Aims. This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures. Methods. This was a retrospective cohort study of patients with acute zone 2 fifth metatarsal fractures who presented to a single large, urban, academic medical centre between December 2012 and April 2022. Zone 2 was the region of the fifth metatarsal base bordered by the fourth and fifth metatarsal articulation on the oblique radiograph. The proportion of patients allowed to bear weight as tolerated immediately after injury was compared between patients treated by orthopaedic surgeons and podiatrists. The effects of unrestricted weightbearing and foot and/or ankle immobilization on clinical healing were assessed. A total of 487 patients with zone 2 fractures were included (mean age 53.5 years (SD 16.9), mean BMI 27.2 kg/m. 2. (SD 6.0)) with a mean follow-up duration of 2.57 years (SD 2.64). Results. Overall, 281 patients (57.7%) were treated by orthopaedic surgeons, and 206 patients (42.3%) by podiatrists. When controlling for age, sex, and time between symptom onset and presentation, the likelihood of undergoing operative treatment was significantly greater when treated by a podiatrist (odds ratio (OR) 2.9 (95% CI 1.2 to 8.2); p = 0.029). A greater proportion of patients treated by orthopaedic surgeons were allowed to immediately bear weight on the injured foot (70.9% (178/251) vs 47.3% (71/150); p < 0.001). Patients treated by podiatrists were immobilized for significantly longer (mean 8.4 weeks (SD 5.7) vs 6.8 weeks (SD 4.3); p = 0.002) and experienced a significantly longer mean time to clinical healing (12.1 (SD 10.6) vs 9.0 weeks (SD 7.3), p = 0.003). Conclusion. Although there was considerable heterogeneity among zone 2 fracture management, orthopaedic surgeons were less likely to treat patients operatively and more likely to allow early full weightbearing compared to podiatrists. Cite this article: Bone Joint J 2024;106-B(9):942–948

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. Patients and Methods. A total of 60 patients were randomised to receive four weeks of treatment, 36 in a double elasticated bandage (symptomatic treatment group) and 24 in a below-knee walking cast (immobilisation group). The primary outcome measure used was the validated Visual Analogue Scale Foot and Ankle (VAS-FA) Score. Data were analysed by a clinician, blinded to the form of treatment, at presentation and at four weeks, three months and six months after injury. Loss to follow-up was 43% at six months. Multiple imputations missing data analysis was performed. Results. At four weeks and six months, symptomatic treatment proved non-inferior in terms of primary outcome. Take home message: Immobilisation is no better than symptomatic treatment in the management of a fracture of the base of the fifth metatarsal when judged by PROMs. Significant loss to follow-up with this injury could be expected in longer term. Cite this article: Bone Joint J 2016;98-B:806–11

Fifth metatarsal fractures in sport are known to be associated with acceleration and cross cutting movements when running. It is also established that playing surface has an impact on the ground reaction forces through the foot, increasing the strain through the fifth metatarsal. But what impact does boot design have on these forces? Current thought is that boots that utilise a blade stud design resist sideways slipping of the planted foot more than boots with a rounded stud. This study aims to compare ground reaction forces through the fifth metatarsal in 2 two different designs of rugby boot to assess what impact stud design might have. The forces across the foot were measured using Tekscan in-shoe pressure plates in 24 rugby players. Each player was asked to complete an agility course to measure acceleration, cutting and cross-cutting in the two different designs of rugby boot, reproducing true playing conditions. The boots used were the Canterbury Phoenix Club 8 Stud boot and the Canterbury Speed Club Blade boot. The trial was conducted on an 4G artificial pitch at the Cardiff Arms Park rugby ground. Ethical approval was obtained from Bath University and a research grant was provided by British Orthopaedic Foot and Ankle Society. The blade boot had significantly higher contact pressures than the stud boot on the fifth metatarsal in the combined movements (17.909 ± 10.442 N/cm2 Blade Vs 16.888 ± 9.992 N/cm2 Boot; P < .0125; n= 864 steps in each boot group). The blade boot also produced higher pressure during cross-cutting (32.331 ± 13.568 N/cm2 Vs 27.651 ± 15.194 N/cm2 p < 0.007). Pressures were also higher in both acceleration and cutting, although not significantly so. These results will guide clinicians advising athletes in shoe design, especially those predisposed to or rehabilitating from a fifth metatarsal fracture

