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Ankle injuries are a common reason for presentation to the pediatric emergency department. An understanding of the anatomy of the ankle joint, the mechanism of injury, and a thorough history and physical examination can help narrow the differential diagnosis. This article will discuss the management of common ankle injuries, including ankle sprains, dislocations, and pediatric fractures, including transitional triplane and Tillaux fractures. A brief review of the literature regarding radiographic evaluation of the ankle and various ankle rules is also discussed.

Injuries of the tarsometatarsal, or Lisfranc, joint are rarely seen. Lisfranc fractures and fracture dislocations are among the most frequently misdiagnosed foot injuries in the emergency department. A misdiagnosed injury may have severe consequences including chronic pain and loss of foot biomechanics. Evaluation of a foot injury should include a high level of suspicion of a Lisfranc injury, and a thorough work-up is needed for correct diagnosis.

Objective: To assess outcomes for different times to the first independent medical evaluation (IME) for work-related lumbosacral sprain., Methods: The 2005 West Virginia workers' compensation claims for "lumbosacral sprain" were used for our analyses. Outcomes included costs, maximal medical improvement status, number of IMEs performed, and the length of temporary total disability. Multiple logistic regression modeling was applied to determine the significance between the timing of first IME and these outcomes., Results: Patients with a first IME within 101 to 150 days after the injury had the best outcomes, measured by no repeat IMEs, appropriately reaching maximal medical improvement, and decreasing the temporary total disability length and related costs., Conclusions: Scheduling the first IME between 101 and 150 days after the injury contained indemnity costs, and shortened the length of disability.

Objectives: In the quest for a cost-effective and quality-preserving solution to manage crowding in the emergency department, the possibility of deploying regular emergency nurses for the treatment of acute ankle injuries was investigated. The aim of this study is to compare the diagnostic accuracy of emergency nurses with that of senior house officers in interpreting ankle and foot radiographs., Methods: A prospective study comparing the assessment of 60 radiographs (30 feet and 30 ankles) by 16 emergency nurses before and after an educational session was performed. Each subset of 30 radiographs contained 12 fractures, hand-picked by a radiologist to represent everyday traumatology in the emergency department. The control group consisted of eight senior house officers representing everyday expertise. The outcome of the diagnostic assessment, represented as the pooled sensitivity and specificity for both groups, was compared using Z-statistics., Results: Before the training session, the specialized emergency nurse group showed a sensitivity of 0.87 (confidence interval 0.83-0.91) compared with 0.93 (confidence interval 0.88-0.96) for the control group (P = 0.05). The specificity of specialized emergency nurses was 0.87 (confidence interval 0.81-0.92) compared with 0.93 (confidence interval 0.89-0.95) for the senior house officers (P < 0.05). After the training session, specialized emergency nurse diagnostic parameters did not differ significantly from the control group, displaying a sensitivity of 0.89 (confidence interval 0.86-0.92) and specificity of 0.92 (confidence interval 0.87-0.95)., Conclusion: Before the training session, the specialized emergency nurse group showed a significantly lower accuracy than the SHO group. After training, however, the diagnostic accuracy did not differ significantly between groups. Therefore, we conclude that emergency nurses are able to accurately interpret foot and ankle radiographs after a short educational session.

Study Design: This report describes a case of successful surgical treatment of eosinophilic granuloma of the atlas in a 3.5-year-old boy who presented with torticollis., Objective: The purpose of this report was to illustrate the rare clinical presentation of eosinophilic granuloma in the atlas., Summary of Background Data: Eosinophilic granuloma, a benign solitary lesion that commonly affects children, has a variable clinical course. Although eosinophilic granuloma has been reported to occur in the cervical spine, there have been only five reported cases of eosinophilic granuloma affecting the atlas. The management of eosinophilic granuloma ranges from observation and immobilization of the cervical spine to surgical excision., Methods: The tumor was located on the left lateral mass of the atlas. Biopsy and curettage were performed through an oblique incision through the posterior border of the sternocleidomastoid muscle. A histopathologic evaluation confirmed the diagnosis of eosinophilic granuloma., Results: The patient tolerated the procedure with no complications, and his torticollis has completely resolved., Conclusion: Eosinophilic granuloma of the atlas initially presented in this patient as torticollis. Biopsy for confirmation of diagnosis and curettage for treatment provided a successful outcome in this patient. We suggest biopsy of the lesion and histopathologic evaluation to confirm the diagnosis in atypical cases.

