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Orthopaedic Surgery - Freiberg Disease (Freiberg Infraction)
Basics
Freiberg disease, also called Freiberg infraction, is an osteochondrosis or osteonecrotic disorder involving the metatarsal head, most commonly the second metatarsal head.
It typically presents in an adolescent, young adult, or occasionally middle-aged adult with well-localized pain at the second metatarsophalangeal (MTP) joint that worsens with activity and improves with rest.
Anatomic Distribution
The second metatarsal head is affected most frequently.
The third or other lesser metatarsal heads may occasionally be involved.
Disease may be unilateral or bilateral.
Disease Progression
The disorder progresses through a spectrum of subchondral injury, necrosis, collapse, and eventually degenerative arthritis.
Early radiographs may demonstrate subtle mottling, sclerosis, or central subchondral collapse.
Moderate disease produces flattening or collapse of the metatarsal head, often accompanied by osteophytes or loose osteochondral fragments.
Advanced disease is characterized by joint-space loss, articular destruction, and secondary MTP arthritis.
Epidemiology
Freiberg disease occurs more commonly in females than males.
The true incidence is uncertain because some cases remain asymptomatic and are discovered incidentally on radiographs.
Age
The condition is classically diagnosed during adolescence, especially between approximately 13 and 18 years of age, although symptoms may persist into adulthood or first become clinically apparent later.
Risk Factors
Important associations include running, dancing, repetitive forefoot loading, and a relatively long second metatarsal.
These factors increase mechanical stress across the affected metatarsal head.
Etiology
The exact cause is likely multifactorial.
Freiberg disease is characterized by compromise of the subchondral bone and blood supply of the metatarsal head, resulting in osteonecrosis and structural collapse.
Vascular Factors
Impaired local microcirculation has been proposed as an important contributor to the development of osteonecrosis.
Acute Trauma
A single traumatic event may damage the subchondral bone or vascular supply and initiate the disease process in some patients.
Repetitive Microtrauma
Repeated forefoot loading from running, jumping, dancing, or other high-impact activity may produce cumulative microtrauma.
Second Metatarsal Anatomy
The second metatarsal is often the longest metatarsal and is relatively rigidly fixed at its base.
These characteristics can subject the second metatarsal head to increased repetitive loading and may explain why it is affected most frequently.
Diagnosis
Signs and Symptoms
The characteristic complaint is pain localized to the second MTP joint.
Pain is aggravated by walking, running, sports, and other weight-bearing activity and generally improves with rest.
Swelling
Localized swelling or soft-tissue thickening may develop around the involved MTP joint.
Swelling may become more noticeable after prolonged activity.
Stiffness
As disease progresses, the affected MTP joint may lose motion because of synovitis, articular collapse, osteophytes, or secondary arthritis.
Physical Examination
Range of Motion
The involved MTP joint may demonstrate reduced active and passive range of motion.
Motion can become progressively restricted in later stages.
Tenderness
Direct palpation over the metatarsal head and MTP joint typically reproduces the patient’s pain.
Swelling
Soft-tissue swelling around the joint may be present, particularly after activity.
Toe-Rise Test
Standing on the toes or performing a heel rise increases loading across the metatarsal heads and may reproduce pain.
Imaging
Plain Radiographs
Initial evaluation should include weight-bearing AP, oblique, and lateral radiographs of the foot.
Radiographic appearance varies according to the stage of disease.
Early Radiographic Findings
Early findings may include localized osteopenia, subtle subchondral lucency, sclerosis, or irregularity of the metatarsal head.
Radiographs can occasionally appear normal in very early disease.
Progressive Disease
With progression, the metatarsal head may become enlarged, flattened, sclerotic, and irregular.
Subchondral cystic changes and osteophytes may also develop.
End-Stage Disease
Advanced disease produces joint-space narrowing, fragmentation, deformity, and degenerative destruction of the MTP joint.
MRI
MRI is particularly useful when early disease is suspected but radiographs are normal or equivocal.
Typical findings include bone marrow edema and abnormalities of the subchondral bone consistent with osteonecrosis or osteochondral injury.
Bone Scintigraphy
Technetium bone scanning can demonstrate focal increased tracer uptake at the involved metatarsal head.
It may help identify occult disease, although MRI is generally more useful for defining early structural abnormalities.
Pathological Findings
Characteristic pathologic changes include synovitis, loose bodies, osteophytes, and osteonecrosis of the metatarsal head.
Metatarsal Head Necrosis
The marrow space may undergo fibrosis with areas of dead trabecular bone.
Subsequent resorption and structural weakening can lead to collapse of the articular surface.
Cartilage Damage
Progressive disease eventually results in articular cartilage loss and secondary degenerative arthritis.
Classification
Several classification systems have been proposed.
The best known is the Smillie classification, which describes progressive stages based largely on the structural and macroscopic appearance of the metatarsal head.
Although useful for describing severity, the classification does not always determine treatment reliably by itself.
Natural History
Freiberg disease may progress through stages of subchondral necrosis, collapse, remodeling, and secondary arthritis.
In some patients, remodeling ultimately produces a reasonably congruent articular surface and substantial improvement in pain.
Others develop persistent deformity or degenerative arthritis.
Differential Diagnosis
Idiopathic Synovitis
MTP synovitis can produce localized pain and swelling without the characteristic osseous abnormalities of Freiberg disease.
Inflammatory Arthritis
Inflammatory arthropathies may cause forefoot pain, swelling, stiffness, and multiple-joint involvement.
Acute Fracture
An acute metatarsal or osteochondral fracture should be considered when symptoms follow trauma.
MTP Sprain
Ligamentous injury around the MTP joint can produce pain and swelling without metatarsal head osteonecrosis.
Metatarsal Stress Fracture
A stress fracture may cause activity-related forefoot pain and focal tenderness and can resemble early Freiberg disease.
Morton Neuroma
Morton neuroma produces forefoot pain, often with burning or paresthesias radiating into the toes, typically from an intermetatarsal space rather than directly from the metatarsal head.
Treatment
General Principles
Treatment depends on the stage of disease, severity of pain, degree of articular collapse, and functional limitation.
Early disease is generally treated nonoperatively.
Activity Modification
Activities that reproduce pain should be reduced or temporarily avoided.
This commonly includes running, jumping, dancing, and other high-impact loading of the forefoot.
Immobilization and Footwear
Early-stage disease may be treated with a stiff-soled shoe, walking boot, or short walking cast to decrease motion and loading across the involved MTP joint.
Metatarsal Pad
A metatarsal pad placed just proximal to the affected metatarsal head can redistribute plantar pressure away from the painful joint.
Taping
Taping or strapping the involved toe can limit MTP motion and reduce mechanical irritation.
Medication
NSAIDs may be used to reduce pain and inflammatory swelling when appropriate.
Corticosteroid Injection
A carefully selected intra-articular corticosteroid injection may temporarily reduce symptomatic synovitis.
Such injections should be used judiciously and do not correct the underlying structural abnormality.
Surgery
Surgery is considered when substantial symptoms persist despite appropriate nonoperative treatment, particularly in patients with progressive collapse or mechanical joint symptoms.
Synovectomy
Synovectomy can be performed when persistent inflammatory synovitis contributes significantly to pain.
Joint Debridement
Debridement may include removal of fibrotic tissue, loose osteochondral bodies, and osteophytes.
