The true history of the Hueter-Volkmann law.

INTRODUCTION: The Hueter-Volkmann law (HVL) of the response of growth plate to compression load is a basic concept in orthopaedics. However, little is known about the origin of HVL and its history. MATERIALS AND METHODS: A literature search was performed in original publications and historical sources. RESULTS: An analysis of all Volkmann´s and Hueter´s texts has shown that none of their publications was based on experiments, but on the data in the literature and their own clinical observations. They did not deal at all with the effect of pressure on the growth plate and mentioned this structure only marginally. The authors coined the opinion that increased pressure retards and decreased pressure accelerates bone growth. Julius Wolff criticized the HVL and concentrated all his arguments in the book "The law of bone remodeling". According to him, increased pressure leads to bone formation, decreased pressure to its resorption. The Wolff-Volkmann dispute was addressed in the German literature by a number of authors. Walther Müller in his monograph "The normal and pathological physiology of the bone" criticized Wolff for his concept of interstitial bone growth. In Müller´s view, HVL applies to the growing bone and Wolff confuses growth with hypertrophy of the mature bone. CONCLUSION: The circumstances of the emergence of HVL are inaccurately and incompletely described in the current literature, as they are mostly taken from secondary sources. HVL, as it is presented today, is not the original formulation, but the result of a long historical evolution.

Bosworth ankle fracture-dislocation: current concept review.

Bosworth fracture (BF) is a special type of locked ankle fracture-dislocation, characterized by displacement of a fragment of the fractured fibula from the fibular notch behind the posterior surface of the distal tibia. BF is a complex injury affecting multiple structures of the ankle joint, which is still frequently misjudged even today, potentially leading to severe complications. CT examination, including 3D reconstructions, should be the diagnostic standard in BF, as it provides a complete picture of the fracture pathoanatomy, most prominently the morphology of the frequently associated posterior malleolar fracture. BF requires early reduction of the displaced fibular fragment without repeated attempts on closed reduction. Non-operative treatment of BF almost always fails. The standard treatment procedure is early open reduction internal fixation. Due to the relative severity and paucity of the injury, BF seems to be particularly prone to soft tissue complications, including compartment syndrome. The results of operative treatment are mixed. Many studies report persistent pain even after a short time interval, with limitations of the range of motion or even stiffness of the ankle joint, and development of degenerative changes. Larger studies with long-term results are still missing.

Terminology of the growing bone: A historical study.

Division of the growing long bone into individual basic parts, that is, diaphysis, metaphysis, physes and epiphyses, has become generally accepted and used. However, the origin of these terms is almost unknown. Therefore, we have analyzed the literature in order to identify their sources. The terms epiphysis and apophysis have been used since the time of Hippokrates, although with different meanings. During the time of Galen, the term apophysis was used to describe all types of bone processes, and epiphyses denoted articular ends. The term diaphysis denoting the middle cylindrical part of the long bone was used for the first time by Heister in 1717. The first to use the term metaphysis was Theodor Kocher in his books on gunshot wounds and on bone inflammation of 1895. On the basis of Kocher's study, Lexer published a radiological study of the vascular supply to bones in which he defined metaphyseal blood vessels as a separate group supplying a particular part of the long bone. The epiphyseal growth plate had no particular name from the time of its first description in 1836. During the second half of 19th century, this structure acquired different names. The term "physis" was therefore introduced in 1964 by the American radiologist Rubin in order to label the growth structure between metaphysis and epiphysis clearly. One year later, the term physis also appeared in the radiological literature, and during the following decades it spread in the orthopedic literature.

Early history of the study of bone growth (1722-1875).

