605 Accessory Ossicles vs. Avulsion Fractures: How can you tell? скачать в хорошем качестве

605 Accessory Ossicles vs. Avulsion Fractures: How can you tell?

Presented by: Mary Lloyd Ireland Professor Dept. of Orthopaedic Surgery and Sports Medicine University of Kentucky Lexington KY www.marylloydireland.com 0:00 Introduction 0:28 Stress Fractures •Definition •Repetitive microtrauma •Forces exceed the ultimate stress of bone, cortical and cancellous •Failure of tensile vs. compression side •High risk of nonunion tension side •Fatigue (repetitive approach of stress to normal bone vs. insufficient application of stress to abnormal bone) 1:51 Stress Fractures (cont) •Foot morphology •Pes cavus more bone problem •i.e., stress fractures •More peroneal tendon problems •Pes planus •More posterior tibial tendon problems 2:23 Valgus 3:58 Physical Exam of the Foot and Ankle Video 4:55 Claw Toes Flex:ed PIPJ/DIPJ: Think Neurologic Involvement 5:56 Freiberg’s Infraction 6:27 Stress Fractures (cont 2) •Specific risk factors •Sport – repetitive microtrauma •Hormonal imbalance •Malalignment •Foot development – rigid high arch •Less muscle mass •Nutritional deficiencies •Surfaces: hard, uneven •Training intensity 4:09 Stress Fractures (cont 3) Risk Factors – Gender Related •Menstrual disturbances •Caloric restriction •Lower bone density •Muscle weakness •Leg length differences •Lower fact diet 7:35 Stress Fractures of the Foot and Ankle Rough Incidence Ranges Metatarsals 50% 40-60% 1st 2% 1-3% 2nd 24% 20-30% 3rd 19% 15-25% 4th 1% 1-4% 5th 5% 1-10% Lateral malleolus 20-30% Medial malleolus 1-5% Os calcis 10% 5-10% Navicular 3% 1-5% Sesamoid 5% 1-5% Others 1-5% 8:26 High Risk Tensile Side 9:41 Low Risk Compression Side 10:13 Body Locations and Level of Concern CRITICAL (at risk, may require surgical intervention) •Anterior tibial cortex •Medial malleolus •Navicular •Proximal 5th MT diaphysis (Jones Fracture) 10:32 Body Locations and Level of Concern NON-CRITICAL (will heal) •Metatarsals distal 1,2,3,4 •Fibula •Os calcis •Talus 10:43 6 weeks & 3 months Pictures 10:27 Fibular Stress Fracture 11:57 Initial 12:20 Femoral neck stress fractureCompression side treated nonoperatively.Healed 60 mo. later. 12:48 Patella Stress Fracture Pictures 13:26 18 YO Freshman Div. I basketball athlete •C/O mid-foot pain, L greater than R •Started when she was running, playing in shoes mandated by her school •History of “normal” periods 14:04 Navicular view 30º ER Torg described 15:47 Stress Fractures 5th metatarsal base fractures TYPE DESCRIPTION I. Acute Nondisplaced Displaced II. Previous injury abnormal Previous radiographs III. Styloid Process No 5th MT – cuboid involvement 5th MT – cuboid involvement 16:10 9 YO very active boy •Does all sports •Casted for 5th metatarsal fracture •Broke cast •Seen for continued pain 16:34 Left foot,5th Metatarsal Fx 17:05 College freshman football athlete. •Refracture of nonunion, Right foot, 5th metatarsal. •initial xrays. 17:22 2.5 months post op 17:38 2 years post op. 17:51 Right Ankle •Ectopic bone in the plantar fascia. Plantar fascia ossification. •Surgery: •Excision of mass in right calcaneus 18:59 15 YO Football Athlete •Running on Hard Ground •C/O heel pain walking or running 19:10 Calcaneal Stress Fractures 19:45 Stress Fractures CALCANEAL APOPHYSITIS (Sever’s Disease) •Repetitive microtrauma •Normal Radiographs •Sclerosis due to normal multicenter ossification 21:24 Accessory Ossicles •Specific names •Os peroneum •In tendon at cuboid level •Os versalianum •Present in 15% •Insertion peroneus brevis •Usually bilateral •Present in 0.1% 22:22 19 YO basketball player Os vesalianum bilateral feet. 23:28 Os peroneum 23:46 9 YO Female Cheerleader •Right ankle pain •Fell from a stunt and has pain and localized bump, medial ankle •Stress reaction, medial malleolar accessory ossification center 24:39 Medial Malleolus Left ankle: 18 yo went up for jump shot & felt pop & sudden onset of pain over medial aspect of ankle 25:03 ~ 2 weeks post ORIF & ~ 2 months post ORIF 25:24 Radiographs in ER post injury 25:59 Post injury – Salter IV distal tibia nonunion (2 and 4 months) 26:18 Surgery – 9 months post injury 26:53 17 YO Male •Left ankle pain x3 weeks •Trying to get in shape, played more basketball than usual •Possible stress fracture of the medial malleolus 27:29 3 months after initial presentation 27:41 5 Months after initial presentation 28:00 7 months after initial presentation 28:22 Small Blue Cell Tumor Ewing’s sarcomavs. Lymphoma 29:18 CONCLUSIONS •Know differences of ossicles vs. stress fractures based on physical exam and radiographic appearance 30:05 The End . . .Thank You!