An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations.

OBJECTIVES: To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes. METHODS: The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted. RESULTS: Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality. CONCLUSION: Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.

Os supranaviculare and navicular osteochondral lesion contributing to the development of a navicular stress fracture in an adolescent male athlete: Case report.

Stress fractures of the tarsal navicular bone can be problematic in the athlete. This case details the injury and outcome of an adolescent male athlete who experienced one year of intermittent foot pain without acute trauma. Radiographs and computed tomography demonstrated a triad of a navicular stress fracture, an os supranaviculare, and an osteochondral defect of the navicular bone. The patient underwent successful operative fixation and returned to painless full function with imaging demonstrating healing at six months. Diagnosis of a navicular stress fracture in the setting of both an os supranaviculare and osteochondral lesion of the navicular bone have not been reported elsewhere in the literature. While repetitive loading on the navicular bone can independently produce a stress fracture, the patient had an increased risk for this injury; the presumably pre-existing navicular osteochondral lesion and os supranaviculare may have resulted in decreased effective articular surface area, thereby increasing force on the navicular bone and producing a stress fracture. Understanding navicular stress fractures and concomitant bony pathology contributing to injury is crucial to successful diagnosis, management, and prevention of recurrence.

Staged Surgical Management of Open Navicular Fracture Secondary to a Gunshot Injury.

The management guidelines of gunshot wound (GSW) injuries to the lower extremities have primarily been described more recently in the literature. A navicular fracture with adjacent joint involvement is presented from a GSW with initial external fixation management to prevent loss of anatomical alignment and successful staged definitive treatment with internal fixation. Based on previous experiences with rearfoot joint involvement from GSW injuries, we were able to direct definitive treatment with arthrodesis of violated joints. After a 1-year follow-up, the patient has returned to normal activities without any limitations. This case report demonstrates a stepwise approach to management of an open navicular fracture secondary to a GSW.

Painful Accessory Navicular and Spring Ligament Injuries in Athletes.

Painful accessory navicular and spring ligament injuries in athletes are different entities from more common posterior tibialis tendon problems seen in older individuals. These injuries typically affect running and jumping athletes, causing medial arch pain and in severe cases a pes planus deformity. Diagnosis requires a detailed physical examination, standing radiographs, and MRI. Initial treatment focuses on rest, immobilization, and restriction from sports. Orthotic insoles may alleviate minor pain, but many patients need surgery to expedite recovery and return to sports. The authors review their approach to these injuries and provide surgical tips along with expected rehabilitation to provide optimal outcomes.

Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects.

Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.

Estudio y descripción anatómica de vías de abordaje del astrágalo / Anatomical study of surgical approaches to the talus

Estudio anatómico descriptivo de las diferentes vías de abordaje de astrágalo, con documentación fotográfica, utilizando técnica en 3 dimensiones. Este estudio tiene como objetivo evaluar puntos de referencia macroscópicos, planos anatómicos, estructuras en riesgo, campo de visualización y posible aplicabilidad de cada vía de abordaje para ayudar a la toma de decisiones en el momento de la planificación quirúrgica ante una fractura de astrágalo. Dieciocho especímenes frescos y 2 inyecciones con látex en la arteria poplítea fueron estudiados realizando 2 veces cada vía de abordaje con documentación fotográfica. Este estudio propone la necesidad de realizar una correcta planificación prequirúrgica para elegir la mejor vía de abordaje en cada caso y la importancia de realizar, en la gran mayoría de casos, la vía combinada para conseguir una reducción correcta

Descriptive anatomical study of the different surgical approaches to the talus with photographic documentation using a 3-dimensional technique. The objective of this study is to evaluate macroscopic reference points, anatomical planes, structures at risk, field of visualization and possible applicability of each approach to help decision-making at the time of surgical planning in the event of a fracture of the talus. Eighteen fresh specimens and two specimens injected with black latex through the popliteal artery were dissected, performing each surgical approach twice with photographic documentation. This study highlights the need for correct pre-surgical planning to choose the best approach in each case and the importance of a combined approach in the vast majority of cases to achieve a correct reduction

The occurrence of tarsal injuries in male mice of C57BL/6N substrains in multiple international mouse facilities.

