We report two new radiographic projections for evaluating avulsion fractures at the lateral malleolus. We used seven freshly amputated legs with simulated avulsion fractures and radiopaque markers to assess their value. The projections allow accurate assessment of the displacement of fragments without superimposition, and also show whether they affect the anterior talofibular or the calcaneofibular ligament or both

Aims

The purpose of this study was to compare symptomatic treatment of a fracture of the base of the fifth metatarsal with immobilisation in a cast.

Our null hypothesis was that immobilisation gave better patient reported outcome measures (PROMs). The alternative hypothesis was that symptomatic treatment was not inferior.

A total of 22 patients with a tibial avulsion fracture involving the insertion of the posterior cruciate ligament (PCL) with grade II or III posterior laxity were reduced and fixed arthroscopically using routine anterior and double posteromedial portals. A double-strand Ethibond suture was inserted into the joint and wrapped around the PCL from anterior to posterior to secure the ligament above the avulsed bony fragment. Two tibial bone tunnels were created using the PCL reconstruction guide, aiming at the medial and lateral borders of the tibial bed. The ends of the suture were pulled out through the bone tunnels and tied over the tibial cortex between the openings of the tunnels to reduce and secure the bony fragment. Satisfactory reduction of the fracture was checked arthroscopically and radiographically.

The patients were followed-up for a mean of 24.5 months (19 to 28). Bone union occurred six weeks post-operatively. At final follow-up, all patients had a negative posterior drawer test and a full range of movement. KT-1000 arthrometer examination showed that the mean post-operative side-to-side difference improved from 10.9 mm (standard deviation (sd) 0.7) pre-operatively to 1.5 mm (sd 0.6) (p = 0.001). The mean Tegner and the International Knee Documentation Committee scores improved significantly (p = 0.001). The mean Lysholm score at final follow-up was 92.0 (85 to 96).

We conclude that this technique is convenient, reliable and minimally invasive and successfully restores the stability and function of the knee.

Cite this article: Bone Joint J 2015;97-B:1220–5.

1. A review of intra-articular and peri-articular fractures of the phalanges has been carried out, and the late results of such injuries have been examined. 2. These fractures usually unite by bone. 3. The results of conservative treatment by immobilisation are satisfactory in the case of mallet fractures, hyperextension sprain fractures and collateral avulsion fractures of the proximal phalanges. 4. The less satisfactory results after collateral avulsion fractures of the interphalangeal joints and avulsion fractures complicating dislocations are discussed

1. Five cases of avulsion fracture of the calcaneus are reported. 2. The "beak" fracture of the calcaneus is thought to be a variant of the avulsion fracture and not a separate entity. 3. The variable attachment of the calcaneal tendon to the calcaneus is described, and its relationship to the different forms of avulsion fractures discussed. 4. Operative reduction and fixation are appropriate for young and active patients in order to restore full heel-cord function. 5. Attention is drawn to the risk of pressure necrosis of skin overlying a displaced fragment. Early operative correction may be required to prevent skin damage

Fractures of the proximal interphalangeal joint include a wide spectrum of injuries, from stable avulsion fractures to complex fracture-dislocations. Stability of the joint is paramount in determining the appropriate treatment, which should aim to facilitate early mobilisation and restoration of function

We report a case of an apparent avulsion fracture of the posteromedial margin of the medial plateau of the tibia. This was associated with a tear of the medial meniscus and rupture of the anterior cruciate ligament (ACL). This triad has been previously reported, and the plateau fracture was related to the insertion of the semimembranosus tendon. The detailed investigation of our case and some experiments on cadaver knees showed that the injury was not an avulsion fracture but was produced by varus and external rotation forces on a flexed knee. It was due to the anterior subluxation of the medial tibial plateau after rupture of the ACL

Aims

Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition.

