Navicular and Cuboid Fractures.

Navicular and cuboid fractures can be complex and difficult to treat. Depending on the mechanism of injury, diagnosis of such fractures is not always possible with conventional radiographs due to the irregularity and overlap of the midfoot bones. Advanced imaging is indicated if a fracture is of high suspicion or to further characterize a displaced fracture. Cuboid and navicular fractures can occur in isolation but are often associated with other midfoot injuries due to their anatomic relationships. Typically, nondisplaced fractures can be treated conservatively, whereas displaced fractures require surgical intervention to prevent future complications.

Lisfranc Injuries.

Lisfranc injuries were thought to primarily occur during high-energy events, leading to a preference for fusion treatment; however, recent data have shifted this perspective by highlighting a greater occurrence of low-energy injuries and reshaping the focus on open reduction internal fixation. This multifaceted process is guided by various factors, including the nature of the injury, specific anatomic considerations, and the involved joints. Our overarching goal remains to achieve anatomic reduction, with flexibility in hardware fixation methods. In cases of comminution, bridge plating may be warranted, potentially followed by arthrodesis in the future.

Pediatric foot fractures on radiographs: distribution and predictors of surgery.

PURPOSE: To examine the distribution and characteristics of pediatric foot fractures on radiographs with respect to age and skeletal maturation, and to identify predictors of surgery. METHODS: This retrospective study included children (≤ 18 years) with foot fractures, who underwent radiographic examinations (2020-2022). Electronic medical records were reviewed to obtain demographic and clinical data. Fracture characteristics, including anatomic location, presence of displacement, angulation, articular involvement, and, if skeletally immature, physeal involvement and Salter-Harris fracture pattern were collected. Logistic regression models were used to identify predictors of surgery. RESULTS: 1,090 (596-boys, 494-girls; mean age, 11.0 ± 4.0 years) patients with 1,325 (59.8% metatarsal, 33.8% phalangeal, and 6.4% tarsal) fractures were included. Fractures of 1st metatarsal were more common among younger children whereas fractures of 2nd-4th and 5th metatarsals were more common among older children (median ages: 5.9 years vs. 10.3 years and 12.4 years, p < 0.001). Intra-articular fractures were more common among maturing and mature than immature bones (25.3% and 20.4% vs. 9.9%, p < 0.001). Physeal involvement was uncommon (162/977, 16.6%) and the most common pattern was Salter-Harris type II (133/162, 82.1%). A minority (47/1090, 4.3%) of patients required surgery and independent predictors of surgery included physeal involvement (OR = 5.12, 95% CI: 2.48-10.39, p < 0.001), multiple fractures (OR = 3.85, 95% CI: 1.67-8.53, p = 0.001), fracture displacement (OR = 9.16, 95% CI:4.43-19.07, p < 0.001), and articular involvement (OR = 2.72, 95% CI:1.27-5.72, p = 0.008). Using these predictors, the likelihood for surgery ranged between 8.0% with 1 and 86.7% with 3 predictors. CONCLUSION: Pediatric foot fracture patterns differed based on age and regional skeletal maturation. Physeal involvement, multiple fractures, fracture displacement, and articular involvement were independent predictors of surgery in our study group.

Turf Toe Injury: A Pictorial Review and a Didactic Case Report.

Hyperextension of the first metatarsophalangeal joint can lead to a turf toe injury of the plantar plate complex, resulting in significant morbidity for athletes. This article reviews the anatomy, pathophysiology, classification, and imaging findings of turf toe injuries. In turf toe trauma, many different structures can be injured, with the sesamoid-phalangeal ligaments the most common. Diagnosis, classification, and treatment options rely on clinical evaluation and specific magnetic resonance imaging findings. It is vital for radiologists to understand the anatomy, pathophysiology, and imaging findings of turf toe injuries to ensure an accurate diagnosis and appropriate management.

Nonunion Rate Following Primary Arthrodesis for Acute Lisfranc Injuries.

