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Background: Ankle sprains are one of the most frequent injuries of the musculoskeletal system. The injury pattern determines the treatment and are crucial for the outcome. Nonoperative treatment is commonly recommended for isolated injuries of the lateral ligaments but no standard strategy exists in combined ankle ligament injuries. The goal of this national survey was to achieve an overview about the current diagnostic strategies and common treatment concepts in Germany., Material and Methods: All members of the German Society for Orthopaedics and Trauma Surgery (DGOU) were invited to participate in an anonymous survey about the diagnostic and therapeutic approach in cases of ankle sprains. The online survey consisted of 20 questions. Besides questions about the speciality and scope of activities the participants were ask to depict their diagnostic and therapeutic strategy., Results: A total of 806 participants completed the survey. Most of them were orthopedic trauma surgeons and worked in a hospital. During the first presentation the anterior drawer test (89.5%) and the inversion/eversion test (81.6%) were most commonly used, 88.1% always make an X‑ray examination and 26.5% an ultrasonography examination. Isolated injuries of the anterior fibulotalar ligament (LFTA) were treated nonoperatively by 99.7% of the participants, 78.8% recommend full weight bearing in an orthesis, 78.8% treat the complete rupture of the lateral ligaments without operation whereas 30.1% stated that they would treat a combined lateral ligaments rupture with an injury of the syndesmosis nonoperatively., Discussion: Due to the heterogeneity of injury patterns after ankle sprain no consistent recommendations for diagnostics and treatment exist. The Ottawa ankle rules and ultrasonography were not often utilized despite of the good evidence. The isolated rupture of the LFTA is diagnosed and treated according to the national guidelines by most of the participants. In cases of combined injuries of the lateral and medial ankle ligaments the majority choose a nonoperative treatment strategy which is justified by the guidelines with a low level of evidence. Combined injuries of the syndesmosis and the lateral ankle ligaments were treated operatively, which also correlates with the recommendations in the literature. The standard care of ankle sprain in Germany is in accordance with the recommendations from the current literature., (© 2024. The Author(s).)

Injuries of the first metatarsophalangeal (1MTP) joint in the performance of sports are normally rare. The term turf toe injury designates a sprain of the first metatarsophalangeal (1MTP) joint. The trauma mechanism describes a hyperextension in contrast to a "sand-toe"-injury which is caused by a hyperflexion. Injuries to the metatarsophalangeal (MTP) joint of the great toe have increased in incidence over the last years following the introduction of synthetic surfaces and the establish use of lighter footwear. Although most common in American football players, similar injuries can also be found in sporting activities like basketball, soccer, gymnastics or dance. The trauma mechanism leads to varying degrees of sprain or disruption of the supporting soft-tissue structures. Furthermore damage to the articular cartilage and adjacent bone can be detected. An assessment of the extent of soft-tissue disruption or even damage of the cartilage is essential in treatment planning. The conservative treatment methods including relative rest, shoe modification, and insoles are in most cases successful. But in case of an advanced stage or failure of conservative treatment, surgical treatment is mostly necessary. The turf toe injury must be diagnosed early and evaluated properly. The injury leads to a loss in sports time and competition and can progress to chronic osteoarthritis of the first metatarsal joint., (© Georg Thieme Verlag KG Stuttgart · New York.)

Injuries to the lateral ankle ligaments are the most common sports injuries. Determination of their severity and exclusion of relevant accompanying injuries requires a subtle clinical and a focussed radiological assessment. Treatment is non-operative and functional in the majority of cases. Consequent application of orthoses limiting supination and proprioceptive training are essential to avoid chronic instability. With recurrent ankle sprains one has to distinguish between functional and mechanical instability. The latter can be treated successfully with anatomic reconstruction and ligamentoplasty in more than 80 % of cases. Extraanatomic tenodeses should be reserved for cases of combined ankle and subtalar instability. Isolated injuries to the medial collateral ligaments are rare. Therefore, osseous injuries or underlying deformities have to be excluded. Isolated deltoid ligament ruptures may be treated non-operatively. Unstable injuries to the distal tibiofibular syndesmosis resulting in a manifest or latent diastasis are treated with open reduction and fixation with two tibiofibular set screws. Anatomic reduction of the distal fibula into the tibial groove is of utmost prognostic relevance and therefore should be reliably proved with either intraoperative 3D fluoroscopy or postoperative CT scanning. For chronic syndesmotic instability an anatomic ligamentoplasty using half the peroneus longus tendon is recommended., (© Georg Thieme Verlag KG Stuttgart · New York.)

