A typical snowboarding injury--fracture of the processus lateralis tali

Before the development of the snowboard sport, the fracture of the lateral process of the talus was a very rare injury. Since the increasing popularity of snowboarding, starting in Europe at about 1980, these fractures occurred more frequently. The largest epidemiological serie from Kirkpatrick in 1998 reports an incidence of 2.3% of all snowboarding injuries representing 15% of all snowboarding ankle injuries [1]. The common mechanism for fracture is dorsiflexion of the ankle and inversion of the hindfoot. Early diagnosis is emphasized in all series reviewed in the literature to prevent long-term complications [4]. Because routine radiographs failed to determine either the size or comminution of the fractured process, CT imaging was used to accurately assess the size, displacement, and comminution of the fractured process. CT scans also showed the extent of subtalar joint involvement, any associated tendon pathology, or additional fractures [5]. Many of these fractures are not visible on plain radiographs and require computed tomography imaging to be diagnosed. Diagnosis of this fracture pattern is paramount; the physician should be very suspicious of anterolateral ankle pain in the snowboarder, where subtle fractures that may require surgical intervention can be confused with anterior talofibular ligament sprains [1]. Most authors agree, that nondisplaced fractures are best treated with cast immobilization and that displaced fractures require a surgical treatment: Single large displaced fragments are reduced and internally fixed, small displaced or comminuted fragments may need surgical excision. After two to three days bedrest with elevated leg, ambulation is started under partial weight bearing of 10-15 kg for 6 weeks. Physicians caring for snowboarders should look specifically for fracture of the lateral process of the talus in a snowboarder with a lateral ankle or foot injury [3]. This fracture can mimic a lateral ankle sprain, yet the fracture is easily missed on plain radiographs of the ankle. Because displaced or comminuted fractures can cause long-term disability, primary care physicians and specialists alike need to be aware of the association of this fracture with snowboarding [3].     

Comminuted fracture of the talus not visible on the initial radiograph

Fractures of the talus are rare injuries and fractures of the body of the talus are particularly rare. Diagnosis of these fractures is also difficult as initial radiographs may be normal, particularly with osteochondral talar dome fractures. Long term morbidity is common after fractures of the talus. A case is presented of a patient with a comminuted fracture of the body of the talus with non-diagnostic initial standard ankle radiographs. Accident and emergency doctors should be aware of this injury, and be suspicious that patients with an appropriate mechanism of injury and pronounced pain may require further investigation despite normal standard ankle radiographs, as an occult fracture of the talus may be present.     

踝关节MR断层解剖、解剖变异和病理——第二部分：解剖变异和病理（续）（英文）

踝关节疼痛是一个非常常见的临床症状,病因很多,本文将引起踝关节疼痛病因的MR影像特征分为三部分进行描述：①侧副韧带损伤：侧副韧带损伤分为拉伤、部分撕裂和完全断裂。急性侧副韧带损伤MRI主要表现为韧带信号增高,韧带不规则断裂,界限不清,周围软组织水肿及邻近的骨水肿;慢性期的主要表现为韧带不规则增粗或变细。②肌腱病变：肌腱的病变大体上可分为肌腱病、部分肌腱撕裂、肌腱的完全断裂、肌腱纵向撕裂、肌腱腱鞘滑膜炎和肌腱脱位。单纯创伤性肌腱断裂很少见,多数肌腱断裂发生在肌腱病的基础之上。MRI能够准确显示以上各种病变的特征。③骨、软骨及其他软组织病变：主要包括踝关节骨隐性压缩骨折、跖骨联合、副舟骨综合征、踝关节后撞击综合征、骨三角综合征、距骨骨软骨病变、和距骨缺血性坏死等。MRI能够准确的对上述疾病作出诊断及鉴别诊断。     

Sonographic diagnosis of talar lateral process fracture.

The frequency of fractures of the lateral process of the talus (LPT) has markedly increased because of the expansion of snowboard activity. These lesions are difficult to diagnose, because they have aspecific signs, and standard radiographs do not show the fractures in 50% of cases. Sonography is used more and more in the assessment of ankle trauma, but it is rarely performed for detection of bone fractures. We report a case of a patient in which sonography directly showed an LPT fracture.     

