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Background: Nurse practitioners (NPs) in the Emergency Department (ED) have been trained to assess a range of clinical problems and minor complaints such as acute ankle injury. This study compared assessment of suspected ankle and foot injuries using the Ottawa Ankle Rules (OAR) by NPs and ED medical doctors (ED-Drs)., Methods: A prospective, comparative, observational study was undertaken in an Australian acute adult and paediatric urban district ED. NPs and ED-Drs recorded information for patients with acute ankle and/or mid-foot injuries on demographic characteristics, OAR features, use of X-ray and patient management. Outcome measures included X-ray rates and identification of fracture., Results: 174 patients were included in this study: 51 received NP and 123 received ED-Dr care. Assessed as requiring X-ray assessment (NP: 78.4%, ED-Dr: 88.6%; p=0.081), and detection of significant fracture (NP: 17.6%, ED-Dr: 22.8%; p=0.453) were similar. ED-based medical registrars were more likely to miss a fracture compared with NP (NP: 0%, ED-based Registrar: 28.6%, p=0.013). There were no significant differences in rates of OAR features for patients seen by NPs or ED-Drs., Conclusion: This study suggests that NPs are less likely to miss significant fractures of the ankle and/or foot compared with ED-based medical registrars. Future research should focus on actual use of the OAR and accuracy of X-ray assessment by NPs., (Copyright © 2013 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.)

Foot and ankle injuries are common in sport. Although many available imaging techniques can be useful in identifying and classifying injuries, magnetic resonance imaging (MRI) provides high levels of sensitivity and specificity for articular and soft-tissue injuries. Arthroscopic and minimally invasive treatment techniques for foot and ankle injuries are rapidly evolving, minimizing morbidity and improving postoperative rehabilitation and return to play. Correlation between MRI and surgical findings can aid in both accessing and treating pathologic processes and structures., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Minimalist running shoes are becoming a more popular choice for runners in the past few years. However, there is little conclusive evidence about the advantages or disadvantages of running in these shoes. Although performance benefits may exist, injury may also occur from the added stress of running without the benefit of cushioning under the foot. Bone marrow edema can be a manifestation of added stress on the foot. This study measured bone marrow edema in runners' feet before and after a 10-wk period of transitioning from traditional to minimalist running shoes., Methods: Thirty-six experienced recreational runners underwent magnetic resonance imaging (MRI) before and after a 10-wk period. Seventeen subjects were in the control group (ran in their traditional shoes only for 10 wk), whereas the other 19 were in the experimental group (gradually transitioned to Vibram FiveFinger running shoes for 10 wk). The severity of the bone marrow edema was scored on a range of 0-4 (0 = no bone marrow edema, 4 = edema in more than 50% of the length of the bone). A score of 4 represented a stress fracture., Results: Pretraining MRI scores were not statistically different between the groups. The posttraining MRI scores showed that more subjects in the Vibram group (10 of 19) showed increases in bone marrow edema in at least one bone after 10 wk of running than that in the control group (P = 0.009)., Conclusion: Runners interested in transitioning to minimalist running shoes, such as Vibram FiveFingers, should transition very slowly and gradually to avoid potential stress injury in the foot.

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

The purpose of this foot and ankle update is to educate the reader on important foot and ankle topics including current controversies, physical examination, diagnostics, and management. Quick-view lists are used to give easy access to the most significant knowledge points for providing patient care for these entities. These topics were chosen either because they are very common or because of the high morbidity involved should there be a misdiagnosis or mismanagement., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Stress reactions and stress fractures are defined as structural damage to bone caused by repetitive stress or stereotypical loading. The balance between loading and unloading of bone is disrupted in stress reactions and stress fractures through the sport-specific demands and by the exogenous or endogenous risk factors present. In sports orthopedics the localization of stress reactions and stress fractures are subdivided into high risk fractures and low risk fractures. Conventional diagnostic radiology can initially be inconclusive. With symptoms persisting over 2 weeks further diagnostics using magnetic resonance imaging (MRI) should be performed. In the area of the foot stress reactions and stress fractures can often occur bilaterally or multifocally and most commonly affect the second metatarsals followed by the third metatarsals. Fractures of the fifth metatarsal, second metatarsal base, medial malleolus as well as navicular and sesamoid fractures are high risk fractures requiring special clinical and radiological monitoring. Basically, conservative treatment using the 2-phase model is the treatment of choice. In delayed union or severe pain surgical treatment is indicated.

