Contrast administration via ultrasound-guided injection of the cranial tibial artery results in contrast enhancement of the soft tissues of the metatarsus in horses undergoing CT

Delivery of mesenchymal stem cells (MSC) via intravascular techniques to treat diffuse and/or inaccessible soft tissue injuries has grown in popularity. The purpose of the current prospective, analytical pilot study was to utilize CT to validate this novel technique and provide additional evidence to support its use for injectate delivery to specific soft tissue structures. Of particular interest was the proximal suspensory ligament, which presents a challenging injection target. Six adult horses without lameness underwent CT of the distal hindlimbs. Scans were obtained prior to ultrasound-guided catheterization of the cranial tibial artery, in addition to early and delayed scans acquired following intra-arterial contrast administration. Region of interest analysis of the superficial and deep digital flexor tendons and suspensory ligament was used to assess contrast enhancement within these structures. Linear mixed models were used to determine statistical significance. Significant (P < 0.05) mean contrast enhancement was seen in all postinjection time points in all soft tissue structures of interest. This indicates that ultrasound-guided injection of the cranial tibial artery results in perfusion of injectate throughout the distal hind limb, including the major soft tissue structures of the metatarsus. This provides further support for this technique as a method of MSC delivery to multifocal or inaccessible injury of these structures, including the proximal suspensory ligament.

Diagnosis and Operation Results for Chronic Lateral Ankle Instability with Subtle Cavovarus Deformity and a Peek-A-Boo Heel Sign

Cavovarus deformity is considered an anatomical risk factor for chronic lateral ankle instability (CLAI). However, subtle deformity can be difficult to detect, and its correction is controversial. The current study aimed to evaluate clinical and radiographic outcomes of a modified Broström procedure (MBP) with additional procedures for CLAI with subtle cavovarus deformity and a positive peek-a-boo heel sign. We reviewed the records of 15 patients who underwent MBP with additional procedures for CLAI with a positive peek-a-boo heel sign between August 2009 and April 2015. Consecutive physical and radiographic examinations were performed. The visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Karlsson-Peterson (KP) ankle score were applied to assess clinical outcomes. Weight bearing radiographs, hindfoot alignment view, and ankle stress radiographs were also examined. The mean follow-up period was 58.5 months. Calcaneal lateral closing wedge osteotomy was performed in seven patients to correct fixed hindfoot varus, and first metatarsal dorsiflexion osteotomy was performed in 11 patients to correct plantarflexion of the first ray. Three patients underwent both procedures. Mean VAS, AOFAS, and KP ankle scores improved significantly (p=0.001), and instability did not recur. Radiographically, all stress parameters improved significantly (p=0.007). Simultaneous correction of a positive peek-a-boo heel sign and cavovarus deformity with MBP for CLAI improves clinical outcomes and prevents recurrent instability. A comprehensive evaluation and cautious approach for subtle cavovarus deformity should be followed when treating patients with CLAI. This trial is registered on Clinical Research Information Service (CRiS, KCT0003287).

Fully automated determination of arch angle on weight-bearing foot radiograph

BACKGROUND AND OBJECTIVE

Flatfeet can be evaluated by measuring the calcaneal-fifth metatarsal angle on a weight-bearing lateral foot radiograph. This study aimed to develop an automated method for determining the calcaneal-fifth metatarsal angle on weight-bearing lateral foot radiograph.

METHOD

The proposed method comprises four processing steps: (1) identification of the regions including the calcaneus and fifth metatarsal bones in a foot image; (2) delineation of the contours of the calcaneus and the fifth metatarsal; (3) determination of the tangential lines of the two bones from the contours; and (4) determination of the calcaneal-fifth metatarsal angle between the two tangential lines as arch angle.

RESULTS

The proposed method was evaluated using 300 weight-bearing lateral foot radiographs. The arch angles determined by the proposed method were compared with those measured by a radiologist, and the errors between the automatically and manually determined angles were used to evaluate the precision of the method. The average error in the proposed method was found to be 1.12° ± 1.57° In the study, in 73.33% of the cases, the arch angles could be determined automatically without redrawing any tangential lines; in 23.00% of the cases, the angles would be correctly determined by redrawing one of the tangential lines; further, in only 3.67% of the cases, both the calcaneal and fifth metatarsal tangential lines needed to be redrawn to determine the arch angles.