Muscle injuries are common in sports. They are usually caused by either acute (mostly eccentric mechanisms) or chronic overloading with a lack of muscle coordination. They present in clinical practice as bruises and muscle sprains. Due to the rigours of a modern society and the high economic cost of time off work, an effective treatment needs to be employed. The key to an optimised therapy rests in the appropriate timing between immobilisation and mobilisation. The interval to muscle repair might be shortened by certain adjuvant therapies. In doing so, it is important that no physiological phases of wound healing are overlooked. Muscle healing can be accelerated by externally induced higher metabolic turnover. Surgical therapy is sometimes necessary in selected cases and in serious injuries.

In the literature, the association between chronic pain syndromes of the spine and sustained "trifle trauma" is a matter of controversy. "Trifle trauma" is identified as a contusion, compression and/or sprain without a definite, acute imaging sign of injury to the bone, the disk or the ligaments of the spine. Most of the time, striking isolated changes to the intervertebral disks are interpreted as preexisting without relevance to an acute injury. However, complex chronic pain syndromes causing permanent and significant functional limitations in daily life and work may occur. Besides the diagnostic and therapeutic challenge for the treating physician, the expert confronted with compensation claims very often has to answer questions as to whether "trifle trauma" of the spine may lead to significant and permanent functional limitations or loss with chronic pain syndromes, and what the importance of possible isolated changes in intervertebral disks is. The data from literature dealing with this topic is contradictory and deficient. In this article, we critically examine the causality between "trifle trauma" to the spine and possible permanent chronic complaints based on currently available data from the literature in order to support the process of decision making in questions of litigation and controversial compensation claims.

In order to gain satisfying results in the treatment of acute hyperflexion trauma to the foot, it is absolutely necessary to achieve an exact primary diagnosis because injuries to the tarsometatarsal joint are frequently missed primarily. Aim of this prospective clinical study was to evaluate the diagnostic reliability of conventional radiography, CT and MRI compared to each other. 75 consecutive patients after hyperflexion trauma to the foot were included. There were 47 males and 28 females with a mean age of 38 years. After admittance, pa-, lateral and 45 degrees oblique radiographs were taken as well as stress views in comparison to the contralateral foot. Furthermore, CT and MRI were performed in any patient. By conventional radiography, 48 metatarsal and 24 tarsal fractures were diagnosed as well as 17 cases of malalignment of the Lisfranc joint. Stress radiographies were not able to provide a more accurate diagnosis. By CT scans, however, 86 metatarsal and 74 tarsal fractures were detected. Moreover, we found malalignment in 31 and bony avulsions of Lisfranc's ligament in 4 patients. By MRI, finally, 85 metatarsal, 100 tarsal fractures and 31 cases of malalignment were diagnosed. Additionally, partial or complete tears of Lisfranc's ligament were depicted in 22 patients. The present study could clearly show the superiority of CT and MRI to conventional radiography in diagnosis of bony and ligamentous disorders of the Lisfranc joint. Therefore, extended diagnosis has to be demanded in all cases of hyperflexion trauma to the foot.

Chronic functional instability is a residual problem after acute ankle sprain. Reasons may be weak ligaments and/or a deficit in the proprioceptive system. Studies have shown that peroneal reaction time (PRT) can be used to quantify proprioceptive performance. To test the influence of anthropometric data on PRT, an experimental study with 120 healthy volunteers was performed. Surface electrodes recorded the activity of the peroneal muscles after a sudden inversion on a tilting platform. It was found that PRT is not influenced by extrinsic or anthropometric data. Furthermore, the results prove a significant slackening in PRT with increasing age. Therefore, the patient's age must to be considered in judging the PRT.

Previous studies have shown that clinical criteria can be used for determining the need for radiographs after spraining injuries of an ankle. Following the criteria of the "Ottawa Ankle Rules" (OAR) fractures could be ruled out with a sensitivity of 100% and a specificity of 50% while reducing radiographs by 28%. The aim of this study was to assess the "OAR" when applied in a German emergency department. Patients older than 18, who presented with blunt ankle trauma were examined by clinicians, then radiographs were ordered in all and the "OAR" were retrospectively applied. In 397 treated injuries 79 fractures were diagnosed and 5 patients had radiologically suspected fractures. Following to the "OAR" 58 were unnecessarly X-rayed and 5 fractures would not have been discovered, all of which were minor. Sensitivity using the "OAR" was 94% and specificity 17%. We found that 15% less radiographs can be ordered applying the "OAR". The "OAR" have the ability to rule out significant fractures at the ankle and midfoot.