Background. Fractures of the metatarsal bones are the most frequent fracture of the foot. Up to 70% involve the fifth metatarsal bone, of which approximately eighty percent are located proximally. Low-intensity pulsed ultrasound (LIPUS) has been shown to be a useful adjunct in the treatment of delayed fractures and non unions. However, there is no study looking at the success rate of LIPUS in fifth metatarsal fracture delayed unions. Objectives. The aim of our study was to investigate the use of LIPUS treatment for delayed union of fifth metatarsal fractures. Study Design & Methods. A retrospective review of patients who were treated with LIPUS following a delayed union of fifth metatarsal fracture was conducted over a three-year period (2013 – 2015). Delayed union was defined as lack of clinical and radiological evidence of union, bony continuity or bone reaction at the fracture site if 3 months has elapsed from the initial injury. Results. There were thirty patients (9 males, 21 females) in our cohort. The average age was 39.3 years. Type 2 fractures made up 43% of our cohort. Twenty-seven (90%) patients went on to progress to union clinically and radiologically following LIPUS treatment. Smoking (p=0.014) and size of fracture gap (p=0.045) were predictive of non-union. Conclusions. This is the first study looking at the use of LIPUS in the treatment of delayed union of fifth metatarsal fractures. We report a success rate of 90%. There is a role in the use of LIPUS in delayed union of fifth metatarsal fractures and can serve as an adjunct prior to consideration of surgery

Design: Retrospective chart and radiographic review. Background: Stress fractures of the fifth metatarsal are increasingly common among elite professional footballers (soccer players). This reflects the use of lighter, less protective and more flexible sports footwear combined with the increasingly physical demands of the professional game at the highest level. Stress fractures of the fifth metatarsal can be satisfactorily treated non-operatively by cast immobilisation and a graduated return to activity. The demands placed on the modern elite professional footballer are such that a different treatment approach is required for the same injury in this subgroup of patients. Methods: Stress fractures of the fifth metatarsal in elite professional footballers are treated by the senior author (JPH) by operative surgical fixation. We reviewed the charts and radiographs of all fifth metatarsal stress fractures that were treated operatively in elite professional footballers over a five year period. Details recorded included fracture location, method of fixation, complications, time to radiological union and time to return to independent weightbearing and competitive sporting activity. Results: There were 32 fifth metatarsal stress fractures in 30 elite professional footballers. All fractures were clinically united at a mean 5.5 weeks and radiologically united at a mean of 10.3 weeks. The patients could weightbear immediately and could independently weightbear from 4 weeks. The mean time to return to full competitive activity was 10.3 weeks. There were no complications. Conclusions: Operative treatment of fifth metatarsal stress fractures is an effective treatment in elite professional footballers that produces consistently good results and allows an early return to full activity

Introduction. Fifth metatarsal fractures are a common injury suffered by professional footballers. It is frequently reported in the media that such an injury will result in a 6-week absence from play. The purpose of this study was to assess frequency of media reporting of fifth metatarsal fractures, the time that is predicted by the media before the player will return to soccer and the actual time taken for the player to return to play. Methods. Internet search engines identified 40 professional footballers that suffered 49 fifth metatarsal fractures between 2001 and 2011. Information was collected from various media and team websites, match reports, photography and video evidence to provide data regarding the mechanism of injury, playing surface conditions, frequency of fractures per season, fracture treatment, estimated amount of time to be missed due to the injury and time taken to return to play. Results. 49 fractures were identified in the 40 players. 6 players suffered a recurrence of a previous fifth metatarsal fracture. 3 players sustained 5. th. metatarsal fractures in their contralateral foot. There was a trend of increased reporting of fifth metatarsal fractures over the course of the decade. 43% of fractures were sustained without contact with another player, 24% were suffered in a tackle. 77% of fractures were sustained in dry conditions. 90% of fractures were treated surgically. Mean return to play time was 14.6 weeks (range 5 to 34 weeks). The mean estimated absence in the media was 7.8 weeks (range 2 to 16 weeks), median 6 weeks. Conclusions. Fifth metatarsal fractures are being commonly reported in professional footballers with an increasing trend. Most are treated surgically. It appears that the commonly quoted period of 6 weeks before return to play is unrealistic. It should be expected that a player would be unavailable for 3 months