Objective: To investigate the predictive capacity of the West Haven-Yale Multidimensional Pain Inventory (MPI) with regard to prolonged pain, using car occupants who had sustained a neck sprain in a traffic accident., Design: A prospective cohort study including a one-year follow-up., Patients: One hundred thirty adults were examined by a specialized neck-injury team after a first visit to an accident and emergency department. The subjects answered the MPI questionnaire within one month of the accident., Outcome Measures: One year later, the patients answered a questionnaire about residual neck pain. The main outcome was determined by the question, "Do you have residual pain which you relate to the accident?", Results: One hundred twenty-three (95%) of the subjects completed the study. Ninety-seven reported pain of some degree that they related to the accident. All but one of the MPI variables differed significantly between the group with residual pain and the group without pain. The variable interference had the strongest correlation with the outcome. Its discriminative capacity was 81% for those with pain and 94% for those without pain one year later., Conclusions: The MPI may be used at an early stage to identify patients who may develop chronic neck-pain after a traffic accident, at least in those who want a follow-up session after an initial visit to an accident and emergency department.

Ganglion cysts of the knee are being reported more frequently secondary to an increased rate of magnetic resonance imaging studies. Although knee pain is the impetus for imaging, ganglion cysts are often incidental findings. Nonoperative treatment is a successful therapeutic option. We report a patient with variable pain presentations over the course of her treatment. The pattern of complaints pointed to different primary etiologies about the knee, but all were common to an interosseous ganglion cyst. A stepwise assessment and expansion of the differential diagnosis allowed for appropriate utilization of modalities and limited morbidity with nonoperative therapy.

We report a patient who had headache and neck pain after whiplash injury and subsequently developed cerebellar infarction due to vertebral artery dissection. This patient's pain was out of proportion to his apparent injury and it was a clue to the final diagnosis. Gross motor examination for cord injury may not be adequate for patients with minor neck trauma. Detailed cranial nerve and cerebellar examination should be performed for detection of circulatory insufficiency. Discharge advice for patients should also include that of stroke or transient ischaemic attack.

Ankle sprains are among the most common injuries sustained by athletes and seen by sports medicine physicians. Despite their prevalence in society, ankle sprains still remain a difficult diagnostic and therapeutic challenge in the athlete, as well as in society in general. The purpose of this section of our two-part study is to review scope of the problem, the anatomy and biomechanics of the lateral ankle ligaments, review the pathoanatomical correlates of lateral ankle sprains, the histopathogenesis of ligament healing, and define the mechanisms of injury to understand the basis of our diagnostic approach to the patient with this common acute and chronic injury. We extensively review the diagnostic evaluation including historical information and physical examination, as well as options for supplementary radiographic examination. We further discuss the differential diagnosis of the patient with recurrent instability symptoms. This will also serve as the foundation for part two of our study, which is to understand the rationale for our treatment approach for this common problem.

Study Design: An analysis of the change in strain distribution of intervertebral discs present after anterior cervical decompression and fusion by an original method. The analytical results were compared to occurrence of herniation of the intervertebral disc on magnetic resonance imaging., Objectives: To elucidate the influence of anterior cervical decompression and fusion on the unfused segments of the spine., Summary of Background Data: There is no consensus regarding the exact significance of the biomechanical change in the unfused segment present after surgery., Methods: Ninety-six patients subjected to anterior cervical decompression and fusion for herniation of intervertebral discs were examined. Shear strain and longitudinal strain of intervertebral discs were analyzed on pre- and postoperative lateral dynamic routine radiography of the cervical spine. Thirty of the 96 patients were examined by magnetic resonance imaging before and after surgery, and the relation between alteration in strains and postsurgical occurrence of disc herniation was examined., Results: In the cases of double- or triple-level fusion, shear strain of adjacent segments had increased 20% on average 1 year after surgery. Thirteen intervertebral discs that had an abnormally high degree of strain showed an increase in longitudinal strain after surgery. Eleven (85%) of the 13 discs that showed an abnormal increase in longitudinal strain had herniation in the same intervertebral discs with compression of the spinal cord during the follow-up period. Relief of symptoms was significantly poor in the patients with recent herniation., Conclusions: Close attention should be paid to long-term biomechanical changes in the unfused segment.

