Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures.

Aims: The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius. Methods: A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective, as well as a broader societal point of view. Health resources and quality of life (the youth version of the EuroQol five-dimension questionnaire (EQ-5D-Y)) data were collected, as part of the Forearm Recovery in Children Evaluation (FORCE) multicentre randomized controlled trial over a six-week period, using trial case report forms and patient-completed questionnaires. Costs and health gains (quality-adjusted life years (QALYs)) were estimated for the two trial treatment groups. Regression was used to estimate the probability of the new treatment being cost-effective at a range of 'willingness-to-pay' thresholds, which reflect a range of costs per QALY at which governments are typically prepared to reimburse for treatment. Results: The offer of a soft bandage significantly reduced cost per patient (saving £12.55 (95% confidence interval (CI) -£5.30 to £19.80)) while QALYs were similar (QALY difference between groups: 0.0013 (95% CI -0.0004 to 0.003)). The high probability (95%) that offering a bandage is a cost-effective option was consistent when examining the data in a range of sensitivity analyses. Conclusion: In addition to the known clinical equivalence, this study found that the offer of a bandage reduced cost compared with rigid immobilization among children with a torus fracture of the distal radius. While the cost saving was small for each patient, the high frequency of these injuries indicates a significant saving across the healthcare system.

Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK.

BACKGROUND: The most common fractures in children are torus (buckle) fractures of the wrist. Controversy exists over treatment, which ranges from splint immobilisation and discharge to cast immobilisation, follow-up, and repeat imaging. This study compared pain and function in affected children offered a soft bandage and immediate discharge with those receiving rigid immobilisation and follow-up as per treating centre protocol. METHODS: In this randomised controlled equivalence trial we included 965 children (aged 4-15 years) with a distal radius torus fracture from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using bespoke web-based randomisation software. Treating clinicians, participants, and their families could not be masked to treatment allocation. Exclusion criteria included multiple injuries, diagnosis at more than 36 h after injury, and inability to complete follow-up. The primary outcome was pain at 3-days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. We performed a modified intention-to-treat and per protocol analysis. The trial was registered with ISRCTN registry, ISRCTN13955395. FINDINGS: Between Jan 16, 2019, and July 13, 2020, 965 children were randomly allocated to a group, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 379 (39%) were girls and 586 (61%) were boys. Primary outcome data was collected for 908 (94%) of participants, all of whom were included in the modified intention-to-treat analysis. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group versus 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was -0·10 (95% CI -0·37 to 0·17) and-0·06 (95% CI -0·34 to 0·21) in the per-protocol population. INTERPRETATION: This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up. FUNDING: UK National Institute for Health and Care Research.

Offer of a bandage versus rigid immobilisation in 4- to 15-year-olds with distal radius torus fractures: the FORCE equivalence RCT.

BACKGROUND: Torus (buckle) fractures of the wrist are the most common fractures in children involving the distal radius and/or ulna. It is unclear if children require rigid immobilisation and follow-up or would recover equally as well by being discharged without any immobilisation or a bandage. Given the large number of these injuries, identifying the optimal treatment strategy could have important effects on the child, the number of days of school absence and NHS costs. OBJECTIVES: To establish whether or not treating children with a distal radius torus fracture with the offer of a soft bandage and immediate discharge (i.e. offer of a bandage) provides the same recovery, in terms of pain, function, complications, acceptability, school absence and resource use, as treatment with rigid immobilisation and follow-up as per usual practice (i.e. rigid immobilisation). DESIGN: A pragmatic, multicentre, randomised controlled equivalence trial. SETTING: Twenty-three UK emergency departments. PARTICIPANTS: A total of 965 children (aged 4-15 years) with a distal radius torus fracture were randomised from January 2019 to July 2020 using a secure, centralised, online-encrypted randomisation service. Exclusion criteria included presentation > 36 hours after injury, multiple injuries and an inability to complete follow-up. INTERVENTIONS: A bandage was offered to 489 participants and applied to 458, and rigid immobilisation was carried out in 476 participants. Participants and clinicians were not blinded to the treatment allocation. MAIN OUTCOME MEASURES: The pain at 3 days post randomisation was measured using the Wong-Baker FACES Pain Rating Scale. Secondary outcomes were the patient-reported outcomes measurement system upper extremity limb score for children, health-related quality of life, complications, school absence, analgesia use and resource use collected up to 6 weeks post randomisation. RESULTS: A total of 94% of participants provided primary outcome data. At 3 days, the primary outcome of pain was equivalent in both groups. With reference to the prespecified equivalence margin of 1.0, the adjusted difference in the intention-to-treat population was -0.10 (95% confidence interval -0.37 to 0.17) and the per-protocol population was -0.06 (95% confidence interval -0.34 to 0.21). There was equivalence of pain in both age subgroups (i.e. 4-7 years and 8-15 years). There was no difference in the rate of complications, with five complications (1.0%) in the offer of a bandage group and three complications (0.6%) in the rigid immobilisation group. There were no differences between treatment groups in functional recovery, quality of life or school absence at any point during the follow-up. Analgesia use was marginally higher at day 1 in the offer of a bandage group than it was in the rigid immobilisation group (83% vs. 78% of participants), but there was no difference at other time points. The offer of a bandage significantly reduced the cost of treatment and had a high probability of cost-effectiveness at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year. LIMITATIONS: Families had a strong pre-existing preference for the rigid immobilisation treatment. Given this, and the inability to blind families to the treatment allocation, observer bias was a concern. However, there was clear evidence of equivalence. CONCLUSIONS: The study findings support the offer of a bandage in children with a distal radius torus fracture. FUTURE WORK: A clinical decision tool to determine which children require radiography is an important next step to prevent overtreatment of minor wrist fractures. There is also a need to rationalise interventions for other common childhood injuries (e.g. 'toddler's fractures' of the tibia). TRIAL REGISTRATION: This trial is registered as ISRCTN13955395 and UKCRN Portfolio 39678. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 33. See the NIHR Journals Library website for further project information.