This can improve motion and reduce mechanical symptoms.
Bone Grafting
Bone grafting of the metatarsal head may be considered in selected earlier-stage lesions when the subchondral bone is compromised but the articular surface has not yet undergone major collapse.
Dorsiflexion Osteotomy
A dorsiflexion osteotomy of the affected metatarsal can rotate relatively healthy plantar articular cartilage dorsally so that it articulates with the proximal phalanx.
This simultaneously unloads the damaged dorsal portion of the metatarsal head.
Resection Arthroplasty
Metatarsal head resection arthroplasty may be considered for severe end-stage disease in selected patients.
However, shortening and loss of the metatarsal head can alter forefoot load distribution.
Prosthetic Joint Replacement
Routine prosthetic replacement of the lesser MTP joint is generally not favored.
Potential problems include transfer metatarsalgia, bone resorption, loosening, and implant failure.
Follow-Up
Prognosis
The prognosis is generally favorable.
In many patients, the acute painful phase gradually resolves and is replaced by only an intermittent ache or mild activity-related discomfort.
Long-Term Outcome
Outcome depends on the degree of articular collapse and secondary arthritis.
Patients treated before extensive joint destruction generally have better preservation of motion and function.
Complications
Articular Collapse
Progressive subchondral failure can lead to flattening and collapse of the metatarsal head.
MTP Arthritis
Loss of joint congruity and cartilage can result in secondary degenerative arthritis of the second MTP joint.
Transfer Metatarsalgia
As the painful joint becomes mechanically unloaded, pressure may shift to adjacent metatarsal heads.
This can produce transfer metatarsalgia and plantar callus formation elsewhere in the forefoot.
Patient Monitoring
Patients should be monitored for pain, swelling, MTP range of motion, progression of metatarsal head collapse, development of arthritis, and ability to return to activity.
Repeat weight-bearing radiographs are useful when symptoms persist or worsen, particularly to assess structural progression and guide the need for operative treatment.
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Orthopaedic Surgery - Fracture Treatment
Basics
Fractures are common injuries caused by trauma or, less commonly, by pathologic weakening of bone.
Management may be operative or nonoperative and depends on the location, displacement, stability, soft-tissue injury, patient age, bone quality, and functional requirements.
Nondisplaced Fractures
A nondisplaced fracture may involve one or both cortices, but the fragments remain essentially in their normal anatomic relationship.
These fractures can be difficult to identify on initial imaging, particularly when the fracture line is subtle.
Persistent unexplained pain after trauma should therefore raise suspicion for an occult nondisplaced fracture.
Displaced Fractures
Displacement can be described according to several features, including angulation, translation, rotation, and shortening.
Precise description is important for communication and treatment planning.
Angulation
One method of describing angular deformity is to state the direction of the fracture apex, such as “apex anterior.”
Another method is to describe the resulting alignment, such as varus or valgus angulation.
Translation
Translation refers to sideways displacement of one main fracture fragment relative to the other.
Rotation
Rotational deformity occurs when one fragment is twisted relative to the other.
Rotational malalignment may be clinically important even when plain radiographs appear relatively well aligned.
Shortening
Shortening results from fracture overlap or loss of bone length.
The amount that can be accepted varies greatly according to the bone involved, patient age, and functional demands.
Open Versus Closed Fracture
Determining whether a fracture is open or closed is one of the most important early decisions in fracture management.
Any wound anywhere near a limb containing a fracture must be treated with suspicion.
If there is a possibility that the wound communicates with the fracture or fracture hematoma, the injury should be considered an open fracture until proven otherwise.
Initial Management of an Open Fracture
Open fractures require prompt intravenous antibiotics, tetanus assessment, sterile wound coverage, fracture stabilization, and urgent surgical evaluation.
The wound should be covered with a sterile dressing after gross contamination is addressed, and repeated unnecessary manipulation should be avoided before operative debridement.
Gustilo-Anderson Classification
The Gustilo-Anderson system classifies open fractures according to wound size, injury energy, contamination, soft-tissue destruction, and vascular involvement.
Definitive grading is best assigned after operative debridement.
Type I
Type I injuries are low-energy open fractures with a relatively clean wound typically less than 1 cm in length and minimal soft-tissue damage.
Type II
Type II injuries have a wound generally greater than 1 cm but less than 10 cm, with moderate soft-tissue injury but without extensive stripping or loss of coverage.
Type III
Type III injuries are high-energy open fractures with severe soft-tissue damage, contamination, or complex injury.
Historically, a wound greater than 10 cm has been included in this category, although wound size alone does not determine severity.
Type IIIA
Type IIIA fractures have substantial soft-tissue injury but retain enough tissue for adequate coverage of the bone without requiring a major flap.
Type IIIB
Type IIIB injuries involve extensive soft-tissue destruction, periosteal stripping, exposed bone, and inadequate local coverage, often requiring flap reconstruction.
Type IIIC
Type IIIC fractures are associated with a vascular injury requiring repair, regardless of wound size.
Fracture Location
Diaphyseal Fractures
Diaphyseal fractures involve the shaft of a long bone and are commonly described according to level, such as proximal third, middle third, or distal third.
Metaphyseal Fractures
Metaphyseal fractures occur near the ends of long bones.
Some extend into the adjacent joint surface.
Intra-Articular Fractures
Intra-articular fractures disrupt the joint surface.
These injuries tolerate relatively little residual incongruity because persistent step-off or malalignment can contribute to joint stiffness and post-traumatic osteoarthritis.
Fracture Patterns
Transverse Fracture
A transverse fracture line runs approximately perpendicular to the long axis of the bone.
Oblique Fracture
An oblique fracture crosses the bone at an angle.
Spiral Fracture
A spiral fracture wraps around the bone and typically results from a rotational mechanism.
Comminuted Fracture
A comminuted fracture consists of three or more fragments at the fracture site.
Increasing comminution usually reflects greater injury energy or poor bone quality.
Segmental Fracture
A segmental fracture occurs when the same bone is broken at two separate levels, creating an isolated or “floating” intermediate segment.
Impacted Fracture
In an impacted fracture, one fragment is driven into another.
Avulsion Fracture
An avulsion fracture occurs when a tendon or ligament pulls off a fragment of bone from its attachment site.
Compression Fracture
Compression fractures occur when bone is crushed under axial load.
They are particularly common in osteoporotic vertebral bodies.
Pediatric Considerations
Children sustain several fracture patterns that are uncommon in adults because pediatric bone is more flexible and the periosteum is thicker.
Greenstick Fracture
In a greenstick fracture, the cortex and periosteum on the concave side remain intact, while the cortex on the convex side fails.
This produces an incomplete fracture with angular deformity.
Buckle or Torus Fracture
A buckle fracture is a stable metaphyseal compression injury characterized by cortical buckling rather than complete disruption.
It is often treated with removable splinting primarily for comfort and protection.
Physeal Injuries
Growth-plate fractures are commonly described using the Salter-Harris classification.
Salter-Harris Type I
Type I extends transversely through the physis alone.
Salter-Harris Type II
Type II passes through the physis and exits through the metaphysis, creating a metaphyseal fragment.
Salter-Harris Type III
Type III extends through the physis and epiphysis into the joint.
It is therefore an intra-articular fracture.