The acromioclavicular joint is commonly involved in athletic injuries. Most commonly, a sprain to the joint occurs with variability in the amount of ligamentous damage and displacement that occurs. In all but the most severe dislocations, treatment consists of initial sling immobilization and early functional rehabilitation. The outcome is usually excellent with full return of function following these injuries. The rarer types (IV, V, and VI) require operative reduction and fixation. Distal clavicle fractures are related injuries, which many times disrupt the stabilizing ligaments of the acromioclavicular joint. Many can be treated nonoperatively, but there are several subtypes that should be considered for early fixation to reduce complications of pain and shoulder dysfunction. An atraumatic, overuse condition, which is becoming more prevalent and seems related to weight training, is osteolysis of the distal clavicle. There is insidious onset of shoulder pain with symptoms and signs consistent with acromioclavicular pathology. Activity modification is the best method of controlling symptoms. Failure of the conservative approach necessitates operative excision of the distal clavicle.

Purpose: Our goal was to evaluate the visibility and incidence of traumatic abnormalities of the sinus tarsi in patients with acute ankle sprain injuries and compare these findings with the extent of lateral ankle ligament injuries on MRI., Method: Sixty athletically active patients (aged 18-45 years) with recent inversion trauma (< or = 7 days) underwent MRI. Replacement of fat tissue in the sinus tarsi was recorded. Inter/intraobserver agreement was calculated (kappa-statistics). Injuries of the three lateral ligaments, evaluated by MRI, were graded according to partial (1 point) or complete (2 points) tears for each of three lateral ligaments (together 0-6 points) and were compared with sinus tarsi abnormalities., Results: In 26 patients (43%), replacement of sinus tarsi fat tissue was depicted by MRI. Inter/intraobserver agreement for MR changes of the sinus tarsi was good to moderate (kappa = 0.675/0.584). Grade of lateral ankle ligament injury showed a statistically significant difference (p = 0.033) between the two sinus tarsi groups (normal/abnormal)., Conclusion: Acute ankle sprain injuries, evaluated by MRI, are associated with acute abnormalities of the sinus tarsi in 43% of patients and correlate with the extent of lateral ankle ligament tears.

Objective: We sought to define the MRI appearance of both complete and partial-thickness tears of the posterior cruciate ligament (PCL) and to describe patterns of injury and associated MRI findings., Materials and Methods: Three radiologists retrospectively reviewed MR images and medical records on 32 patients with PCL tears (15 complete, 17 partial) and correlated MRI findings to results of clinical testing and surgery., Results: The PCL had indistinct margins in 27 (84%) of 32 patients and was abnormally thick in 25 (78%) patients. In 31 (97%) patients, the torn PCL showed increased signal intensity on both T1- and T2-weighted pulse sequences. Although there was no statistically significant difference between patients with complete tears and those with partial tears with regard to thickness, margination, and signal intensity of the PCL, MR images in patients with complete tears were more likely to show focal areas of ligamentous discontinuity (10 of 15 cases) (p = 0.01). Associated knee injuries were seen in 21 (66%) patients and were seen more frequently in patients with complete PCL tears (p = 0.015). Bony injury (n = 11, 34%) and tears of the medial collateral ligament (n = 13, 41%) and menisci (n = 10, 31%) were common. No specific pattern of bony injury was found., Conclusion: Posterior cruciate ligament tears can be diagnosed readily by multiplanar MRI using both morphological and signal intensity characteristics. Although differentiation between complete and partial-thickness PCL tears by MRI criteria alone is more problematic, complete tears are more likely to show focal areas of discontinuity and partial tears are more likely to show at least some intact fibers.