Dislocation in hindlimb tarsals are being observed at a low, but persistent frequency in group-housed adult male mice from C57BL/6N substrains. Clinical signs included a sudden onset of mild to severe unilateral or bilateral tarsal abduction, swelling, abnormal hindlimb morphology and lameness. Contraction of digits and gait abnormalities were noted in multiple cases. Radiographical and histological examination revealed caudal dislocation of the calcaneus and partial dislocation of the calcaneoquartal (calcaneus-tarsal bone IV) joint. The detection, frequency, and cause of this pathology in five large mouse production and phenotyping centres (MRC Harwell, UK; The Jackson Laboratory, USA; The Centre for Phenogenomics, Canada; German Mouse Clinic, Germany; Baylor College of Medicine, USA) are discussed.

Fractures of the Cuboid Bone: A Critical Analysis Review.

Cuboid fractures rarely occur in isolation, and a high index of suspicion for the presence of Chopart, Lisfranc, or complex midfoot injuries should be raised. The cuboid is the cornerstone of the lateral column and acts as a bridge between the lateral column and the transverse plantar arch. Its most important role is maintenance of lateral column length and associated motion in the midtarsal and tarsometatarsal joints. To date, a classification system that is validated for clinical practice (i.e., guidance for management and prediction of outcome and prognosis) is lacking. The principles of operative treatment are restoration of articular congruity, lateral column length, and stability of the Chopart and Lisfranc joints. Nonoperative management is reserved for nondisplaced articular fractures (<1 mm) or avulsion fractures that are caused by low-energy trauma.

[The PHILOS plate-also an indication for osteosynthesis of the distal tibia?] / Die PHILOS-Platte ­ auch an der distalen Tibia eine Indikation zur Osteosynthese?

According to the manufacturer's instructions the application of a PHILOS plate is restricted to humeral fractures. An extension to other anatomical regions of the body is not provided; however, based on the anatomical design of the plate it was observed that the application of this plate also appears to be possible for the distal tibia. This article reports three different osteosyntheses by a reverse PHILOS plate on the medial malleolus and on the distal tibia posteriorly with a short and a long PHILOS plate design. In summary, the applications have so far resulted in primary wound healing with correct consolidation of the fractures.

[Arthroscopically assisted fracture treatment and open reduction of the posterior malleolus : New strategies for management of complex ankle fractures. Video article]. / Arthroskopisch assistierte Frakturversorgung und offene Reposition des posterioren Malleolus : Neue Strategien zur Versorgung komplexer Sprunggelenksfrakturen. Videobeitrag.

OBJECTIVE: Identification and treatment of intra-articular injuries, stabilization of the syndesmotic complex by open reduction and internal fixation (ORIF) of the posterior malleolus (PM). INDICATIONS: Bimalleolar and trimalleolar fractures, patients with functional demands. CONTRAINDICATIONS: Soft tissue injuries/infections in the area of the surgical approach, higher grade circulatory disorders, diabetes mellitus. SURGICAL TECHNIQUE: The video exemplarily depicts the arthroscopically assisted treatment (AORIF) of a trimalleolar fracture and ORIF of the PM via the dorsolateral approach. Positioning in an unstable lateral position, arthroscopy via standard ventral portals in external rotation, resection of interposing capsular ligamentous structures, removal of loose bodies, diagnosis and treatment of cartilage lesions. Dorsolateral approach dorsal to the peroneal tendons and incision of the fascia of the lateral and deep lower leg compartments, retraction of the flexor hallucis longus muscle medially, visualization of the PM, reduction and fixation with an antiglide plate. Development of a full thickness flap above the superficial fascia to visualize the lateral malleolus, fixation according to AO principles. Repositioning to the supine position without changing the sterile covers, medial approach for fixation of the medial malleolus, stability testing of the distal tibiofibular joint, final arthroscopy, and wound closure. FOLLOW-UP: Cooling and elevation, 6 weeks of partial weight-bearing (20 kg), early functional exercises, full weight-bearing after clinical radiological follow-up at 6 weeks postoperatively. RESULTS: It is known that relevant chondral injuries frequently occur in complex ankle fractures and that ORIF of the PM leads to stabilization of the distal tibiofibular joint. So far only few clinical results have been published regarding AORIF and ORIF of the PM; however, the majority of the studies available found significantly better results for AORIF and ORIF of the posterior malleolus compared to conventional treatment.

Posterior malleolus fractures in Bosworth fracture-dislocations. A combination not to be missed.

OBJECTIVES: Posterior malleolar fractures (PM) have been linked to inferior outcome in malleolar fractures. This study aims to analyze the prevalence and pathoanatomy of PM fractures in Bosworth fracture-dislocations (BF). MATERIALS & METHODS: Radiographs and computed tomography (CT) scans of 13 patients treated at our institution and 97 cases published between 1947 and 2018, identified in a systematic literature search, were evaluated with respect to the pathoanatomy of BF. In all 13 cases from the present study and in 10 cases from the literature, axial CT scans were performed. RESULTS: All 13 patients (100%) with BF from the present series and 61 of 97 documented cases (63%) of BF from the literature were associated with a PM fracture. In patients with a complete CT analysis, dislocation of the fibula behind the posterior tibial rim was associated with extraincisural (Bartonícek / Rammelt type 1) PM fractures. Displacement of the fibula between the displaced PM fragment and the tibia was associated with Bartonícek / Rammelt types 2 and 3 PM fractures. CONCLUSIONS: Seventy prevent of all reported BF are associated with a PM fracture. The true prevalence may be even higher because of the historically infrequent use of CT imaging. The pathoanatomy of the PM fragment is highly variable as is the kind of fibular displacement in BF. Therefore, CT scanning should be performed routinely in BF. Displaced PM fractures in BF involving the incisura should be treated operatively via a direct posterolateral approach.

A review of the management and outcomes of tarsal navicular fracture.

Fractures of the navicular are uncommon. This review focusses on the anatomy, classification, surgical management, post-operative rehabilitation, and outcomes of tarsal navicular fractures, to better inform decision making for clinicians managing these injuries. This review does not discuss navicular stress fractures because of the differing aetiology compared to other fractures of the navicular.

Radiographic Value of the Lisfranc Diastasis in a Standardized Population.

Introduction. Injury to the Lisfranc's joint, in particular to the second metatarsal-medial cuneiform (second MMC) joint, can be difficult to evaluate, especially in subtle Lisfranc injuries. The purpose of this study was to determine the value of the Lisfranc joint width (diastasis) of the adult foot in a standardized population thereby establishing a potential reference range when investigating this area for potential injury. Methods. The 2nd MMC joint in 50 men and 50 women was evaluated. Individuals with a history of foot/ankle pain, previous foot/ankle operation or fracture, or a history of systemic disease were excluded from the study. Bilateral weightbearing digital anterior-posterior and lateral radiographs were taken using a standardized method. Results. The mean 2nd MMC diastasis in 200 feet was 5.6 mm (95% CI 5.39-5.81). In the female population, the mean 2nd MMC diastasis was 5.8 mm (95% CI 5.51-6.09) as compared with 5.6 mm (95% CI 5.31-5.89) in males. The mean distance between the fifth metatarsal base and first cuneiform in the entire study population was 16.3 mm (95% CI 15.57-17.03). Conclusion. This study helps define baseline measurements of the Lisfranc joint for the general population, which can provide a standard measurement against which suspected foot injuries can be compared.Level of Evidence: Level IV.