Salter-Harris Type IV
Type IV passes through the metaphysis, physis, and epiphysis, crossing the articular surface.
Precise reduction is important because both the joint and growth plate are involved.
Salter-Harris Type V
Type V is a crush injury of the physis.
It can be difficult to recognize initially and carries a significant risk of growth disturbance.
Perichondral Ring Injury
Injury to the peripheral physeal ring has sometimes been referred to as a Type VI injury, although this was not part of the original Salter-Harris classification.
Prevention
General fracture prevention includes trauma avoidance, fall prevention, appropriate safety equipment, and prevention or treatment of osteoporosis.
Pathophysiology
A fracture occurs when an applied force exceeds the mechanical strength of bone.
Healthy bone generally requires greater force to fracture than bone weakened by osteoporosis, tumor, infection, or metabolic disease.
Diagnosis
History
Most fractures follow trauma such as a motor vehicle collision, fall, sports injury, or direct blow.
Older patients may sustain fractures after relatively minor trauma because of osteoporosis.
Suspected Pathologic Fracture
When the reported mechanism seems too minor to explain the injury, an underlying pathologic process should be considered.
Examples include a humeral fracture while performing a trivial household activity or a femoral fracture after a minimal step or twist.
Possible causes include metastatic disease, primary bone tumor, osteoporosis, metabolic bone disease, or other structural abnormalities.
Nonaccidental Injury
Child abuse should be considered when fractures or bruises of different ages are present, the mechanism is inconsistent with the child’s developmental abilities, or the reported history does not adequately explain the injury.
Any concern should trigger a formal multidisciplinary safeguarding evaluation.
Physical Examination
The involved area should be inspected for deformity, swelling, bruising, warmth, skin wounds, fracture blisters, and focal tenderness.
Movement of the injured region may cause substantial pain and should be performed cautiously.
Neurovascular Examination
Motor function, sensation, pulses, capillary refill, and distal perfusion should be documented before and after reduction or splinting.
Soft-Tissue Examination
Any wound near the fracture must be examined carefully because even a small wound may communicate with the fracture.
Imaging
Plain Radiographs
Plain radiographs in at least two orthogonal planes are the basic imaging study for most fractures.
The images should generally include the joint above and below the fracture when practical, especially for long-bone injuries.
CT
CT is superior to plain radiography for defining many complex fractures, particularly those involving the spine, pelvis, hindfoot, and articular surfaces.
It is especially useful when operative planning requires detailed assessment of joint involvement and fragment morphology.
MRI
MRI can detect radiographically occult fractures and associated soft-tissue injury.
It is especially useful for stress fractures, occult hip fractures, and injuries involving ligaments or cartilage.
Bone Scintigraphy
Bone scintigraphy can identify occult or multifocal fractures when other imaging is unavailable or nondiagnostic, although MRI is now preferred for many indications.
Initial Treatment
Ice and Elevation
Ice and elevation may help limit pain and swelling in appropriate extremity injuries.
Immobilization
Early immobilization reduces pain, limits further soft-tissue injury, and helps maintain alignment.
Reduction
Displaced fractures should be reduced when necessary under appropriate analgesia, sedation, regional anesthesia, or general anesthesia.
Principles of Definitive Fracture Treatment
Regardless of whether management is operative or nonoperative, two fundamental goals apply:
Restoration of acceptable alignment and provision of sufficient stability to permit healing and function.
Splinting
During the acute swollen phase, a splint is often preferred over a circumferential cast.
Splints accommodate swelling and therefore reduce the risk of excessive pressure, skin injury, and compartment syndrome.
Casting
Casts are commonly used for stable or nondisplaced fractures and for fractures that remain acceptably aligned after closed reduction.
Cast Valving
A cast may be univalved or bivalved when significant swelling is anticipated.
This reduces circumferential pressure.
Three-Point Mold
A well-applied cast uses three-point molding to resist the deforming forces acting across the fracture and maintain reduction.
Functional Bracing
Functional braces permit controlled motion while maintaining fracture alignment.
They have been used successfully for selected humeral shaft and tibial shaft fractures.
Activity
Weight-bearing and joint-motion recommendations depend on fracture location, stability, fixation, and healing.
Operative fixation often permits earlier motion and, in some cases, earlier weight bearing than prolonged cast treatment.
Nursing Care
Careful monitoring is required for complications such as compartment syndrome, cast pressure, skin breakdown, swelling, neurovascular compromise, and uncontrolled pain.
Medication
Open Fracture Antibiotics
Open fractures require prompt intravenous antibiotic prophylaxis, ideally as soon as possible after injury.
Antibiotic selection depends on the Gustilo grade, contamination, local resistance patterns, and institutional protocol.
First-generation cephalosporins such as cefazolin are commonly used for gram-positive coverage in lower-grade injuries.
Broader gram-negative coverage is generally added for selected severe Type III injuries rather than simply for all Type II fractures.
Farm or Grossly Contaminated Injuries
Fractures contaminated with soil, farm material, fecal material, or other high-risk substances may require additional anaerobic coverage according to local trauma and infectious-disease protocols.
Tetanus Prophylaxis
Tetanus immunization status should be assessed in all open wounds, with booster vaccination or immune globulin provided when indicated.
Analgesia
Pain control should be tailored to injury severity.
Options include acetaminophen, NSAIDs when appropriate, regional anesthesia, and opioids for severe pain.
Surgery
The decision for operative treatment depends on fracture severity, instability, soft-tissue condition, patient factors, need for early mobilization, and ability to obtain or maintain acceptable alignment nonoperatively.
Intra-Articular Fractures
Displaced intra-articular fractures often require anatomic or near-anatomic reduction and stable fixation to restore the joint surface and allow early motion.
Failure to restore congruity increases the risk of stiffness and post-traumatic arthritis.
Diaphyseal Fractures
Shaft fractures may require fixation to restore length, rotation, and alignment and to permit earlier mobilization.
Plates and Screws
Plate-and-screw constructs are frequently used for intra-articular, metaphyseal, periarticular, and selected diaphyseal fractures.
They allow direct or indirect restoration of alignment and stable fixation.
Intramedullary Nails
Intramedullary nails are commonly used for long-bone diaphyseal fractures, particularly of the femur and tibia.
They function as load-sharing implants and often permit relatively early weight bearing.
External Fixation
External fixation is useful when there is severe soft-tissue injury, gross contamination, vascular compromise, marked swelling, or a need for temporary damage-control stabilization.
It may also be used definitively in selected injuries.
Damage-Control Orthopaedics
Severely injured polytrauma patients may not tolerate lengthy definitive fracture surgery immediately.
In these cases, temporary external fixation can provide rapid skeletal stabilization while minimizing the additional physiologic stress sometimes described as a “second hit.”
Definitive fixation is performed later after resuscitation and physiologic stabilization.
Referral and Safeguarding
When nonaccidental injury is suspected in a child, a pediatrician, child-protection team, and social worker or equivalent safeguarding professional should be involved promptly.
Prognosis
Prognosis depends on fracture location, displacement, soft-tissue injury, vascular status, infection, and patient factors.
In general, intra-articular fractures and fractures with major soft-tissue damage have a worse prognosis than uncomplicated shaft fractures.
Complications
Delayed Union
Delayed union refers to fracture healing that is progressing more slowly than expected.