Injury to the tarsometatarsal joint (TMT) results in instability throughout the midfoot that does not often improve with conservative management. If instability is identified, surgical intervention is frequently recommended, either open reduction and internal fixation (ORIF) or primary arthrodesis (PA). These 2 treatment options have been compared in the literature multiple times, often reporting similar outcomes. Due to this, as well as the need for subsequent hardware removal after ORIF has led many surgeons towards PA at the index surgery. Concern for nonunion is a leading concern with surgeons who advocate instead for ORIF. The purpose of this study is to review patients who underwent PA and observe nonunion rates. Nonunion at the TMT has been previously studied, but only in the chronic setting. We performed a retrospective study of 34 patients who had PA in the management of an acute Lisfranc injury. The average age in our study was 43.9 years old (range 19-72, SD 17.4) with an average follow-up of 9.4 months (range 4-33, SD 6.2). Radiographs were evaluated for signs of nonunion at regular postoperative intervals. Within the patients included in the study, a total of 71 TMT joints were fused. Overall successful fusion rate was 95.8% at an average of 7.9 weeks (range 6-12, SD 1.4) postoperatively. Individual nonunion rates at the first, second, and third TMT were 0%, 1.4% and 2.8% respectively. Our study demonstrates that primary arthrodesis provides a predictable outcome with low nonunion rates in the management of acute Lisfranc injury.

Common Foot Fractures.

Foot fractures account for about one-third of lower extremity fractures in adults. They are typically caused by a crush injury or an axial or twisting force on the foot. Patients usually present with bony point tenderness and swelling of the affected area. Weight-bearing varies based on the extent of the fracture and the patient's pain tolerance. When a foot or toe fracture is suspected, anteroposterior, lateral, and oblique radiography with weight-bearing should be obtained. The Ottawa foot and ankle rules can help determine the need for radiography after an acute ankle inversion injury. Many foot fractures can be managed with a short leg cast or boot or a hard-soled shoe. Weight-bearing and duration of immobilization are based on the stability of the fracture and the patient's pain level. Most toe fractures can be managed nonsurgically with a hard-soled shoe for two to six weeks. Close attention should be paid to the great toe because of its role in weight-bearing, and physicians should follow specific guidelines for orthopedic referral. Meta-tarsal shaft fractures are managed with a boot or hard-soled shoe for three to six weeks. The proximal aspect of the fifth metatarsal has varied rates of healing due to poor blood supply, and management is based on the fracture zone. Lis-franc fractures are often overlooked; radiography with weight-bearing should be obtained, and physicians should look for widening of the tarsometatarsal joint. Other tarsal bone fractures can be managed with a short leg cast or boot for four to six weeks when nonsurgical treatment is indicated. Common foot fracture complications include arthritis, infection, malunion or nonunion, and compartment syndrome.

Identification of fractures on pediatric foot radiographs: do localization cues improve diagnostic accuracy and reduce interpretation time?

OBJECTIVE: To investigate the diagnostic accuracy and time in the detection of fractures on pediatric foot radiographs marked without and with localization cues. METHOD: One-hundred randomly selected foot radiographic examinations that were performed on children (<18 years old) after injury and with at least 4 weeks of follow-up were included. Blinded to history and diagnosis, 4 readers (one each: medical student, pediatrician, pediatric orthopedic surgeon, and pediatric musculoskeletal radiologist) retrospectively and independently reviewed each examination twice (without and with cue, at least 1 month apart, and after randomization). Each reader recorded the presence or absence of a fracture, fracture location, diagnostic confidence, and the total (interpretation) time spent on each study. Diagnostic accuracy, reader confidence, and interpretation time were compared between examinations without and with cues. RESULTS: Our study included 59 examinations without and 41 with fractures (21 phalangeal, 18 metatarsal, and 2 tarsal fractures). Localization cues improved inter-reader agreement (κ=0.36 to 0.64), overall sensitivity (68 to 72%), specificity (66 to 73%), and diagnostic accuracy (67 to 73%); thus, overcalled and missed rates also improved from 34 to 27% and 32 to 28%, respectively. Reader confidence improved with cue (49 to 61%, p<0.01) with higher incremental improvement with younger children (30% for 1-6 years; 14% for 7-11 years; and 10% for 12-17 years). Interpretation time decreased by 40% per examination (40±22 s without to 24±13 s with cues, p<0.001). CONCLUSION: Localization cues improved diagnostic accuracy and reader confidence, reducing interpretation time in the detection of pediatric foot fractures.

Surgical Treatment for Isolated Closed Multi-metatarsal Fractures: At Least 2-Year Outcomes in 79 Feet.