Proximal fifth metatarsal fractures distal to the tuberosity, also known as Jones’ fractures, are troublesome fractures to manage with a high incidence of delayed union and nonunion. We conducted a retrospective study of 32 patients with fractures of the fifth metatarsal distal to the tuberosity over a three year period. The aim was to assess healing with non-weight bearing and variations of weight bearing mobilization including minimal, partial and full weight bearing. This is one of the largest reported series of such fractures. These fractures were classified as acute fractures (14 fractures), fractures with features of delayed union (15 fractures) and fractures with features of nonunion (three fractures) at presentation according to the radiological classification used by Torg in 1984. These patients were treated in a plaster cast and mobilised either non-weight bearing or with variations of weight bearing. These patients were followed up for a mean of 16 months. Our findings correspond with those observed by Torg and we describe a correlation between the radiological appearance of the fracture at presentation and the clinical course. Prevailing guidelines for the management of these fractures are ambiguous. A standardized classification is important because there is great variability in the types of fractures and appropriate treatment. It is important that radiological features are correlated with clinical features and appropriate treatment instituted. The treatment of choice for acute fractures is immobilization of the limb in a below-knee non-weight bearing plaster for 6 to 8 weeks. Fractures with delayed union may eventually heal if treated non-operatively, although this may take up to 20 weeks. An active athlete will benefit from early surgery. Fractures with symptomatic nonunion require surgery

Background: This prospective study was done to evaluate functional outcomes after acute avulsion fractures of the fifth metatarsal base. The objective was to compare the results of two different casting methods adopted as a treatment of non-displaced avulsion fractures of the fifth metatarsal. Methods: Fifty-two patients who sustained an avulsion fracture of the fifth metatarsal base and presented to the outpatient clinic of our hospital system were treated according to the advice of the attending clinicians. A total of 49 patients were available for 3 months follow up. There were eight men and 41 women with an average age of 41.9 (range 17 to 81) years. The lower extremity was placed in a below knee [n=28] or slipper cast [n=21] and patients were allowed to bear weight as tolerated. Baseline data collection consisted of demographic information, and radiographic, and functional evaluation. Patients were seen at regularly scheduled visits for 6 weeks and then at 3 months to obtain follow up information. A Short Musculoskeletal Function Assessment (SMFA) questionnaire was obtained at 3/12 year. Analyses were performed to determine differences in outcome based on demographics and injury information. Results: Based on self-reports, 10 patients with slipper cast had returned to pre-injury functional status by 3 weeks, compared to 22 patients with below knee cast by 6 weeks. An average of 22 days were lost from work, with 9 patients taking up to 10 days, 13 taking 3 weeks or longer off work. Twenty eight patients were losing more than 6 weeks of work in the other group. All were provided with pain killers, crutches if needed and none required thromboembolic prophylaxis with low molecular heparin. After twelve weeks none of the patients complained about pain. Radiographic consolidation of the fracture was noticed after 7 weeks for the avulsion fractures. As regard to the costing approximately 4 pounds for the slipper cast and 12 pounds were spent on the below knee casting. Conclusions: Fracture of the fifth metatarsal base often is a source of lost work productivity. Patients can be expected to return to their preinjury level of function with slipper type of cast earlier than below knee cast. Slipper types of casting are cost effective, efficient and offer greater mobility to the patients