Objective: The purpose of our study was to evaluate (a) the characteristics of muscle strain injuries on MRI and (b) the potential of a frequency-selective fat suppression technique for diagnosing such injuries., Materials and Methods: Muscle strain injuries in seven athletes were examined by MRI. Spin echo sequences were obtained with and without fat suppression sequences. The absolute values of the contrast-to-noise (C/N) ratios for lesion versus muscle or fat were then compared for both types of images., Results: We obtained two types of characteristic findings for muscle strain. Lesions of the fascia and adjacent muscles showed a characteristic spray-like or fan-like appearance, extending longitudinally from a shared tendon to the muscle belly in five athletes. This finding was better displayed on coronal images. In contrast, lesions inside a muscle showed a diffuse and inhomogeneous appearance in two athletes. The absolute C/N ratios for lesion versus fat and lesion versus muscle were not significantly different for images with and without fat suppression according to the sign test. However, fat-suppressed images revealed subtle abnormalities that were not seen on conventional images., Conclusion: Magnetic resonance can provide detailed information on muscle strain injuries, especially when coronal fat-suppressed images are obtained.

We evaluated the ability of opposed-phase T2*-weighted gradient-echo (T2*GE) MRI to demarcate soft tissue lesions. The series contained 37 cases, including 18 benign tumors, 8 malignant tumors, and 11 miscellaneous nonneoplastic soft-tissue lesions. Images were obtained on a 0.5 T magnet with T2*GE imaging (TR/TE 300/22 ms, 20 degrees). Results were compared with those of T1-weighted SE images (500/20-40) and T2-weighted SE (T2SE) images (2,000/80). The T2*GE images were similar to T2SE images with respect to the signal behavior and internal architecture of the masses in many cases. In some instances, they were better than T2SE images in delineating the lesions and adjacent fat tissue, in delineating the lesions and adjacent small vessels, and in depicting special features such as hemosiderin deposits. They were inferior to T2SE images in delineating the lesions and adjacent muscles. Because of reduced lesion-muscle delineation, T2*GE images can not be substituted for T2SE images in the evaluation of soft-tissue lesions, but are useful as an adjunct in some cases.

We retrospectively evaluated the lateral collateral ligamentous complex of 43 patients who had complained of ankle pain following ankle sprain. The MR signs of ligamentous abnormality included discontinuity or absence, increased signal within the ligament, and ligamentous irregularity or waviness with normal thickness and signal intensity. Using these criteria, 30 anterior talofibular, 20 calcaneofibular, and no posterior talofibular ligament injuries were diagnosed. Compared with surgery (nine patients), MRI demonstrated six of seven anterior talofibular ligament injuries and six of six calcaneofibular ligament injuries. Magnetic resonance showed ligamentous abnormalities in 12 of 23 cases with normal stress radiography. Magnetic resonance imaging provides useful information for the evaluation of patients presenting with chronic pain after ankle sprain.

Indirect or strain injury to muscle is a common cause of athletic disability. Strain injuries often occur during powerful muscle eccentric contractions. Clinical studies suggest that most injuries cause partial disruption of certain characteristic muscles. Diagnostic imaging studies can demonstrate the location of many injuries. Laboratory studies show that partial and complete injuries exhibit disruption of muscle fibers near the muscle-tendon junction. Healing of partial injuries is characterized by an initial inflammatory response followed by a healing phase marked by fibrosis. Biomechanical studies show that muscle failure occurs at forces much larger than maximal isometric force, and stretch is necessary to create injury. Compared to the passively stretched muscle, muscle activated by nerve contraction and stretched to failure attains a small increase in force at failure, no change in strain to failure, and a large increase in energy absorbed prior to failure. These studies emphasize the ability of muscles to function as energy absorbers in preventing injury to themselves and to bones and joints. Experimental muscle stretching protocols show significant stress relaxation and reduction of stiffness in muscle due to inherent viscoelastic properties of muscle rather than to reflex-mediated effects. These viscoelastic properties may be useful in understanding how muscle injury might be prevented.