BACKGROUND: Torus fractures (also called buckle fractures) of the wrist are the most common type of broken bone in children, affecting 60,000 children in the UK per year. They are the mildest form of broken bone, in which the bone crushes (or buckles). Despite these fractures being so common, there is no 'standard treatment'. The traditional treatment is to use a plaster cast and arrange outpatient follow-up. Recent medical research has suggested that wearing a bandage, or even having no treatment, might result in similar healing. In this study, we looked into whether or not a bandage (which was optional to wear) and no further follow-up resulted in the same recovery as a hard splint and usual follow-up. A total of 965 children aged 4­15 years from 23 emergency departments in the UK took part in the study. Children were evenly divided between the bandage and hard splint groups in a process called randomisation. Prior to the study, families told us that managing pain after injury was the most important issue to them. We asked children and their families to tell us about pain, recovery using the arm, quality of life, complications encountered and school absences. We also looked at the financial costs to families and the NHS. WHAT DID THE TRIAL FIND?: The two treatments resulted in the same outcomes. The majority of those offered a bandage chose to wear it immediately. There was no difference at all in the levels of pain between those treated with a hard splint and usual outpatient follow-up and those offered a bandage and discharge (i.e. no further follow up) from hospital the same day. Similarly, there was no difference in the recovery using the arm, quality of life, complications encountered or school absences. There was a very slight increase in pain killer use in the bandage group at day 1, but not at any other time point. Overall, the cost of the offer of a bandage was slightly lower for families and the NHS. In conclusion, the findings of this study support offering a bandage to be used at the discretion of families to treat children with a torus fracture of the wrist.

A multicentre prospective randomized equivalence trial of a soft bandage and immediate discharge versus current treatment with rigid immobilization for torus fractures of the distal radius in children: protocol for the Forearm Fracture Recovery in Children Evaluation (FORCE) trial.

AIMS: Torus fractures are the most common childhood fracture, accounting for 500,000 UK emergency attendances per year. UK treatment varies widely due to lack of scientific evidence. This is the protocol for a randomized controlled equivalence trial of 'the offer of a soft bandage and immediate discharge' versus 'rigid immobilization and follow-up as per the protocol of the treating centre' in the treatment of torus fractures . METHODS: Children aged four to 15-years-old inclusive who have sustained a torus/buckle fracture of the distal radius with/without an injury to the ulna are eligible to take part. Baseline pain as measured by the Wong Baker FACES pain scale, function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb, and quality of life (QoL) assessed with the EuroQol EQ-5D-Y will be collected. Each patient will be randomly allocated (1:1, stratified by centre and age group (four to seven years and ≥ eight years) to either a regimen of the offer of a soft bandage and immediate discharge or rigid immobilization and follow-up as per the protocol of the treating centre. RESULTS: At day one, three, and seven, data on pain, function, QoL, immobilization, and analgesia will be collected. Three and six weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the Wong-Baker FACES pain scale at three days post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardian.Cite this article: Bone Joint Open 2020;1-6:214-221.

Pain scores in torus fractures: Using text messages as an outcome collection tool.

