Trauma to the medial ray of the foot: A classification of patterns of injury and their management.

AIMS: Fractures and dislocations of the midfoot are relatively uncommon but can be life changing injuries. Within the literature, there has been scant specific reference to the identification and management of medial ray injuries in midfoot trauma. Moreover, it is appreciated that these injuries are associated with poor outcomes. We aim to clearly define these injury characteristics and demonstrate fixation techniques. PATIENTS AND METHODS: A retrospective review of the case notes and imaging was conducted for operatively treated midfoot injuries between January 2013 and January 2018. RESULTS: 161 patients were identified, 31 of these with imaging and operative diagnosis suggestive of medial ray injury. Studying these 31 injuries revealed five patterns of injury. CONCLUSION: When treating midfoot trauma, it is important to fully understand the injury pattern as this dictates the principles and techniques of fixation. Identification and knowledge of these five injury patterns will aid surgeons in future management of these injuries and may improve treatment outcomes.

[Metatarsal and toe fractures]. / Mittel- und Vorfußfrakturen.

Metatarsal and toe fractures are the most frequent injuries of the foot skeleton. Nondislocated fractures can be conservatively treated with good success. Long-term relief and immobilization including the ankle joint are unnecessary. Metatarsal fractures close to the base are nearly always associated with Lisfranc luxation and treatment must also take the instability of the tarsometatarsal joints into consideratíon. Basal fractures of the 5th metatarsal bone require a differentiated consideration. The correct classification is necessary in order to initiate an adequate treatment. In general, intra-articular layer formation, inclination >10° and shortening between 3 mm and 5 mm, taking the position of the head of the metatarsal bone into consideration, are recommended as indications for surgery. Operative treatment of toe fractures is only rarely necessary.

Return to sport following Lisfranc injuries: A systematic review and meta-analysis.

BACKGROUND: Information regarding return rates (RR) and mean return times (RT) to sport following Lisfranc injuries remains limited. METHODS: A systematic search of nine major databases was performed to identify all studies which recorded RR or RT to sport following lisfranc injuries. RESULTS: Seventeen studies were included (n=366). For undisplaced (Stage 1) injuries managed nonoperatively (n=35), RR was 100% and RT was 4.0 (0-15) wks. For stable minimally-displaced (Stage 2) injuries managed nonoperatively (n=16), RR was 100% and RT was 9.1 (4-14) wks. For the operatively-managed injuries, Percutaneous Reduction Internal Fixation (PRIF) (n=42), showed significantly better RR and RT compared to both: Open Reduction Internal Fixation (ORIF) (n=139) (RR - 98% vs 78%, p<0.019; RT - 11.6 wks vs 19.6 wks, p<0.001); and Primary Partial Arthrodesis (PPA) (n=85) (RR - 98% vs 85%, p<0.047; RT - 11.6 wks vs 22.0 wks, p<0.002). CONCLUSIONS: Stage 1 and stable Stage 2 Lisfranc injuries show good results with nonoperative management. PRIF offers the best RR and RT from the operative methods, though this may not be possible with high-energy injuries. LEVEL OF EVIDENCE: IV. Systematic Review of Level I to Level IV Studies.

A new and reliable classification system for fractures of the navicular and associated injuries to the midfoot.

AIMS: Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot. PATIENTS AND METHODS: We undertook a retrospective review of 285 consecutive patients presenting over an eight- year period with a fracture of the navicular. Five common patterns of injury were identified and classified according to the radiological features. Type 1 fractures are dorsal avulsion injuries related to the capsule of the talonavicular joint. Type 2 fractures are isolated avulsion injuries to the tuberosity of the navicular. Type 3 fractures are a variant of tarsometatarsal fracture/dislocations creating instability of the medial ray. Type 4 fractures involve the body of the navicular with no associated injury to the lateral column and type 5 fractures occur in conjunction with disruption of the midtarsal joint with crushing of the medial or lateral, or both, columns of the foot. RESULTS: In order to test the reliability and reproducibility of this new classification, a cohort of 30 patients with a fracture of the navicular were classified by six independent assessors at two separate times, six months apart. Interobserver reliability and intraobserver reproducibility both had substantial agreement, with kappa values of 0.80 and 0.72, respectively. CONCLUSION: We propose a logical, all-inclusive, and mutually exclusive classification system for fractures of the navicular that gives associated injuries involving the lateral column due consideration. We have shown that this system is reliable and reproducible and have described the rationale for the subsequent treatment of each type. Cite this article: Bone Joint J 2018;100-B:176-82.