踝部骨折治疗效果与距骨生物力学的关系

背景距小腿(踝)关节的解剖结构并不复杂,但其生物力学关系十分重要.距骨参与组成3个关节,对距小腿关节功能起极其重要作用.因此恢复踝穴的解剖关系,稳定距骨在其中的位置甚为重要.目的探讨踝部骨折的治疗与距骨生物力学的关系.设计非随机非对照的研究.地点和对象1985-01/2000-10中国医科大学附属第一医院收治距小腿关节骨折患者95例.收集患者因恶性肿瘤截肢后小腿标本3只.干预通过离体小腿标本,对距骨在踝部骨折中生物力学关系做简要观察,并对95例距小腿关节骨折治疗后的临床及X射线加以分析.主要观察指标①观察不同骨折类型受力情况.②观察距小腿关节恢复的临床疗效与距骨生物力学变化的关系.结果随访65例,优41例,良12例,尚可7例,差5例.生物力学结果双踝骨折时,头颈压缩0.48 cm;外踝骨折,垂直压力时外踝面受力大于内踝面,腓骨下1/3骨折,内翻位时距骨外踝面受力轻于内踝面.结论距小腿关节骨折不论手法复位外固定或手术复位内固定,均应注意距骨在踝穴内解剖关系,并注意下胫腓关节间隙距离.恢复踝穴和距骨的生物力学关系是极为重要的治疗标准.     

Sonographic detection of occult fractures in the foot and ankle.

PURPOSE: The purpose of this retrospective study was to determine whether high-resolution sonography can aid in the diagnosis of radiographically occult fractures in the foot and ankle. METHODS: High-resolution sonography with a 10-MHz linear-array transducer was performed in 268 patients with foot and ankle injuries whose initial plain x-ray films were negative for fracture. RESULTS: Twenty-four patients had occult fractures demonstrated by sonography. On sonography, the occult fractures appeared as a discontinuity of cortex echogenicity. The fractures were found at the calcaneus (n = 8), metatarsus (n = 6), talus (n = 3), navicular bone (n = 3), cuboid bone (n = 2), cuneiform bone (n = 1), and lateral malleolus (n = 1). Review of the patients' radiographs revealed tiny fractures at the sonographically identified locations in 2 patients. The first 5 patients underwent bone scans, which confirmed the presence of the fractures. The first 11 patients received follow-up sonographic examination 6 weeks after diagnosis; in all 11, an echogenic line over the previous fracture site, presumably representing callus formation, was noted. CONCLUSIONS: Sonography-a readily available, noninvasive imaging technique-can provide important information about soft tissue injuries and cortical discontinuities in the foot and ankle area. Using this procedure, occult fractures can be identified and delineated, and costly procedures such as MRI can be avoided.     

踝关节MR断层解剖、解剖变异和病理——第二部分:解剖变异和病理

踝关节疼痛是一个非常常见的临床症状,病因很多,本文将引起踝关节疼痛病因的MR影像特征分为三部分进行描述：①侧副韧带损伤：侧副韧带损伤分为拉伤、部分撕裂和完全断裂。急性侧副韧带损伤MRI主要表现为韧带信号增高,韧带不规则断裂,界限不清,周围软组织水肿及邻近的骨水肿;慢性期的主要表现为韧带不规则增粗或变细。②肌腱病变：肌腱的病变大体上可分为肌腱病、部分肌腱撕裂、肌腱的完全断裂、肌腱纵向撕裂、肌腱腱鞘滑膜炎和肌腱脱位。单纯创伤性肌腱断裂很少见,多数肌腱断裂发生在肌腱病的基础之上。肌腱病变的MRI表现包括肌腱内信号增高,肌腱变粗或变细,边缘变得不锐利,肌腱周软组织水肿及肌腱鞘内积液。③骨、软骨及其他软组织病变：主要包括踝关节骨隐性压缩骨折、跖骨联合、副舟骨综合征、踝关节后撞击综合征、骨三角综合征、距骨骨软骨病变、和距骨缺血性坏死等。MRI能够准确的对上述疾病作出诊断及鉴别诊断。     

Assessment of Bosworth-type fracture by external oblique radiographs

Introduction

Bosworth described an unusual fracture dislocation of the ankle with fixed posterior fracture dislocation of the fibula. This ankle fracture variant is often not recognized in initial radiographs and requires a computed tomographic scan for verification. It is usually not reducible by the closed method, and repeated trials induce more damage. The purpose of this study was to verify the usefulness of simple external oblique radiographs for diagnosis of Bosworth-type fracture.

