Kinematics of the first metatarsophalangeal joint

The kinematics of both the first metatarsophalangeal joint and the articulation of the hallux sesamoid bones with the metatarsal head were investigated with fifteen fresh-frozen below-the-knee amputation specimens using a radiographic technique. Six feet were of normal structural anatomy, six displayed hallux valgus, and three had hallux rigidus. Normal specimens demonstrated an average total range of motion in the sagittal plane of 111 degrees, with about 76 degrees of dorsiflexion and 34 degrees of plantar flexion. The abnormal specimens revealed a decreased total arc of motion, with a limitation of plantar flexion in feet with hallux valgus and a loss of dorsiflexion in feet with hallux rigidus. Motion analysis of the normal metatarsophalangeal joints demonstrated minimum scattering of instant centers of rotation. This was in contrast to the diseased articulations, which displayed markedly displaced instant centers of rotation located eccentrically about the metatarsal head. Surface motion in the normal joints was characterized as tangential sliding from maximum plantar flexion to moderate dorsiflexion, with some compression at maximum dorsiflexion. The feet with hallux valgus and the feet with hallux rigidus displayed distinctive patterns of distraction and jamming throughout specific portions of the range of motion in the sagittal plane. Motion of the metatarsophalangeal joint in the transverse plane concomitant with motion in the sagittal plane, which has been hypothesized by other investigators, was confirmed and quantified in this study. The feet with hallux rigidus displayed a reduction in this motion.(ABSTRACT TRUNCATED AT 250 WORDS)

Resistant metatarsus adductus deformity (illustrated surgical reconstructive techniques)

The dilemma of metatarsus adductus was reviewed in this clinically illustrated essay. A modification of the traditional Berman-Gartland procedure was also reported, along with 5 methods of osseous fixation. A retrospective analysis of 17 surgical cases, performed at Atlanta Hospital, revealed adherence to published indications and guidelines.

The roentgenographic appearance of the "corrected clubfoot"

Roentgenographic changes associated with a corrected clubfoot may not be readily apparent. In some individuals with minimal residual deformity, these roentgenographic changes are quite subtle. The roentgenographic abnormalities of the corrected clubfoot are described.

Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot

We reviewed the cases of four female ballet dancers with a stress fracture of a type that has not been reported previously. This fracture occurs in the proximal portion of the second metatarsal and involves the volar and medial aspects of Lisfranc's joint. A differential diagnosis of pain in the middle part of the foot in a dancer should include a consideration of this entity, which can be very difficult to diagnose on initial assessment. Oblique radiographs, tomograms, and a bone scan may be necessary to confirm the diagnosis. With early recognition and diagnosis, in three of the four patients the fracture healed with immobilization and modified training. One patient required surgical resection because of persistent non-union of the necrotic fracture fragment.

Axial computed tomographic anatomy of the foot. Part II: Midfoot

Osseous and soft tissue anatomy of the human midfoot is presented as visualized on high resolution axial computed tomography (CT). Because of the proven and potential capabilities of CT in the diagnosis of midfoot disorders, this report serves as an important standard for comparison with clinical studies.

CT evaluation of tarsometatarsal fracture-dislocation injuries

Fracture-dislocation in the tarsometatarsal region (Lisfranc) may be subtle and difficult to recognize on standard radiographic projections. Computed tomography (CT) was used to study the normal anatomy of the forefoot and to evaluate three patients with suspected tarsometatarsal fracture dislocation. The advantages of CT in the evaluation of forefoot trauma are emphasized.

Roentgenographic and mathematical analysis of first metatarsal osteotomies for metatarsus primus varus: a comparative study

The operative effectiveness of five different first metatarsal osteotomies for nonarthritic hallux valgus and metatarsus primus varus were objectively evaluated roentgenographically. The series consisted of 120 feet (75 patients) seen over a 5-year period. The osteotomies were biplanar neck, Chevron, biplanar basilar, basilar concentric, and basilar concentric combined with a lateral closing wedge. All the osteotomies except for the Chevron had varying degrees of plantar displacement of the distal fragment and crossed Kirschner wire fixation. The operative techniques and failures are discussed. Special x-ray studies confirmed misleading pseudocorrections caused by bandage compression and intraoperative and early postoperative roentgenographic distortion. The Chevron gave the least correction, 2 degrees, and did not permit plantar displacement to obviate late metatarsal transfer lesions. The biplanar neck osteotomies were technically the simplest, giving 86% satisfactory corrections, averaging 4.3 degrees. The biplanar basilar osteotomies yielded the most erratic results. The poor results were due to medial tilt during fixation, thereby negating any correction. The technical difficulties with the basilar concentric osteotomy were overcome by the addition of a small lateral closing wedge. This procedure gave by far the most consistently good results with corrections of up to 12 degrees, averaging 7.9 degrees.