INTRODUCTION: Bone growth is a fascinating process, primarily due to its complexity. Equally engaging is the history of its study, which, however, remains unknown to most anatomists and surgeons. MATERIALS AND METHODS: A literature search was performed in original publications and historical sources. RESULTS: The early history of bone growth study may be divided into two periods. Firstly, the experimental one, between 1722 and 1847, which consisted in the study of bone growth by the drilling of benchmark holes into the diaphysis, and examination of growing bones in madder-fed animals. In the course of one century, four French scientists (Henri-Louis Duhamel du Monceau, Marie-Jean-Pierre Flourens, Gaspard Auguste Brullé and Frédéric Léopold Hugueny) and one British researcher (John Hunter) proved experimentally that the longitudinal growth of long bones occurred only at its epiphyseal ends and their final shape resulted from apposition and resorption processes taking place simultaneously both on the periosteal and intramedullary surfaces of the bone. In the second, the microscopic period (1836-1875), the physeal growth cartilage was discovered and described in detail, including its importance for the longitudinal growth of long bones. The first description of growth cartilage was published by a Swiss anatomist Miescher in 1836. Subsequently, this structure was studied by a number of English, German and French anatomists and surgeons. This whole period was concluded by Alfred Kölliker´s extensive study of bone resorption and its significance for typical bone shapes and Karl Langer´s study of the vascular supply of the growing and mature bone. CONCLUSION: Research by French, English, German and Swiss scientists between 1727 and 1875 yielded fundamental insights into the growth of long bones, most of which are still valid today.

History of proximal femur fractures in the German literature.

INTRODUCTION: German-speaking surgeons have left a deep imprint on the history of diagnostics and treatment of proximal femur fractures. Some of the studies published in German have fell into oblivion, others are cited until today, although sometimes quite inaccurately. The cause of such inaccuracies are citations from secondary sources due to unavailability of the original or inability to read it because of a language barrier. In the current literature, globally predominated by English articles, the "German history" of treatment of proximal femur fractures remains undervalued. The aim of the present article is to point out its contribution. MATERIALS AND METHODS: Literature search was performed in original publications and historical sources. RESULTS: The German-speaking surgeons have considerably contributed to the development of the treatment of proximal femur fractures. The analyzed period between 1847 and 1970 may be divided into three basic periods. In the first period (1847-1896), the German-speaking surgeons (Langenbeck, Trendelenburg, König, Heine, Dolinger) were the first worldwide to start treating the fractures of proximal femur operatively. In the second period (1897-1935), mainly in the 1930s, the initiative in Europe was taken over by surgeons publishing studies in France and in Belgium. Overseas, American surgeons were coming to the forefront. In Germany, only Pauwels developed the first biomechanical classification of femoral neck fractures. In the third period (1936-1970), mainly in the 1940s and 1950s, implants were designed (Pohl, Künstcher), based on close collaboration between German engineers and surgeons, that served as a model for a dynamic hip screw and a proximal femoral nail, which are currently the implants of choice in the treatment of trochanteric fractures. CONCLUSION: The historical contribution of German-speaking surgeons to understanding the issue of proximal femur fractures and their operative treatment is far more significant than presented in the historical studies published in English.

Early history of posterior malleolus fractures in ankle fractures.

INTRODUCTION: No comprehensive treatise on the early history of fractures of posterior malleolus (PM) has yet been published, and many substantial discoveries have fallen into oblivion-particularly if not having been published in English originally. MATERIALS AND METHODS: Literature search was performed in original publications and historical sources. RESULTS: Early history of PM fractures from their first description up to the beginnings of their operative treatment may be divided into three basic periods, covering the era between 1828 and 1940. In the pre-radiological period (1828-1895), description of PM injuries was based merely on the autopsy findings in deceased patients. The first mentions of this injury were published by the British authors. In the radiologic period (1899-1916), the x-ray examination started a revolution also in diagnostics of ankle fractures, with the first radiographs performed as early as in 1899. Radiographic examination had subsequently become an integral part of the diagnostics of these injuries and initiated a number of significant studies of PM fractures. The first detailed mention of a PM injury may be found in the French and German literature. The period of early operative treatment (1918-1940), i.e., open reduction and internal fixation of PM, was started by the younger post-WWI generation, primarily the French surgeons, represented by Gaston Picot. His operative technique and the first six cases treated operatively between 1918 and 1921 were described in 1921 by Edouard Huc. Picot himself published his technique in great detail in 1923. CONCLUSION: The early history of diagnostics and treatment of PM fractures witnesses the remarkable body of knowledge gathered about that topic by numerous visionary surgeons predominantly French and German surgeons immediately before and after World War I. They substantially contributed to the radiological examination and operative treatment of this injury.

Injury to the posterior malleolus in Maisonneuve fractures.