Review article: Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series).

Ankle and foot injuries are the most common musculoskeletal injuries presenting to Australian EDs and are associated with a large societal and economic impact. The quality of ED care provided to patients with ankle and foot fractures or soft tissue injuries is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common ankle and foot injuries in the ED. Databases including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English language articles published in the last 12 years that addressed the acute assessment, management or prognosis in the ED were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 1242 articles, of which 71 were included in the review (n = 22 primary articles, n = 35 systematic reviews and n = 14 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the ankle and foot in the ED a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. Following a thorough history and physical examination, including the application of the Ottawa ankle rules, ED clinicians should not only provide a diagnosis, but rate the severity of soft tissue injuries, or stability of fractures and dislocations, which are the pivotal decision points in guiding ED treatment, specialist referral and the follow-up plan.

Do columns or sagittal displacement matter in the assessment and management of Lisfranc fracture dislocation? An alternate approach to classification of the Lisfranc injury.

AIM: The classification of a Lisfranc injury has conventionally been based around Myerson's system. The aims of this study were to review whether a novel classification system based on sagittal displacement of the tarsometatarsal joint and breadth of injury as determined by a columnar theory was associated with functional outcomes and thus had a greater utility. PATIENTS: We retrospectively reviewed 54 Lisfranc injuries with a minimum follow up of two years at our Level One Trauma Centre. Each fracture was sub-classified based on our novel classification system which assessed for evidence of sagittal displacement and involvement of columns of the midfoot. Our primary outcome measures were the FFI and AOFAS midfoot scores. RESULTS: Injuries involving all three of the columns of the midfoot were associated with significantly worse functional outcome scores (FFI p=0.004, AOFAS p=0.036). Conversely, sagittal displacement, whether dorsal or plantar, had no significance (FFI p=0.147, AOFAS p=0.312). The best predictor of outcome was the quality of anatomical reduction (FFI p=0.008, AOFAS p=0.02). CONCLUSION: Column involvement and not sagittal displacement is the most significant factor in considering the severity Lisfranc injury and long term functional outcomes. This classification system has greater clinical utility than those currently proposed.

Complex Foot Injury: Early and Definite Management.

Complex foot injuries occur infrequently, but are life-changing events. They often present with other injuries as the result of a high-energy trauma. After initial stabilization, early assessment should be regarding salvagability. All treatment strategies are intensive. The initial treatment includes prevention of progression ischemia/necrosis, prevention of infection, and considering salvage or amputation. Definitive treatment for salvage includes anatomic reconstruction with stable internal fixation and early soft tissue coverage followed by aggressive rehabilitation. Prognosis after complex injuries is hard to predict. The various stages of the treatment are reviewed and recommendations are made.

Risk factors for lower leg, ankle and foot injuries during basic military training in the Maltese Armed Forces.

OBJECTIVES: Basic military training is physically and psychologically demanding placing recruits at high risk of injury and premature discharge. This study aimed to identify risk factors for lower leg, ankle and foot injury in Maltese military recruits during basic training. DESIGN: This was a prospective cohort study. SETTING: An armed forces barracks. PARTICIPANTS: 127 recruits commencing one basic military training course agreed to participate in the study. The cohort comprised 114 males and 13 females with a mean age of 21.7 ± 2.4 years. MAIN OUTCOME MEASURES: All injuries to the lower leg, ankle and foot were recorded using the Orchard Sports Injury Classification System. Injuries were analysed for associations with fitness scores, smoking status, body mass index and foot type. RESULTS: A total of 34 (26.2%) recruits sustained at least one injury, with 10 recruits (7.9%) terminating their training prematurely (three due to musculoskeletal injury). Smoking history, body mass index and foot type were not associated with injury risk. Lower fitness levels at the commencement of basic military training compared with fitness levels measured six months prior, were associated with higher injury risk. CONCLUSIONS: Lower fitness at the commencement of basic training was associated with higher injury risk in army recruits. Thus, conditioning programmes aimed at improving recruit fitness should be considered within an injury prevention strategy.