CONCLUSION

The results revealed that the proposed method has potential for assisting doctors in measuring the arch angles on weight-bearing lateral foot radiographs more efficiently.

A reappraisal of the relationship between metatarsus adductus and hallux valgus

BACKGROUND

A causal link between the metatarsus adductus and hallux valgus is not clear. The aim of this study was to investigate the configurations of the metatarsus adductus deformity by radiological measurements and reappraise the relationship between hallux valgus and metatarsus adductus.

METHODS

The first step was evaluation of the relationship between metatarsus adductus and hallux valgus on 143 dorsoplantar weight-bearing radiographs diagnosed as hallux valgus which was also known as bunions. Measurements including the hallux valgus angle (HVA), the intermetatarsal angle (IMA), the Kilmartin angle (KA), the tibial sesamoid position (TSP), and metatarsus adductus angle were taken. The metatarsus adductus angle is defined by Sgarlato's angle (SMA) and Engel's angle (EMA) respectively.

RESULTS

The metatarsus adductus angle positively correlates with the HVA (r = 0.590, P = 0.000) and KA (r = 0.601, P = 0.000), yet negatively correlates with the grade of TSP, (r = -0.348, P = 0.000). Contradiction of diagnosis existed in 22 (22/100) subjects diagnosed as metatarsus adductus by SMA yet normal by EMA. In this group, the correlation between HVA and metatarsus adductus angle was negative (r = -0.472, P = 0.027).

CONCLUSIONS

EMA and SMA defined metatarsus adductus by different deformity apexes. Metatarsus adductus configurations in that the apex of the deformity lay in either the base of metatarsals or tarsus. They respectively correlate positively or negatively to the HVA.

Impact of Charcot neuroarthropathy on metatarsal bone mineral density and geometric strength indices

Charcot neuroarthropathy (CN), an inflammatory condition characterized by rapid and progressive destruction of pedal bones and joints, often leads to deformity and ulceration in individuals with diabetes mellitus (DM) and peripheral neuropathy (PN). Repetitive, unperceived joint trauma may trigger initial CN damage, causing a proinflammatory cascade that can result in osteolysis and contribute to subsequent neuropathic fracture. We aimed to characterize osteolytic changes related to development and progression of CN by measuring bone mineral density (BMD) and geometric strength indices using volumetric quantitative computed tomography. Twenty individuals with DM+PN were compared to twenty age-, sex-, and race-matched individuals with DM+PN and acute CN. We hypothesized that individuals with acute CN would have decreased BMD and decreased total area, cortical area, minimum section modulus, and cortical thickness in the diaphysis of the second and fifth metatarsals. Results showed BMD was lower in both involved and uninvolved feet of CN participants compared to DM+PN participants, with greater reductions in involved CN feet compared to uninvolved CN feet. There was a non-significant increase in total area and cortical area in the CN metatarsals, which helps explain the finding of similar minimum section modulus in DM+PN and CN subjects despite the CN group's significantly lower BMD. Larger cortical area and section modulus are typically considered signs of greater bone strength due to higher resistance to compressive and bending loads, respectively. In CN metatarsals, however, these findings may reflect periosteal woven bone apposition, i.e., a hypertrophic response to injury rather than increased fracture resistance. Future research using these techniques will aid further understanding of the inflammation-mediated bony changes associated with development and progression of CN and other diseases.

A case of polydactyly in the hind-limbs of a West African Dwarf goat in South-West Nigeria

This report describes a case of polydactyly in the hind-limb of a West African Dwarf goat kid in South West Africa. Physical examination revealed the presence of four digits in each of the hind limbs. Radiological examination and macerated bones of the animal showed a bifid shape of each metatarsal that was more prominent from the distal half of the diaphysis. This resulted in the presence of four articulating surfaces per limb at the distal extremity. Though this condition is rare in goats, we advise that continuous reporting by researchers can give a better prevalence statistics of these occurrences.