Objective: Chiropractic techniques are of particular importance for the examination of the cervical spine. The aim of this study was to assess interexaminer reliability of examination techniques of the cervical spine in subjects with and without musculoskeletal distortions of the neck. The interrater method was used with five independent examiners., Method: Twenty patients suffering from neck diseases and 20 asymptomatic subjects of similar age and gender were randomized and assessed by five examiners blind to patient histories. Statistical analysis was carried out using multiple logistic regression and the calculation of kappa., Results: Compared to asymptomatic subjects, patients experienced pain significantly often when pressure was applied to the cervical zygapophysial joints and the superficial neck muscles (p < or = 0.05 and p < or = 0.01). In addition, segmental function tests induced kinesialgia significantly more often in patients than in asymptomatic subjects (p < or = 0.05 and p < or = 0.01). A significant relationship was not found between the patient's health status and the findings from muscle palpation and functional examination of the motion segments. The assessment of agreement within examiners beyond chance had to be calculated, aside from for few exceptions, little to moderate (0.2 < kappa < or = 0.6)., Conclusions: Chiropractic techniques are an essential part of every examination of the cervical spine. The clinical impact has not been scientifically established until up to now. Based on our findings and literature, we conclude that interexaminer reliability of manual diagnosis in the examination of the cervical spine should be improved by standardizing the examination process and setting guidelines for documentation and evaluation criteria. Controlled and frequently repeated training sessions also contribute to the reproducibility of findings from manual examinations.

After cervical sprain not only pain and neuropsychological disturbances may occur, but also the following sequelae: cervical dystonia, and torticollis, dizziness, hearing loss for low frequencies, dysphonia and globus. Except for dystonia the symptoms often respond to manipulation of a blocked articulation between occiput and atlas or axis and the third cervical vertebra.

Closed rupture of the anterior tibial tendon is rare. Fewer than 50 cases have been reported in the literature, perhaps because the symptoms are often neglected by the patient as well as by the doctor. Most often the rupture occurs as a consequence of a sudden plantar flexion of the ankle and pre-existing degenerative changes of the tendon tissue due to systemic disease or iatrogenic local corticoid injections. Clinically, the tendon rupture presents as acute weakness of the ankle extensors without reddening, swelling or neurological signs. Differential diagnoses such as anterior tibial syndrome and peroneal nerve palsy can thus be excluded. During the clinical examination the distal stump and the discontinuity of the anterior tibial tendon are often palpable. The clinical diagnosis can be confirmed by an ultrasound examination. An operation may be undertaken up to 3 months after the injury. Preferred procedures are end-to-end anastomosis and transosseous refixation of the tendon, followed by a plaster cast for 6 weeks post-operatively. High-risk patients can be treated conservatively, but the functional results are less satisfactory. We describe a case of an acute closed rupture of the anterior tibial tendon. A yet unpublished method of osseous reinsertion of the tendon is presented.

Injuries of the finger joints with damage to the capsule and ligaments are quite common. Nevertheless early diagnosis may be missed since patients look for relief only after a period of longstanding pain. A careful clinical and X-ray diagnosis is the prerequisite for appropriate treatment. Surgery is still indicated for most of the injuries of the ulnar ligament of the MP-joint of the thumb. Sprains or dislocations of the middle joint of fingers are quite usual. In most instances they may be treated by immobilisation or functional treatment. Persistent subluxation after reduction of the joint or large avulsion-fractures have to be treated by open surgery. Injuries of the MP-ligaments are frequently misinterpreted. Their treatment should be based on a very careful evaluation of the case.