Background. Avulsion fractures of the base of the fifth metatarsal are some of the commonest foot injuries. The robust scientific evidence on the optimal non-operative treatment of these fractures is scant. We designed and conducted a prospective randomised non-inferiority controlled trial of symptomatic treatment versus cast immobilisation with the null hypothesis that cast immobilisation gave substantial benefit over the symptomatic treatment in terms of patient reported outcome measures(PROMs). The alternative hypothesis was that symptomatic treatment was not inferior. Methods. The primary outcome was the validated Visual Analogue Scale Foot and Ankle (VAS FA) score ranging from 0 to 100. The non-inferiority boundary was set at −10 points. Power sizing determined a minimum of 12 patients per group. Anticipating a significant loss to follow up, 60 patients of 16 years of age or older were randomised to receive either below knee walking cast immobilisation (n = 24) or symptomatic double- elasticated bandage (n = 36) for 4 weeks. Secondary outcome measures were EuroQol-5D, and American Orthopaedic Foot and Ankle Society scores. Data was analysed at the baseline, 4 weeks, 3 months and 6 months post injury by a clinician blinded to a treatment arm. Results. Symptomatic treatment proved to be non-inferior to cast immobilisation treatment in terms of VAS FA at baseline, 4 weeks and 6 months. Secondary outcomes showed similar comparative values between two treatment groups. Loss to follow up reached 43% at 6 months. The imputation of missing data was done and confirmed the non-inferiority of symptomatic treatment. Conclusions. Cast immobilisation does not appear to give benefits over symptomatic treatment of these injuries in terms of validated PROMs in adults. A significant loss to follow up should be expected with these fractures in medium term. Level of Evidence. II. Approval. NRES Yorkshire and the Humber reference: 11/YH/0297. Disclosure. This study was supported with a small research grant from a British Orthopaedic Foot and Ankle Society

Aims: To explore potential predictors of functional outcome after conservative treatment of acute fractures of the base of the fifth metatarsal. These fractures are the most frequent fracture of the foot. The factors that influence final clinical outcome are rarely investigated. Regression analysis regarding this problem was never performed. Methods: The study design was observational and retrospective. Adults, conservatively treated for an acute fracture of the base of the fifth metatarsal included. All patients were given a plaster cast at the emergency department and were instructed not to bare weight (NWB) on the affected limb for at least one week. The further modalities of treatment were decided by individual surgeons according to their current clinical practice. A validated scoring system was used. Additional questions were asked about residual cosmetic and shoe problems and also about intensity of pain and the general feeling of comfort. The respective influences of factors on clinical outcome were examined using multiple linear and logistic regression modeling. Results: 38 patients (11 men, 27 women) were analysed. The mean age was 48 years. 6 had a Jones fracture, while 32 had a tuberosity avulsion fracture. The mean non-weight bearing period was 2 weeks and 4 days (range 1 to 5 weeks) while the cast was worn for a mean of 5 weeks and 3 days (range 1 to 10 weeks). Three Jones fractures and all the avulsion fractures were healed at the end of treatment. The mean follow-up time was 298 days, ranging from 51 to 603 days. The mean result of the ankle score at follow-up was 77.5 (range 20 to 100). Thirteen of the 38 patients reported problems in wearing shoes. Only 8 patients experienced cosmetic problems. The mean linear analogue score for pain was 2.34, that for general comfort was 8.11. Overall, the most significant predictors of poor functional outcome at final follow-up evaluation were increasing duration of NWB and longer follow-up time. Longer NWB was importantly associated with worse global score, pain, comfort and reported stiffness. Neither gender nor fracture type had any significant influence on the overall clinical outcome. Conclusions: The most important variable linked to final clinical outcome is the duration of the non-weight bearing period. Neither gender, age, length of casting nor even fracture type, had any significant influence on the overall clinical outcome. Therefore NWB should be kept to a minimum for acute avulsions

Fifth metatarsal fractures are common and the majority unite regardless of treatment. A sub-type of these fractures carries a risk of non-union and for this reason many centres follow up all 5. th. metatarsal fractures. In 2011, a standardised protocol was introduced to promote weight-bearing as pain allowed with a tubigrip or Velcro boot according to symptoms. No routine fracture clinic appointments were made from A&E but patients were provided with information and a help-line number to access care if required. Some patients still attended fracture clinics, but only after review of their notes/X-rays by an Orthopaedic Consultant, or after self-reported “failure to progress” using the special help-line number. Audit of a year prior to the introduction of the protocol and the year following it was performed. All x-rays taken at presentation in A&E were reviewed and classified independently (KBF/JM) for validation. During 2009/2010, 279 patients presented to A&E with a 5. th. metatarsal fracture and were referred to a fracture clinic. 106(38%) attended 1 appointment, 130(47%) attended 2 appointments and 31 (11%) attended 3 or more appointments – 491 appointments in total. 3% failed to attend the clinic. Operative fixation was performed in 3 patients (1.07%). In 2011/2012, of 339 A&E fractures, only 63 (19%) attended fracture clinic. 37 (11%) attended 1 appointment, 12 (4%) 2 and 9 (3%) 3 or more appointments – 96 appointments in total. Four patients (1.17%) required operative fixation. Our study did not demonstrate any added value for routine outpatient follow-up of 5. th. metatarsal fractures. Patients can be safely allowed to weight bear and discharged at the time of initial presentation in the A&E department if they are provided with appropriate information and access to a “help line” run by experienced fracture clinic staff. The result is a more efficient, patient-centred service