[The efficacy assessment of cuboid and medial cuneiform bone wedge ostetomy in the treatment of metatarsus adductus]

Metatarsus adductus is usually a morphologic feature of the clubfoot or occurs as an isolated defect. Such deformation causes shortening of the medial foot column and lengthening of the lateral. The purpose of the study is a retrospective evaluation of long-term therapeutic effects in a group of patients, who underwent closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy. Surgery was performed in 19 persons, procedure was applied to 26 feet, of which 3 presented congenital metatarsus adductus and 23 presented recurrent clubfoot. During ostoetomy we performed additional corrective procedures on soft tissues. Foot and gait deformation, pain associated with activities, presence of calluses on the lateral plantar surface of the foot, difficulty in footwear were evaluated before and after surgery on clinical examination. The pre- and post operative X-rays were used to determine: in AP view the Kite's angle and the angle between the calcaneal bone and the 5th metatarsalbone (forefoot adduction evaluation), in lateral view the Kite's angle, the angle between the calcaneal bone and the 1st metatarsal bone (forefoot supination evaluation) and the angle between the talus and the 1st metatarsal bone (cavus evaluation). An early recurrence of the deformation after the removal of wire fixation occurred in 2 patients. Late complications taking the form of adduction and supination of the forefoot occurred in 5 cases. In general recurrences of adduction of the metatarsus occurred in 27 % operated feet. Radiographic evaluation proved a significant statistical effect of the "plus-minus" osteotomy limited to the reduction of the adduction angle of the forefoot and not affect improvement of the supination of the forefoot and the foot excavation.

Shock waves in the treatment of stress fractures

In soccer players, lower extremity stress fractures are common injuries and are the result of repetitive use damage that exceeds the intrinsic ability of the bone to repair itself. They may be treated conservatively but this may cause long-term complications, such as delayed union, muscle atrophy and chronic pain. Stress fractures that fail to respond to this management require surgical treatment, which is also not without risks and complications. Extracorporeal shock wave therapy (ESWT) has been used successfully on fracture complications, such as delayed union and nonunion. As such, we want to examine ESWT in the management of stress fractures. In this article, we present a retrospective study of 10 athletes affected by chronic stress fractures of the fifth metatarsus and tibia that received three to four sessions of low-middle energy ESWT. At the follow-up (8 wk on average), the clinical and radiography results were excellent and enabled all players to gradually return to sports activities. These reports show that ESWT is a noninvasive and effective treatment for resistant stress fractures in soccer players.

Skeletal lesions and arterial calcifications of the feet in diabetics

A radiological study of the feet was performed in 162 unselected diabetic patients with gangrene. They were compared with 59 diabetic patients without gangrene, 45 patients with familial amyloidosis and polyneuropathy and 30 healthy controls. The patients with familial amyloidosis had severe distal neuropathy but normal oral glucose tolerance test curves. Radiographic findings, e.g. skeletal destructions (diabetic osteopathy) and arterial calcification of the medial type were classified without knowledge of the clinical findings. Osteopathy was more common in diabetic patients with gangrene than in the other groups of patients. Medial arterial calcification was more common among diabetics with gangrene compared to patients with amyloidosis and to controls. There were no differences between diabetics without gangrene and patients with amyloidosis, but both of these groups had more calcifications than the controls. Our study suggests that diabetic osteopathy is not caused by peripheral neuropathy per se. The skeletal and skin lesions in diabetic patients are probably equivalent lesions localized to different tissues in the feet. It has been suggested that medial degeneration in the arterial wall is due to neuropathy. In agreement with this suggestion, the patients with familial amyloidosis and neuropathy had medial calcification. However, in diabetic patients this does not exclude other etiological agents.

The risk of avascular necrosis following chevron osteotomy: a prospective study using bone scintigraphy

Controversy exists with regard to the effects of chevron osteotomy on blood supply and subsequent development of avascular necrosis (AVN) of the first metatarsal head. The aim of this study was to assess the incidence of avascular necrosis in our centre following chevron osteotomy for hallux valgus, using bone scintigraphy. Thirty nine patients who had a chevron osteotomy for treatment of hallux valgus were prospectively studied. Mean follow-up was 14 months. Bone scintigraphy was used to assess metatarsal head perfusion at an average 8.5 weeks post operatively. Three patients (7.7%) showed abnormal bone scan around the metatarsal head. Further evaluation of these patients did not show any sign of AVN. We conclude there appears to be a risk of circulatory disturbance to the metatarsal head following chevron osteotomy of the first metarsal (7.7% in this study); however this does not translate into clinically significant AVN.

Magnetic resonance imaging, ultrasonography and histology of the suspensory ligament origin: a comparative study of normal anatomy of warmblood horses

REASONS FOR PERFORMING STUDY

The diagnosis of lameness caused by proximal metacarpal and metatarsal pain can be challenging. Magnetic resonance imaging (MRI) offers the possibility for further diagnosis but there have been no studies on the normal MRI appearance of the origin of the suspensory ligament (OSL) in conjunction with ultrasonography and histology.