PURPOSE: The aim of this study was to describe the incidence and a complex pathoanatomy of posterior malleolus fractures in a Maisonneuve fracture. METHODS: The study included 100 prospectively collected patients with a complete clinical and radiological documentation of an ankle fracture or fracture-dislocation including a fracture of the proximal quarter of the fibula. RESULTS: A posterior malleolus fracture was identified in 74 patients, and in 27% of these cases it carried more than one quarter of the fibular notch. Displacement of the posterior fragment by more than 2 mm was shown by scans in 72% of cases. Small intercalary fragments were identified in 43% of cases. Fractures of the Tillaux-Chaput tubercle were identified in 20 patients. CONCLUSION: Our study has proved a high rate of posterior malleolus fractures associated with a Maisonneuve fracture, and documented their considerable variability in terms of involvement of the fibular notch, tibiotalar contact area, direction of displacement and frequency of intercalary fragments. Of no less importance is a combination of Tillaux-Chaput fractures with a Maisonneuve fracture.

Long-term results of valgus intertrochanteric osteotomy for partial avascular necrosis of the femoral head after femoral neck fracture in adolescents.

PURPOSE: The study evaluates long-term results in patients treated by valgus intertrochanteric osteotomy (VITO) for partial avascular necrosis of the femoral head (ANFH) after fracture of the femoral neck in adolescent age. Although this method is mentioned in literature frequently, there are only few studies in the literature dealing with it in detail. METHODS: Authors evaluated five patients at the interval of 15 to 20 years following VITO. The mean age of the patients at the time of injury was 13.6 years and at the time of VITO 16.7 years. The studied parameters included resorption of necrotic segment of femoral head, development of posttraumatic osteoarthritis and leg shortening. RESULTS: Comparison of radiographs and MRI scans before and after VITO showed resorption of the necrotic segment of the femoral head and its remodeling in all five patients. However, two patients gradually developed slight osteoarthritic changes. In one patient, remodeling of the femoral head occurred during the first 6 years postoperatively. Subsequently, the patient developed severe osteoarthritis with marked clinical symptoms. CONCLUSION: VITO can improve the long-term function of the hip joint in adolescents with ANFH after a femoral neck fracture, but cannot restore completely the original shape and structure of the femoral head.

Pathoanatomy of pertrochanteric fractures - a postmortem study.

BACKGROUND: Recent pathoanatomic studies based on 3D CT reconstructions have questioned validity of AO/OTA classification because it does not reflect the reality and requires revision. These 3D CT studies, however, do not allow analysis of all details. Therefore, we have exploited the possibility to analyze the pathoanatomy of pertrochanteric fractures on postmortem specimens. MATERIAL AND METHODS: From the collection of the Institute of Anatomy, the authors obtained 16 specimens of hip joints of individuals who had sustained a pertrochanteric fracture and died within 30 days of the injury, with anteroposterior radiographs of the injured hip available in all of them. The number of major fragments and their shape, and the courses of the main fracture lines were studied. RESULTS: Three major fragments (a proximal head and neck fragment, a distal diaphyseal fragment and a posterior flat fragment), separated by three types of fracture lines (primary, secondary and tertiary lines) were identified. The primary line separated the proximal fragment (head and neck) from the distal diaphyseal fragment. The secondary fracture line separated the posterior flat fragment from the distal diaphyseal fragment. The tertiary fracture line split the posterior fragment into two parts. A key factor for fracture instability is the defect of the posterior cortex, which depends on the size and shape of the posterior fragment. Avulsion of the lesser trochanter and the adjacent cortex results in an unstable configuration of fracture lines on the medial side, while on the lateral side a large posterior fragment weakens the lateral trochanteric wall. CONCLUSION: In agreement with recent CT studies, the findings of this pathoanatomical study change, in a number of aspects, the traditional view of the pathoanatomy and classification of pertrochanteric fractures, and introduces the concept of three, instead of the traditional four, main fragments.

Internal architecture of the proximal femur: calcar femorale or Adams' arch?