Introduction. Fifth metatarsal fracture is a common injury. Current practice supports conservative management, with surgery in the event of non-union. Early fracture clinic review is not perceived to improve patient experience or increased detection of non-union. A new protocol standardises treatment to symptom level and discharges patients from ED with advice but without any routine follow-up arranged. A leaflet advises on management, prognosis and helpline details and there is an open-access policy for those whose symptoms persist to investigate potential non-union. Method. A prospective audit evaluated the protocol, surveying patients at 8-weeks and 6-months post-injury. A minor injuries unit continued to refer to fracture clinic and was the control group. During 6-months 46 acute fractures were recorded in the new protocol(group 1) and 47 in the control(group 2). 1 patient in each group was known to experience non-union. 31 of group 1 and 22 of group 2 responded to at least one survey. Results. Satisfaction with information provided at initial presentation was high for both protocols. 87%(27/31) satisfied in group 1 and 90%(20/22) group 2(p=1.0000). At 8-weeks 82%(19/23) were satisfied with their progress following the new protocol compared to 89%(17/19) in the control(p=0.6729). At 6-months 88%(22/25) were satisfied compared to 76%(13/17) respectively(p=0.4133). The new protocol is not associated with a significant symptoms increase. At 8 weeks 22%(5/23) described their pain severity as >5/10 reducing to 8%(2/25) by 6-months. Compared to 10%(2/19) of the control at 8-weeks and 6%(1/17) at 6-months. Patients rating fracture management overall as ‘good or excellent’ were comparable between both new, 67%(21/31) and traditional, 77%(17/22) protocols(p=0.5441). Conclusion. No significant difference in patient satisfaction and symptom levels between the old and new protocol was found. The new protocol reduces unnecessary patient appointments. This reduces demands on fracture clinic while maintaining a safe, resource efficient service

Tuberosity ‘avulsion’ fractures to the base of the fifth metatarsal respond well to symptomatic treatment. The purpose of this study was a prospective comparison of clinical and radiological outcome with treatment in a plaster slipper, compared to a tubigrip support. Ethical approval was obtained and written consent with an information sheet issued at the first fracture clinic appointment. Forty three patients with this fracture were allocated to one of our two treatment groups and followed up at regular intervals over a 12 week period or until they were suitable for discharge. A combined foot score (maximum 100 points) was used at each follow up appointment to measure levels of pain (40 points) and function (60 points). A check radiograph was taken prior to discharge to assess union. A repeated measures analysis was used to assess any difference between the two treatment groups and whether this changed with time. Results indicated no overall significant difference between the two treatment groups with a mean foot score of 73.5 for the tubigrip group and 80.3 for the plaster slipper group over the entire treatment period. At 2 weeks post injury the plaster group (70.9) had a significantly (p< 0.01) better combined foot score at assessment in comparison to the tubigrip group (54.1).By the 5–8 week stage, the mean combined foot scores had improved and were comparable at 89.5 (tubigrip) and 90 (plaster slipper). Radiographs taken prior to discharge indicated two patients in each treatment group with significant fracture site displacement. One patient remained clinically symptomatic and underwent surgical fixation. In this small cohort of patients the eventual clinical and radiological outcomes were comparable. During the initial 2 week treatment phase the plaster slipper group recorded a significantly better mean foot score

Introduction

Treatment pathways of 5^th metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management.