Multimetatarsal fractures are a particular type possibly associated with worse functional outcomes. Existing studies are scarce, fragmented, and lack control for confounders. This study aimed to explore the functional prognosis of isolated closed extra-articular multimetatarsal fractures and the different outcomes between the plate-screw and K-wire fixation. This retrospective study included 79 patients who underwent surgery for isolated closed extra-articular multimetatarsal fractures from May 2017 to December 2020. We recorded baseline characteristics. The primary outcome measure was Visual Analogue Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Outcome Score (FAOS). Exploratory correlation analysis of the variables with VAS, AOFAS score, and FAOS was performed. The differences between the plate-screw group (n = 58) and K-wire group (n = 21) were compared. Seventy-nine patients (79 feet) were included with a follow-up of (47.3 ± 12.7) months (range, 26-70). Full weight bearing time was (11.7±5.3) weeks. VAS was (1.4±1.8) points, AOFAS score was (86.4±13.3) points, and FAOS was (79.0±11.1) points. Complications were observed in 17 cases (21.5%). According to exploratory correlation analysis, VAS was weakly associated with fixation method and gender, AOFAS was weakly associated with fixation method, FAOS was weakly associated with trauma mechanism. When the plate-screw group (n = 58) was compared with the K-wire group (n = 21), we found the former was superior to the latter in terms of full weight bearing time, VAS, AOFAS score, and malunion rate (all p < .05). FAOS was nonsignificant (p = .056). Operative treatment of isolated closed extra-articular multimetatarsal fractures showed good mid-term results. Plate-screw fixation was associated with faster rehabilitation as well as a lower malunion rate. The mid-term follow-up results showed patients with plate-screw fixation had better VAS and AOFAS scores.

Inconsistent radiographic diagnostic criteria for lisfranc injuries: a systematic review.

PURPOSE: To evaluate the radiographic diagnostic criteria and propose standardised radiographic criteria for Lisfranc injuries. METHODS: A systematic review of the PubMed and Embase databases was performed according to the PRISMA guidelines. The various radiographic criteria for the diagnosis of Lisfranc injuries were extracted. Descriptive statistics were presented for all continuous (as mean ± standard deviation) and categorical variables (as frequencies by percentages). RESULTS: The literature search included 29 studies that totalled 1115 Lisfranc injuries. The risk of bias ranged from "Low" to "Moderate" risk according to the ROBINS-I tool. The overall recommendations according to the GRADE assessment ranged from "Very Low" to "High". 1st metatarsal to 2nd metatarsal diastasis was the most common of the 12 various radiographic diagnostic criteria observed, as was employed in 18 studies. This was followed by 2nd cuneiform to 2nd metatarsal subluxation, as was employed in 11 studies. CONCLUSION: The radiographic diagnostic criteria of Lisfranc injuries were heterogeneous. The proposition for homogenous radiographic diagnostic criteria is that the following features must be observed for the diagnosis of Lisfranc injuries: 1st metatarsal to 2nd metatarsal diastasis of ≥ 2 mm on anteroposterior view or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior or oblique views. Further advanced imaging by CT or MRI may be required in patients with normal radiographs but with continued suspicion for Lisfranc injuries. LEVEL OF EVIDENCE: 4, systematic review.

[Do not overlook Lisfranc injuries]. / Mis het Lisfranc-letsel niet.

BACKGROUND: Lisfranc injury is rare and often very subtle. Subsequently, 20-50% of injuries are initially missed. Late or missed diagnosis increases the risk of post-traumatic osteoarthritis. CASE: A 51-year old men visited our surgical outpatient clinic with plantar hematoma and inability to bear weight on the right foot after he tripped three weeks earlier. Initial visitation to the emergency department after trauma led to the diagnosis contusion or ligament injury of the foot/ankle. After additional CT-scan of the foot, the final diagnosis of subtle/stable Lisfranc injury was made. Twelve weeks after trauma, the patient still experienced pain and was dissatisfied with the course of treatment. CONCLUSION: Timely diagnosis of Lisfranc injury is important to ensure adequate treatment may take place immediately. This achieves the most optimal prognosis. Always think of Lisfranc joint injury in case of plantar hematoma together with an inability to bear weight of the foot.

Accuracy of ultrasound in diagnosing ankle injuries in emergency care.

