Fracture of the os trigonum: A report of two cases and review of the literature.

We report two cases of acute fractures of the os trigonum. The os trigonum fracture related to the first case was sustained following a hyper-plantar flexion injury during a game of soccer. The second case involved a patient who fell from height and also sustained open fractures of the left distal tibia and lateral malleolus as well as the right calcaneus. In both cases, a preliminary diagnosis of a posterior talar process fracture was made from the initial radiographs of the ankle. The correct diagnosis of an os trigonum fracture rather than a fracture of the posterior talar process was only made following further assessment with CT imaging. Given that the course of treatment is largely determined by imaging findings, CT for further imaging evaluation should be performed in cases of suspected acute bony injuries of the posterior ankle, particularly when the limitations of using radiographs for the assessment of such injuries are expected to be encountered.

Consensus statements and guideline for the diagnosis and management of plantar fasciitis in Singapore.

Introduction: Plantar fasciitis (PF) is a common cause of heel pain among the general population. The lack of standard practice guideline in Singapore presents challenges in education and clinical practice for this painful condition. These consensus statements and guideline were developed to streamline and improve the management of PF, covering key aspects such as diagnosis, investigations, risk factors, treatment modalities, monitoring and return to work/play. Method: A multidisciplinary expert panel consisting of 6 sports physicians, 2 orthopaedic surgeons, 2 podiatrists and 1 physiotherapist from SingHealth Duke-NUS Sport & Exercise Medicine Centre (SDSC) was convened based on their clinical and academic experience with PF. The Grading of Recommen-dations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of the evidence and subsequently prepare a set of clinical recommen-dations pertaining to the manage-ment of PF. A modified Delphi process was used to reach consensus. Results: Eighteen consensus statements were developed to cover key components of PF management, from initial diagnosis to treatment modalities and finally, clinical progression. They were subsequently consolidated under a proposed treatment pathway guideline for PF. Conclusion: The SDSC consensus statements and guideline provide concise recommendations for the management of PF in Singapore.

Rare Bosworth Fracture-Dislocation Variant of an Irreducible Distal Fibula Dislocation of the Ankle Without Fibula Fracture.

BACKGROUND: Irreducible fracture-dislocations of the ankle are rare orthopedic emergencies that should not be missed. The Bosworth fracture-dislocation is a rare fracture where an incarcerated fibula fragment remains locked behind the posterior lateral tubercle of the tibia. We present a case describing a variation of a Bosworth injury, with a dislocation of an intact distal fibula with an associated medial malleolus fracture. METHODS: Our patient is a 55-year old male who presented to the emergency department with a left ankle injury after being involved in a road traffic accident. Radiographs show a posterior dislocation of an intact distal fibula associated with a fracture of the medial malleolus and disruption of the ankle mortise. RESULTS: An attempt to reduce the dislocation at the emergency department under sedation was unsuccessful. The patient was subsequently taken to the operating theatre for manipulation and reduction and application of an external fixator. Definitive fixation was performed successfully a week later. CONCLUSION: A high index of suspicion is critical for diagnosing a Bosworth fracture-dislocation, as this diagnosis is commonly missed. Early diagnosis and proper surgical anatomic reduction are important to prevent chronic ankle instability and evolution towards ankle arthritis. LEVEL OF EVIDENCE: Level IV, case study.