Although Lisfranc injuries are uncommon, prompt and accurate diagnosis of such injuries in athletes is essential in preventing career-ending injury. Undisplaced injuries have an excellent result with nonoperative treatment. The presence of any displacement warrants open reduction and anatomic fixation; although current evidence mostly supports screw fixation, plate fixation may avoid joint intrusion. It is imperative to warn athletes with significantly displaced injuries that there is a risk of a poor outcome, although some recent evidence suggests that return to elite competitive sports is still likely after surgical intervention. Severe injuries may have better outcomes with limited arthrodesis., (Copyright © 2013 Elsevier Inc. All rights reserved.)

This update summarizes recent research pertaining to orthopaedic foot and ankle surgery that was published or presented between August 2011 and July 2012. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes); Foot and Ankle International; and the proceedings of Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), on February 11, 2012, in San Francisco, California, and the summer meeting of the American Orthopaedic Foot & Ankle Society (AOFAS), on June 20 through 23, 2012, in San Diego, California.

Sports ankle injuries are very common worldwide. In the United States, it is estimated that 2 million acute ankle sprains occur each year, averaging to $318 to $914 per sprain. Magnetic resonance imaging is excellent for depicting normal ankle anatomy and can elegantly demonstrate ligamentous injuries of the ankle and associated conditions after ankle sprain. This article encompasses epidemiology, biomechanics, normal anatomy, and pathologic conditions of the ankle and foot ligaments. The specific ligaments discussed include the syndesmotic ligaments, lateral ligament complex of the ankle, deltoid ligament, spring ligament, ligaments of the sinus tarsi, and the Lisfranc ligament., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Forefoot and midfoot injuries are relatively common and can lead to chronic disability, especially if they are not promptly diagnosed and appropriately treated. A focused history and physical examination must be coupled with a thorough review of imaging studies to identify the correct diagnosis. Subtle radiographic changes can represent significant ligamentous Lisfranc injury. Midfoot swelling in the presence of plantar ecchymosis should be considered to be a Lisfranc injury until proven otherwise. While most metatarsal fractures can be treated with some form of immobilization and protected weight-bearing, this article will distinguish these more common injuries from those requiring surgical intervention. We will review relevant anatomy and biomechanics, mechanisms of injury, clinical presentation, imaging studies, and diagnostic techniques and treatment.

Purpose: To determine prevalence of heel strike in a midsize city marathon, if there is an association between foot-strike classification and race performance, and if there is an association between foot-strike classification and gender., Methods: Foot-strike classification (forefoot, midfoot, heel, or split strike), gender, and rank (position in race) were recorded at the 8.1-km mark for 2112 runners at the 2011 Milwaukee Lakefront Marathon., Results: 1991 runners were classified by foot-strike pattern, revealing a heel-strike prevalence of 93.67% (n = 1865). A significant difference between foot-strike classification and performance was found using a Kruskal-Wallis test (P < .0001), with more elite performers being less likely to heel strike. No significant difference between foot-strike classification and gender was found using a Fisher exact test. In addition, subgroup analysis of the 126 non-heel strikers found no significant difference between shoe wear and performance using a Kruskal-Wallis test., Conclusions: The high prevalence of heel striking observed in this study reflects the foot-strike pattern of most mid-distance to long-distance runners and, more important, may predict their injury profile based on the biomechanics of a heel-strike running pattern. This knowledge can help clinicians appropriately diagnose, manage, and train modifications of injured runners.

Unlabelled: Reconstruction of the foot's distal portion has always been a difficult problem in plastic surgery. Moreover, isolated soft tissue defects of the hallux are not common in daily practice. In the case of tissue loss over the hallux, it is common practice to treat the soft tissue defect conservatively or to apply a skin graft. But the loss of tissue leaves a shortened, hypersensitive, and deformed toe. A method for reconstruction of a soft tissue defect on the tip of the hallux by means of a pedicled heterodigital artery flap from the second toe is presented, and alternative flap choices for this challenging area of the distal foot are discussed. To the best of the authors' knowledge, this surgical approach for reconstruction of hallux tip defects has not been reported previously., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Complex foot and ankle fractures, such as calcaneum fractures or Lisfranc dislocations, are often associated with a poor outcome, especially in terms of gait capacity. Indeed, degenerative changes often lead to chronic pain and chronic functional limitations. Prescription footwear represents an important therapeutic tool during the rehabilitation process. Local Dynamic Stability (LDS) is the ability of locomotor system to maintain continuous walking by accommodating small perturbations that occur naturally during walking. Because it reflects the degree of control over the gait, LDS has been advocated as a relevant indicator for evaluating different conditions and pathologies. The aim of this study was to analyze changes in LDS induced by orthopaedic shoes in patients with persistent foot and ankle injuries. We hypothesised that footwear adaptation might help patients to improve gait control, which could lead to higher LDS:, Methods: Twenty-five middle-aged inpatients (5 females, 20 males) participated in the study. They were treated for chronic post-traumatic disabilities following ankle and/or foot fractures in a Swiss rehabilitation clinic. During their stay, included inpatients received orthopaedic shoes with custom-made orthoses (insoles). They performed two 30s walking trials with standard shoes and two 30s trials with orthopaedic shoes. A triaxial motion sensor recorded 3D accelerations at the lower back level. LDS was assessed by computing divergence exponents in the acceleration signals (maximal Lyapunov exponents). Pain was evaluated with Visual Analogue Scale (VAS). LDS and pain differences between the trials with standard shoes and the trials with orthopaedic shoes were assessed., Results: Orthopaedic shoes significantly improved LDS in the three axes (medio-lateral: 10% relative change, paired t-test p < 0.001; vertical: 9%, p = 0.03; antero-posterior: 7%, p = 0.04). A significant decrease in pain level (VAS score -29%) was observed., Conclusions: Footwear adaptation led to pain relief and to improved foot & ankle proprioception. It is likely that that enhancement allows patients to better control foot placement. As a result, higher dynamic stability has been observed. LDS seems therefore a valuable index that could be used in early evaluation of footwear outcome in clinical settings.

Severe traumatic bone and soft-tissue defects are often treated by lower leg amputation. The amputation level becomes a very important factor with respect to the patient's basic daily activities. We report the case of a 51-year-old man who was referred to us with severe traumatic metatarsal bone and dorsum pedis skin and soft-tissue defects. To avoid amputation, a free fibular osteomyocutaneous flap incorporating the soleus muscle was used to reconstruct the second and third metatarsal bones and the soft-tissue defect, respectively. Now, 2 years after the procedure, the patient is able to walk independently. To the best of our knowledge, this is the first report of use of such a composite transfer for a complex midfoot defect., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The running portion of the triathlon represents the final leg of the competition and, by some reports, the most important part in determining a triathlete's overall success. Although most triathletes spend most of their training time on cycling, running injuries are the most common injuries encountered. Common causes of running injuries include overuse, lack of rest, and activities that aggravate biomechanical predisposers of specific injuries. We discuss the running-associated injuries in the hip, knee, lower leg, ankle, and foot of the triathlete, and the causes, presentation, evaluation, and treatment of each.

A young farmer presented with cardiogenic shock 5 days after a scorpion sting. He was managed with norepinephrine, atropine and supportive measures and made a complete recovery. The role of atropine in treating scorpion sting has to be defined better.

The calcaneonavicular ligament lesion may be single or related to posterior tibial tendon involvement; the clinical and image-based diagnosis is difficult, without pathognomonic signs. The diagnosis is made during surgery and the calcaneonavicular ligament should always be explored whenever the posterior tibial tendon is involved., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The objective of the present study was to assess the utility of magnetic resonance imaging in evaluating injury to the plantar plate and to determine whether conventional low-field magnetic resonance imaging is a valid tool for diagnostic evaluation. Magnetic resonance imaging scans of 45 feet in 41 patients (38 females and 3 males, with an average age of 52.1 years) were prospectively evaluated to assess the integrity of the plantar plate ligament and compared with a reference standard of intraoperative findings. The concordance of tear severity observed on magnetic resonance imaging with the intraoperative findings was also assessed using a newly proposed grading scheme for plantar plate injuries. Intraoperatively, 41 plantar plate tears and 4 intact ligaments were found. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value was 96%, 95%, 100%, 100%, and 67%, respectively. The clinical diagnosis of plantar plate injury was also highly accurate in our study population (41/45, 91%). Finally, we observed moderate concordance between the magnetic resonance imaging grade and surgical grade of plantar plate tear (28/45, 62%), with greater concordance occurring at higher grades. Our results have demonstrated that magnetic resonance imaging is an accurate and valid test for the diagnosing injuries of the plantar plate ligament. Given the high accuracy of the clinical findings, magnetic resonance imaging is most useful when the decision to operate will be sufficiently influenced by either a normal magnetic resonance imaging appearance of the plantar plate or the presence of a high-grade tear., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Plantar plate rupture is a common cause of forefoot pain, multiplanar malalignment, subluxation, or dislocation of the metatarsophalangeal joint (MTPJ). The treatments that have been described for MTPJ instability of lesser toes include amputation, lengthening and/or tendon transfer, periarticular soft-tissue release (capsule, collateral ligaments, and plantar plate), colateral ligament reconstruction, metatarsal shortening osteotomy, and suture of plantar plate lesion. This article outlines the anatomy, pathogenesis, and diagnosis of plantar plate rupture, and describes a new technique that combines joint decompression by Weil osteotomy with a plantar plate repair using a pull-out technique., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: This article selectively reviews several areas in which imaging can play a major role in the diagnosis and treatment of sports injuries of the foot., Conclusion: Diagnostic imaging provides useful evaluation of capsuloligamentous sports injuries and Morton neuroma in the foot and facilitates appropriate treatment. An understanding of the relevant anatomy, normal imaging appearance, and the spectrum of imaging findings in the setting of injury is important for the practicing radiologist.

In the present case report, we describe the surgical repair of a complete laceration of the anterior tibial tendon using acellular human dermal tissue matrix. A 17-year-old, elite league hockey player was injured in the locker room when a teammate still clad in ice skates stepped on his bare left foot. After evaluation at a local emergency department, the patient presented to our office the next day for additional evaluation. It was determined that surgery would be performed using acellular tissue graft augmentation, followed by physical therapy. Within 7 weeks of the injury, the athlete returned to his original level of activity. At 3 years of follow-up, he was playing Division 1 hockey at the university level. We believe that augmentation of the tendon repair with the grafting material enhanced the tendon tensile strength and promoted ingrowth through vascular channels. This, combined with the patient's dedication to physical therapy, led to excellent recovery in less time than anticipated., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Few studies have evaluated the incidence of talar dome lesions and injuries to the peroneal tendons occurring concomitantly. The purpose of our research was to evaluate the incidence of osteochondral lesions of the talus (OLT) with peroneal tendon pathologic features according to the magnetic resonance imaging (MRI) findings. A database search was conducted in the Department of Radiology at the Western Pennsylvania Hospital and Forbes Regional Campus for all MRI examinations ordered by attending physicians of the Department of Foot and Ankle Surgery from 2008 to 2010. A total of 810 MRI reports were reviewed, of which 198 contained a diagnosis of peroneal tendon pathologic features (e.g., tenosynovitis, split tears) or OLT (i.e., chondral, osteochondral, subchondral edema, cystic changes), or both. MRI scans were then reviewed to confirm the report findings and findings not identified in the report. A total of 76 patients were identified as having an OLT. Of these 76 patients, 49 had associated peroneal tendon pathologic features. MRI evaluation revealed that 49 (65.3%) of the 76 patients with a talar dome lesion had concomitant peroneal pathologic features. Talar dome lesions with concomitant tears/tendinopathy of the peroneus brevis were associated in 14.6%. The incidence of an OLT with tears/tenosynovitis of the peroneus longus was 10.6%, because tears/tendinopathy of both peroneal tendons was present in 18.6%. Tenosynovitis of the brevis and longus were seen in 21.3% of those with an OLT. Our findings suggest the need for an increased level of suspicion for injuries to the lateral ankle ligaments, peroneal tendon complex, and ankle joint when evaluating a patient with ankle instability and chronic pain., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The results achieved with this technique after a mean follow-up of 8 years (85% excellent and good results) allow neoligamentplasty to be considered as a viable alternative to the classic procedures in the treatment of subtle intercuneiform and tarsometatarsal joint lesions., (Copyright © 2012 Elsevier Inc. All rights reserved.)

This article is centred around the similarities and highlights some differences between a sports injury compared with any other injury profile. The authors use a musculoskeletal assessment, diagnosis and management of an injury based on a particular case study. The intention is to highlight how problems may be masqueraded in the history and perception of the injured athlete and how this perception may have complicated the injury and the rehabilitation process. This issue generates a renewed awareness for all primary care nurses and health practitioners who may be involved in treatment pathways for associated injuries related to sports medicine problems. The article gives an insight into peroneal dislocation/subluxation, but primarily focuses on peroneal tendonitis/tendonosis. The management of the injury briefly touches on the associated benefits (and risks) of barefoot running and its role in the prevention of sporting injuries. This article illustrates how the frustration of a chronic injury can lead to the athlete making ill-informed decisions and highlights the need for a thorough assessment and an evidence-based management plan that is negotiated with the athlete.

A reconstructive technique and physical therapy protocol is presented for the treatment of extensor hallucis longus (EHL) lacerations with critical size defects caused by tendon retraction. The primary goal of treatment was to restore EHL structure and function without the use of a bridging allograft or tendon transfer. The technique is performed by split lengthening the distal segment of the lacerated EHL and rotating the lengthened segment proximally 180° to bridge the tendon defect. The lengthened tendon is then sutured to the proximal segment of the EHL. The EHL is then tubularized with an acellular dermal scaffold at the region of tendon rotation to improve tendon strength, minimize the probability of tendon overlengthening or re-rupture, and improve the tendon gliding motion, which can be compromised by the tendon irregularity caused by rotation of the tendon. Postoperative range of motion therapy should be initiated at 3 weeks postoperatively. A case report of this technique and postoperative mobilization protocol is presented. The American Orthopaedic Foot and Ankle Society midfoot score at 3 and 6 months postoperatively was 90 of 100. The patient regained active dorsiflexion motion of the hallux without functional limitations, deformity, or contracture of the hallux. The advantages of this technique include that a large cadaveric allograft is not needed to bridge a critical size tendon defect and tendon lengthening provides a biologically active tendon graft without the secondary comorbidities and dysfunction commonly associated with tendon transfer procedures., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Puncture wounds of the foot are a common injury, and infection associated with these injuries may result in considerable morbidity. The pathophysiology and management of a puncture wound is dependent on the material that punctures the foot, the location and depth of the wound, time to presentation, footwear, and underlying health status of the patient. Puncture wounds should not be treated lightly, so accurate diagnosis, assessment, and treatment are paramount. Early incision and drainage, vaccination, and the use of proper antibiotics can lead to positive outcomes and prevent limb-threatening circumstances., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The true incidence and primary predictors of foot compartment syndrome remain controversial. Our aim was to better define the overall incidence of foot compartment syndrome in relation to the frequency and location of various foot injuries. We hypothesized that (1) the incidence would increase in proportion to the number of anatomic locations of injury, (2) the incidence would be higher in association with hindfoot and crush injuries compared with any other injury categories, and (3) not only would the incidence associated with calcaneal fractures be lower than the often quoted 10% but foot compartment syndrome would also be fairly uncommon after such fractures., Methods: The National Trauma Data Bank was used to identify patients who had undergone a fasciotomy for the treatment of isolated foot compartment syndrome. Strict inclusion and exclusion criteria were used to identify only patients with foot injuries who had undergone fasciotomy for foot compartment syndrome., Results: Three hundred and sixty-four patients with an isolated foot compartment syndrome were identified. The highest incidence of foot compartment syndrome was seen in association with a crush mechanism combined with a forefoot injury (18%, nineteen of 106), followed by an isolated crush injury (14%, twenty-three of 162). Only 1% (thirty-two) of 2481 patients with an isolated calcaneal fracture underwent fasciotomy. An increase in the number of anatomic locations of injury did not appear to correspond to an increased incidence of foot compartment syndrome., Conclusion: Our results demonstrate that injuries involving a crush mechanism, either in isolation or in combination with a forefoot injury, should raise suspicion about the possibility that a foot compartment syndrome will develop.

Excessive or prolonged foot pronation has been linked to the development of numerous overuse injuries affecting the lower limb. The originally proposed pathomechanical model suggests foot motion affects more proximal structures through disruption of distal to proximal coupling between the foot, tibia, femur, and hip. Research evidence supports the presence of a dynamic coupling mechanism between lower limb segments, however, the direction of the coupling is inconclusive. Recent prospective investigations of the role of the lumbo-pelvic hip complex have identified a strong association between proximal dysfunction and increased risk of lower limb injuries. Strength of muscles of the lumbo-pelvic hip complex (core muscles) is suggested to be essential to controlling hip abduction, subsequent internal rotation of the femur and potentially more distal movement. Proximal muscle weakness and altered motor control have also been implicated in the development of numerous lower limb injuries, many of which have previously been attributed to excessive foot pronation. This review discusses the theoretical basis for the role of proximal and distal structures in biomechanical dysfunction of the lower limb and the development of lower limb overuse injury. Current prospective evidence relating to the contributions of excessive foot pronation and core muscle function to the development of lower extremity injury is evaluated., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Musculoskeletal injury as a result of seizure activity is not uncommon, posterior shoulder dislocation being a well-described example. In this report, we describe what we believe to be the first published case of bilateral talar avulsion fractures secondary to seizure., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Ruptures of the peroneus longus tendon are uncommon, with a small number of case reports found in published studies. The presence of an os peroneum can predispose the peroneus longus tendon to rupture at the cuboid level with or without concomitant fracture, or fracture through a partite os peroneum. Whether the os peroneum can be represented by various stages of ossification is still a matter of debate. We present 2 cases of acute peroneus longus tendon rupture at the cuboid notch in the presence of an intact os peroneum in the ossified and nonossified form. We treated patients with excision of the os peroneum and tenodesis of the peroneus longus to the peroneus brevis tendon., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Children represent 30% of all burn cases seen by accident and emergency physicians in the UK every year, with toddlers being most at risk within this age group. With the emergence of walking autonomy, the need for constant supervision is sometimes not enough to prevent this type of injury from happening. However, in remembering the importance of children's health and safety, non-accidental injury is always to remain a differential diagnosis. The authors review a paediatric burns case underlying the importance of keeping an open mind to allow a proper clinical diagnosis to be formed.

Brodie abscess is a subacute localized osteomyelitis with a presenting report of intermittent pain of long duration. In this article, we report a case of talus Brodie abscess with tenosynovitis of posterior tibialis and long flexor tendons of the foot. We describe the radiologic and diagnostic features of this osteomyelitis and outline its management and prognosis. To our knowledge, this is the first report of such a case with this unusual presentation.

The purpose of this article is to discuss the features of Lisfranc injuries and identify their typical imaging findings on radiographs, CT, and MR imaging. Lisfranc injuries are most often caused by hyperplantarflexion of the foot, often during a sporting injury or in high-speed motor vehicle collisions. The most common radiographic findings include diastasis of the base of the first and second metatarsals and the "fleck" sign, though neither is necessarily present in every Lisfranc fracture-dislocation. Owing to their often subtle radiographic presentation, clinically suspected Lisfranc injuries warrant imaging with a more sensitive test for the detection of osseous and ligamentous Lisfranc injuries. 3D CT imaging provides a comprehensive evaluation of the injury for optimal treatment planning, with resultant decreased long-term patient morbidity. Furthermore, 3D volume-rendered CT and CT multiplanar reconstructions (MPRs) provide osseous and neurovascular anatomic detail that may be a considerable help with surgical planning for operative cases of Lisfranc injuries. Also, with 3D CT and MPRs, other occult fractures, which are common in patients with high-energy injury and multiple trauma, may become evident.

An osteocartilaginous exostosis developed in a 4-year-old boy in whom a distally-based lateral supramalleolar adipofascial flap had been used to cover a defect in the dorsum of the foot. The bony exostosis was first noticed four months after the operation. It was excised with no complications and there has been no recurrence after two years follow-up. The exostosis was thought to result from stripping the perichondrium over the epiphyseal plate while the flap was being raised. This unique complication has not to our knowledge been reported after harvest of a flap before.

Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.

Background: To evaluate the operative method and clinical outcome for the treatment of posttraumatic equinus deformity and concomitant soft tissue defect of the heel., Methods: Between June 2006 and May 2010, seven cases of posttraumatic equinus deformity and concomitant unstable scar or ulcer of the heels were treated by using a hinged Ilizarov apparatus and reversed sural fasciocutaneous island flap transfer. Achilles tendon lengthening was also done in all patients. The average duration of follow-up was 21 months. The sizes of sural flaps were from 7 cm × 6 cm to 10 cm × 9 cm. Two weeks after the flap transfer, distraction of the Ilizarov fixator was initiated to gradually correct the equinus position of the foot., Results: Results were evaluated by using the following criteria: (1) the degree of active dorsiflexion of the ankle, (2) the total active range of motion of the ankle, and (3) walking ability and flap durability. For active dorsiflexion of the ankle, the results were good in three patients and fair in four patients. For range of active motion of the ankle, the results were good in five patients and fair in two patients. For walking ability and flap durability, the results were good in six patients and fair in one patient., Conclusion: This study showed that posttraumatic equinus deformity accompanied by soft tissue defect of the heel can be treated effectively with Achilles tendon lengthening, reversed sural fasciocutaneous island flap transfer, and a hinged Ilizarov technique.

Purpose: The purpose of the study was to observe the frequency of complete documentation of the elements of the Ottawa Ankle Rules (OAR) in acute foot and ankle injuries in an emergency department with an electronic medical record., Procedure: Seven hundred patient visits for acute ankle/foot injuries were reviewed. Each component of the OAR was tabulated as positive, negative, or not documented. Radiograph ordering and results were collected. Descriptive statistics were calculated., Main Findings: Of the 700 charts evaluated, 663 received a radiograph, with 138 fractures identified. The OAR components were completely documented in 288 subjects (41%; 95% confidence interval, 37%-45%). One hundred percent of the charts documented weight-bearing status (template provided), but less than 0.5% (n = 3) documented a navicular examination (not mentioned on the template)., Conclusion: Incomplete documentation of examination components is common, even with prompting from an electronic medical record. This engenders both medicolegal risk and an inability to perform quality analyses to minimize unnecessary radiograph use., (Copyright © 2011 Elsevier Inc. All rights reserved.)

With more people running--and incurring lower extremity injuries--than ever before, you'll have many occasions to use this handy diagnostic and treatment guide.