PURPOSE: The calcar femorale (femoral calcar) is used in the English literature to designate the thickened medial cortex of the femoral neck. This term is, however, incorrect, as the calcar femorale is actually quite another structure. METHODS: Searching was performed in original and historic publication. RESULTS: The importance of the thickened medial cortex of the proximal femur in femoral neck fractures was discussed already by Robert Adams in 1834-1836. Therefore, the German surgeon C.W. Streubel, in 1847, called it Adamscher Knochenbogen (Adams' arch). Due to misspelling, this term was gradually changed to Adambogen, and at the turn of twentieth century, it was commonly used primarily in the German literature. Then, it fell into oblivion and its "renaissance" came as late as during the 1960s, again in the German literature, in connection with operative treatment of trochanteric fractures. CONCLUSIONS: However, under the influence of the English literature, it has been replaced by the term calcar femorale (femoral calcar), used ever since. The term Adams' arch should be reserved for the thickened medial cortex of the proximal femur, while the term calcar femorale (femoral calcar) should be used for the vertical plate arising from the medial cortex close below the lesser trochanter.

Lateral malleolar crest and its clinical importance.

PURPOSE: During study of anatomy of a fractured posterior malleolus of the ankle on CT scans, the authors noticed a prominent crest on the lateral malleolus, which they termed the lateral malleolar crest (LMC). As, in their view, LMC is a clinically important structure which was only briefly mentioned by a few authors without an official term, they focused on the anatomy of this structure. MATERIALS AND METHODS: A total of 352 dry fibulae were analyzed and the following parameters recorded: (F) length of the fibula, (LMC) total length of LMC, (A) length of the part of the examined crest from the superior border of the articular facet of the lateral malleolus (AFLM) to its most proximal intersection with the midline of the fibula, (B) height of the medial triangular rough surface, and (A/F) A/F ratio. RESULTS: The crest was observed in all specimens. (F) was 346.5 ± 26 mm (95% confidence interval [CI] 344-349), (LMC) was 85.4 ± 11.6 mm (95% CI 84.2-86.6), (A/F) was 25% ± 3% (95% CI 24.7-25.3) in the whole group. (A) was 25.9 ± 6.5 mm (95% CI 24.8-26.8) in the whole group, (B) was 34.9 ± 4.7 mm (95% CI 34.3-35.5) in the whole group, 36 ± 6.1 mm (95% CI 35.1-36.9). CONCLUSION: LMC is an important structure on the lateral malleolus. The knowledge of its anatomy is essential for placement of syndesmotic screws or/and the fibular plate.

Intercalary fragments in posterior malleolar fractures: incidence, treatment implications, and distribution within CT-based classification systems.

INTRODUCTION: Complex ankle fractures frequently include the posterior malleolus (PM). Despite advances in diagnostic and treatment strategies, PM fracture involvement still predisposes to worse outcomes. While not incorporated into the most common PM fracture classifications, the presence of an intercalary fragment (ICF) complicates treatment. This study aims to describe the incidence, morphology, and location of ICFs in PM fractures. MATERIALS AND METHODS: A total of 135 patients with a mean age of 54.4 (SD ± 18.9) years and PM fractures were analyzed for the presence of an ICF. Patients with an ICF were compared to those without in terms of age, gender, and treatment received. Characteristics of the ICFs in terms of location and size were assessed. Furthermore, the presence of an ICF in relation to the PM fracture classification according to Haraguchi et al., Bartonícek/Rammelt et al., and Mason et al. was investigated. RESULTS: ICFs presented in 55 (41%) of the 135 patients. Patients with an ICF were younger, and the PM was more often operatively treated when compared to patients without an ICF. A posterolateral approach was used significantly more often in patients with an ICF. Almost all ICFs were found in the posterolateral (58%) and posterocentral (35%) regions. The majority of fragments were found in Bartonícek/Rammelt type 2 fractures, the most common fracture type. Bartonícek/Rammelt type 3 fractures had the highest relative frequency of ICFs. CONCLUSION: ICFs are frequently found in PM fractures; however, they are not incorporated into any of the common classifications. They are generally found in younger patients and associated with more complex PM fractures. As they can complicate reduction of the main fragment and may require direct exposure to restore joint congruency, ICFs should be considered in PM fracture classifications. Due to their location, the majority of ICFs are able to be accessed using a posterolateral approach.

Circumflex arterial sulcus of the scapula (sulcus arteriae circumflexae scapulae): its anatomy and clinical relevance.

