Joseph S. Torg

Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management.

Between 1973 and 1982 forty-six fractures of the base of the fifth metatarsal, distal to the tuberosity, were treated and followed for a mean of forty months (range, six to 108 months). Roentgenographic criteria were used to define three types of fractures: acute fractures characterized by a narrow fracture line and absence of intramedullary sclerosis; those with delayed union, with widening of the fracture line and evidence of intramedullary sclerosis; and those with non-union and complete obliteration of the medullary canal by sclerotic bone. Of the twenty-five acute fractures in this series, fifteen were treated with a non-weight-bearing toe-to-knee cast, and fourteen of them healed in a mean of seven weeks. Only four of the other ten, which were treated with various weight-bearing methods, progressed to union. Of the twelve patients with delayed union, one refused treatment, one was treated with a bone graft, and ten were treated initially by immobilization of the limb in a plaster cast and weight-bearing. Of these ten fractures, seven healed in a mean of 15.1 months and three eventually required grafting for non-union. Of the nine non-unions in the series, which were treated primarily with medullary curettage and bone-grafting, eight healed in a mean of three months. In all, twenty fractures were treated surgically with an autogenous corticocancellous graft that was inlaid after thorough curettage and drilling of the sclerotic bone that obliterated the intramedullary cavity. Of these twenty fractures, nineteen progressed to complete healing and one, to asymptomatic non-union.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurapraxia of the cervical spinal cord with transient quadriplegia.

The purpose of this study was to define as a distinct clinical entity the syndrome of neurapraxia of the cervical spinal cord with transient quadriplegia. The sensory changes include burning pain, numbness, tingling, and loss of sensation, while the motor changes range from weakness to complete paralysis. The episodes are transient and complete recovery usually occurs in ten to fifteen minutes, although in some patients gradual resolution occurs over a period of thirty-six to forty-eight hours. Except for burning paresthesia, pain in the neck is not present at the time of injury and there is complete return of motor function and full, pain-free motion of the cervical spine. In our series, routine roentgenograms of the cervical spine were negative for fractures or dislocations in all patients. However, the roentgenographic findings did include developmental spinal stenosis in seventeen patients, congenital fusion in five patients, cervical instability in four patients, and intervertebral disc disease in six patients. Spinal stenosis was determined by two different roentgenographic methods. The first was the standard method, and the second was a ratio method devised by us. Both measurements were made at the level of the third through the sixth vertebral body on a routine lateral roentgenogram of the cervical spine that was available for twenty-four of the thirty-two patients and for a control group of forty-nine male subjects of similar age who did not have any neurological complaints. Using the ratio method, a measurement of less than 0.80 indicated significant spinal stenosis in the group of twenty-four patients for whom roentgenograms were available, as compared with a ratio of approximately 1.00 or more in the control group. There was statistically significant spinal stenosis (p less than 0.0001) in all of the patients as compared with the control subjects by both methods of determining spinal stenosis. A survey of 503 schools participating in National Collegiate Athletic Association (NCAA) football in the 1984 season found that 1.3 per 10,000 athletes had a history that was suggestive of neurapraxia of the cervical spinal cord. The phenomenon of neurapraxia of the cervical spinal cord occurs in individuals with developmental stenosis of the cervical spine, congenital fusion, cervical instability, or protrusion of an intervertebral disc in association with a decrease in the anteroposterior diameter of the spinal canal. We postulate that in athletes with diminution of the anteroposterior diameter of the spinal canal the spinal cord can, on forced hyperextension or hyperflexion, be compressed, causing transitory motor and sensory manifestations.(ABSTRACT TRUNCATED AT 400 WORDS)

Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism

Background: The combined positioning of the trunk and knee in the coronal and sagittal planes during non-contact anterior cruciate ligament (ACL) injury has not been previously reported. Hypothesis: During ACL injury female athletes demonstrate greater lateral trunk and knee abduction angles than ACL-injured male athletes and uninjured female athletes. Design: Cross-section control-cohort design. Methods: Analyses of still captures from 23 coronal (10 female and 7 male ACL-injured players and 6 female controls) or 28 sagittal plane videos performing similar landing and cutting tasks. Significance was set at p⩽0.05. Results: Lateral trunk and knee abduction angles were higher in female compared to male athletes during ACL injury (p⩽0.05) and trended toward being greater than female controls (p = 0.16, 0.13, respectively). Female ACL-injured athletes showed less forward trunk lean than female controls (mean (SD) initial contact (IC): 1.6 (9.3)° vs 14.0 (7.3)°, p⩽0.01). Conclusion: Female athletes landed with greater lateral trunk motion and knee abduction during ACL injury than did male athletes or control females during similar landing and cutting tasks. Clinical relevance: Lateral trunk and knee abduction motion are important components of the ACL injury mechanism in female athletes as observed from video evidence of ACL injury.

Natural history of the posterior cruciate ligament-deficient knee.

This paper documents the clinical course of the posterior cruciate ligament-deficient knee. By obtaining an understanding of the natural history of this lesion, the indications for surgical repair, reconstruction, and conservative treatment will be more clearly defined, and the clinician will be able to more critically evaluate the results of both acute repair and reconstruction of this ligament. Forty-three patients with an average interval of 6.3 years (range, one to 37 years) between injury and evaluation were included in this study. Fourteen patients had a straight unidirectional posterior instability and 29 had a combined multidirectional instability. The follow-up evaluation included functional assessment, physical and roentgenographic evaluation, arthrometric laxity measurement, and isokinetic dynametric testing of quadriceps function. Statistical treatment of the data, utilizing both nonparametric methods and logistic modeling, clearly delineated the natural history of the injury to the posterior cruciate ligament (PCL). It was established that the functional outcome can be predicted on the basis of the instability type. Specifically, those knees with PCL disruption without associated ligamentous laxity will probably remain symptom-free. However, when PCL disruption is associated with combined instabilities, a less than desirable functional result will probably occur. Application of logistic modeling to the data demonstrated that the functional result was not due to the type of instability per se, but rather to associated factors, i.e., chondromalacia of the patella, meniscal derangement, quadriceps atrophy, or degenerative changes. A direct correlation has been established between combined multidirectional instability and the occurrence of those associated secondary problems resulting in the patients complaints and functional disability.(ABSTRACT TRUNCATED AT 250 WORDS)

Video Analysis of Anterior Cruciate Ligament Injury Abnormalities in Hip and Ankle Kinematics

Background Most anterior cruciate ligament research is limited to variables at the knee joint and is performed in the laboratory setting, often with subjects postinjury. There is a paucity of information on the position of the hip and ankle during noncontact anterior cruciate ligament injury. Hypothesis When landing after maneuvers, athletes with anterior cruciate ligament injury (subjects) show a more flatfooted profile and more hip flexion than uninjured athletes (controls). Study Design Case control study; Level of evidence, 3. Methods Data from 29 videos of subjects were compared with data from 27 videos of controls performing similar maneuvers. Joint angles were analyzed in 5 sequential frames in sagittal or coronal planes, starting with initial ground-foot contact. Hip, knee, and ankle joint angles were measured in each sequence in the sagittal plane and hip and knee angles in the coronal plane with computer software. The portion of the foot first touching the ground and the number of sequences required for complete foot-ground contact were assessed. Significance was set at P <. 05. Results In sagittal views, controls first contacted the ground with the forefoot; subjects had first ground contact with the hindfoot or entirely flatfooted, attained the flatfoot position significantly sooner, had significantly less plantar-flexed ankle angles at initial contact, and had a significantly larger mean hip flexion angle at the first 3 frames. In coronal views, no significant differences in knee abduction (initial contact) or hip abduction angle were found between groups; knee abduction was relatively unchanged in controls but progressed in subjects. Conclusion Initial ground contact flatfooted or with the hindfoot, knee abduction and increased hip flexion may be risk factors for anterior cruciate ligament injury.

Management and Rehabilitation of Ligamentous Injuries to the Ankle

SummaryThe management of ligamentous injuries to the ankle is controversial. Neither the methods for classification and diagnosis, or the procedures for treatment are clear cut.Ankle sprains are a common occurrence, with the majority involving the lateral ligament complex. Within this complex, the anterior talofibular ligament is injured most frequently, usually while the foot is in the plantar flexed position.Ankle injuries can be diagnosed through physical exam, including the anterior drawer test and/or a stress exam, or through roentgenographic evaluation. The purpose of the stress roentgenogram is to measure the degree of talar tilt. However, it does not always yield consistent, reliable results. This inconsistency has led to the use of arthrography. There is debate over its use as well, howeverAnkle sprains can be classified into three groups, according to functional loss. Treatment for first and second degree sprains is usually non-operative. The best approach to Grade III sprains is debatable. The issues in the treatment of Grade III sprains are first, whether treatment should be operative or non-operative, and second, whether non-operative treatment should emphasise immobilisation or mobilisation. Brostrom’s work is cited as noteworthy. He recommended adhesive strapping followed by mobilisation as the treatment of choice, and reserves surgery for cases of chronic instability. Results demonstrated that strapping yielded shorter disability periods, while surgery produced less instability. The prevention of functional instability is a major concern in the treatment of ankle injuries.There is no consensus for treating a lateral ligament rupture. The authors suggest immobilisation followed by a rehabilitative programme. Three methods of immobilisation are plaster casting, adhesive strapping, and the air-stirrup. The physiological mechanism of cryotherapy and thermotherapy are discussed briefly and recommendations for their use are provided. Aspiration is also discussed.Loss of motion is designated as a primary cause of chronic pain and reinjury, and exercises intended to restore range of motion are provided. Exercises aimed at restoring strength and proprioception are also presented. This allows for return to activity and serves to prevent reinjury.

Noncontact anterior cruciate ligament injuries: mechanisms and risk factors.

&NA; Significant advances have recently been made in understanding the mechanisms involved in noncontact anterior cruciate ligament (ACL) injury. Most ACL injuries involve minimal to no contact. Female athletes sustain a two‐ to eightfold greater rate of injury than do their male counterparts. Recent videotape analyses demonstrate significant differences in average leg and trunk positions during injury compared with control subjects. These findings as well as those of cadaveric and MRI studies indicate that axial compressive forces are a critical component in noncontact ACL injury. A complete understanding of the forces and risk factors associated with noncontact ACL injury should lead to the development of improved preventive strategies for this devastating injury.

Analysis of Failed Surgical Management of Fractures of the Base of the Fifth Metatarsal Distal to the Tuberosity: The Jones Fracture

Failure of surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity is uncommon. Only one such failure has been reported in the literature to date. The purpose of this article is to present the clinical course of 11 patients with failure of surgically managed Jones fractures reviewed by the senior author (J.S.T.). Surgical management was complicated by delayed union in three patients, refracture in seven patients, and nonunion in one patient. The 11 procedures were divided between two established techniques: (1) intramedullary screw fixation (N = 6) and (2) inlaid corticocancellous bone graft (N = 5). In the six intramedullary fixation procedures, using other than a 4.5-mm ASIF malleolar screw for internal fixation correlated with failure. In the five inlaid bone graft procedures, undersized corticocancellous grafts and incomplete reaming of the medullary canal correlated with failure. Also, after both procedures, early return to vigorous physical activity is believed to have played a role in delayed union and refracture.

Proximal diaphyseal fractures of the fifth metatarsal —treatment of the fractures and their complications in athletes

Twenty-one patients (age range, 15 to 26; 18 patients 15 to 20 years old) had proximal diaphyseal fractures of the fifth meta tarsal. Clinical records and radiographs for all patients were available for review. Patient treatment had been individualized and included several methods, including rest, plaster immobili zation, and bone grafting. Twenty of the 21 patients were boys or men participating in athletics. Nine of the 21 fractures and 8 of the reinjuries were sustained while playing basketball. Healing required a minimum of 3 months (with bone graft) and some fractures were not radiographically healed at 20 months, although the patients were clinically asymptomatic. The frac ture of the proximal shaft of the fifth metatarsal, particularly the 1.5-cm segment distal to the tuberosity, is a troublesome injury in the active athlete. The clinical course does not appear to be influenced by the usual initial conservative treatment modalities, although many of these fractures will heal if the athlete is willing to restrict activities for a prolonged period of time. In this series, bone grafting with a tibial corticocancellous graft after thorough curettage of sclerotic bone obliterating the medullary canal was the most effective treatment modality for delayed union.

Injuries to the Cervical Spine in American Football Players

A national registry has documented data on more than 1300 cervical spine injuries resulting from tackle football. Axial loading of the cervical spine is the primary injury mechanism, an observation with profound implications regarding implementation of preventative measures. Characteristic injury patterns involving the middle (third and fourth) cervical segment and the more favorable response to prompt reduction of these injuries are emphasized. The marked instability and grave prognosis of axial load teardrop fractures are attributed to the associated sagittal vertebral body and posterior arch fractures. Spear tackler’s spine is described and is classified as an absolute contraindication to participation in collision sports. Cervical cord neurapraxia, with or without transient quadriplegia, is neither associated with nor presages permanent neurologic sequelae. However, there is a considerable risk of recurrence, which can be predicted on the basis of canal diameter data. The concept of spinal cord resuscitation is proposed as a means of obtaining maximum neurologic recovery by reversing the secondary injury phenomenon that occurs in acute spinal cord trauma. Athletic trauma to the cervical spine resulting in injury to the spinal cord is an infrequent but potentially catastrophic event. Recognition of the problems presented by injury to the cervical spine and spinal cord led to a series of field, clinical, and basic research studies conducted over the past twenty-five years. As a result of these efforts, basic questions have been answered regarding the epidemiology, prevention, pathomechanics, pathophysiology, and histochemical responses of reversible and irreversible cervical cord injuries. Allen et al.1 studied 165 closed indirect fractures and dislocations of the lower cervical spine, demonstrating various “spectra of injuries,” and developed a classification based on the mechanism of injury as determined by the presumed attitude of the cervical spine at the time of failure and the initial dominant mode of failure. The common …