AIMS: This study sought to estimate the clinical outcomes and describe the nationwide variation in practice, as part of the feasibility workup for a National Institute for Health and Care Excellence (NICE) recommended randomized clinical trial to determine the optimal treatment of torus fractures of the distal radius in children. METHODS: Prospective data collection on torus fractures presenting to our emergency department. Patient consent and study information, including a copy of the Wong-Baker Faces pain score, was issued at the first patient contact. An automated text message service recorded pain scores at days 0, 3, 7, 21, and 42 postinjury. A cross-sectional survey of current accident and emergency practice in the UK was also undertaken to gauge current practice following the publication of NICE guidance. RESULTS: In all, 30 patients with a mean age of 8.9 years were enrolled over a six-week period. Of the 150 potential data points, data was captured in 146, making the data 97.3% complete. Pain scores were recorded at day 0 (mean 6.5 (95% confidence interval (CI) 5.7 to 7.3)), day 3 (4.4 (95% CI 3.5 to 5.2)), day 7 (3.0 (95% CI 2.3 to 3.6)), day 21 (1.2 (95% CI 0.7 to 1.7)) and day 42 (0.4 (95% CI 0.1 to 0.7)). Of the 100 units who participated in the nationwide survey, 38% were unaware of any local or national protocols regarding torus fractures, 41% treated torus fractures with cast immobilization, and over 60% of patients had follow-up arranged, both contradictory to national guidelines. CONCLUSION: We have demonstrated the severity, recovery trajectory, and variation in pain scores among children with torus fractures. We demonstrate excellent follow-up of patient outcomes using text messages. Despite national guidelines, there is significant variation in practice. This data directly informed the development of an ongoing nationwide randomized clinical trial - the FORearm Fracture Recovery in Children Evaluation (FORCE) study.

Paediatric orthopaedics in lockdown: A study on the effect of the SARS-Cov-2 pandemic on acute paediatric orthopaedics and trauma.

AIMS: To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS). METHODS: A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods. RESULTS: Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32). CONCLUSION: During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast.Cite this article: Bone Joint Open 2020;1-7:424-430.

Posterior Malleolar Ankle Fractures: An Effort at Improving Outcomes.

BACKGROUND: There is increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. We report our results of posterior malleolar fracture management based on the classification by Mason and Molloy. METHODS: All fractures were classified on the basis of computed tomographic (CT) scans obtained preoperatively. This dictated the treatment algorithm. Type-1 fractures underwent syndesmotic fixation. Type-2A fractures underwent open reduction and internal fixation through a posterolateral incision, type-2B fractures underwent open reduction and internal fixation through either a posteromedial incision or a combination of a posterolateral with a medial-posteromedial incision, and type-3 fractures underwent open reduction and internal fixation through a posteromedial incision. RESULTS: Patient-related outcome measures were obtained in 50 patients with at least 1-year follow-up. According to the Mason and Molloy classification, there were 17 type-1 fractures, 12 type-2A fractures, 10 type-2B fractures, and 11 type-3 fractures. The mean Olerud-Molander Ankle Score was 75.9 points (95% confidence interval [CI], 66.4 to 85.3 points) for patients with type-1 fractures, 75.0 points (95% CI, 61.5 to 88.5 points) for patients with type-2A fractures, 74.0 points (95% CI, 64.2 to 83.8 points) for patients with type-2B fractures, and 70.5 points (95% CI, 59.0 to 81.9 points) for patients with type-3 fractures. CONCLUSIONS: We have been able to demonstrate an improvement in the Olerud-Molander Ankle Score for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. Mason classification type-3 fractures have marginally poorer outcomes, which correlates with a more severe injury; however, this did not reach significance. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medial Approach to the Subtalar Joint.

Surgical access to the subtalar joint is required in a plethora of pathologic conditions of the hindfoot. The conventional lateral approach can give excellent access to subtalar joint; however, in hindfoot valgus deformities, there can be unacceptable risks of wound problems and incomplete deformity corrections. The medial approach offers good access to the subtalar joint with an increasing evidence base for its use, especially with double fusions in pes planus deformities. The authors review the current evidence in the use of the medial approach for the subtalar joint.

Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle.