A radiographic study of infant metatarsus adductus treatment by serial casting

Although many papers have been written on metatarsus adductus, few have used radiographic criteria for either the diagnosis of or in determining correction of metatarsus adductus. Most use objective clinical appearance as their sole criteria for diagnosis and correction. This paper establishes radiographic criteria for both the diagnosis and correction of metatarsus adductus.

Pedal dislocations. An overview

Identification of the mechanism of injury is the hallmark of dislocation management. If the mechanism can be established by history, anatomic disruptions can be logically explained and identified. Conversely, the injury pattern clinically may help deduce the mechanism. Once the mechanism is established, either historically or clinically, relocation maneuvers can be planned and executed. A review of pedal dislocations has been presented with emphasis on anatomic relationships and mechanism of injury. These principles encompass diagnosis, treatment, and management. They must be understood to manage not only the acute emergency situation but the chronic disability of post-traumatic arthritis.

Tarsometatarsal fracture-dislocation

Closed and open treatment were compared in 12 cases of tarsometatarsal dislocation. When the dislocation involved the lateral component only, good results were observed in one of three cases treated closed and six of seven cases treated open. It is essential to reduce and stabilize the dislocation which is often overlooked unless carefully analyzed clinically and radiographically.

Avascular necrosis after first metatarsal head osteotomies

Thirty patients who were surgically treated for hallux valgus by first metatarsal head osteotomies between 1975 and 1980 were reviewed. The average follow-up was 41 months, with the longest being 78 months and the shortest 16 months. Radiographs were obtained to determine if avascular necrosis of the first metatarsal head had occurred. Two cases of avascular necrosis were discovered.

Distal splint bone fractures in the horse: an experimental and clinical study

An experimental and clinical study to investigate the aetiology of distal splint bone fractures is described. In vitro, extension of the fetlock did not appear to alter the position of the distal ends of the splint bones, although tension in the interosseous tendons increased. Flexion of the fetlock resulted in slight outward displacement of the distal ends of the splint bones. It is suggested that concurrent desmitis of the suspensory ligament can cause movement of the ends of the splint bones thus predisposing to a fatigue fracture. In a clinical study of 87 horses, 114 splint bone fractures were identified. In at least 70 per cent of horses, suspensory desmitis was present. Follow up information was available in 24 horses in which more than 80 per cent of the fractures healed spontaneously. Non-union fractures were not painful and did not cause lameness.

Medial condylar fractures of the third metatarsal bone in horses

Fifteen longitudinal fractures involving the medial condyle of the third metatarsal bone were diagnosed in racing Thoroughbreds and Standardbreds. Twelve were repaired surgically with lag screws placed through stab incisions. Two of the horses suffered catastrophic fracture of the third metatarsal bone during recovery from anesthesia, and 3 more sustained complete fractures within 4 days of the repair. Of 3 horses with fractures treated without surgery, 2 healed without complication. Preoperative radiography did not demonstrate a nonlongitudinal fracture component in any of the horses that sustained complete fractures. The complete fractures were uniformly "Y" shaped. Horses in which the fractures healed had a good prognosis for return to racing.

[Segregation of figural units by the proximity and resemblance of their components]

In this second paper about structural analysis of the radiological image, we propose to teach three figural sets thanks to the practical application of resemblance and proximity. It consists in cervical triplet, metatarsal triplet and two metacarpal doublets.

Primary acute haematogenous osteomyelitis of an isolated metatarsal in children

Acute haematogenous osteomyelitis of an isolated metatarsal is a rare condition in childhood. Fourteen children diagnosed with this condition were followed up for an average of 3 years. Organisms responsible were found to be either Staphylococcus aureus or Streptococcus pyogenes. Growth disturbances of the metatarsal were seen in the majority, but the radiographic features were not serious in the long term, and no child was subsequently disabled. Since these children often present with symptoms akin to trauma, a better recognition of the condition is required to avoid misdiagnosis.