Self-Reported Minimalist Running Injury Incidence and Severity: A Pilot Study.

INTRODUCTION: Minimalist running entails using shoes with a flexible thin sole and is popular in the United States. Existing literature disagrees over whether minimalist running shoes (MRS) improve perceived severity of injuries associated with running in traditional running shoes (TRS). Additionally, the perceived injury patterns associated with MRS are relatively unknown. OBJECTIVES: To examine whether injury incidence and severity (ie, degree of pain) by body region change after switching to MRS, and to determine if transition times affect injury incidences or severity with MRS. METHODS: Runners who were either current or previous users of MRS were recruited to complete an Internet-based survey regarding self-reported injury before switching to MRS and whether self-reported pain from that injury decreased after switching. Questions regarding whether new injuries developed in respondents after switching to MRS were also included. Analyses were calculated using t tests, Wilcoxon signed rank tests, and Fischer exact tests. RESULTS: Forty-seven runners completed the survey, and 16 respondents reported injuries before switching to MRS. Among these respondents, pain resulting from injuries of the feet (P=.03) and knees (P=.01) decreased. Eighteen respondents (38.3%) indicated they sustained new injuries after switching to MRS, but the severity of these did not differ significantly from no injury. Neither time allowed for transition to MRS nor use or disuse of a stretching routine during this period was correlated with an increase in the incidence or severity of injuries. CONCLUSION: After switching to MRS, respondents perceived an improvement in foot and knee injuries. Additionally, respondents using MRS reported an injury rate of 38.3%, compared with the approximately 64% that the literature reports among TRS users. Future studies should be expanded to determine the full extent of the differences in injury patterns between MRS and TRS.

Translation, Cultural Adaptation and Validation of Polish Version of Foot and Ankle Outcomes Questionnaire.

BACKGROUND: The Polish orthopaedic literature lacks a tool to measure patient reported treatment outcomes in the foot and ankle. MATERIAL AND METHODS: The translation and cultural adaptation of the Foot and Ankle Outcomes Questionnaire was performed in accordance with relevant guidelines. The Polish version of the questionnaire was tested to check its test retest reliability, internal consistency and construct validity. RESULT: The Polish version of the questionnaire was prepared. Testing of the questionnaire revealed acceptable test retest reliability, internal consistency and construct validity. CONCLUSION: The translation, cultural adaptation and testing of the Polish version of patient related outcome measuring tool for the foot and ankle is described.

Reliability of the Lisfranc injury radiological classification (Myerson-modified Hardcastle classification system).

PURPOSE: The objective of our study was to assess the reliability of the radiological classification system (Myerson-modified Hardcastle Classification System) for Lisfranc injury. The classification system is a three-grade ordinal scale based on fracture displacement. METHODS: Thirty-nine Lisfranc injury radiographs were evaluated by 38 independent observers consisting of consultant orthopaedic surgeons (18), orthopaedic surgery residents (17) and consultant musculoskeletal radiologists (3) on two separate occasions after receiving training in the use of the classification. RESULTS: The intra- and inter-observer reliability was assessed using the intraclass correlation coefficient (ICC) and found to be excellent. The mean weighted intra- and inter-observer ICCs were 0.94 (95 % CI 0.89-0.97, p < 0.01) and 0.81 (95 % CI 0.68-0.89, p < 0.01), respectively. CONCLUSION: The Myerson-modified Hardcastle classification system in our study was shown to be reliable and can be used in outcome studies and provide standard terminology among clinicians for Lisfranc injuries.