OBJECTIVES

To describe the MRI appearance of the OSL in fore- and hindlimbs of sound horses and compare it to the ultrasonographic and histological appearance. The findings can be used as reference values to recognise pathology in the OSL.

METHODS

The OSL in the fore- and hindlimbs of 6 sound horses was examined by ultrasonography prior to death, and MRI and histology post mortem. Qualitative evaluation and morphometry of the OSL were performed and results of all modalities compared.

RESULTS

Muscular tissue, artefacts, variable SL size and shape complicated ultrasonographic interpretation. In MRI and histology the forelimb OSL consisted of 2 portions, the lateral being significantly thicker than medial. The hindlimb SL had a single large area of origin. In fore- and hindlimbs, the amount of muscular tissue was significantly larger laterally than medially. Overall SL measurements using MRI were significantly higher than using histology and ultrasonography and histological higher than ultrasonographic measurements. Morphologically, there was a good correlation between MRI and histology.

CONCLUSIONS

MRI provides more detailed information than ultrasonography regarding muscle fibre detection and OSL dimension and correlates morphologically well with histology. Therefore, ultrasonographic results should be regarded with caution.

POTENTIAL RELEVANCE

MRI may be a diagnostic aid when other modalities fail to identify clearly the cause of proximal metacarpal and metatarsal pain; and may improve selection of adequate therapy and prognosis for injuries in this region.

Modified Crescentic Proximal Metatarsal Osteotomy and Distal Soft Tissue Procedures in Hallux Valgus

The results of a modified crescentic proximal metatarsal osteotomy and distal soft tissue procedures for patients with symptomatic, incongruent, metatarsophalangeal joint, hallux valgus deformity were reviewed. Forty-nine feet of 41 patients were evaluated. All of the patients were male military personnel of different ranks, and their mean age was 23 years (range, 20-43 years). The mean follow-up period was 25 months (range, 10-60 months). The patients were evaluated according to the American Orthopedic Foot and Ankle Society forefoot scoring system. The mean preoperative score was 54.4, and the mean postoperative score was 95.4. The mean hallux valgus angle was 39.4 degrees before surgery and 12.8 degrees after surgery (26.6 degrees correction); the mean intermetatarsal angle was 15.9 degrees before surgery and 7.1 after surgery (8.8 degrees correction). A total of 93.8% of the patients were satisfied with the results of the procedure. Complications included delayed union in one case and superficial wound infections in two cases. We also emphasize small modifications performed while shifting the metatarsal shaft laterally and compare the results of our study with those of similar studies.

Mitchell and Wilson metatarsal osteotomies for the treatment of hallux valgus: comparison of outcomes two decades after the surgery

BACKGROUND

At short-term followup, the Mitchell osteotomy appears to provide more symptomatic improvement than the Wilson osteotomy. We compared the outcomes of the two procedures two decades after the surgeries.

METHODS

In a two-center retrospective study, 30 patients (35 feet) who had Mitchell osteotomies and 28 patients (35 feet) who had Wilson osteotomies were evaluated 20 to 22 years after surgery for correction of the hallux valgus angle (HVA) and intermetatarsal (IMA) angle, changes in the shortening of the first metatarsal and improvement in the overall status (a composite radiographic and clinical outcome according to Bonney and McNab).

RESULTS

With adjustment for the preoperative values and surgical center (analysis of covariance), the HVA (degrees) had a higher correction in the Mitchell group (p = 0.075), while IMA was comparably corrected by the two methods. Shortening of the first metatarsal was greater in the Wilson group (Mitchell-Wilson = -1.93, 95% CI -2.69 to -1.17, p < 0.001). Before the surgery, overall status was graded "poor" or "good" in all feet (28/7 Mitchell, 29/6 Wilson). After the surgery, the status was graded "excellent" or "good" (29/6) in the Mitchell group, and "excellent," "good" or "poor" (25/7/3) in the Wilson group. The status was improved by at least one grade-level in all 35 feet in the Mitchell group and in 31 of 35 feet in the Wilson group. With stratification for the preoperative status, the proportion of "improvements" was higher in the Mitchell group (Mitchell-Wilson = 11.1%, 95% CI 0.7 to 21.5%, p = 0.036). In an alternative analysis (logistic regression), with adjustment for the preoperative status, center, and IMA values, the Mitchell method also appeared superior in this outcome (likelihood ratio test p = 0.021).