BACKGROUND: We present a classification system that progresses in severity, indicates the pathomechanics that cause the fracture and therefore guides the surgeon to what fixation will be necessary by which approach. METHODS: The primary posterior malleolar fracture fragments were characterized into 3 groups. A type 1 fracture was described as a small extra-articular posterior malleolar primary fragment. Type 2 fractures consisted of a primary fragment of the posterolateral triangle of the tibia (Volkmann area). A type 3 primary fragment was characterized by a coronal plane fracture line involving the whole posterior plafond. RESULTS: In type 1 fractures, the syndesmosis was disrupted in 100% of cases, although a proportion only involved the posterior syndesmosis. In type 2 posterior malleolar fractures, there was a variable medial injury with mixed avulsion/impaction etiology. In type 3 posterior malleolar fractures, most fibular fractures were either a high fracture or a long oblique fracture in the same fracture alignment as the posterior shear tibia fragment. Most medial injuries were Y-type or posterior oblique fractures. This fracture pattern had a low incidence of syndesmotic injury. CONCLUSION: The value of this approach was that by following the pathomechanism through the ankle, it demonstrated which other structures were likely to be damaged by the path of the kinetic energy. With an understanding of the pattern of associated injuries for each category, a surgeon may be able to avoid some pitfalls in treatment of these injuries. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

A simplified, validated protocol for measuring fibular reduction on ankle CT.

BACKGROUND: Inadequate ankle syndesmotic reduction is a common and important cause of poor outcome after surgery. It is not clear what magnitude or planes of displacement impact most. Many computerised tomography (CT) measurement techniques rely on landmarks that are difficult to reproduce, and none measure all types of mal-positioning in a single protocol. The purpose of this study was to design and validate a protocol for measuring the distal tibio-fibular relationship. METHODS: We devised a method for measuring fibular diastasis, antero-posterior translation (APT) and fibular length on CT images. CTs of sixteen un-injured ankles were examined using our protocol and that of an established alternative method for comparison. The measurements were recorded by two independent observers and repeated for inter- and intra-observer agreement scores. RESULTS: Our method showed inter- and intra-observer agreement of r=0.994 and r=0.999, demonstrating strong agreement. This compared to r=0.218 and r=0.820 respectively for the comparative protocol. CONCLUSION: This ankle CT measurement protocol is accurate, reproducible and simple to use. Its aim is to be a useful tool for clinicians to quantify post-operative mal-positioning of the distal fibula in comparison to the un-injured ankle. We believe that routine, bilateral, post-operative CT imaging will lead to improvements in the understanding and outcomes of the treatment of complex ankle fractures. To our knowledge no other validated measurement of fibular length on CT images exists in the literature.

Scarf osteotomy.

The term scarf osteotomy was first used by Weil when presenting his results from more than 1000 cases. Scarf is a carpentry term describing beveling the ends of 2 pieces of wood and securely fastening them so that they overlap to create one continuous piece. This technique was popularized by Weil and Barouk as a versatile method of correcting hallux valgus while maintaining the blood supply to the metatarsal head. It also has rigid fixation, allowing early mobilization. This article addresses the surgical technique of the scarf osteotomy together with the results and complications of hallux valgus correction.

An evaluation of retrospective outcome scores in elective foot and ankle surgery.

BACKGROUND: Patient reported outcome measures are becoming more popular in their use. Retrospective scoring is not yet a validated method of data collection but one that could greatly decrease the complexity of research projects. We aim to compare preoperative and retrospective scores in order to assess their correlation and accuracy. METHODS: 36 patients underwent elective foot and ankle surgery. All patients were scored preoperatively using the SF-12 (including both the physical and mental subsets) and FFI. Patients then recorded both PROMs at the 3-month follow up (av. 139 days). Results were then analyzed for statistical significance. RESULTS: 36 patients (av. age 54.6): completed both sets of questionnaires. There were 15 hindfoot and 21 forefoot procedures. No retrospective scores were identical. The mean percentage difference between the preoperative scores was -7.9% (-17.3 to 1.6%, 95% CI) for Physical Component of SF12, -3.2% (-10.3 to 3.9%, 95% CI) for mental component of SF12 and 40.7% (25.3 to 56.1%, 95% CI) for FFI. This retrospective accuracy was statistically significant (p<0.001). When the scores were plotted against each other, the outcome measurements showed positive correlations (Physical SF 12 p=0.48, Mental SF 12 p=0.80 and FFI p=0.81). With both PROMs mean percentage differences combined, patients undergoing hindfoot procedures (3.5%; -5.0 to 12.1%, 95% CI) were more accurate with retrospective scoring than their forefoot counterparts (17.5%; 5.0 to 30.0%, 95% CI). This was not statistically significant (p=0.07). Using regression analysis, we found no significant statistical difference in the retrospective accuracy when compared against both time to retrospective scoring and the outcome measure at 3 months post operatively. CONCLUSION: Retrospective scoring appears to lack accuracy when compared to prospective methods. However, our data shows the SF12 is recalled more accurately than the FFI (p<0.001) and both the mental and physical components are recalled to within 10% of the pre-operative score. These results show patients tend to recall their symptoms at a worse level preoperatively than originally described, especially those with forefoot problems.

