 years ago.
gitchyville_stitches says:
OOOOOhhhhhh gorgeous. I'm hooked by anything with that olivey-chartruse color (my all time favorite)!
kirpa says:
Great collection, Julie!! I love the colors, too!
cjldesigns uploaded a fabric image for
cjldesigns's design
Hakea green small :
© 2008-2015 Spoonflower Inc


text:
Lady Volunteers cruise into round of 16
Alicia Manning scored a career-high 17 points and had 10 rebounds to help No. 1-seeded Tennessee beat eighth-seeded Dayton 92-64 in the second round of the NCAA women's tournament on Monday night at Knoxville, Tenn.
The Lady Vols (32-2) have been absent from the round of 16 only once in the tournament's 29-year history, losing to Ball State last year in the opening round.
Dayton (25-8) was tasked with playing its second all-time NCAA tournament game in front of about 10,000 orange-clad fans.
University graduate Angie Bjorklund had 11 points for Tennessee, going 3 of 4 from behind the 3-point line.
Stanford 96, Iowa 67: Rosalyn Gold-Onwude hit a career-high seven 3-pointers on the way to a career-best 26 points and the top-seeded Cardinal shot a sizzling 68.8 percent in the first half and rolled past the eighth-seeded Hawkeyes at Stanford, Calif.
Gold-Onwude knew this game was going to be about the guards and 3-point shooting – and the Cardinal made their first nine shots from long range before JJ Hones' miss 3:21 before halftime.
Nnemkadi Ogwumike added 23 points, nine rebounds and seven assists in Stanford's 24th straight victory.
Florida State 66, St. John's 65 (OT): Jacinta Monroe scored Florida State's final four points of regulation to spark a last-ditch rally, then scored the game winner with 28.9 seconds left as the Seminoles beat the Red Storm at Tallahassee, Fla., in a game featuring 19 ties and 19 lead changes.
Monroe scored a game-high 16 points for Florida State (28-5).
Nadirah McKenith scored 15 for St. John's (25-7), which was trying to reach the NCAA round of 16 for the first time.
St. John's had a chance at the buzzer to win it. Da'Shena Stevens had a good look from the left wing, but her bank shot bounced off the rim as the horn sounded.
Duke 60, LSU 52: Jasmine Thomas scored 15 points to help the Blue Devils pull away late and beat the Tigers at Durham, N.C.
Bridgette Mitchell scored 12 points for Duke (29-5), who went ahead to stay on Thomas' layup with 3 1/2 minutes left. Typically sure-handed LSU (21-10) matched a season high with 22 turnovers and had one field goal in the final 4 minutes.
Allison Hightower had 19 points and LaSondra Barrett added 12 for LSU.
Kentucky 70, Michigan State 52: Victoria Dunlap scored 21 points to lead the fourth-seeded Wildcats into the regional semifinals for the first time in 28 years with a victory over the Spartans at Louisville, Ky.
The Wildcats (27-7) moved on behind a dominant second half and a defense that held the Spartans (23-10) to 35 percent shooting while forcing 18 turnovers.
Kentucky used a 24-6 run midway burst shortly after halftime to turn a two-point game into a rout.
Baylor 49, Georgetown 33: Brittney Griner blocked an NCAA tournament record 14 shots in a horrid offensive game for both teams, leading the Bears to a victory over the Hoyas at Berkeley, Calif.
Griner broke the mark Pauline Jordan of UNLV set against Colorado in 1989 to help Baylor (25-9) advanced to play top-seeded Tennessee (32-2) in Saturday's Memphis Regional semifinal.
Georgetown (26-7) missed its first 14 shots and had no answer offensively when Griner was in the game or when she was out with foul trouble. The Hoyas shot 17 percent and made fewer shots than Griner blocked, finishing 12 for 70 and matching the fifth fewest points ever scored in the tournament.
Georgia 74, Oklahoma State 71 (OT): Freshman Jasmine James scored 14 of her career-high 27 points in overtime to lead the Bulldogs to a victory over the Cowgirls at Tempe, Ariz.
Andrea Riley, the nation's No. 3 scorer at 26.6 points per game, returned from a one-game suspension to score 31 for Oklahoma State. Her attempt for a game-tying 3-pointer banked off the rim at the buzzer.
Angel Robinson had 16 points and 15 rebounds for the Lady Bulldogs (25-8), who advanced to the NCAA regional semifinals for the 18th time under coach Andy Landers.
Political geeks may love new elections website
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The dog days of summer are about to be kicked to the sidelines
A GRIP ON SPORTS • A weekend in late July. It's more than 90 degrees outside. Is this the proverbial "dog days of summer?" Read on.
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I scratched another back yard honey-do off my list this weekend already by finishing another one of those projects that had been on the waiting list for years. It involved ...
Civility, news reporting and a silver anniversary…
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Saving for the future
sponsored According to two 2015 surveys, 62 percent of Americans do not have enough savings to handle an unexpected emergency, much less any long-term plans.


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owens-illinois inc (OI:New York)
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Director, Chairman of Audit Committee and Member of Compensation Committee
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New Year's Eve in Denver: So many parties, so many concerts, so many things to do
Latest Word will be dark until Monday, what with New Year's Eve 2010 upon us.
If you're still looking for something to do, or something else to do, on Friday night, check out our top 10 lists below.
Does the snow and sub-zero forecast have you looking to make different plans? Whatever your New Year's Eve challenge, we have a solution. Well, unless you're Anika. In which case... we're sorry.
Other than that, though, whether you're looking for a cab ride home or a vegan menu plan, we're here to help. It's the worst night of the year to be a bartender, but here's how to drink your way into the new year like a pro.