Older definitions often used approximately 3–4 months, but the diagnosis should be interpreted according to the bone, fracture pattern, and biologic environment.
Nonunion
Nonunion is failure of a fracture to unite despite sufficient time and biologic opportunity.
Traditionally, absence of healing by about 6 months has been used in some settings, although modern definitions depend on clinical and radiographic progression rather than time alone.
Malunion
Malunion occurs when the fracture heals in an unacceptable position, producing deformity such as angulation, rotation, shortening, or translation.
Osteonecrosis
Osteonecrosis, or avascular necrosis, results from disruption of the blood supply to bone.
It is particularly associated with fractures involving the femoral head and neck, talar neck, proximal scaphoid, proximal humerus, and selected periarticular regions.
Osteomyelitis
Bone infection is a major complication, particularly after open fractures, severe contamination, or infected fixation.
Compartment Syndrome
Acute compartment syndrome occurs when pressure within a closed fascial compartment compromises tissue perfusion.
It is a surgical emergency.
Disproportionate pain, pain with passive stretch, tense swelling, neurologic changes, and progressive symptoms require immediate attention.
Pulmonary Complications
Major fractures, especially long-bone and pelvic injuries, may be associated with serious pulmonary complications.
Acute Respiratory Distress Syndrome
Severe trauma and systemic inflammation may contribute to acute respiratory distress syndrome.
Fat Embolism Syndrome
Fat embolism syndrome may follow long-bone or pelvic fractures and can produce respiratory, neurologic, and hematologic abnormalities.
Venous Thromboembolism
Deep venous thrombosis and pulmonary embolism are important risks, particularly in patients with lower-extremity fractures, major trauma, or prolonged immobility.
Complex Regional Pain Syndrome
The condition historically called reflex sympathetic dystrophy is now generally termed complex regional pain syndrome.
It may cause persistent pain, swelling, stiffness, and autonomic changes after fracture or surgery.
Post-Traumatic Arthritis
Fractures involving joint surfaces may eventually lead to degenerative arthritis, particularly when residual incongruity, cartilage injury, or instability remains.
Geriatric Considerations
Treatment decisions in older adults require careful balancing of operative risk against the consequences of immobility and deformity.
Common comorbidities include diabetes, coronary artery disease, peripheral vascular disease, osteoporosis, and frailty.
Early mobilization is often particularly important in this population.
Patient Monitoring
Patients with fractures should be followed clinically and radiographically until healing is established.
Serial assessment should evaluate alignment, stability, callus formation, pain, function, neurovascular status, implant position when applicable, and evidence of complications such as infection, nonunion, malunion, or post-traumatic arthritis.
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Orthopaedic Surgery - Foot and Ankle Anatomy and Examination
Basics
For normal function, the foot should be plantigrade, meaning that it rests evenly on the ground, and it should permit painless weight bearing and propulsion.
Foot and ankle function depends on coordinated activity of both extrinsic muscles, which originate in the leg, and intrinsic muscles, which originate within the foot.
Extrinsic Muscles
The major extrinsic muscle-tendon groups can be divided functionally into dorsiflexors, evertors, plantarflexors, and invertors.
Dorsiflexors
The principal anterior extensor tendons include the tibialis anterior, extensor digitorum longus, peroneus tertius, and extensor hallucis longus.
These tendons cross superficially over the anterior ankle and are readily palpable.
Because of their superficial position, they are vulnerable to laceration from sharp objects.
Evertors
The primary evertors are the peroneus longus and peroneus brevis.
Their muscle bellies lie along the lateral leg, and their tendons pass posterior to the lateral malleolus.
Damage to the peroneal tendon sheath or superior peroneal retinaculum may allow the tendons to subluxate or dislocate over the lateral malleolus.
Plantarflexors and Invertors
Several important tendons pass posteromedial to the ankle.
The posterior tibial tendon is the major dynamic inverter and an important supporter of the medial longitudinal arch.
In adults, posterior tibial tendon degeneration, tenosynovitis, or rupture can contribute to adult-acquired flatfoot deformity.
Extrinsic Toe Flexors
The major extrinsic flexors of the toes are the flexor digitorum longus and flexor hallucis longus.
They contribute to toe flexion and assist with propulsion during gait.
Intrinsic Foot Muscles
The intrinsic muscles consist of one dorsal layer and three plantar layers.
Together, they control fine toe movements, support the arches, and contribute to balance and stabilization during stance.
Muscle Imbalance
An imbalance between intrinsic and extrinsic muscle forces may contribute to deformities such as hammer toes, claw toes, and mallet toes.
Bony Anatomy
Most bones and major bony landmarks of the foot and ankle are readily palpable, making systematic examination particularly useful.
The foot is conventionally divided into the hindfoot, midfoot, and forefoot.
Ankle Joint
The ankle, or tibiotalar joint, is formed by the articulation of the distal tibia, fibula, and talus.
It primarily permits plantarflexion and dorsiflexion.
Range of Motion
Normal ankle motion is approximately 40° of plantarflexion and 20° of dorsiflexion, although values vary among individuals.
Ankle Ligaments
Syndesmotic Ligaments
The distal tibiofibular syndesmosis is stabilized by the anterior and posterior tibiofibular ligaments, together with other components of the syndesmotic complex.
Injury to this complex produces a high ankle sprain.
Deltoid Ligament
The superficial and deep portions of the deltoid ligament extend from the medial malleolus to the talus, calcaneus, and navicular region.
They provide important medial ankle stability.
Lateral Ligament Complex
The lateral ankle is supported by the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL).
The ATFL is the ligament most commonly injured during a typical inversion ankle sprain.
Hindfoot
The hindfoot consists principally of the talus and calcaneus.
These bones articulate at the subtalar joint.
Subtalar Motion
The subtalar joint permits inversion and eversion, with an overall motion arc of approximately 40°.
This motion allows the foot to adapt to irregular or uneven surfaces.
Talus
The talus is covered extensively by articular cartilage and has a relatively vulnerable blood supply.
Fracture or major subtalar dislocation can disrupt its vascular supply and lead to avascular necrosis.
Calcaneus
The calcaneus is the major weight-bearing bone of the heel and acts as an important shock absorber.
An axial load after a fall from height is a classic mechanism of calcaneal fracture.
Midfoot
The midfoot is organized into two principal rows.
Proximally, the navicular and cuboid articulate with the hindfoot.
Distally, the three cuneiforms and cuboid articulate with the metatarsals through the tarsometatarsal joints.
Tarsometatarsal Complex
Ligaments connect most adjacent metatarsal bases.
A notable exception exists between the first and second metatarsal bases, where there is no strong direct intermetatarsal ligament.
Lisfranc Ligament
The strong Lisfranc ligament extends from the medial cuneiform to the base of the second metatarsal.
It is a key stabilizer of the tarsometatarsal complex.
Forefoot
The forefoot consists of five metatarsals and 14 phalanges.
These structures contribute to balance, load distribution, and propulsion.
Gait Cycle
The gait cycle can be divided into stance and swing phases.
Stance Phase
The stance phase consists broadly of heel strike, foot-flat or midstance, and toe-off.
Heel Strike
At heel strike, the tibialis anterior and long toe extensors are active.
The foot undergoes pronation, which increases midfoot flexibility and allows better absorption of impact and accommodation to the ground.