BACKGROUND: Ankle injuries are one of the most common presentations in the ED. Although fractures can be ruled out using the Ottawa Ankle Rules, the specificity is low, which means many patients may still receive unnecessary radiographs. Even once fractures are ruled out, assessment of ankle stability is recommended to rule out ruptures, but the anterior drawer test has only moderate sensitivity and low specificity and should be performed only after swelling has receded. Ultrasound could be a reliable, cheap and radiation free alternative to diagnose fractures and ligamentous injuries. The purpose of this systematic review was to investigate the accuracy of ultrasound in diagnosing ankle injuries. METHODS: Medline, Embase and the Cochrane Library were searched up to 15 February 2022 to include studies of patients of 16 years or older presenting to the ED with acute ankle or foot injury, who underwent ultrasound and had diagnostic accuracy as outcome. No restrictions were applied for date and language. Risk of bias and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach were assessed. RESULTS: Thirteen studies evaluating 1455 patients with bony injuries were included. In 10 studies, the reported sensitivity for fracture was >90%, but varied among studies between 76% (95% CI 63% to 86%) and 100% (95% CI 29% to 100%). In nine studies, the reported specificity was at least 91%, but varied between 85% (95% CI 74% to 92%) and 100% (95% CI 88% to 100%).Six studies including 337 patients examined the use of ultrasound for ligamentous injuries and found a sensitivity and specificity >94% and 100%. Overall quality of evidence for both bony and ligamentous injuries was low and very low. CONCLUSION: Ultrasound has the potential to be a reliable method for diagnosing foot and ankle injuries, however, higher grade evidence is needed. PROSPERO REGISTRATION NUMBER: CRD42020215258.

Bone Stress Injuries at the Ankle and Foot.

Bone stress injuries (BSIs) are a frequent finding in athletes, particularly of the foot and ankle. A BSI is caused by recurring microtrauma to the cortical or trabecular bone exceeding the repair capacity of normal bone. The most frequent fractures at the ankle are low risk, characterized by a low risk for nonunion. These include the posteromedial tibia, the calcaneus, and the metatarsal diaphysis. High-risk stress fractures have a higher risk for nonunion and need more aggressive treatment. Examples are the medial malleolus, navicular bone, and the base of the second and fifth metatarsal bone.Imaging features depend on the primary involvement of cortical versus trabecular bone. Conventional radiographs may remain normal up to 2 to 3 weeks. For cortical bone, early signs of BSIs are a periosteal reaction or the "gray cortex sign," followed by cortical thickening and fracture line depiction. In trabecular bone, a sclerotic dense line may be seen. Magnetic resonance imaging enables early detection of BSIs and can differentiate between a stress reaction and a fracture. We review typical anamnestic/clinical findings, epidemiology and risk factors, imaging characteristics, and findings at typical locations of BSIs at the foot and ankle that may help guide treatment strategy and patient recovery.

Imaging of Overuse Injuries of the Ankle and Foot in Sport and Work.

Overuse injuries of the ankle and foot are common injuries both in sport and in a work-related context. After clinical assessment, imaging is key for early diagnosis. In this overview article, we focus on imaging techniques, protocols, and imaging findings of overuse injuries of the ankle and foot; we emphasize the important role of structured reporting; and we discuss clinical symptoms, epidemiology, and risk factors in sports and in a work-related context.

Imaging of Acute Ankle and Foot Sprains.

Ankle and foot injuries are very common injuries in the general population, and more so in athletes. MR imaging is the optimal modality to evaluate for ligamentous injuries of the ankle and associated conditions after ankle sprain. In this article, the authors discuss the epidemiology, biomechanics, normal anatomy, and pathology of the ankle as well as injuries of the hindfoot and midfoot that are often associated with ankle injuries.

Nonoperative management of lisfranc injuries - A systematic review of outcomes.

BACKGROUND: Historically, most Lisfranc injuries have been considered to be unstable and treated with surgical intervention. However, with better access to cross-sectional imaging, stable injury patterns are starting to be recognised. The aims of the current study were to perform a systematic review of outcomes of Lisfranc injuries treated non-operatively. METHODS: A literature review was performed of studies reporting nonoperative management of Lisfranc injuries (PROSPERO registered and following PRISMA guidelines). Following exclusions, 8 papers were identified: 1 prospective and 7 retrospective studies. A total of 220 patients were studied with a mean age of 39.8 years and a mean follow-up of 4.3 years. Outcomes included function, displacement, and rates of surgery. RESULTS: High heterogeneity was observed with variable outcomes. Four papers reported good outcomes, with adjusted functional scores ranging from 82.6 to 100 (out of 100). However, one study reported late displacement in 54 % of patients. Rates of secondary osteoarthritis ranged from 5 % to 38 %. Rates of surgical intervention were as high as 56 %. Several studies compared operative to non-operative treatment, reporting superior outcomes with surgery. Those injuries with no displacement on CT, measured at the medial cuneiform-second metatarsal had the best outcomes. CONCLUSION: Reported outcomes following nonoperative treatment of Lisfranc injuries vary widely, including high rates of conversion to surgery. In contrast, some studies have reported excellent functional outcomes. CT seems to be an important diagnostic tool in defining a stable injury. Due to limited data and lack of a clear definition of a stable injury or treatment protocol, prospective research is needed to determine which Lisfranc injuries can be safely treated nonoperatively.