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And once you've navigated your way from the bar to the home with that special someone in tow, we've got the top five foods to help you get laid.
As for what to do, well, that depends on your budget. Check our top ten picks for cheap, expensive, and in between. And if nothing strikes you, check our complete NYE listings.
- Top 10 Denver New Year's Eve Parties under $20
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-Top 10 Denver New Year's Eve concerts
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text:
Ram Rugged Field Watch
Item # WX2-229316SOLD OUT
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Ram Rugged Field Watch is classic military looks and modern function - water resistant to 200 meters!
Strap on the rugged field looks you love AND a dose of modern features you need. This Ram Field Watch is the same style that's been favored by G.I.s since WWII, but it's been upgraded for serious use: from the long-life silver oxide battery to the 200-meter water-resistance, you won't find a better field watch. Best of all, you can enlist this watch for less thanks to a timely volume buy.Let's march through the features:
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- Verona Police Blotter: July 8-15, 2016Posted 4 days ago
- Newark Man Arrested, Charged In Fatal Hit-And-RunPosted 2 weeks ago
- Claremont Construction Halt? Not ReallyPosted 2 weeks ago
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San Diego Loves DePalma
Keep your fingers crossed Verona: The San Diego Chargers apparently like what they see in Dan DePalma.
The Verona High School graduate signed a two-year deal with the Chargers in April and he has been working hard in the off-season. Here's what the Chargers' official news site has to say this week of his efforts:
"He's done a nice job and he's made the most of his opportunities," McCoy said last week following the end of the team's final mini camp. "The way we rotate practice, we give everyone an opportunity to play. All the receivers have bought in to what we're doing and they are in the best shape of their lives. We're going to run them a lot, and (DePalma's) done a nice job."
Boltbeat.com, a fan site that is part of Sports Illustrated, takes things one step further. It says that DePalma–a mild-mannered guy in real life–is "destined to be Chargers fans new bromance". ("Bromance", if you haven't heard the term, is a kind of crush that Hollywood has decided that men get.)
"San Diego Chargers fans have this affinity for little, white receivers in the pre-season," writes Boltbeat. "It has a little to do with the fact that we let go of Wes Welker and he turned into a stud. Everyone loves an underdog."
Of course, neither underdog status, nor bromance nor praise is a lock on a spot on the roster. We'll keep you posted.
Photo copyright San Diego Chargers. Used by permission.
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text:
Oil spill responders established a Matagorda Bay Forward Branch in Port O'Connor, Texas, to coordinate protection of the environment of the Matagorda Bay area, as a portion of the oil spilled on Saturday in a ship-barge collision near Texas City, Texas, moves south along the Texas Coast.
A Unified Command including the U.S Coast Guard, Texas General Land Office and Kirby Inland Marine, the owner of the vessel from which the oil was spilled, began their response efforts today implementing aggressive plans intended to protect environmentally sensitive areas against impact from the oil, based on priorities already established in the Area Contingency Plan.
While a notable portion of the approximately 168,000 gallons of the marine fuel oil has been removed by responders in the Texas City-Galveston area, an area of floating oil approximately fifteen miles off Matagorda Island is expected to be pushing shoreward by the weather over the next 24 to 48 hours. Today's response actions are focused on placing protective boom along the sensitive areas along the coast of Matagorda Island, including Sundown Island.
Approximately 150 response personnel, utilizing 11 response vessels, are actively working to deploy over 50,000 feet of protective boom today. In addition, responders currently have staged 40,000 feet of absorbent boom, with another 45,000 feet en route to Port O'Connor.
As access to Matagorda Island is by boat, members of the public are discouraged from accessing the island until the Unified Command announces that response operations are complete.
Wildlife Response Service, a Texas-based wildlife rehabilitation service, has also been deployed to assist in the event that birds or marine life are impacted by the oil. Persons who observe any impacted wildlife should not attempt to capture or handle them but are urged to call 888-384-2000. No reports of affected wildlife have been received.
A claims number has been established for persons who may have questions in regard to personal impact by the incident. The number is 855-276-1575.
Maritime Today
The Maritime Industry's original and most viewed E-News Service
Container-on-barge services have returned to the Port of Greater Baton Rouge to provide the petrochemical industry with another option to move its products.
Operated by SEACOR AMH,
Enterprise Products Partners on Thursday said the first ship to load ethane for export from its new terminal on the Houston Ship Channel will arrive on Aug. 1,
Eastern Shipbuilding Group, Inc. has launched Laura B, the final vessel in a series of four Robert Allan, LTD. (RAL) designed Z-Tech 2400 Class terminal and escort
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Gulf Petrochem Group, the UAE based global bunker supplier, has announced that it is now officially offering physical bunker supply in the port of Rotterdam, out of its new office based in Dordrecht.
As part of the ongoing Blue Star Delos Renewable Energy Innovation Project, Eco Marine Power (EMP) stated that the Aquarius Management & Automation System (MAS)
The Panama Canal authority (ACP) says a Chinese container ship's damaging scrape with the canal's new wider locks was caused by bad weather, Reuter quotes ACP's administrator, Jorge Quijano.
The Fishing Company of Alaska, based in Renton, owns the 238-foot Alaska Juris that started sinking in the Bering Sea shortly before noon on Tuesday, says a report in Seattle Times.
A barge sank east of the Galveston Causeway railroad bridge Tuesday, causing the U.S. Coast Guard to issue a safety zone and temporarily restrict traffic on the Gulf Intracoastal Waterway.
A ceremony will be held July 29 at Cenac Marine Services headquarters in, Houma, La. To commemorate the christening of its newest vessel, M/V Quincey Cenac, as