Could failure of the spring ligament complex be the driving force behind the development of the adult flatfoot deformity?

We conducted an investigation into the relative associations of magnetic resonance imaging (MRI)-defined pathologic features of the spring ligament and/or tibialis posterior tendon with radiographic evidence of a planovalgus foot position. A total of 161 patient images (MRI and plain radiographs) obtained from the foot and ankle clinic (2008 to 2011) were retrospectively reviewed. All 161 patients (64 male and 97 female; mean age 45.9 years, range 18 to 86) were included in the analysis. Lateral weightbearing radiographs were analyzed for the talo-first metatarsal angle ≥ 5°, calcaneal pitch ≤ 20°, and talocalcaneal angle ≥ 45°. A positive finding for ≥ 1 measurements identified a radiographic planovalgus position of the foot. The radiographic deformity was analyzed against the MRI evidence of either spring ligament or tibialis posterior tendon pathologic features for significance (p < .05). Evidence of a spring ligament abnormality was strongly associated with a planovalgus foot position, reaching high levels of statistical significance in all 3 categories of radiographic deformity (odds ratio 9.2, p < .0001). Abnormalities of the tibialis posterior tendon failed to demonstrate significance, unless grade I changes were excluded, and grade II and III appearances were analyzed in isolation (odds ratio 2.9, p = .04). Although absolute causal relationships were not tested, this investigation has clearly demonstrated that MRI-defined abnormalities of the spring ligament complex are possibly of at least equal importance to tibialis posterior dysfunction for the presence of a moderate to severe radiographic planovalgus foot position.

The use of shoulder hemiarthroplasty and humeral head resurfacing: a review of current concepts.

Since Neer's early work in the 1950s shoulder arthroplasty has evolved as a treatment option for various glenohumeral joint disorders. Both hemiarthroplasty and total shoulder prostheses have associated problems. This has led to further work with regards to potential resurfacing, with the aim of accurately restoring native proximal humeral anatomy while preserving bone stock for later procedures if required. Hemiarthroplasty remains a valuable treatment option in the low demand patient or in the trauma setting. Additional work is required to further define the role of humeral resurfacing, with the potential for it to become the gold standard for younger patients with isolated humeral head arthritis.

Proximal humeral fractures: a review of current concepts.

The majority of proximal humerus fractures are sustained via low energy falls in the elderly population. These patients can attain an acceptable level of function via non-operative treatment. There is yet to be a clear consensus on treatment options suitable for those that fall outside of this majority group. Open reduction internal fixation, intra medullary nailing and arthroplasty surgery have all been used to varying effects. Good results are achievable if complications such as mal-union, non-union and avascular necrosis can be avoided. This review aims to clarify the options available to the current day trauma surgeon.

MRI features most often associated with surgically proven tears of the spring ligament complex.

OBJECTIVES: The authors aim to present the common MRI appearances of surgically proven spring ligament tears as minimal radiological literature exists regarding injury to this increasingly important structure. MATERIALS AND METHODS: Our retrospective review identified a treatment group comprising 13 cases of surgically proven spring ligament injury and a 96-patient comparison group. All patients underwent standard musculoskeletal MRI sequences of the foot and ankle. Images were reviewed by a registrar-grade orthopedic surgeon and a consultant musculoskeletal radiologist for abnormalities of the spring ligament complex. RESULTS: MRI findings in relation to surgically proven injury of the superior-medial portion of the spring ligament included proximal thickening >5 mm in 92 % and distal thinning <2 mm in 85 % of proven injures to the spring ligament complex. Common abnormalities of the medio-plantar portion comprised ligament thickening >7 mm in 31 % and intra-substance signal heterogenicity demonstrated in 38 % of cases. CONCLUSIONS: The complex orientation of the medio-plantar ligament makes its evaluation unreliable due to the difficulty obtaining diagnostic quality imaging and our inability to correlate MRI findings in this portion of the ligament with surgically proven injury. However, MRI abnormalities of the superior-medial ligament are consistent, reproducible, and correlate with surgical pathology. As our incomplete understanding of the flexible flatfoot deformity evolves, our ability to recognize injury to the spring ligament may encourage novel surgical treatments looking to incorporate its repair or reconstruction into deformity correction.