CONCLUSIONS

As assessed 20 to 22 years after the surgery, the Mitchell osteotomy resulted in less shortening of the first metatarsal in a somewhat greater proportion of feet with an improved overall status than the Wilson method.

Dynamic sonography of the forefoot in Morton’s syndrome: correlation with magnetic resonance and surgery

PURPOSE

The aim of this paper is to demonstrate the efficacy of the dynamic study of the forefoot during lateral compression of the metatarsal heads (Mulder's manoeuvre) in the visualisation of Morton's neuroma. The data were compared with clinical signs, conventional ultrasound (US), magnetic resonance (MR) and surgical findings.

MATERIALS AND METHODS

Forty forefeet in 38 patients were investigated with conventional and dynamic US using a 10-MHz linear probe (Esaote Technos). MR was performed in 26 forefeet with a 0.2-T scanner (Esaote Artoscan). Twenty intermetatarsal spaces in 18 forefeet were explored surgically.

RESULTS

Thirty-seven intermetatarsal masses were identified through dynamic US in the 40 forefeet investigated (two double localisations). This method was clearly more effective than conventional US, which could only locate 25. In those forefeet investigated with MR, it was possible to confirm dynamic US findings in 16 out of 22. In one of the six cases unconfirmed by MR, a neuroma was removed following surgery. Twenty masses (19 neuromas and one synovial ganglion) were found in the 18 forefeet treated by surgery.

CONCLUSIONS

Clinical evaluation, which is fundamental for accurate diagnosis, can make use of dynamic US in the first instance in order to confirm clinical signs and identify the correct site and number of masses. In our opinion, MR maintains a primary role in differential diagnosis with other diseases (mainly stress fractures, bursitis, ganglion cysts or tendon tumour sheaths).

Sonography of the first dorsal metatarsal artery of the foot

PURPOSE

To describe the gray-scale and Doppler sonographic examination technique and appearances of the first dorsal metatarsal artery (FDMA) of the foot and discuss its clinical significance.

METHODS

The dorsal arteries of foot-including the FDMA and the first plantar metatarsal artery-of 374 feet were studied using gray-scale and color Doppler sonography. Due to the difficulty of detecting the FDMA, a majority of them were identified by studying the web area just distal to the intermetatarsal space. The interosseous muscle was identified to determine the classification of the anatomic type of the FDMA. The sonographic results of 152 feet were compared with surgical findings.

RESULTS

The average caliber of the FDMA was 1.0 +/- 0.5 mm. The FDMA was classified into 3 groups of variants based on its relationship with the first dorsal interosseous muscle. The groups were identified as the superficial artery (54.5%), intramuscular artery (39.6%), and submuscular artery (9%) variants. The rates of visualization of the distal and proximal portions of the FDMA were 86.6% and 47%, respectively. In the first intermetatarsal space, there were anastomoses between the FDMA and the first plantar metatarsal arteries in 87.6% of the feet.

CONCLUSIONS

The FDMA varies greatly; however, sonography can clearly show its morphologic characteristics, such as caliber and location. Sonography also provides valuable preoperative information in microsurgery of the foot.

Synovial chondromatosis of the foot presenting with Lisfranc dislocation

Primary synovial chondromatosis is rare in the foot. We report a case of synovial chondromatosis affecting multiple sites of the foot and causing bone erosions in a 44-year-old woman. Radiographs demonstrated erosions of multiple metatarsals including the tarsometatarsal joints, resulting in Lisfranc tarsometatarsal dislocation. Magnetic resonance imaging showed the widespread synovial proliferation and soft tissue masses affecting the foot and helped in arriving at a differential diagnosis and plan for needle biopsy. Diagnosis was made initially by needle biopsy under computed tomography guidance and was subsequently confirmed by histopathological assessment of the surgically excised synovial masses. To our knowledge, multifocal synovial chondromatosis causing Lisfranc dislocation in the foot has not been reported previously.

Use of internal callus distraction in the treatment of congenital brachymetatarsia

Congenital bilateral brachymetatarsia of the fourth metatarsal bone was treated by osteotomy and bone lengthening using the internal distraction technique. The patient was cosmetically improved. This technique has some advantages over the method of external distraction.

A technique for creating critical-size defects in the metatarsus of sheep for use in investigation of healing of long-bone defects

OBJECTIVE

To develop a technique for use in investigation of healing of long-bone defects by creation of a critical-size defect in the left metarsal III and IV bone (metatarsus) of sheep.