Fractures of the talus.

The talus is the most proximal bone of the hindfoot that couples the foot to the leg. It is the second most common fracture of the tarsal bones, second in frequency to the calcaneous. However, overall injuries to the talus are relatively rare, and most surgeons have little experience in managing them. This article discusses fractures of the talus, including injuries to the talar neck, body, head, and processes. Although subtalar dislocations and osteochondral injuries are important topics, they are not addressed in this article.

Classification of metatarsophalangeal joint plantar plate injuries: history and physical examination variables.

Although metatarsophalangeal (MTP) plantar plate tears are common, they are still often missed. The purpose of this study is to find the best clinical variables to define and grade the plantar plate injuries. Sixty-eight patients (100 MTP joints) were graded arthroscopically and divided into five groups (0 to IV) according to the anatomical classification. Their medical records were reviewed to establish correlations of clinical findings with the anatomical lesions. The positive correlations found were acute pain, widening of the interdigital space, loss of ground touch, positivity of the MTP joint drawer test, reduction of the toe purchase, and toe supination. The drawer test is the most reliable and accurate tool to classify and grade the plantar plate lesion, followed by ground touch and rotational deformities. It is possible to improve the accuracy of diagnosis of plantar plate tears by means of the combination of both clinical history and physical examination data.

Fractures of the proximal fifth metatarsal: keeping up with the Joneses.

Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.

Open reduction and internal fixation of OTA type C2-C4 fractures of the calcaneus with a triple-plate technique.

The purpose of this study was to present a surgical technique of open reduction and internal fixation of displaced intra-articular calcaneal fractures with 3 AO mini-fragment plates and to evaluate the clinical and radiological outcome of a consecutive group of patients after a mean follow-up of 41.7 months. A series of 54 patients (16 women and 38 men) with 62 calcaneal fractures were treated over a period of 6.5 years. Forty-five patients with 50 calcaneal fractures were completely clinically and radiologically followed up. Clinical follow-up included assessment of range of motion, pain according to a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score, and the short-form 36 health survey. Radiological follow-up included plain axial and lateral radiographs and measurement of the Böhler's angle and Gissane's angle. Independent Student's t test and paired Student's t test were used alongside the chi-square test to compare clinical and radiological data and score values between different groups of patients. Eleven patients showed breakage of the osteosynthesis material during the healing process and 2 patients sustained deep wound infection requiring revision surgery. At the final follow-up all fractures had healed. The average range of motion was supination 26.4° (range 0° to 50°; SD 11.6°), pronation 15.4° (range 0° to 30°; SD 6.4°), dorsal extension 14.3° (range -10° to 30°; SD 8.0°), and plantarflexion 39.6° (range 20° to 65°; SD 11.7°). Patients with OTA type C4 fractures achieved significantly lower supination (p < .01) and plantarflexion (p < .01) compared with other fracture types. The mean visual analog scale pain score was 3.6 (range 0 to 8; SD 2.3) points, average American Orthopaedic Foot and Ankle Society hindfoot score was 70.8 (range 33 to 100; SD 17.1) points, and the mean short-form 36 score was 60.98 (range 22.9 to 93.0; SD 18.4) points. The mean postoperative Böhler's angle was 28.9° (range 8° to 38°; SD 7.1°), which decreased to 23.6° (range 4° to 34°; SD 8.7°) at the final follow-up, and the mean postoperative Gissane's angle was 108.6° (range 80° to 140°; SD 11.8°), which finally decreased to 102.4° (range 72° to 126°; SD 12.7°). No statistically significant differences regarding Böhler's and Gissane's angles were found between different OTA fracture types. In conclusion, the presented surgical technique was found to provide comparable and adequate reduction of OTA type C2-C4 injuries based on statistically insignificant differences in radiographic measures of postoperative fracture reduction. Greater limitation in subtalar motion was observed in OTA type C4 fractures in comparison with less severe fractures (p < .01).