Methods

We reviewed the 327 patients who were diagnosed as unilateral malleolus ankle fracture in 2002 to 2012. Four cases of Bosworth-type fracture were identified. External oblique radiograph was taken initially, immediately after first closed reduction, and after open reduction (3 phases) was undertaken to check the position of fibula in relation with the talus. Fifty cases of bimalleolar fractures and unaffected ankle were compared. Longitudinal bisecting line along the proximal fibula was drawn, and the talus was divided in 2 parts. Anterior and posterior part of the talus was defined as part α and β. The ratio resulted from dividing α with (α + β) implies the fibula position relative to the talus.

Results

Mean α/(α + β) ratio of each phase were 0.4994, 0.4891, 0.2875, 0.2698, and 0.2709. There was significant difference in initial and first reduction phase of Bosworth-type fracture than other groups (P = < .0001). There was no significant difference in open reduced Bosworth-type fracture with bimalleolar fractures and unaffected ankles (P = .528, .602).

Conclusions

An external oblique radiograph provides useful information that can differentiate Bosworth-type fracture from other reducible bimalleolar fractures.     

Ultrasonography of anterosuperior calcaneal process fracture: report of 2 cases.

OBJECTIVE: The purpose of this series is to describe the ultrasonographic findings of anterosuperior calcaneal process (ASCP) fracture. METHODS: Two patients with ASCP fractures were examined with ultrasonography. Both of them had pain over the lateral aspect of the ankle 10 to 13 months after an injury. Initial radiographs had shown no evidence of bone fracture or bone avulsion. RESULTS: In both cases, ultrasonography revealed the presence of a bone fragment adjacent to the ASCP suggestive of a misdiagnosed fracture. The latter was confirmed by radiographs. In 1 case, a hypoechoic thickening of the calcaneocuboid component of the bifurcate ligament was also identified on ultrasonographic scans. CONCLUSIONS: Ultrasonography is potentially valuable in detecting clinically or radiographically occult ASCP fractures.     

Foot fractures frequently misdiagnosed as ankle sprains

Most ankle injuries are straightforward ligamentous injuries. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. Lateral talar process fractures are characterized by point tenderness over the lateral process. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. Delays in treatment can result in long-term disability and surgery. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films.     

Compression arthrodesis of the knee and ankle with the Hoffmann external fixator

We performed 12 arthrodeses of the knee and eight of the ankle, using the Hoffmann device as a compressor-fixator. For the knees, the double rectangular frame was used with the added fixation of a cylinder cast in six cases. In four cases a separate half frame was used in the anterior plane. Posttraumatic arthritis was the indication in seven cases, and failed arthroplasties in five cases (three of them infected). For the ankles, a double triangular compression frame was used, with transfixing pins across the talus (after trauma) or the calcaneus (after ankle replacement). The ankle arthrodeses were done for posttraumatic arthritis in five cases (ankle fracture in one case, pylon fracture in three cases, fracture of the talus in one case), and failed ankle arthroplasty in three cases. Solid union occurred in all but one of the knee arthrodeses and in all but two of the ankle arthrodeses. Two infected total ankle replacements eventually terminated in amputation.     

踝关节隐匿性损伤的MRI表现

目的探讨踝关节隐匿性骨折 MRI表现.方法回顾性分析 17例有明确外伤史, X线表现为阴性、MRI表现阳性的病例.使用 Siemens vision- plus 1.5T超导高场 MRI系统成像.常规 SE序列 T1W成像( TR/TE=700/20)、FSE序列 WI( TR/TE=4700/100)和 T2WI脂肪抑制( FS)序列.结果 17例有 9例表现关节软骨不规则缺失; 7例有软骨下骨小梁骨折; 13例患者共有 16处骨髓片状异常信号, 10处为 T1低信号 T2高信号, 6处为 T1低信号 T2混杂信号,脂肪抑制序列表现为明显高或混杂偏高信号;其中 4例伴有关节腔积液、1例有踝关节外侧韧带损伤.结论 MRI是发现踝关节隐匿性损伤的有效检查技术,表现包括关节表面软骨缺失、软骨下皮质骨骨折、皮质下松质骨骨小梁骨折以及骨松质内不规则出血或水肿.     