Foot Flat
As weight progresses over the foot, the posterior tibialis and peroneal muscles contribute to dynamic control.
External rotation of the leg and subsequent foot supination help make the midfoot more rigid and stable for weight bearing.
Toe-Off
During push-off, the gastrocnemius-soleus complex becomes highly active.
This produces plantarflexion and propels the body forward.
Windlass Mechanism
Dorsiflexion of the toes, particularly the great toe, tightens the plantar fascia.
This windlass mechanism elevates the medial longitudinal arch and increases midfoot rigidity.
The foot is thereby converted from a flexible shock absorber into a stable lever for push-off.
Swing Phase
During swing, the tibialis anterior and long toe extensors remain active to dorsiflex the ankle and prevent the toes from dragging.
Clinical History
A thorough history should establish the nature of the patient’s symptoms and relevant systemic factors.
Acute Injury
For trauma, the mechanism should be documented carefully because it can suggest the injured bone, ligament, tendon, or joint.
Pain
Pain should be characterized according to severity, location, quality, radiation, duration, aggravating factors, and relieving factors.
Mechanical Symptoms
Locking, catching, clicking, giving way, or instability may suggest an intra-articular or ligamentous abnormality.
Neurologic Symptoms
The patient should be asked about numbness, dysesthesia, tingling, burning, or weakness.
Relevant Medical History
Important conditions include diabetes mellitus, neurologic disease, peripheral vascular disease, and inflammatory arthritis.
Surgical History
Previous surgery involving the foot, ankle, leg, or associated joints should be documented.
Functional History
Shoe wear, occupation, sports participation, and recreational activities can provide important information about repetitive loading and functional demands.
Physical Examination
The involved extremity should always be compared with the contralateral side.
The examination should be performed both standing and seated when possible.
Standing Examination
Alignment
While the patient stands, foot and ankle alignment should be observed.
Viewed from behind, the hindfoot can be categorized as varus, neutral, or valgus.
Too-Many-Toes Sign
When more lateral toes are visible from behind on the affected side than on the opposite side, the finding is called the too-many-toes sign.
This suggests forefoot abduction associated with collapse of the medial arch, as seen in flatfoot deformity.
Gait
The patient’s gait should be observed for abnormalities such as steppage gait, circumduction, scissoring, or an antalgic pattern.
Heel Rise
Double- and single-leg heel-rise testing evaluates dynamic foot function.
It helps assess posterior tibial tendon strength, arch reconstitution, hindfoot inversion, and balance.
Seated Examination
Vascular Examination
The dorsalis pedis pulse is palpated on the dorsum of the foot, typically just lateral to the extensor hallucis longus tendon.
The posterior tibial pulse is palpated posterior to the medial malleolus.
Venous Status
The foot and ankle should also be examined for pitting edema, venous stasis changes, skin discoloration, and other evidence of vascular insufficiency.
Sensory Examination
Sensation should be assessed according to peripheral nerve distribution.
Superficial Peroneal Nerve
The superficial peroneal nerve supplies most of the dorsum of the foot.
Deep Peroneal Nerve
The deep peroneal nerve is tested in the first dorsal web space.
Saphenous Nerve
The saphenous nerve supplies the medial border of the foot.
Sural Nerve
The sural nerve supplies the lateral border of the foot.
Tibial Nerve
The plantar surface of the foot is supplied primarily through branches of the tibial nerve.
Protective Sensation
The ability to perceive a 5.07 Semmes-Weinstein monofilament on the plantar surface correlates with protective sensation.
Loss of this sensation is particularly important in patients with diabetic or other peripheral neuropathy.
Neurologic Examination
Deep tendon reflexes should be assessed when appropriate.
The examination may also include evaluation for Babinski response and clonus when upper motor neuron disease is suspected.
Motor Examination
Strength testing should be combined with palpation of the corresponding tendons.
Ankle Dorsiflexion
Dorsiflexion primarily tests the tibialis anterior.
Ankle Plantarflexion
Plantarflexion is generated mainly by the gastrocnemius-soleus complex.
Eversion
Eversion evaluates the peroneal muscles.
Inversion
Inversion, especially with the foot slightly plantarflexed, assesses the posterior tibial tendon.
Great Toe Motion
Flexion of the distal phalanx of the great toe assesses the flexor hallucis longus, while extension tests the extensor hallucis longus.
Range of Motion
Both active and passive motion should be evaluated.
Ankle Motion
Ankle plantarflexion and dorsiflexion should be measured, preferably with any correctable hindfoot deformity brought into a neutral position.
Subtalar Motion
Hindfoot inversion and eversion assess the mobility of the subtalar joint.
Chopart Joint
Abduction and adduction through the transverse tarsal, or Chopart, joint can be assessed while stabilizing the hindfoot.
Lisfranc Joint
The tarsometatarsal complex should be palpated and stressed gently with plantarflexion and dorsiflexion of the metatarsals.
Pain or instability may indicate a Lisfranc injury.
Metatarsophalangeal and Toe Joints
Motion of the MTP and interphalangeal joints should be assessed for stiffness, instability, pain, and deformity.
Palpation
Systematic palpation helps localize pathology.
Malleoli
The medial and lateral malleoli should be palpated for tenderness suggestive of fracture or ligament injury.
Ankle Joint
The ankle joint should be assessed for joint-line tenderness or effusion, which may suggest synovitis or an osteochondral lesion.
Posterior Tibial Tendon
The posterior tibial tendon should be palpated from behind the medial malleolus to its insertion on the navicular.
Tenderness may indicate posterior tibial tendinitis or tendon dysfunction.
Navicular Tuberosity
The navicular tuberosity is located approximately 2 cm distal and plantar to the medial malleolus.
Tenderness in this region may reflect an accessory navicular, navicular stress fracture, posterior tibial tendon insertional pathology, or talonavicular disorder.
Achilles Tendon
The Achilles tendon and retrocalcaneal bursa should be palpated along the posterior ankle and hindfoot.
The examiner should look for defects, nodules, thickening, swelling, or tenderness suggestive of tendinopathy or rupture.
Peroneal Tendons
The peroneal tendons should be palpated posterior to the lateral malleolus.
The peroneus brevis can be followed to the base of the fifth metatarsal, while the peroneus longus passes beneath the foot through a groove near the cuboid.
Tenderness may reflect tendinitis or associated fifth-metatarsal pathology.
Peroneal Subluxation
The ankle can be circumducted while the tendons are observed and palpated for abnormal subluxation over the lateral malleolus.
Sinus Tarsi
The sinus tarsi lies approximately 1 cm distal to the lateral malleolus.
Tenderness may suggest subtalar joint inflammation or instability.
Syndesmosis
Tenderness between the distal tibia and fibula just proximal to the ankle joint raises concern for a syndesmotic, or high ankle, sprain.
Plantar Fascia
The plantar fascia should be palpated from its origin at the plantar calcaneus.
Tenderness near the medial plantar heel that becomes more pronounced with toe dorsiflexion is characteristic of plantar fasciitis.
Lisfranc Region
Tenderness at the base of the second metatarsal is concerning for a Lisfranc injury.
Plantar ecchymosis in this region is particularly significant.
Sesamoids
The plantar aspect of the great-toe MTP joint should be examined for tenderness related to sesamoiditis or sesamoid fracture.