INTRODUCTION: The circumflex scapular artery (CSA) has been described in detail in the literature, but the groove, i.e., the circumflex sulcus (CFS), formed by the artery on the lateral pillar of the scapula has been completely neglected. The aim of the present study was to describe the variability and anatomy of the CFS. MATERIALS AND METHODS: The study was based on the examination of 103 pairs of dry bone specimens of adult scapulae, i.e., 206 specimens, including 92 (46 pairs) male and 114 (57 pairs) female specimens. In the first step, quantitative criteria were defined for assessment of the CFS presence and type. Subsequently, statistical analysis of the obtained data was performed. RESULTS: The study revealed considerable variability of the arterial groove, which was well developed in 33% (type A), shallow in 40% (type B), and absent in 27% (type C) of cases. The mean distance between CFS and the infraglenoid tubercle was 3.3 cm CI0.95 (3.1-3.3), which corresponds to the proximal third of the lateral border of the scapula. CONCLUSION: The study has confirmed variability of the arterial groove (CFS) and its localization in relation to the inferior glenoid rim. The findings are clinically important, particularly in relation to the Judet approach to scapular fractures (localization of the CSA course).

Diagnosis and Treatment of Scapular Fractures in Children and Adolescents: A Critical Analysis Review.

¼: Fractures of the growing scapula account for about 0.1% of all pediatric fractures, with the majority occurring at an age of ≥10 years. ¼: Radiographic diagnosis requires a detailed knowledge of the ossification sequence of the growing scapula. Computed tomography examination is indicated for displaced fractures of the glenoid fossa, the scapular neck, and complex fractures; magnetic resonance imaging should be performed in cases of suspected injury to the physis and with stress fractures, depending on patient age and the potential need for general anesthesia during the scanning process. ¼: Separation of the base of the coracoid process is often associated with acromioclavicular dislocation. Clavicular fractures rarely occur in combination with injuries to the growing scapula. ¼: The majority of scapular fractures can be treated nonoperatively. Indications for surgery are displaced intra-articular fractures, scapular neck fractures with a displacement of >2 cm, coracoid base separation associated with acromioclavicular dislocation, and scapulothoracic dissociation. ¼: Displaced intra-articular fractures of the glenoid fossa should be followed after healing until skeletal maturity. Complications are rare and occur most frequently with scapulothoracic dissociation.

Maisonneuve Fractures of the Ankle: A Critical Analysis Review.

¼: Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures. ¼: The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT). ¼: The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN. ¼: Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome. ¼: Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.

Pathoanatomy of the Anterolateral Tibial Fragment in Ankle Fractures.

BACKGROUND: The anterior distal tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered a fourth, or anterior, malleolus (AM). Fractures of the AM may extend into the tibial incisura and tibial plafond. The purpose of this study was to analyze the pathoanatomy of AM fractures and associated ankle injuries. METHODS: One hundred and forty patients (median age, 61.0 years) with a total of 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with computed tomography (CT) imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all patients with malleolar fractures treated during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients <18 years of age were excluded. RESULTS: Of the 140 AM fractures, 52.9% were classified as type 1 (extra-articular avulsion); 35.7%, type 2 (incisura and plafond involvement); and 11.4%, type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%; the medial malleolus, in 66.4%; and the posterior malleolus, in 68.6%. An isolated AM fracture was seen in 4.3%. The size of the AM fractures correlated negatively with that of the posterior malleolar fractures. The proportion of pronation-abduction fractures increased and the proportion of supination-external rotation fractures decreased as the type of AM fracture increased. A fracture involving the AM occurred in 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries and elderly patients. No supination-adduction fractures with AM involvement were seen. The intraclass correlation coefficient for the proposed classification of the AM fractures was 0.961 (95% confidence interval [CI] = 0.933 to 0.980) for interobserver agreement and 0.941 (95% CI = 0.867 to 0.974) for intraobserver agreement. CONCLUSIONS: Knowledge of the 3D pathoanatomy of AM fractures and associated malleolar fractures may help with surgical decision-making and planning. CT imaging should be employed generously in the diagnosis of complex ankle fractures, in particular with pronation-type injuries. CLINICAL RELEVANCE: Depending on the individual 3D fracture pattern, fixation of displaced anterolateral distal tibial fragments potentially contributes to the restoration of joint congruity, tibiofibular alignment, and syndesmotic stability in complex malleolar fractures.

History of diagnostics and treatment of scapular fractures in children and adolescents and its clinical importance.