Injuries of the ankle and foot

The important points in evaluation of the traumatized foot and ankle are discussed in detail. Also considered are specific injuries, including contusion; injuries of the musculotendinous unit, ligaments, and capsule; stress fractures; and puncture wounds.

The management of metatarsus adductus et supinatus

Forty-three patients with 69 feet affected by isolated metatarsus adductus et supinatus were reviewed. Of these, 20 patients (with 31 involved feet) had been treated expectantly and spontaneous resolution had occurred with time. The remaining 23 patients (with 38 feet) had required anteromedial release; the operative technique is described. Excellent results were uniformly achieved in both groups, with neither recurrence nor complications in the operatively treated feet. There was a consistent correlation between good clinical results and a naviculo -metatarsal angle of less than 100 degrees. The timing of soft-tissue release did not influence the final outcome.

The primary deformity in hallux valgus and metatarsus primus varus

Analysis of radiographs from patients with hallux valgus showed that following surgical correction there were statistically significant reductions in the hallux valgus, intermetatarsal, and metatarsus primus varus angles. Normal values for these angles were established from a control group of asymptomatic feet and from previously published reviews. If the metatarsus primus varus deformity returns to normal following correction of the hallux valgus by a procedure that does not directly realign the metatarsal, the deformity must be secondary to hallux valgus. This is of importance in planning surgical procedures for the correction of these deformities and confirms the relative popularity and success of distal metatarsal osteotomies. Any operation designed to correct both hallux valgus and metatarsus primus varus must aim to correct the primary hallux valgus lesion rather than the secondary metatarsal deviation.

Shortening of the first metatarsal as a complication of metatarsal osteotomies

There have been few reports of shortening of the first ray of the foot because of damage to the physis of the first metatarsal during the performance of metatarsal osteotomy for residual metatarsus adductus. In a retrospective study of twenty-seven feet in twenty patients who underwent this procedure, eight feet in seven patients were noted to have some degree of residual shortening of the first ray. This is an incidence of 30 per cent. The follow-up period after osteotomy ranged from two years to seven years and four months (average, four years). We could find no clear correlation between the occurrence of shortening and the patient's age at osteotomy, sex, or race, or the etiology of the adduction for which the osteotomy had been done. A clear correlation was found, however, with the surgical technique that had been employed. In two of the eight feet with a short first ray, the osteotomy had been done within the physis of the first metatarsal. In the other feet the procedure had employed an osteotomy site close to the physis or extensive periosteal dissection, or both. The results in our patients implicate subperiosteal dissection of the first metatarsal as an important, previously unreported cause of damage to the physis and of the resultant shortening. We recommend radiographic determination of the relationship of the osteotomy site to the physis before dissection is performed.

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)

Lisfranc dislocations: fractures and/or dislocations through the tarso-metatarsal joints

Because of the anatomical configuration of the tarso-metatarsal joints with their strong ligamentous connections, pure dislocations in this region are rare. We describe our experience of 24 cases of Lisfranc dislocation. Classification is according to Wilson. In the long term, functional and radiological results appear to depend on the accuracy of reduction. For good anatomical results, immediate closed or, if necessary, open reduction and stabilization by percutaneous Kirschner wires is required. Because of the severity of soft tissue damage, decompression with dorsal skin incisions should also be considered.

Deformities of the metacarpus and metatarsus in fallow deer (Dama dama L.)

Radiographic examination of the metacarpus and metatarsus from 333 fallow deer revealed a high incidence of animals with an angular deviation of at least one epiphysis. The incidence in males (59 per cent) was significantly higher than that in females (21 per cent). The cloven hoof is bent laterally and a deviation of up to 23 degrees was recorded. A deer with one deformed foot is equally likely to have 2, 3 or 4 deformed feet and no bone is more susceptible than others. Fusion of the epiphyses commenced at about 16 months and was complete by about 32 months, and the angular deformity occurred before this age. The incidence increases with increasing age in deer whose epiphyses have not yet fused. Other radiographic changes noted were growth plate deformities in young deer of 8 to 12 months of age and bowing of the shaft of the cannon bone in some older animals. It is suggested that the following sequence of events could involve all 3 defects and provide an explanation for the gross angular deviation of the foot seen in some deer. First, a defect in the process of calcification as a result of a nutritional deficiency causes hypertrophy of the cartilage of the growth plate, with local epiphyseal damage. Second, a compression or a breakdown of the cartilage of the cannon bone, particularly if on one side only, causes angular deviation of the epiphysis. Subsequent ossification leads to fusion of the diaphysis with the epiphysis at an abnormal angle. Third, the defect in calcification of the diaphysis leads to a weakness in the bone which, if stressed, becomes deformed and, after subsequent ossification, is seen as a bowing of the cannon bone.