Lesser Metatarsal Heads
Tenderness beneath the lesser MTP joints may indicate metatarsalgia.
Intermetatarsal Spaces
Tenderness in the metatarsal interspaces, sometimes accompanied by radiating paresthesias into the toes, may suggest an interdigital neuroma.
Special Tests
Anterior Drawer Test
The anterior drawer test assesses lateral ankle instability, particularly the ATFL.
The examiner stabilizes the distal tibia and translates the heel and talus anteriorly relative to the tibia.
The ATFL is stressed most effectively with the ankle in slight plantarflexion, whereas testing nearer neutral places relatively greater contribution on the broader lateral ligament complex.
Excessive anterior translation or a soft endpoint compared with the opposite ankle suggests instability.
Thompson Test
The Thompson test evaluates integrity of the Achilles tendon.
With the patient prone and the foot hanging freely, the examiner squeezes the calf.
An intact Achilles tendon produces plantarflexion of the foot.
Failure of plantarflexion strongly suggests Achilles tendon rupture.
Lesser-Toe Deformities
Mallet, hammer, and claw toe deformities should be assessed systematically.
Calluses
The location of callus formation helps identify areas of abnormal pressure.
Flexibility
The examiner should determine whether the deformity is flexible and manually correctable or rigid and fixed.
MTP Stability
A modified drawer test can assess MTP joint instability by attempting to translate and reduce the proximal phalanx relative to the metatarsal head.
Hallux Valgus Examination
Calluses and Medial Eminence
Callus formation and tenderness over the medial eminence should be documented.
MTP Motion
Range of motion of the first MTP joint should be assessed with the valgus deformity gently corrected.
This helps identify associated arthritis or stiffness.
First Tarsometatarsal Hypermobility
The lateral forefoot is stabilized while the first metatarsal is translated dorsally and plantarly.
Excessive mobility suggests first tarsometatarsal joint hypermobility.
Lesser-Toe Deformities
Associated lesser-toe deformities should be identified because they may contribute to pain and influence treatment planning.
Laboratory Tests
Laboratory testing is generally guided by the suspected diagnosis.
Suspected Infection
When infection is a concern, laboratory studies may include white blood cell count, erythrocyte sedimentation rate, and C-reactive protein.
Joint Aspiration
Synovial fluid from a suspicious joint should be sent for cell count with differential, Gram stain, culture, and crystal analysis.
Imaging
Plain Radiographs
Radiographs are the first-line imaging study for most structural foot and ankle disorders.
Acute Trauma
When acute fracture or dislocation is suspected and the patient cannot safely stand, non-weight-bearing radiographs are appropriate.
Weight-Bearing Radiographs
When the patient can stand safely, weight-bearing views are generally preferred for evaluation of alignment and deformity.
Standing radiographs demonstrate bony relationships under physiologic load and may reveal pathology that is not apparent on non-weight-bearing images.
Stress Radiographs
Stress views can indirectly assess the integrity of ligamentous structures by demonstrating abnormal joint translation or widening under applied force.
CT
CT provides excellent bony detail and is particularly useful for complex fracture patterns and disorders of the midfoot and hindfoot.
It is valuable for evaluating articular congruity and planning reconstruction.
MRI
MRI is especially useful for soft-tissue and occult osseous disorders.
It can demonstrate tendon and ligament injuries, soft-tissue masses, subtle fractures, marrow abnormalities, and infection.
Bone Scintigraphy
Technetium-99m bone scintigraphy can help localize pathology when pain is vague or multifocal.
It may detect stress fractures, tumors, and other metabolically active skeletal abnormalities, although MRI is often more specific for many modern indications.
General Examination Principles
A complete foot and ankle assessment combines history, standing alignment, gait analysis, vascular and neurologic examination, muscle testing, range of motion, palpation, provocative maneuvers, and appropriately selected imaging.
Because disorders of one region frequently alter mechanics elsewhere, the entire lower extremity should be considered rather than evaluating only the painful site.
- Published on
Orthopaedic Surgery - Foot and Ankle Anatomy and Examination
Basics
For normal function, the foot should be plantigrade, meaning that it rests evenly on the ground, and it should permit painless weight bearing and propulsion.
Foot and ankle function depends on coordinated activity of both extrinsic muscles, which originate in the leg, and intrinsic muscles, which originate within the foot.
Extrinsic Muscles
The major extrinsic muscle-tendon groups can be divided functionally into dorsiflexors, evertors, plantarflexors, and invertors.
Dorsiflexors
The principal anterior extensor tendons include the tibialis anterior, extensor digitorum longus, peroneus tertius, and extensor hallucis longus.
These tendons cross superficially over the anterior ankle and are readily palpable.
Because of their superficial position, they are vulnerable to laceration from sharp objects.
Evertors
The primary evertors are the peroneus longus and peroneus brevis.
Their muscle bellies lie along the lateral leg, and their tendons pass posterior to the lateral malleolus.
Damage to the peroneal tendon sheath or superior peroneal retinaculum may allow the tendons to subluxate or dislocate over the lateral malleolus.
Plantarflexors and Invertors
Several important tendons pass posteromedial to the ankle.
The posterior tibial tendon is the major dynamic inverter and an important supporter of the medial longitudinal arch.
In adults, posterior tibial tendon degeneration, tenosynovitis, or rupture can contribute to adult-acquired flatfoot deformity.
Extrinsic Toe Flexors
The major extrinsic flexors of the toes are the flexor digitorum longus and flexor hallucis longus.
They contribute to toe flexion and assist with propulsion during gait.
Intrinsic Foot Muscles
The intrinsic muscles consist of one dorsal layer and three plantar layers.
Together, they control fine toe movements, support the arches, and contribute to balance and stabilization during stance.
Muscle Imbalance
An imbalance between intrinsic and extrinsic muscle forces may contribute to deformities such as hammer toes, claw toes, and mallet toes.
Bony Anatomy
Most bones and major bony landmarks of the foot and ankle are readily palpable, making systematic examination particularly useful.
The foot is conventionally divided into the hindfoot, midfoot, and forefoot.
Ankle Joint
The ankle, or tibiotalar joint, is formed by the articulation of the distal tibia, fibula, and talus.
It primarily permits plantarflexion and dorsiflexion.
Range of Motion
Normal ankle motion is approximately 40° of plantarflexion and 20° of dorsiflexion, although values vary among individuals.
Ankle Ligaments
Syndesmotic Ligaments
The distal tibiofibular syndesmosis is stabilized by the anterior and posterior tibiofibular ligaments, together with other components of the syndesmotic complex.
Injury to this complex produces a high ankle sprain.
Deltoid Ligament
The superficial and deep portions of the deltoid ligament extend from the medial malleolus to the talus, calcaneus, and navicular region.
They provide important medial ankle stability.
Lateral Ligament Complex
The lateral ankle is supported by the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL).
The ATFL is the ligament most commonly injured during a typical inversion ankle sprain.
Hindfoot
The hindfoot consists principally of the talus and calcaneus.
These bones articulate at the subtalar joint.
Subtalar Motion
The subtalar joint permits inversion and eversion, with an overall motion arc of approximately 40°.
This motion allows the foot to adapt to irregular or uneven surfaces.
Talus
The talus is covered extensively by articular cartilage and has a relatively vulnerable blood supply.