Wrist hyperextension is a common injury. However, obvious ligamentous ruptures are apparently seldom. The intracarpal locking phenomenon, allowing for correct load transmission, or overlooked pathology might explain this remarkable discrepancy. If the muscle tension fails, i.e., no locking phenomenon happens, and the ligaments are put under abnormal constraints with a high risk of secondary rupture. Such constraints might also appear secondary to bony alteration or previous ligamentous weakening. Patient history allows to define the pathophysiology of the accident, examination will locate the points of maximal tenderness whereas radiology allows to detect malalignment, step-off or bony anomaly. To be valid, radiology must be standardized. Accordingly we describe the radiological techniques. Scintigraphy will show if the lesion is focal (mainly osseous) or not (dystrophy). Arthrography helps to find out which group of ligaments are torn, whereas arthroscopy will quantify the tears and find out additional chondromalacia or synovitis. Magnetic resonance imaging remains limited to vascular trouble shooting. We propose a diagnostic and therapeutical scheme that will help the physician in advising the patient.

In follow-up examinations of 112 patients who had been diagnosed as having a sprained foot, bony lesions, confirmed by X-ray films, were found in 96 (85.7%) patients. Up to this time the fractures had not been found in 58 of them. The fractures were found to be distributed in a point-specific location, i.e., a precisely defined anatomical area in 43 cases (44.8%) and a linear presentation in 53 (55.2%). This linear grouping of bony injuries is seen to develop along the path of joints, bones and ligamental insertions that anatomically follow one another in a functional manner. The line-like pattern to these presentation permitted us to develop 3 line sets that could be attributed to specific mechanisms of injury. The lateral line (56.6%) specially follows a supination sprain to the foot. The medial line (20.8%) is seen to follow injuries that involved a blow along the longitudinal axis. The transverse line (22.6%) follows trauma involving the Chopart joint. Six diagrams are presented to illustrate the mechanisms of foot trauma, with their vectors of force and the corresponding injuries that may result. Radiological examples of several clinical cases are given to demonstrate these three fracture lines.

In thermographic control studies of temperature profiles legs of 93 patients with a sprained ankle temperature phenomenon was observed, which super-imposes the hyperthermia due to inactivity. This complicates correct interpretation.

50 patients with complaints in the region of the sacroiliacal joints and the hip, but negative radiographs following injury to the pelvis were investigated by bone scan. Scintigraphic diagnosis always showed involvement of the pelvis ring other than the apparent fractures. Together with the clinical symptoms scintigraphic findings are interpreted as sacroiliacal strain or subluxation. Additional injuries to the acetabulum and to the lumbosacral joints may be present. The patients' complaints are explained, the injuries are localized and documented.

Radial-head subluxations were noted in 194 patients in the course of two years. It was more frequent in girls than boys (57.7% and 42.3%). The highest incidence was between the first and fourth year of life, with a peak in the first and second years. It no longer occurs after the seventh year. In 82.5% of cases the history was typical: a sudden longitudinal pull of the affected arm. In the remaining 17.5% no exact event could be ascertained. A questionnaire sent to the attending doctors provided replies in 82 cases (42.3%). Reposition by pull and pressure on the head of the radius, supination and acute flexing achieved repositioning in 92.7%, while in 7.3% repeat repositioning was necessary on the same or the next day. After successful repositioning complete absence of symptoms occurred in 98.8%. Incidence of recurrence was 30.5% during a follow-up period of up to a year and a half. The diagnosis had at first been had at first been missed 9.8% of cases.

Experimental tibial-plateau fractures had been produced to a series of 12 knee joints of corpses. The knee-joints had been exposed to vertical pressure in an extended position. The exerted pressure and the achieved deformation had been noted down in a diagram. The following radiological and morphological examination of the specimen showed that clear impressed fractured had arrived in case of a small deformation, whereas stronger compression had always caused combinated impression and split fractures. Impressions up to a depth of 3 to 5 mm cannot be proved radiologically. A certain unknown figure must be reckoned with in cases of distorsions of the knee-joint without a striking radiological finding. This will, however, hardly involve therapeutic consequences, because the carrying capacity of the tibial condyle will not be considerably reduced by such small impressions, and there is no fear of a further impression under load.

Injuries of the shoulder joint require exact diagnostic assessment. Soft tissue lesions which lead to instability of the joint must be recognized and treated adequately. Besides clinical and radiological examination, arthroscopy and sonography are becoming increasingly important. Acute sprain of the shoulder joint without instability is treated by a short immobilisation followed by active exercises, sprain (distorsion) with instability (dislocation!) may be treated by short immobilisation (two weeks) and early functional exercises or operatively by repair of a Bankart lesion, rupture of the rotatorcuff etc. A correlation between duration of immobilisation and subsequent recurrent dislocation has not be proven yet.