Propionibacterium acnes Osteomyelitis after Intraosseous Cannulation in a Child.

Propionibacterium acnes osteomyelitis secondary to intraosseous (IO) cannulation is not well documented in literature. We report here an extremely rare incident of P. acnes tibial osteomyelitis at the IO access site, in a 4-year-old child, who presented 3 months after an episode of fluid resuscitation for streptococcal toxic shock syndrome necessitating irrigation and debridement and prolonged antibiotic therapy. We advocate for heightened awareness of osteomyelitis in patients with continued pain after IO cannulation. Low-grade persistent symptoms may be caused by less virulent organisms and may dictate need for early magnetic resonance imaging studies for diagnosis and treatment planning.

Musculoskeletal Health Literacy in Patients With Foot and Ankle Injuries: A Cross-Sectional Survey of Comprehension.

PURPOSE: Approximately 33% of Americans have inadequate health literacy, which is associated with decreased medical knowledge, increased hospitalization and use of emergency care, and worse control of diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients presenting to the emergency department (ED) with foot and ankle-related complaints, as these individuals may be at increased risk for inferior outcomes. METHODS: In this cross-sectional study, individuals ≥18 years of age presenting with foot and ankle-related complaints to the ED were invited to participate. Participants completed a demographic survey and the LiMP questionnaire, with scores ≥6 indicative of adequate musculoskeletal literacy. The prevalence of adequate health literacy and the influence of demographic parameters was assessed. P values <.05 were considered significant. RESULTS: The mean LiMP score was 5 ± 2.06. Limited musculoskeletal health literacy was seen in 32% of participants (18/56). Although gender (male), a current or prior employment in a health care field, and having previously seen a physician for a musculoskeletal complaint correlated with higher literacy rates, these values did not reach statistical significance (P > .05). However, Caucasians and those with higher levels of education (equal to or more than college) were significantly more likely to possess adequate literacy (P = .008, P = .04, respectively). CONCLUSIONS: Approximately one third of patients presenting to the ED with foot and ankle-related complaints have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning and has tremendous socioeconomic implications, as more than 23 000 people per day require medical care for ankle sprains in the United States, with average treatment costs for this injury in the ED setting estimated at $1498. Identification of those most at risk is thus crucial and will facilitate the development of interventions geared toward those most vulnerable. LEVELS OF EVIDENCE: Prognostic, Level IV study.

Evaluating the Quality, Accuracy, and Readability of Online Resources Pertaining to Hallux Valgus.

BACKGROUND: The Internet is one of the most widely utilized resources for health-related information. Evaluation of the medical literature suggests that the quality and accuracy of these resources are poor and written at inappropriately high reading levels. The purpose of our study was to evaluate the quality, accuracy, and readability of online resources pertaining to hallux valgus. METHODS: Two search terms ("hallux valgus" and "bunion") were entered into Google, Yahoo, and Bing. With the use of scoring criteria specific to hallux valgus, the quality and accuracy of online information related to hallux valgus was evaluated by 3 reviewers. The Flesch-Kincaid score was used to determine readability. Statistical analysis was performed with t tests and significance was determined by P values <.05. RESULTS: Sixty-two unique websites were evaluated. Quality was significantly higher with use of the search term "bunion" as compared to "hallux valgus" (P = .045). Quality and accuracy were significantly higher in resources authored by physicians as compared to nonphysicians (quality, P = .04; accuracy, P < .001) and websites without commercial bias (quality, P = .038; accuracy, P = .011). However, the reading level was significantly more advanced for websites authored by physicians (P = .035). Websites written above an eighth-grade reading level were significantly more accurate than those written at or below an eighth-grade reading level (P = .032). CONCLUSION: The overall quality of online information related to hallux valgus is poor and written at inappropriate reading levels. Furthermore, the search term used, authorship, and presence of commercial bias influence the value of these materials. It is important for orthopaedic surgeons to become familiar with patient education materials, so that appropriate recommendations can be made regarding valuable resources. LEVELS OF EVIDENCE: Level IV.

Bilateral distal tibial transitional ankle fractures.

A 13-year-old boy presented to the emergency department with bilateral ankle pain and swelling following a 5-foot fall from a swing set.

Acute fractures of the tarsal navicular.

The tarsal navicular plays an integral role in hind-foot motion and gait, and is the keystone of the foot's medial longitudinal arch. As such, injuries to the navicular can be devastating. Acute avulsion, tuberosity, and body fractures have been described. Fractures of the body result from high-energy trauma and are often seen in conjunction with additional ipsilateral foot injuries. Plain radiographs are the gold standard for diagnosis, with computed tomography helpful in the presence of intra-articular fracture extension. Non-operative treatment is reserved for avulsion injuries and non-displaced body fractures. Open reduction and internal fixation must be performed for all other types, as failure to achieve an anatomic reduction can impede proper locomotion. Complications following operative intervention include pain, stiffness, posttraumatic arthritis, avascular necrosis, nonunion, and hindfoot deformity.

Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon.

Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.

The foot and ankle examination.