Fracture or major subtalar dislocation can disrupt its vascular supply and lead to avascular necrosis.
Calcaneus
The calcaneus is the major weight-bearing bone of the heel and acts as an important shock absorber.
An axial load after a fall from height is a classic mechanism of calcaneal fracture.
Midfoot
The midfoot is organized into two principal rows.
Proximally, the navicular and cuboid articulate with the hindfoot.
Distally, the three cuneiforms and cuboid articulate with the metatarsals through the tarsometatarsal joints.
Tarsometatarsal Complex
Ligaments connect most adjacent metatarsal bases.
A notable exception exists between the first and second metatarsal bases, where there is no strong direct intermetatarsal ligament.
Lisfranc Ligament
The strong Lisfranc ligament extends from the medial cuneiform to the base of the second metatarsal.
It is a key stabilizer of the tarsometatarsal complex.
Forefoot
The forefoot consists of five metatarsals and 14 phalanges.
These structures contribute to balance, load distribution, and propulsion.
Gait Cycle
The gait cycle can be divided into stance and swing phases.
Stance Phase
The stance phase consists broadly of heel strike, foot-flat or midstance, and toe-off.
Heel Strike
At heel strike, the tibialis anterior and long toe extensors are active.
The foot undergoes pronation, which increases midfoot flexibility and allows better absorption of impact and accommodation to the ground.
Foot Flat
As weight progresses over the foot, the posterior tibialis and peroneal muscles contribute to dynamic control.
External rotation of the leg and subsequent foot supination help make the midfoot more rigid and stable for weight bearing.
Toe-Off
During push-off, the gastrocnemius-soleus complex becomes highly active.
This produces plantarflexion and propels the body forward.
Windlass Mechanism
Dorsiflexion of the toes, particularly the great toe, tightens the plantar fascia.
This windlass mechanism elevates the medial longitudinal arch and increases midfoot rigidity.
The foot is thereby converted from a flexible shock absorber into a stable lever for push-off.
Swing Phase
During swing, the tibialis anterior and long toe extensors remain active to dorsiflex the ankle and prevent the toes from dragging.
Clinical History
A thorough history should establish the nature of the patient’s symptoms and relevant systemic factors.
Acute Injury
For trauma, the mechanism should be documented carefully because it can suggest the injured bone, ligament, tendon, or joint.
Pain
Pain should be characterized according to severity, location, quality, radiation, duration, aggravating factors, and relieving factors.
Mechanical Symptoms
Locking, catching, clicking, giving way, or instability may suggest an intra-articular or ligamentous abnormality.
Neurologic Symptoms
The patient should be asked about numbness, dysesthesia, tingling, burning, or weakness.
Relevant Medical History
Important conditions include diabetes mellitus, neurologic disease, peripheral vascular disease, and inflammatory arthritis.
Surgical History
Previous surgery involving the foot, ankle, leg, or associated joints should be documented.
Functional History
Shoe wear, occupation, sports participation, and recreational activities can provide important information about repetitive loading and functional demands.
Physical Examination
The involved extremity should always be compared with the contralateral side.
The examination should be performed both standing and seated when possible.
Standing Examination
Alignment
While the patient stands, foot and ankle alignment should be observed.
Viewed from behind, the hindfoot can be categorized as varus, neutral, or valgus.
Too-Many-Toes Sign
When more lateral toes are visible from behind on the affected side than on the opposite side, the finding is called the too-many-toes sign.
This suggests forefoot abduction associated with collapse of the medial arch, as seen in flatfoot deformity.
Gait
The patient’s gait should be observed for abnormalities such as steppage gait, circumduction, scissoring, or an antalgic pattern.
Heel Rise
Double- and single-leg heel-rise testing evaluates dynamic foot function.
It helps assess posterior tibial tendon strength, arch reconstitution, hindfoot inversion, and balance.
Seated Examination
Vascular Examination
The dorsalis pedis pulse is palpated on the dorsum of the foot, typically just lateral to the extensor hallucis longus tendon.
The posterior tibial pulse is palpated posterior to the medial malleolus.
Venous Status
The foot and ankle should also be examined for pitting edema, venous stasis changes, skin discoloration, and other evidence of vascular insufficiency.
Sensory Examination
Sensation should be assessed according to peripheral nerve distribution.
Superficial Peroneal Nerve
The superficial peroneal nerve supplies most of the dorsum of the foot.
Deep Peroneal Nerve
The deep peroneal nerve is tested in the first dorsal web space.
Saphenous Nerve
The saphenous nerve supplies the medial border of the foot.
Sural Nerve
The sural nerve supplies the lateral border of the foot.
Tibial Nerve
The plantar surface of the foot is supplied primarily through branches of the tibial nerve.
Protective Sensation
The ability to perceive a 5.07 Semmes-Weinstein monofilament on the plantar surface correlates with protective sensation.
Loss of this sensation is particularly important in patients with diabetic or other peripheral neuropathy.
Neurologic Examination
Deep tendon reflexes should be assessed when appropriate.
The examination may also include evaluation for Babinski response and clonus when upper motor neuron disease is suspected.
Motor Examination
Strength testing should be combined with palpation of the corresponding tendons.
Ankle Dorsiflexion
Dorsiflexion primarily tests the tibialis anterior.
Ankle Plantarflexion
Plantarflexion is generated mainly by the gastrocnemius-soleus complex.
Eversion
Eversion evaluates the peroneal muscles.
Inversion
Inversion, especially with the foot slightly plantarflexed, assesses the posterior tibial tendon.
Great Toe Motion
Flexion of the distal phalanx of the great toe assesses the flexor hallucis longus, while extension tests the extensor hallucis longus.
Range of Motion
Both active and passive motion should be evaluated.
Ankle Motion
Ankle plantarflexion and dorsiflexion should be measured, preferably with any correctable hindfoot deformity brought into a neutral position.
Subtalar Motion
Hindfoot inversion and eversion assess the mobility of the subtalar joint.
Chopart Joint
Abduction and adduction through the transverse tarsal, or Chopart, joint can be assessed while stabilizing the hindfoot.
Lisfranc Joint
The tarsometatarsal complex should be palpated and stressed gently with plantarflexion and dorsiflexion of the metatarsals.
Pain or instability may indicate a Lisfranc injury.
Metatarsophalangeal and Toe Joints
Motion of the MTP and interphalangeal joints should be assessed for stiffness, instability, pain, and deformity.
Palpation
Systematic palpation helps localize pathology.
Malleoli
The medial and lateral malleoli should be palpated for tenderness suggestive of fracture or ligament injury.
Ankle Joint
The ankle joint should be assessed for joint-line tenderness or effusion, which may suggest synovitis or an osteochondral lesion.
Posterior Tibial Tendon
The posterior tibial tendon should be palpated from behind the medial malleolus to its insertion on the navicular.
Tenderness may indicate posterior tibial tendinitis or tendon dysfunction.
Navicular Tuberosity
The navicular tuberosity is located approximately 2 cm distal and plantar to the medial malleolus.
Tenderness in this region may reflect an accessory navicular, navicular stress fracture, posterior tibial tendon insertional pathology, or talonavicular disorder.
Achilles Tendon
The Achilles tendon and retrocalcaneal bursa should be palpated along the posterior ankle and hindfoot.