ANIMALS

18 healthy adult sheep.

PROCEDURE

Sheep were allocated to 4 groups (3, 3, 5, and 7 sheep in groups 1 to 4, respectively). An ostectomy with various segmental length-to-diaphyseal diameter ratios (0.5, 1.0, 2.0, and 2.0 for groups 1 to 4, respectively) was performed on the left metatarsus of each sheep. The defect was left empty in sheep of groups 1, 2, and 3, whereas the defect was filled with a massive corticocancellous bone autograft in sheep of group 4.

RESULTS

All sheep tolerated the surgical procedure well and were able to use the affected limb the day after surgery. Radiographic and histologic examinations conducted 16 weeks after surgery revealed nonunion in all sheep of groups 1, 2, and 3, whereas consistent bone healing with abundant bone formation was observed in all sheep of group 4.

CONCLUSIONS AND CLINICAL RELEVANCE

Analysis of these findings suggests that the sheep metatarsal model is a critical-size defect model with low morbidity. It should allow the assessment of new technologies for bone regeneration in conditions closely mimicking the clinical setting.

IMPACT FOR HUMAN MEDICINE

Use of this technique in sheep should be of benefit for the preclinical study of osteoconductive, osteoinductive, or osteogenic biomaterials for use in humans.

A case of Freiberg's disease in an adult patient

Freiberg's disease is an osteochondrosis of the IInd metatarsal head that prevalently develops during the second decade of life and that is the cause of important painful symptoms that resist conservative treatment. The disease is quite rare and must be treated surgically during its early phase in order to prevent progression that may result in permanent changes in the metatarsal head. It is the purpose of this study to describe the clinical case of a patient aged 30 years affected with Freiberg's disease, diagnosed at the age of 15 years, and never submitted to either conservative treatment or surgery.

Scintigraphic appearance of the dorsal cortex of the third metacarpus and third metatarsus in the horse

The lack of "standard uptake pattern" to refer to when interpreting scintigraphic images poses a problem to anyone working with skeletal scintigraphy. An article written by Koblik et al. stated that in the normal scintigraphic image of older horses, the dorsal cortex of the metacarpus and metatarsus is not identifiable, whereas it can be identified in younger horses. In this retrospective study we evaluated the association between the age of a horse and visibility of the dorsal cortex of the metacarpus and metatarsus. We found that dorsal cortical uptake can be seen in the normal adult horse. The population in the study consisted of 139 horses scanned under general anesthesia in lateral recumbency. Scintigraphic images of 202 limbs were examined visually and by using a profile image tool. In almost all limbs the dorsal cortex was identifiable (82%); only 7% of the dorsal cortices were not identifiable; and 11% of the scintigraphic images were not interpretable.

Lisfranc injuries

Lisfranc/midfoot injuries are complex injuries that are frequently overlooked. The consequences of missing these injuries can lead to long-term deformity and disability. Timely diagnosis, whether by primary or later treating physicians, can ensure this does not happen. Proper physical examination and imaging studies allow the physician to find these injuries and determine if open treatment is required. Open treatment can be approached and performed in a number of ways, depending on geographical preference. However, one concept that remains across all the various techniques is perfect anatomical reduction before the fixation technique is applied. Intraoperative and postoperative variations are all secondary concerns after anatomical reduction.

Plantar dislocation of lateral tarsometatarsal joint: a case of subtle Lisfranc injury

INTRODUCTION

We present a rare case of plantar dislocation of the cuboid, fourth and fifth metatarsal joints. Fracture-dislocation in the midfoot region may be subtle and difficult to recognise at the emergency department.

CLINICAL PICTURE

A 16-year-old girl presented with lateral foot pain and swelling following a fall from a height of 3 m. Initial radiograph revealed a third metatarsal shaft fracture; however, additional views reviewed a plantar direction of fourth and fifth metatarsal dislocation from the cuboid.

TREATMENT

Open reduction and internal fixation with Kirschner wires followed by immobilisation in plaster was performed.

OUTCOME

She made an uneventful recovery and the wires had since been removed.

CONCLUSION

This case was unusual in that there was lateral tarsometatarsal disruption with neither diastasis between the first and second metatarsals nor injury to either the first or second tarsometatarsal joints. The plantar direction of dislocation was also unusual as these injuries are usually dorsal.