Most foot and ankle disorders can be diagnosed after a proper history and clinical examination and can be effectively managed in a primary care setting. It is important to assess the entirety of patient disorders that present as they can be multifactorial in cause. A broad differential should include disorders of bones, joints, muscles, neurovasculature, and surrounding soft tissue structures. Physical examination should be thorough and focused on inspection, palpation, range of motion, and appropriate special tests when applicable. This article highlights some of the salient features of the foot and ankle examination and diagnostic considerations.

Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot.

Forefoot pain in the adult often alters mobility and has a negative impact on quality of life. Metatarsalgia describes pain localized to the forefoot. Forefoot pain may be caused by conditions of the lesser toes themselves (eg, hammertoes, mallet toes, claw toes). The pathophysiology of lesser toe deformities is complex and is affected by the function of intrinsic and extrinsic muscle units. In addition to lesser toe and metatarsal abnormality, forefoot pain can be attributed to interdigital neuritis, disorders of the plantar skin, and gastrocsoleus contracture. Treatment of these conditions may include shoe modifications, appliances, therapeutic exercises, and surgical repair.

Ankle sprains and instability.

Ankle injuries are among the most common injuries presenting to primary care providers and emergency departments and may cause considerable time lost to injury and long-term disability. Inversion injuries about the ankle involve about 25% of all injuries of the musculoskeletal system and 50% of all sports-related injuries. Medial-sided ankle sprains occur less frequently than those on the lateral side. High ankle sprains occur less frequently in the general population, but do occur commonly in collision sports. Providers should apply the Ottawa ankle rules when radiography is indicated and refer fractures and more severe injuries to orthopedic surgery as needed.

Plantar heel pain.

Plantar heel pain is a common complaint encountered by orthopedic surgeons, internists, and family practitioners. Although it is most often caused by plantar fasciitis, this is a diagnosis of exclusion. Other mechanical, rheumatologic, and neurologic causes must be considered first. The history and physical examination are typically all that is needed to make the proper diagnosis, but diagnostic adjuncts are available to assist the clinician. When plantar fasciitis is diagnosed, conservative modalities must be tried first. Corticosteroid injections and extracorporeal shock-wave therapy may also be used. After 6 months of failed conservative treatments, surgical intervention should be considered.

Outpatient assessment and management of the diabetic foot.

Patients with diabetes and peripheral neuropathy are at risk for foot deformities and mechanical imbalance of the lower extremity. Peripheral neuropathy leads to an insensate foot that puts the patient at risk for injury. When combined with deformity due to neuropathic arthropathy, or Charcot foot, the risks of impending ulceration, infection, and amputation are significant to the diabetic patient. Education of proper foot care and shoe wear cannot be overemphasized. For those with significant malalignment or deformity of the foot and ankle, referral should be made immediately to an orthopedic foot and ankle specialist.

The management of ankle fractures in diabetics: results of a survey of the American Orthopaedic Foot and Ankle Society membership.

BACKGROUND: Ankle fractures in diabetics are challenging to treat, and only generalized clinical guidelines specific to their treatment exist. As such, the American Orthopaedic Foot and Ankle Society (AOFAS) membership was polled regarding the management of different types of ankle fractures in this patient population. METHODS: We developed a multiple-choice survey with 3 clinical scenarios involving diabetic ankle fractures that was sent via e-mail to the 895 active members of the AOFAS. In addition to providing demographic information, respondents identified their preferred stabilization method, the need for supplemental fixation, and each patient's weight-bearing status. RESULTS: Respondents' number of years in practice, number of ankle fractures treated monthly, and type of fellowship training did not correlate with management strategies. Enhanced fixation with syndesmotic screws was advocated in the setting of displaced fractures without syndesmotic injury, while casting was selected as the treatment for those that were nondisplaced. Prolonged periods of non-weight bearing were chosen by survey participants in all cases. CONCLUSION: We identified several treatment trends among AOFAS membership regarding ankle fractures in diabetics. However, it is pivotal that further investigation evaluate both optimal fixation strategies and the factors that influence surgeon decision making in the setting of diabetic ankle fractures, as the orthopaedic surgeon is encountering such patients more than ever before.

Review of distal tibial epiphyseal transitional fractures.

The closure of the distal tibial physis occurs over an 18-month period between ages 12 and 15 years. During this time period, children are susceptible to several transitional fractures, so labeled because they are transitioning to skeletal maturity. In the setting of an external rotation force, triplane and Tillaux fractures can occur. These fractures, which present similarly to other Salter-Harris growth plate injuries, do not fit neatly into any 1 classification scheme and are not easily evaluated on plain radiographs. Computed tomography scans are required to optimally assess these fractures and to determine the need for closed vs open treatment. Regardless of which treatment modality is chosen, anatomic reduction is the goal. This article discusses the approach to these unique fractures.

Treatment of ankle fractures in patients with diabetes.

Patients with diabetes mellitus have a higher risk of complications after sustaining an ankle fracture, including fracture displacement, superficial and deep infection, hardware failure, and neuropathic arthropathy. With the increased incidence of diabetes among the aged, the increased incidence of complications due to diabetes mellitus and its sequelae are important to keep in mind when treating ankle fractures.