Aims

Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

1. The literature on fractures of the postero-superior aspect of the calcaneus is reviewed. 2. The mechanical distinction between "beak" fractures and avulsion fractures is questioned, and the dangers of a purely radiological diagnosis are stressed. 3. When a complete avulsion is suspected on clinical grounds, open reduction should be done

We have reviewed 16 patients with avulsion fractures of the tibial tubercle, mostly boys who sustained left-sided injuries during sport. Two-thirds had type I or II injuries and were treated conservatively. Fractures involving the knee joint (type III) had internal fixation. The final results were good except for minor complications such as a prominent and uncomfortable tibial tubercle

We classified fractures of the base of the middle phalanx into five types: 1) single palmar fragment; 2) single dorsal fragment; 3) two main fragments; 4) not involving the articular surface, including epiphyseal separation in children; and 5) all others. Types 1 and 2 were subclassified into avulsion, split and split-depression. Surgery is recommended for unstable type-1 avulsion fractures, type-2 avulsions which may develop buttonhole deformities, and all fractures which displace articular cartilage surfaces. Long-term follow-up showed that surgical treatment which produced good stability and congruity gave good results. These should be the primary aims of treatment

We report the cases of three children with chronic injuries of the medial tibial malleolus caused by traction injuries during sport. All three had the triad of swelling of the medial malleolus, tenderness over its anterior part, and pain on forced valgus movement of the foot. Radiographs showed bilateral accessory ossification centres and MRI demonstrated partial avulsion or avulsion fracture of the apophyseal cartilage and fragmentation of the accessory centres. A review of 134 young basketball players showed that 25% had tenderness of the anterior medial malleolus. This high rate indicates that traction apophysitis of the medial malleolus is not uncommon in children as a sports-related disorder

We reviewed 19 adults and 12 children who had been treated for avulsion fractures of the tibial spine. Adult injuries have not previously been reported at length; most were caused by road-traffic accidents, and 68% were associated with other injuries, of which 58% were around the knee. The higher incidence of associated injuries in adults as compared with children, indicates that the injury is the result of greater energy and perhaps a different mechanism. The worse outcome in some adults was due to other associated intra-articular fractures and tears of the medial collateral ligament. Arthroscopy is useful in both diagnosis and treatment. Early accurate diagnosis and the correct treatment produce a good outcome

Aims

The aim of this study was to describe the introduction of a virtual pathway for the management of patients with a suspected fracture of the scaphoid, and to report patient-reported outcome measures (PROMs) and satisfaction following treatment using this service.

We describe 24 fractures of the tuberosity of the calcaneus in 22 patients. Three were similar to the type of avulsion fracture which has been well-defined but the remainder represent a group which has been unrecognised previously. Using CT and operative findings we have defined the different patterns of fracture of the calcaneal tuberosity. Ten fractures extended into the subtalar joint, but did not fit the pattern of the common intra-articular fracture as described classically. We have defined a new pattern which consists of a fracture of the medial calcaneal process with a further fracture which separates the upper part of the tuberosity in the semicoronal plane. Non-operative treatment of displaced fractures resulted in a mis-shapen heel and a poor functional outcome. Open reduction and internal fixation with either a plate or compression screw did not give satisfactory fixation. We prefer to use an oblique lateral tension-band wire. This technique gave excellent fixation and we recommend it for the treatment of displaced fractures of the tuberosity of the calcaneus

Aims

We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial.

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis.

After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy.

Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve.

Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment.

Cite this article: Bone Joint J 2020;102-B(5):556–567.

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management.

Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury.

This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients.

Cite this article: Bone Joint J 2020;102-B(10):1281–1288.

Aims

The removal of the cruciate ligaments in total knee arthroplasty (TKA) has been suggested as a potential contributing factor to patient dissatisfaction, due to alteration of the in vivo biomechanics of the knee. Bicruciate retaining (BCR) TKA allows the preservation of the cruciate ligaments, thus offering the potential to reproduce healthy kinematics. The aim of this study was to compare in vivo kinematics between the operated and contralateral knee in patients who have undergone TKA with a contemporary BCR design.