液电式体外冲击波治疗创伤性距骨缺血性坏死

背景:创伤性距骨坏死至今为止尚无理想的治疗方法,体外冲击波是目前一种微创、简单、疗效显著的骨肌系统疾病治疗新方法,其是否能够治疗距骨坏死尚无相关研究.目的:应用液电式体外冲击波治疗创伤性距骨缺血性坏死并分析其治疗效果,探索创伤性距骨坏死新的治疗方法.方法:纳入2004-09/2009-06武装警察部队医学院附属医院收治的创伤性距骨缺血性坏死患者34例,均为单侧发病,按随机数字表达分为体外冲击波疗法组和对照组,每组17例.采用体表痛点定位结合X射线定位,工作电压8～10 kV,能流密度0.12～0.16 mJ/mm2,冲击频率40～50次/min,冲击次数800～1000次.1次/周,共治疗3～5次.治疗前后采用目测类比评分评估疼痛情况;参照美国足踝关节外科协会踝关节功能评分进行功能评价;治疗后18个月时复查踝关节MRI,比较治疗前后坏死面积的变化.结果与结论:两组病例治疗后18个月,体外冲击波疗法组的疼痛、踝关节功能、踝关节MRI坏死面积的改善情况均优于对照组(P<0.01).对照组有1例因创伤性关节炎剧烈疼痛致踝关节活动受限,于治疗后第15周行踝关节融合术.提示液电式体外冲击波治疗创伤性距骨缺血性坏死是一种值得提倡的非侵入性、方法简单、疗效显著、并发症少的微创治疗方法.     

The Proximal Fibula Should Be Examined In All Patients with Ankle Injury: A Case Series of Missed Maisonneuve Fractures

Background

The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula. It occurs from violent twisting of the ankle that characteristically causes ligament damage and severe instability. Most patients complain of significant ankle pain but very little pain over the fracture. The clinical and radiographic examination is usually directed to the ankle region; and the proximal fibula is often ignored.

Objective

The authors intend to show the ease of missing the proximal fibular fracture when the clinical examination is directed to the ankle region. They discuss the importance of palpating the proximal fibula and ordering appropriate radiographs.

Case Studies

The authors report on 5 patients who presented to the Emergency Department, where the Maisonneuve fracture was missed despite having ankle radiographs taken. All patients required open reduction and internal fixation.

Conclusion

The Maisonneuve fracture injury pattern causes untoward consequences if not promptly recognized and treated. To avoid misdiagnosis, the proximal fibula should be examined in all patients with ankle injury.     

螺旋CT重建在距骨骨折诊断中的价值

目的：研究距骨骨折螺旋CT轴扫、多平面（MPR）和三维（3D）重建图像的特点及其临床意义。方法：收集距骨骨折患者术前螺旋CT资料12例,同时进行了MPR和3D重建图像。着重分析距骨骨折线的走行、与关节面的关系、关节面塌陷程度等,并评价轴扫、MPR和3D重建图像的优势。结果：在12例距骨骨折者骨踝关节受累7例。MPR和3D重建图像可直观显示骨折详细情况。结论：螺旋CT轴扫、多平面和三维重建图像相结合,可更好显示距骨骨折的情况,能为临床术前诊断和治疗提供有价值的影像信息。     

Occult ankle fracture detected by an ankle effusion on plain radiography: A case report

Subtle ankle fractures may escape detection on plain radiography. These occult fractures can cause prolonged disability and pain. We present a case of blunt ankle trauma where plain radiography failed to reveal any bony abnormalities. The recognition of an ankle effusion on plain radiographs prompted us to perform a computed tomography (CT) scan of the ankle. The CT scan demonstrated an anterior plafond fracture of the distal tibia, which required surgical fixation. Had the fracture not been identified, our patient would have been treated inappropriately for a ligament sprain. An occult fracture should be suspected if an ankle is grossly swollen after blunt trauma, and plain radiography demonstrates an effusion. In this circumstance, performance of further imaging studies, such as conventional or CT, are advised to rule out an occult ankle fracture.     