Almost 70 scapular fractures in children and adolescents, up to the age of 17 years, have been described in detail in the literature since 1839. The diagnosis of these injuries was based on autopsy, radiographs, CT and MRI examinations. The most frequent findings were fractures/epiphyseolyses of the coracoid, followed by fractures of the infraspinous part of the body and avulsion of the inferior angle of the scapular body. Less common were fractures of the acromion. Intra-articular fractures of the glenoid, or separation of an intact glenoid along the line of the anatomical or surgical necks, were reported only sporadically. Scapulothoracic dissociation was also recorded in several cases. The majority of fractures were treated non-operatively; operative treatment was used in glenoid fractures, certain fractures of the coracoid and fractures of the scapular body with intrathoracic penetration. Except for scapulothoracic dissociation, outcomes of treatment of these injuries were very good.

Bosworth fracture complicated by unrecognized compartment syndrome: a case report and review of the literature.

INTRODUCTION: Compartment syndrome (CS) is exceedingly rare in ankle fractures. However, the risk of CS development seems to be increased in the presence of a Bosworth fracture-dislocation (BF), a rare variant of locked dislocation of the fibula behind the tibia. MATERIALS AND METHODS: Here, we report the case of a 39-year old man with delayed diagnosis of CS after having sustained a BF and failed attempts on closed reduction. The patient developed a flexion contracture of the hallux necessitating secondary fusion. RESULTS: At 3 years after the injury, the patient was capable of running, but had 10 degrees limitation of ankle dorsiflexion, persisting decreased sensation on the plantar surface and clawing of the lesser toes. A thorough review of the literature revealed nine cases of CS after 167 reported BF resulting in a calculated prevalence of 5.4%. CONCLUSIONS: Given the extreme paucity of CS in malleolar fractures, CS in BF has a relatively high prevalence. Risk factors include severe dislocations, repeated attempts on closed reduction, and a long interval to definite surgery. A high index of suspicion is required because delayed diagnosis leads to lasting functional restrictions.

"Double Maisonneuve fracture": an unknown fracture pattern.

PURPOSE: The aim of this study was to describe pathoanatomy and to raise awareness of a fracture of the lateral malleolus combined with a high subcapital fracture of the fibula caused by a dislocation mechanism. METHODS: The study comprised 11 patients, 5 men and 6 women, with the mean age of 57 years (range, 21-87), with a "Double Maisonneuve fracture". Individual lesions of ankle structures were described on the basis of radiographs, CT, and intraoperative findings. RESULTS: The distal fibular fracture was classified as Weber type B in 1 case and Weber type C in 10 cases. The proximal fibular fracture was described as a subcapital oblique spiral fracture with metadiaphyseal involvement in nine cases and a high short oblique fracture with fibular head involvement in two cases. Injury to the deltoid ligament was revealed in six cases; a bicollicular fracture of the medial malleolus was found in five patients. Posterior malleolar fractures were classified as type 1 in eight cases and type 2 in three cases. Avulsion of the Chaput tubercle was detected in four cases. Injury to the interosseous tibiofibular ligament was assessed in nine patients. CONCLUSION: Double Maisonneuve fracture is a rare but probably underreported injury that must be taken into consideration during examination, as it may be easily overlooked. The essential part of diagnosis is a careful clinical examination and radiological assessment of the lower leg with additional CT examination of the ankle.

Fractures of the Base of the Fifth Metatarsal Bone: A Critical Analysis Review.

¼: Fractures of the proximal fifth metatarsal (PFMT) are one of the most common foot injuries, accounting for 61% to 78% of all foot fractures, but full consensus on their classification, diagnosis, and treatment has not yet been reached. ¼: The most commonly accepted classification is that of Lawrence and Botte, who divided the location of PFMT fractures into 3 zones with respect to their healing potential. ¼: Avulsion fractures of the tuberosity of the base (zone 1) generally heal well, and nonoperative treatment is commonly recommended. ¼: Internal fixation may be considered for displaced fractures that extend into the fourth-fifth intermetatarsal joint (zone 2) as well as for nondisplaced fractures in athletes or high-demand patients, with the aims of reducing the healing time and expediting return to sport or work. ¼: Stress fractures of the proximal diaphysis (zone 3) are preferably treated operatively, particularly in the presence of signs of delayed union. With nonoperative treatment, supportive measures such as ultrasonography or external/extracorporeal shockwave therapy have been demonstrated to have limited potential for the enhancement of fracture-healing.