The majority of 5th metatarsal fractures are successfully treated conservatively, with few patients requiring surgical fixation for symptomatic non-union. Tuberosity avulsion fractures are generally considered benign injuries with more distal fractures showing a propensity to develop delayed/non-union. We studied a cohort of patients who underwent surgery as treatment for non-union. We reported on outcome, rate of complications and requirement for additional surgery.

All patients who required surgery to their 5th metatarsal from June 2008 to May 2018 were included. Demographic, clinical outcome data and radiographic classification of fracture types were collected, reviewed and analysed.

35 patients had undergone surgery for 5th metatarsal fractures during this time period and 31 of these had been operated on for a painful non-union. 12 were tuberosity avulsion fractures (Lawrence and Botte Type1) and 23 were Type 2/3. 5 patients (14.3%) experienced a further symptomatic non-union after initial surgery; Type 1 fractures were 11 times more likely to result in non-union (p=0.0375). 22.9% of the group required some form of further surgery, with a significant association between Type 1 fractures and the need for further surgery (p=0.0107).

This study is the first of its kind, reporting specifically on the outcome after surgical fixation of a non-union of 5th metatarsal fractures. Overall, surgery had a good outcome with a low complication rate, though it is interesting to note that Type 1 fractures, which traditionally have a low non-union rate after conservative treatment, are associated with a significantly increased incidence of non-union if operated for symptomatic non-union.

The August 2024 Foot & Ankle Roundup. 360. looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery

The October 2024 Foot & Ankle Roundup. 360. looks at: Hemiarthroplasty for hallux rigidus; Fixed or mobile-bearing ankle arthroplasty? A meta-analysis; Bone grafting for periprosthetic bone cysts following total ankle arthroplasty; Diabetic foot ulcer after first-ray amputation; Early motion after ankle surgery: the path to faster recovery?; Are podiatrists and orthopaedic surgeons approaching zone 2 fifth metatarsal fractures in the same way?

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

3D accurate measurements of the skeletal structures of the foot, in physiological and impaired subjects, are now possible using Cone-Beam CT (CBCT) under real-world loading conditions. In detail, this feature allows a more realistic representation of the relative bone-bone interactions of the foot as they occur under patient-specific body weight conditions. In this context, varus/valgus of the hindfoot under altered conditions or the thinning of plantar tissues that occurs with advancing age are among the most complex and interesting to represent, and numerous measurement proposals have been proposed. This study aims to analyze and compare these measurements from CBCT in weight-bearing scans in a clinical population. Sixteen feet of diabetic patients and ten feet with severe adult flatfoot acquired before/after corrective surgery underwent CBCT scans (Carestream, USA) while standing on the leg of interest. Corresponding 3D shapes of each bone of the shank and hindfoot were reconstructed (Materialise, Belgium). Six different techniques found in the literature were used to calculate the varus/valgus deformity, i.e., the inclination of the hindfoot in the frontal plane of the shank, and the distance between the ground and the metatarsal heads was calculated along with different solutions for the identification of possible calcifications. Starting with an accurate 3D reconstruction of the skeletal structures of the foot, a wide range of measurements representing the same angle of hindfoot alignment were found, some of them very different from each other. Interesting correlations were found between metatarsal height and subject age, significant in diabetic feet for the fourth and fifth metatarsal bones. Finally, CBCT allows 3D assessment of foot deformities under loaded conditions. The observed traditional measurement differences and new measurement solutions suggest that clinicians should consider carefully the anatomical and functional concepts underlying measurement techniques when drawing clinical and surgical conclusions

Background. Lisfranc fracture dislocations are uncommon injuries, which frequently require surgical intervention. Currently, there is varying evidence on the diagnostic utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification. Methods. A retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative XR and CT images were reviewed independently by 2 reviewers to identify the presence of associated fractures. Results. A total of 175 patients were included. Our assessment identified that XR images significantly under-diagnosed all metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p<0.001), medial cuneiform (20% vs 51%, p=0.008), lateral cuneiform (4% vs 36%, p=0.113), second metatarsal (57% vs 82%, p<0.001), third metatarsal (37% vs 61%, p<0.001) and fourth metatarsal (26% vs 43%, p<0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%). Conclusion. From our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning