John A. DiPreta

Ankle Sprains and Instability

Ankle injuries are among the most common injuries presenting to primary care providers and emergency departments and may cause considerable time lost to injury and long-term disability. Inversion injuries about the ankle involve about 25% of all injuries of the musculoskeletal system and 50% of all sports-related injuries. Medial-sided ankle sprains occur less frequently than those on the lateral side. High ankle sprains occur less frequently in the general population, but do occur commonly in collision sports. Providers should apply the Ottawa ankle rules when radiography is indicated and refer fractures and more severe injuries to orthopedic surgery as needed.

Plantar Heel Pain

Plantar heel pain is a common complaint encountered by orthopedic surgeons, internists, and family practitioners. Although it is most often caused by plantar fasciitis, this is a diagnosis of exclusion. Other mechanical, rheumatologic, and neurologic causes must be considered first. The history and physical examination are typically all that is needed to make the proper diagnosis, but diagnostic adjuncts are available to assist the clinician. When plantar fasciitis is diagnosed, conservative modalities must be tried first. Corticosteroid injections and extracorporeal shock-wave therapy may also be used. After 6 months of failed conservative treatments, surgical intervention should be considered.

Subtle injuries to the lisfranc joint.

The tarsometatarsal joint complex is an osseous and capsuloligamentous network that includes the 5 metatarsals, their articulations with the cuneiforms and cuboid, and the Lisfranc ligament, a strong interosseous attachment between the medial cuneiform and second metatarsal. A multitude of injury patterns exist involving the tarsometatarsal joint complex; a Lisfranc injury does not delineate a specific injury, but instead a spectrum of processes involving the tarsometatarsal joint complex.

Review of distal tibial epiphyseal transitional fractures.

The closure of the distal tibial physis occurs over an 18-month period between ages 12 and 15 years. During this time period, children are susceptible to several transitional fractures, so labeled because they are transitioning to skeletal maturity. In the setting of an external rotation force, triplane and Tillaux fractures can occur. These fractures, which present similarly to other Salter-Harris growth plate injuries, do not fit neatly into any 1 classification scheme and are not easily evaluated on plain radiographs. Computed tomography scans are required to optimally assess these fractures and to determine the need for closed vs open treatment. Regardless of which treatment modality is chosen, anatomic reduction is the goal. This article discusses the approach to these unique fractures.

Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon.

Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.

Evaluating the Quality, Accuracy, and Readability of Online Resources Pertaining to Hallux Valgus

Background. The Internet is one of the most widely utilized resources for health-related information. Evaluation of the medical literature suggests that the quality and accuracy of these resources are poor and written at inappropriately high reading levels. The purpose of our study was to evaluate the quality, accuracy, and readability of online resources pertaining to hallux valgus. Methods. Two search terms (“hallux valgus” and “bunion”) were entered into Google, Yahoo, and Bing. With the use of scoring criteria specific to hallux valgus, the quality and accuracy of online information related to hallux valgus was evaluated by 3 reviewers. The Flesch–Kincaid score was used to determine readability. Statistical analysis was performed with t tests and significance was determined by P values <.05. Results. Sixty-two unique websites were evaluated. Quality was significantly higher with use of the search term “bunion” as compared to “hallux valgus” (P = .045). Quality and accuracy were significantly higher in resources authored by physicians as compared to nonphysicians (quality, P = .04; accuracy, P < .001) and websites without commercial bias (quality, P = .038; accuracy, P = .011). However, the reading level was significantly more advanced for websites authored by physicians (P = .035). Websites written above an eighth-grade reading level were significantly more accurate than those written at or below an eighth-grade reading level (P = .032). Conclusion. The overall quality of online information related to hallux valgus is poor and written at inappropriate reading levels. Furthermore, the search term used, authorship, and presence of commercial bias influence the value of these materials. It is important for orthopaedic surgeons to become familiar with patient education materials, so that appropriate recommendations can be made regarding valuable resources. Levels of Evidence: Level IV

Treatment of Ankle Fractures in Patients With Diabetes

Patients with diabetes mellitus have a higher risk of complications after sustaining an ankle fracture, including fracture displacement, superficial and deep infection, hardware failure, and neuropathic arthropathy. With the increased incidence of diabetes among the aged, the increased incidence of complications due to diabetes mellitus and its sequelae are important to keep in mind when treating ankle fractures.

Outpatient assessment and management of the diabetic foot.

Patients with diabetes and peripheral neuropathy are at risk for foot deformities and mechanical imbalance of the lower extremity. Peripheral neuropathy leads to an insensate foot that puts the patient at risk for injury. When combined with deformity due to neuropathic arthropathy, or Charcot foot, the risks of impending ulceration, infection, and amputation are significant to the diabetic patient. Education of proper foot care and shoe wear cannot be overemphasized. For those with significant malalignment or deformity of the foot and ankle, referral should be made immediately to an orthopedic foot and ankle specialist.

Acute fractures of the tarsal navicular.

The tarsal navicular plays an integral role in hind-foot motion and gait, and is the keystone of the foots medial longitudinal arch. As such, injuries to the navicular can be devastating. Acute avulsion, tuberosity, and body fractures have been described. Fractures of the body result from high-energy trauma and are often seen in conjunction with additional ipsilateral foot injuries. Plain radiographs are the gold standard for diagnosis, with computed tomography helpful in the presence of intra-articular fracture extension. Non-operative treatment is reserved for avulsion injuries and non-displaced body fractures. Open reduction and internal fixation must be performed for all other types, as failure to achieve an anatomic reduction can impede proper locomotion. Complications following operative intervention include pain, stiffness, posttraumatic arthritis, avascular necrosis, nonunion, and hindfoot deformity.

Metatarsalgia, Lesser Toe Deformities, and Associated Disorders of the Forefoot

Forefoot pain in the adult often alters mobility and has a negative impact on quality of life. Metatarsalgia describes pain localized to the forefoot. Forefoot pain may be caused by conditions of the lesser toes themselves (eg, hammertoes, mallet toes, claw toes). The pathophysiology of lesser toe deformities is complex and is affected by the function of intrinsic and extrinsic muscle units. In addition to lesser toe and metatarsal abnormality, forefoot pain can be attributed to interdigital neuritis, disorders of the plantar skin, and gastrocsoleus contracture. Treatment of these conditions may include shoe modifications, appliances, therapeutic exercises, and surgical repair.