Double oblique displacement osteotomy for hallux valgus

Surgical treatment of adult hallux valgus was carried out in 57 feet using the double oblique displacement osteotomy described by Wilson. Twenty weeks after the operation, no patients had inconvenient problems when walking. The results were classified as excellent in 52 feet. Wilson's operation was found to be a simple, reliable procedure, giving satisfactory correction of the valgus deformity.

[Metatarsophalangeal lesions of the diabetic foot. Radiologic outcome]

Radiological evidence of progression of diabetic foot lesions was studied in 31 patients. Three types of progression could be distinguished: lesions became worse (16 cases), improved (8 cases), or fluctuated in extent (6 cases). Mechanisms of production of the lesions and their prognostic significance are analyzed. Progression of the lesion is usually the result of infection. Reconstructive therapy requires evidence of a satisfactory vascular integrity in patients with associated arterial and neurological disorders. A fluctuating course is a typical finding in diabetic osteoarthropathy.

[A case of hexametatarsia with hypoplasia of the 5th toe]

The Author describes a case of supernumetary metatarsos with hypoplasy of the little finger of the foot and pseudoarthrosis of the 5th metatarsus. Is very important an early surgical treatment.

Early epiphyseal fusion in Freiberg's infraction

A case of Freiberg's Infraction of the third metatarsal which demonstrates early epiphyseal closure in this condition is presented. The etiology of this phenomenon is unclear.

Metatarsus adductus: classification and relationship to outcomes of treatment

In a retrospective study of results of treatment in 160 children (265 feet) who had metatarsus adductus prospectively defined by severity and flexibility, we found that in 147 patients treated with plaster casts or casts followed by derotation splints the only significant predictor of a good outcome was the age of the patient. Results were statistically significantly better when treatment was begun from ages 1 day to 8 months. No significant correlations with poor results were found using the severity and flexibility grading systems. Given the public attitude toward deformity, it seems wiser to treat in infancy those feet graded "moderate" or "severe." If treatment is not commenced until the child is old enough to preclude conservative treatment, extensive surgery will be necessary to correct a "severe" deformity.

Compensatory hypertrophy of bone following surgery on the foot

Compensatory hypertrophy of bone developed in 5 patients following surgery on the foot. The typical finding of diffuse cortical thickening of the entire ray is thought to represent a static compensatory response which occurs when the usual dynamic response of altered weight-bearing is inadequate or overridden.

Multifocal chronic osteomyelitis of unknown etiology. Report of five cases

Five cases of chronic, inflammatory, multifocal bone lesions of unknown etiology are reported. Although bone biopsy confirmed osteomyelitis in each case in none of them were organisms found inspite of an extensive work up. Different clinical course of the disease reflects different aetiology in respective cases. These cases present changing aspects of osteomyelitis emerging since introduction of antibiotics.

Mineral metabolism and immobilization osteopenia in ponies treated with 25-hydroxycholecalciferol

The left thoracic limb was immobilized in a plaster cast in 6 grade weanling ponies for 6 weeks. Two ponies were injected intramuscularly each day with 2.4 micrograms of 25-hydroxycholecalciferol [25(OH)D3] per kg bodyweight, two with 1.2 micrograms and two received no injections. Immobilization of 25(OH)D3 treatment had no significant effect on mineral metabolism. Immobilization resulted in significantly decreased weight and specific gravity of metacarpus III (MCIII). Histologic examination and triple fluorochrome incorporation showed that the osteopenia was caused by atrophy of osteoblasts with failure of bone apposition. Immobilization caused retardation or cessation of proliferation of cartilage in the epiphyseal plate with thinning or premature closure. Treatment with 25(OH)D3 further reduced apposition and enhanced significantly the osteopenia as shown by quantitative morphometry of microradiographs of the MCIII metaphyses. There was parathyroid gland atrophy and fibrosis in proportion to the level of 25(OH)D3 treatment, which, in absence of hypercalcemia in all ponies, was interpreted to be a direct result of vitamin D treatment. It was concluded that immobilization osteopenia under the present design and duration is caused by failure of bone apposition and that treatment with 25(OH)D3 at dose levels applied is contraindicated.