[The choice of the treatment and surgical intervention for patients with fractures and dislocation fractures of front and middle parts of the foot].

For the period from 2004 till 2009 142 patients were observed in our clinic. We were able to follow up 53 of the 74 patients in the main group and 49 of the 68 ones in the control group for 12 months. The majority of injuries were located in the front area of foot; most of them were dislocation fractures. It was shown that the frequency of isolated stable and unstable traumas was roughly equal. Multiple injuries were generally unstable. We designed a simple convenient classification of fractures and dislocation fractures in front and middle parts of the foot. An original algorithm is proposed for the treatment and choice of operating methods based on our classification and ensuring satisfactory results in the majority of cases. Relief incisions outside projection of the surgical intervention field make it possible to close the operating wounds and avoid extension of their edges, prevent enlargement of edema, and avoid severe pyoinfectious complications in the early postoperative period. Overall, we achieved reduction of their frequency to 1% compared with 10% in the control group. The frequency of late complications was 9.44% versus 42.85% in controls.

Outcome after complex trauma of the foot.

BACKGROUND: In 1997, H. Zwipp. proposed a 5-point scoring system for the classification of complex trauma of the foot. However, outcome and quality of life after this type of injury have not been studied systematically. PATIENTS: Seventy-four patients with a complex injury of the foot were treated between 2001 and 2007. Fifty patients met the inclusion criteria for a prospective cross-sectional study. American Foot and Ankle Society score, the Short Form 12, and the Visual Analogue Scale-Foot and Ankle Score were recorded. All patients were examined by an experienced orthopedic surgeon and a certified pedorthist. Functional assessment was completed by dynamic baropedography. RESULTS: Primary amputation was necessary in 11, secondary amputation in 7 patients. A compartment syndrome was diagnosed in 29 patients. Soft tissue coverage was achieved in eight patients using a free vascular flap. The complication rate was 32%. Mean follow-up was 4 years (1-7 years). At that time, the American Foot and Ankle Society score was 66.2, the Short Form 12 score 38.2 (physical health component scale), and the Visual Analogue Scale-Foot and Ankle score was 51.9. Orthopedic shoes were necessary in 44% of the patients; however, compliance was low, and 52% of the orthopedic devices were insufficient. Pedographic evaluation demonstrated changes in gait in 82% of the patients. CONCLUSION: Early outcome after complex trauma of the foot was essentially determined by soft tissue injury, whereas long-term outcome was determined more by the trauma of the bones and joints. Objective measurements such as dynamic pedography helped to better understand patients' limitations. Orthotic supply could be improved in a reasonable number of the patients.

Common fractures and injuries of the ankle and foot: functional anatomy, imaging, classification and management.

The ankle and foot are functionally important and complex joints. Bony fractures and ligamentous injuries are common. In this review paper we will discuss the functional anatomy, imaging, classification and the management of common ankle and foot injuries including ankle fractures, Achilles tendon ruptures, Lisfranc joint injuries, calcaneo fractures and fractures of the metatarsals and phalanges.

Cold damage to the extremities: frostbite and non-freezing cold injuries.

The treatment of cold injuries to the periphery has advanced substantially in the last 10 years and optimal outcomes are only likely to be achieved if a multidisciplinary team uses the full range of diagnostic and treatment modalities that are now available. The internet and satellite phones with digital images allow immediate access by patients from remote geographical locations to hospital based specialists who can assess cold injuries and advise on early field care. The severity of frostbite injuries can now be assessed with triple phase bone scanning, allowing early prediction of likely subsequent tissue loss. Early hyperbaric oxygen therapy appears to improve outcome and the use of intravenous drugs such as synthetic prostaglandin analogues infusions and tissue plasminogen activator have been shown to reduce amputation rates. In non-freezing cold injuries the early administration of analgesia, the avoidance of secondary exposure, and the use of infrared thermography to assess the injuries are among newer approaches being introduced.