Avaliação biomecânica das lesões ligamentares do complexo articular de Lisfranc: novo modelo cadavérico utilizando estresse em supinação e pronação / Biomechanical evaluation of ligament injuries of the Lisfranc joint complex: new cadaveric model using stress in supination and pronation

Introdução: as lesões no complexo articular de Lisfranc ocorrem devido a trauma direto ou indireto, no qual forças de torção ou axiais são transmitidas ao pé. Os modelos cadavéricos são úteis para avaliar padrões de lesões e modelos de fixação, mas frequentemente a quantidade de deslocamento articular após a lesão torna-se um limitador. O objetivo deste estudo foi testar um modelo cadavérico que inclui carga axial, flexão plantar do pé e movimentos de pronação-supinação, recriando diástase óssea semelhante ao observado em lesões sutis de Lisfranc na prática clínica. Nossa hipótese é de que a aplicação do movimento de pronação e supinação em um modelo cadavérico produziria deslocamentos ósseos confiáveis e mensuráveis. Métodos: foram utilizadas 24 amostras cadavéricas frescas congeladas amputadas abaixo do nível do joelho. Os ossos cuneiformes medial e intermédio, o primeiro e o segundo metatarsos, foram marcados. Uma lesão ligamentar completa foi realizada entre os cuneiformes medial e intermédio e entre o cuneiforme medial e o segundo metatarso em 12 amostras (grupo 1) e adicionou-se a lesão dos ligamentos entre o primeiro metatarso e o cuneiforme medial e entre o segundo metatarso e o cuneiforme intermédio em 12 amostras correspondentes (grupo 2). Pronação e supinação do pé, além de uma carga axial de 400 N, foram aplicadas às amostras, utilizando-se o Instrom Testing Machine. Um digitalizador tridimensional (3D) foi utilizado para medir as distâncias entre os ossos. Resultados: para o grupo de lesão parcial (grupo 1), as distâncias referentes aos ossos nos quais os ligamentos foram seccionados apresentaram aumento na condição lesionada tanto em pronação quanto em supinação, como esperado. Em relação à distância entre o cuneiforme intermédio e o primeiro metatarso e entre o primeiro e o segundo metatarsos, observou-se diminuição na condição lesionada em pronação e aumento em supinação. Para o grupo de lesão completa (grupo 2), as distâncias referentes aos locais de secção dos ligamentos apresentaram aumento na condição lesionada tanto em pronação quanto em supinação, como esperado. No tocante à distância entre o cuneiforme intermédio e o primeiro metatarso e entre o primeiro e o segundo metatarsos, verificou-se o mesmo padrão de comportamento das lesões parciais. Conclusão: o modelo biomecânico cadavérico para lesões do complexo articular de Lisfranc desenvolvido neste estudo simula o mecanismo de estresse clínico da lesão e o tipo de lesão mais comum, exibe variações de distâncias fidedignas e mensuráveis e foi desenvolvido para permitir o teste do tratamento da lesão sem interferência nos dispositivos de aferição, podendo se constituir em excelente método para a comparação de técnicas de fixação das lesões ligamentares tarsometatarsais.

Introduction: Lesions in the Lisfranc joint complex occur due to direct or indirect trauma, where a torsional or axial force is transmitted to the foot. Cadaveric models are a useful way to assess injury patterns and fixation models, but a frequent limitation is the amount of joint dislocation after injury. The aim of this study was to test a cadaveric model that includes axial load, plantar flexion of the foot and pronation-supination movement, recreating bone diastasis similar to that observed in subtle Lisfranc lesions in clinical practice. Our hypothesis is that the application of pronation and supination motion in a cadaveric model would produce reliable and measurable bone displacements. Methods: Twenty-four fresh frozen cadaveric leg samples were used. The medial (C1) and intermediate (C2) cuneiform bones, the first (M1) and second (M2) metatarsal bones were marked. A complete ligament injury was performed between C1-C2 and C1-M2 in 12 samples (Group 1) and between C1-C2, C1-M2, C1-M1 and C2-M2 in 12 corresponding samples (Group 2). Foot pronation and supination, in addition to an axial load of 400 N, were applied to the samples. A 3D scanner was used to measure the distances between the bones. Results: For the partial lesion group (Group 1), in which the ligaments between C1-C2 and C1-M2 were injured, these distances increased in the injured condition in both pronation and supination, as expected. Regarding the distance C2-M1 and M1-M2, there was a decrease in the injured condition in pronation and an increase in supination. For the complete lesion group (Group 2), in which the ligaments between C1-C2, C1-M2, C1-M1, and C2-M2 were injured, these distances increased in injured condition both in pronation and supination, as expected. Regarding the behavior of distances C2-M1 and M1-M2, the same behavior pattern was observed as in partial injuries. Conclusion: The cadaveric biomechanical model for Lisfranc joint complex injuries developed in this study simulates the mechanism of clinical stress of the lesion and the most common type of lesion, exhibits reliable and measurable distances, and allows lesion treatment without compromise, being, possibly, an excellent method for comparing tarsometatarsal ligament injury fixation methods.