Sonographic Findings of Chondral Avulsion Fractures of the Lateral Ankle Ligaments in Children

In this series, we aimed to describe the sonographic findings of chondral avulsion fractures that develop concomitant with lateral ankle ligament injury in children. We performed stress sonography during a manual anterior drawer stress procedure of the ankle in 9 skeletally immature patients who had recently had a lateral ankle sprain. Echo videos were obtained through the course of treatment, and all videos were reviewed. We elucidated the common features of chondral avulsion fractures of the lateral ankle ligaments in the children. The features of avulsion fractures on conventional sonography included absence of a fracture with hyperechoic spots (sonographic occult fracture type), cortical discontinuity with hyperechoic spots (cortical disruption fracture type), fracture line in the cortical bone (double‐line fracture type), and a step‐off deformity of the cortical bone with cartilage (displaced fracture type). In contrast, the features of chondral fractures on stress sonography included abnormal motion of the chondral lesions and mobility/fluidity of hyperechoic spots along the chondral fracture site. The presence of hyperechoic spots around the chondral lesion is an important sonographic sign for diagnosing chondral fractures concomitant with ankle lateral ligament injury. Hence, we believe that stress sonography should be considered for the detection of chondral fractures concomitant with radiographically negative ankle lateral ligament injuries in skeletally immature patients with lateral ankle pain and ankle sprains, if hyperechoic spots are present in the cartilage of the distal fibula.     

Pure isolated medial talonavicular joint dislocation following low-energy trauma: a case report

Midtarsal dislocations are relatively rare injuries secondary to high-energy trauma and are typically accompanied by disruption of ligamentous structures and fractures of the midfoot. We herein present a case of a pure isolated medial swivel dislocation of the talonavicular joint (TNJ) that was sustained following low-energy trauma without an associated fracture. A 78-year-old woman visited our emergency department with severe pain in the midfoot area of the right foot without neurovascular deficits. She had sustained this injury after severe ankle inversion while going downstairs. Plain radiographs of the right foot showed that the navicular was dislocated medially on the talus; no other malalignments were present. Three-dimensional computed tomography revealed dislocation of the TNJ, but no other tarsal or midtarsal bone fractures or dislocations. A medial dorsal incision was made to expose the TNJ. The dorsal talonavicular ligament was ruptured and interposed between the navicular and talus. The ligament was removed and the TNJ was reduced. The clinical outcome at the 1-year follow-up was satisfactory with no limitations in daily activities. In summary, we have reported an extremely rare case of a pure isolated medial TNJ dislocation in which the interposed dorsal talonavicular ligament served as an obstacle to reduction.     

创伤性踝关节病变的关节镜诊治

目的对创伤性踝关节疼痛关节镜下的诊断和治疗进行初步探讨。方法43例病程半年以上创伤性踝关节疼痛患者行关节镜检查，并进行治疗。结果镜检下与关节疼痛有关病理类型：（1）关节不稳定征（外侧和下胫腓联合韧带损伤）；（2）撞击征（前踝骨赘和前外侧软组织损伤）；（3）软骨和骨软骨骨折；（4）非特异性骨关节炎和（或）滑膜炎。作镜下关节内清理、关节软骨面修整、骨赘切除、纤维束带切除等，术后关节腔内注射透明质酸钠和关节功能锻炼。术后随访25例，优10例，良13例，可2例，优良率92．0％。结论踝关节镜对诊断和治疗创伤性踝关节疼痛有重要价值。     

Manual therapy in addition to physiotherapy does not improve clinical or economic outcomes after ankle fracture.

OBJECTIVE: The primary aim of this study was to determine the effectiveness and cost-effectiveness of adding manual therapy to a physiotherapy programme for ankle fracture. DESIGN: Assessor-blinded randomized controlled trial. PARTICIPANTS: Ninety-four adults were recruited within one week of cast removal for isolated ankle fracture. Inclusion criteria were: they were able to weight-bear as tolerated or partial weight-bear, were referred for physiotherapy, and experienced pain. Ninety-one participants completed the study. METHODS: Participants were randomly allocated to receive manual therapy (anterior-posterior joint mobilization over the talus) plus a standard physiotherapy programme (experimental), or the standard physiotherapy programme only (control). They were assessed by a blinded assessor at baseline, and at 4, 12 and 24 weeks. The main outcomes were activity limitation and quality of life. Information on costs and healthcare utilization was collected every 4 weeks up to 24 weeks. RESULTS: There were no clinically worthwhile differences in activity limitation or quality of life between groups at any time-point. There was also no between-group difference in quality-adjusted life-years, but the experimental group incurred higher out-of-pocket costs (mean between-group difference = AU$200, 95% confidence interval 26-432). CONCLUSION: When provided in addition to a physiotherapy programme, manual therapy did not enhance outcome in adults after ankle fracture.