The purpose of this study was to determine whether surface electromyography (EMG) from the erector spinae muscles could correctly identify individuals with low back pain without a population of elite athletes. A similar technique had previously been successful in identifying low back pain patients within a non-athletic population. A Back Analysis System was used to compute the median frequency of the EMG power density spectrum to monitor metabolic changes in back muscles associated with muscle fatigue. Twenty-three members of a men's collegiate varsity crew team consisting of port (N = 13) and starboard (N = 10) rowers were tested in a laboratory during a fatigue-inducing isometric contraction sustained at a relatively high, constant force. Six of the rowers tested were further classified as having low back pain. A brief test contraction was repeated at a fixed interval following the fatiguing contraction to monitor recovery. A two-group discriminant analysis procedure correctly classified 100% of the rowers with low back pain and 93% of the rowers without back pain on the basis of the median frequency data. The median frequency parameters related to recovery were the best discriminators of back pain. A similar analysis correctly classified 100% of the port rowers and 100% of the starboard rowers on the basis of their spectral parameters. The best discriminating variables in this instance were the median frequency parameters relating to both fatigability and recovery. Results from this study demonstrate that low back pain and asymmetrical muscle function in rowers can be assessed on the basis of EMG spectral analysis.

The hand is the most commonly injured part in sport. Fortunately, most injuries are minor and do not interfere with the sport participation, but even these leave residual functional deficits that may increase with time. More severe injuries of the hand are appreciated instantly by the player and health care personnel and generally receive better care. The goal is to maintain the best functioning hands now for the sport and in the future for the life's work of the hand. A program is herein described outlining the care of minor and major sports injuries to the hand that tries to return the injured player quickly to the sport participation while not jeopardizing the future. Because injuries to this most important tool are so frequent, it is recommended that a lecture be given to each sport group prior to the season to describe and raise the awareness of the players regarding hand and finger injury.

The authors have previously reported myalgic hyperalgesia as a useful localizing sign in "low-back sprain" patients with no physical findings. This paper describes some other subtle signs related to the phenomenon of denervation supersensitivity which is well known to physiologists and clinicians involved in peripheral nerve disease, yet its related signs have not been applied to low-back pain. Following denervation of some neurons, muscle and peripheral receptors become supersensitive to transmitter substances and to different forms of stimuli. Since the peripheral nerve is a mixed nerve, findings are multiphasic and include autonomic dysfunction, trophic changes, cutaneous and myalgic hyperalgesia, and increased muscle tone. One or more of these signs occurred in 30 patients with secondary low-back pain but less often in 30 patients with primary or mechanical low-back pain; their presence, though slight, in asymptomatic controls may identify those individuals with a vulnerable back.

A strain, by definition, is a stretching or tearing of a musculotendinous unit. The degree of disability associated with this injury is dictated by the location and severity of the injury and the specific needs of the patient. A strain can be arbitrarily classified as first, second, or third degree. A first-degree strain consists of minimal stretching of the musculotendinous unit without permanent injury; a second-degree strain indicates partial tearing of the musculotendinous unit; and a third-degree strain indicates complete disruption of a portion of this unit. Swelling, bleeding, and localized discomfort accompany the injury which may produce temporary disability. Initial treatment following an acute strain should consist of the use of ice, immobilization of the musculotendinous unit, and subsequent rehabilitation. Depending on the degree of disability and the specific structure injured, surgery may be indicated. Rehabilitation to a normal state following the initial healing phase is required prior to return to athletic competition.

We report the first series of proximal interphalangeal joint sprains and reviewed 50 sprains in 48 patients. The majority of patients were males injured at work. The radial collateral ligament was injured about twice as often as the ulnar ligaments. The little finger was injured significantly less than the others. Proximal interphalangeal joint sprains can be diagnosed by the following: pain localized to the injured ligament, swelling greatest at the site of the injured ligament, tenderness greatest at the site of the injured ligament, pain at the site of the injured ligament during lateral stress, and/or mild lateral instability on radiographs or physical examination during stress testing. All patients required several different splints for treatment; in decreasing frequency, we used immobilizing, coupling, dynamic proximal interphalangeal flexion, dynamic proximal interphalangeal and distal interphalangeal flexion, and dynamic proximal interphalangeal extension splints. The mean active range of motion before treatment was 70 degrees and after treatment was 95 degrees. Significantly more patients had loss of full extension than had loss of full flexion. Forty-six percent of the patients had no pain after treatment, 46 percent had mild pain, 8 percent had moderate pain, and none had severe pain. Patients treated within 4 weeks of their injury (group 1) gained significantly greater range of motion (35 degrees) than those treated between 5 and 14 weeks after their injury (10 degrees) (group 2).(ABSTRACT TRUNCATED AT 250 WORDS)