Distraction Osteogenesis in Two Wild Raptors.

Distraction osteogenesis was used in 2 wild raptor patients for the repair of tibiotarsal fractures. The first case was a hatching year female peregrine falcon (Falco peregrinus) admitted with an open oblique right distal tibiotarsal fracture. The fracture was surgically managed with the external skeletal fixator intramedullary pin tie-in technique (ESF-IM pin tie-in). Appropriate healing of the fracture site occurred with the ESF-IM pin tie-in. However, there was significant pelvic limb shortening of the affected leg, and the bird consequently developed pododermatitis on the contralateral foot. The second case was an adult female great horned owl (Bubo virginianus) that was admitted with a closed, partially healed, overriding right tibiotarsal fracture. Because of the advanced stage of this fracture, which presented with a fibrous callus, and the already apparent pelvic limb shortening, the ESF-IM pin tie-in was not used. Both patients were fitted with a circular external skeletal fixator (CESF), and distraction osteogenesis was performed until the length of the pelvic limb was deemed anatomically adequate. It is critical that rehabilitated raptors be released without any physical conditions that may reduce their ability to survive and reproduce in the wild. Pelvic limb shortening can potentially predispose a raptor patient to pododermatitis, even with fatal consequences, in both captive and wild environments. The orthopedic technique used here proved useful to repair the limb shortening in both raptor cases, and each bird fully recovered and was released.

Medial Swivel Dislocation of the Talonavicular Joint with Associated Cuboid Fracture.

Medial talonavicular dislocation associated with cuboid fracture is rare. We report an 18-year-old man with this injury who exhibited excellent results after open reduction and stabilization of the joint with temporary Kirshner wires.

Radiographically Occult Medial Cuneiform Impaction Fracture.

A 25-year-old woman reported to the emergency department with right medial midfoot pain after kicking a wall. Radiographs were noncontributory and the patient was diagnosed with a metatarsal contusion. Persistent pain post injury led her to seek a direct-access physical therapy evaluation. Following examination, the physical therapist requested magnetic resonance imaging, which confirmed a medial cuneiform fracture. J Orthop Sports Phys Ther 2019;49(9):675. doi:10.2519/jospt.2019.8778.

Categorization of single cuneiform fractures and investigation of related injuries: A 10-year retrospective study.

PURPOSE: The purpose of this study was to define the fracture type and investigate the injuries related to single medial, intermediate, or lateral cuneiform fracture. METHODS: From January 2008 to December 2018, 30 consecutive patients (30 cases) who were treated in the single institution for the single cuneiform fractures were reviewed retrospectively. Each fracture was categorized by location and type (intra- or extra-articular avulsion, axial compression, and direct blow). We also investigated the related foot bone fractures or dislocations on the affected side. RESULTS: Twenty-one, one, and eight cases with single medial, intermediate, and lateral cuneiform bone fractures, respectively, were identified. More than two-thirds of the single cuneiform fractures were observed in the medial cuneiform bone. The single medial cuneiform fracture was associated with various types of foot injuries including Lisfranc injury, naviculo-cuneiform joint dislocation, or calcaneo-cuboidal dislocation. Single lateral cuneiform fractures were more frequently observed than single intermediate cuneiform fractures. CONCLUSION: More than two-thirds of the single cuneiform fractures were observed in the medial cuneiform bone. Most intra-articular avulsion fractures were associated with high-energy trauma. LEVEL OF EVIDENCE: 4.