Incidence and clinical results of tendinous injuries in calcaneus and pilon fractures.

PURPOSE: The aims of this study were: (1) to define the incidence of tendinous injuries in calcaneus and pilon fractures with different fracture severity and (2) to determine the clinical impact of such injuries. STUDY DESIGN AND METHODS: CT-scans of 121 patients with calcaneus and pilon fractures were retrospectively analyzed over a 4-year period. The tendinous injuries were identified and correlated with the type of fracture (location and classification). Clinical analysis was performed using the American Orthopedic Foot and Ankle Society (AOFAS) and SF-36 (Short Form-36 Health Survey) scores. RESULTS: Tendinous injuries were observed in 36% of all CT-scans analyzed, with the most common injury being incarceration (n = 20) and dislocation (n = 24). Calcaneus fractures sanders type 3/4 were 9 times more prone to tendon injury (p < 0.001; OR 8.67; 95% CI 2.49-30.24). Pilon fractures Ruedi-Allgower type 2/3 were 8 times more prone to tendon injury (p = 0.005; OR 7.5; 95% CI 1.72-32.80). No significant differences (p > 0.05) were found in AOFAS and SF-36 scores between patients with/without tendon injuries for fractures with the same severity. CONCLUSION: The incidence of tendon injuries in calcaneus/pilon fractures is high and may be underreported. Calcaneus fractures are prone to peroneal tendon injury. In pilon fractures, it is important to look for tibialis posterior tendon injury, especially entrapment. The presence of tendinous injuries does not affect function and pain for the same type of calcaneus and pilon fractures at the long term. LEVEL OF EVIDENCE: Level 3 retrospective study.

Acute, isolated fractures of the metatarsal bones: an epidemiologic study.

INTRODUCTION: Although metatarsal fractures are common, the significance of previous epidemiologic studies is limited to specific fracture entities, subpopulations, or heterogeneous fracture aetiologies. The aim of the study was to assess the epidemiology of isolated metatarsal fractures in an adult population at a level-1 trauma centre. MATERIALS AND METHODS: Radiological and clinical databases were searched for a five-year period. Eligible were all patients with acute isolated metatarsal fractures over the age of 18 years with radiographs in two planes available. Stress fractures, injuries affecting Lisfranc joint stability, and concomitant injuries to other regions than the metatarsals were excluded. Data collection included general demographics, mechanism of injury, season of the trauma and fracture details. RESULTS: Out of 3259 patients, 642 patients met the inclusion criteria and were included for the analysis. The patients' mean age was 44.5 ± 18.9 years, 50.6% were female. 83.3% suffered an isolated, 16.7% multiple metatarsal fractures. Single metatarsal fractures occurred predominantly at the fifth metatarsal bone (81.3%), their frequency decreased with increasing age, with a seasonal peak during the summer. Patients suffering multiple metatarsal fractures were significantly older (51.6 ± 21.2 vs. 43.0 ± 18.1 years; p < 0.001) and the injury resulted significantly more often from a high-energy trauma (6.7% vs. 23.4%; p < 0.001). Multiple metatarsal fractures occurred evenly throughout all metatarsals but revealed a focus on female population with no seasonal differences. CONCLUSION: Single metatarsal fractures predominantly occurred at the fifth metatarsal bone and showed a seasonal, gender and age dependency. Multiple metatarsal fractures were homogeneously distributed between the different metatarsals with distinct age-dependent gender differences. LEVEL OF EVIDENCE: Level III.

Lisfranc Injuries in the Athlete.

LisFranc injuries in the active, athletic, and military populations can be devastating injuries. There has been much debate over open reduction and internal fixation versus arthrodesis as primary treatment in these injuries. This article aims to present the existing evidence-based medicine to help guide appropriate treatment in this population. With the introduction of flexible fixation, the variety of ways to address these injuries surgically has expanded.