The examiner should look for defects, nodules, thickening, swelling, or tenderness suggestive of tendinopathy or rupture.
Peroneal Tendons
The peroneal tendons should be palpated posterior to the lateral malleolus.
The peroneus brevis can be followed to the base of the fifth metatarsal, while the peroneus longus passes beneath the foot through a groove near the cuboid.
Tenderness may reflect tendinitis or associated fifth-metatarsal pathology.
Peroneal Subluxation
The ankle can be circumducted while the tendons are observed and palpated for abnormal subluxation over the lateral malleolus.
Sinus Tarsi
The sinus tarsi lies approximately 1 cm distal to the lateral malleolus.
Tenderness may suggest subtalar joint inflammation or instability.
Syndesmosis
Tenderness between the distal tibia and fibula just proximal to the ankle joint raises concern for a syndesmotic, or high ankle, sprain.
Plantar Fascia
The plantar fascia should be palpated from its origin at the plantar calcaneus.
Tenderness near the medial plantar heel that becomes more pronounced with toe dorsiflexion is characteristic of plantar fasciitis.
Lisfranc Region
Tenderness at the base of the second metatarsal is concerning for a Lisfranc injury.
Plantar ecchymosis in this region is particularly significant.
Sesamoids
The plantar aspect of the great-toe MTP joint should be examined for tenderness related to sesamoiditis or sesamoid fracture.
Lesser Metatarsal Heads
Tenderness beneath the lesser MTP joints may indicate metatarsalgia.
Intermetatarsal Spaces
Tenderness in the metatarsal interspaces, sometimes accompanied by radiating paresthesias into the toes, may suggest an interdigital neuroma.
Special Tests
Anterior Drawer Test
The anterior drawer test assesses lateral ankle instability, particularly the ATFL.
The examiner stabilizes the distal tibia and translates the heel and talus anteriorly relative to the tibia.
The ATFL is stressed most effectively with the ankle in slight plantarflexion, whereas testing nearer neutral places relatively greater contribution on the broader lateral ligament complex.
Excessive anterior translation or a soft endpoint compared with the opposite ankle suggests instability.
Thompson Test
The Thompson test evaluates integrity of the Achilles tendon.
With the patient prone and the foot hanging freely, the examiner squeezes the calf.
An intact Achilles tendon produces plantarflexion of the foot.
Failure of plantarflexion strongly suggests Achilles tendon rupture.
Lesser-Toe Deformities
Mallet, hammer, and claw toe deformities should be assessed systematically.
Calluses
The location of callus formation helps identify areas of abnormal pressure.
Flexibility
The examiner should determine whether the deformity is flexible and manually correctable or rigid and fixed.
MTP Stability
A modified drawer test can assess MTP joint instability by attempting to translate and reduce the proximal phalanx relative to the metatarsal head.
Hallux Valgus Examination
Calluses and Medial Eminence
Callus formation and tenderness over the medial eminence should be documented.
MTP Motion
Range of motion of the first MTP joint should be assessed with the valgus deformity gently corrected.
This helps identify associated arthritis or stiffness.
First Tarsometatarsal Hypermobility
The lateral forefoot is stabilized while the first metatarsal is translated dorsally and plantarly.
Excessive mobility suggests first tarsometatarsal joint hypermobility.
Lesser-Toe Deformities
Associated lesser-toe deformities should be identified because they may contribute to pain and influence treatment planning.
Laboratory Tests
Laboratory testing is generally guided by the suspected diagnosis.
Suspected Infection
When infection is a concern, laboratory studies may include white blood cell count, erythrocyte sedimentation rate, and C-reactive protein.
Joint Aspiration
Synovial fluid from a suspicious joint should be sent for cell count with differential, Gram stain, culture, and crystal analysis.
Imaging
Plain Radiographs
Radiographs are the first-line imaging study for most structural foot and ankle disorders.
Acute Trauma
When acute fracture or dislocation is suspected and the patient cannot safely stand, non-weight-bearing radiographs are appropriate.
Weight-Bearing Radiographs
When the patient can stand safely, weight-bearing views are generally preferred for evaluation of alignment and deformity.
Standing radiographs demonstrate bony relationships under physiologic load and may reveal pathology that is not apparent on non-weight-bearing images.
Stress Radiographs
Stress views can indirectly assess the integrity of ligamentous structures by demonstrating abnormal joint translation or widening under applied force.
CT
CT provides excellent bony detail and is particularly useful for complex fracture patterns and disorders of the midfoot and hindfoot.
It is valuable for evaluating articular congruity and planning reconstruction.
MRI
MRI is especially useful for soft-tissue and occult osseous disorders.
It can demonstrate tendon and ligament injuries, soft-tissue masses, subtle fractures, marrow abnormalities, and infection.
Bone Scintigraphy
Technetium-99m bone scintigraphy can help localize pathology when pain is vague or multifocal.
It may detect stress fractures, tumors, and other metabolically active skeletal abnormalities, although MRI is often more specific for many modern indications.
General Examination Principles
A complete foot and ankle assessment combines history, standing alignment, gait analysis, vascular and neurologic examination, muscle testing, range of motion, palpation, provocative maneuvers, and appropriately selected imaging.
Because disorders of one region frequently alter mechanics elsewhere, the entire lower extremity should be considered rather than evaluating only the painful site.
- Published on
Orthopaedic Surgery - Flexor Tendon Laceration
Basics
Flexor tendon lacerations may occur anywhere along the volar surface of the fingers, palm, wrist, or forearm.
They are commonly described according to the anatomic zone of injury because tendon anatomy, repair technique, rehabilitation, and prognosis vary substantially by location.
Flexor Tendon Zones
For the fingers, flexor tendon injuries are traditionally divided into Zones I through V.
The thumb has a corresponding three-zone classification.
Zone I
Zone I extends from the fingertip proximally to the proximal interphalangeal (PIP) flexion crease.
In this region, the flexor digitorum profundus (FDP) is the principal flexor tendon because the flexor digitorum superficialis (FDS) inserts more proximally.
Zone II
Zone II extends from the PIP flexion crease proximally to the distal palmar transverse crease near the A1 pulley.
Both the FDS and FDP tendons travel together within the flexor sheath in this region.
Zone II: “No-Man’s Land”
Zone II was historically called “no-man’s land” because repairs in this region were associated with a particularly high risk of postoperative adhesions, scarring, and poor tendon gliding.
The anatomy is complex because both the superficial and deep flexor tendons pass through a confined fibro-osseous pulley system.
Modern repair techniques and early mobilization protocols have substantially improved outcomes, but Zone II injuries remain technically demanding.
Zone III
Zone III extends from the distal palmar transverse crease proximally to the distal wrist flexion crease or transverse carpal ligament.
Zone IV
Zone IV corresponds to the carpal tunnel.
Multiple flexor tendons and the median nerve are closely packed within this confined space, so associated injuries may be substantial.
Zone V
Zone V is located proximal to the carpal tunnel, extending into the distal forearm.
Lacerations in this region may involve multiple tendons together with the median or ulnar nerves and major vessels.
Classification
Flexor tendon injuries are described according to both the specific tendon injured and the zone of injury.
They may involve the FDS, FDP, flexor pollicis longus, or combinations of these structures.
Function
Each flexor tendon contributes to finger strength, coordinated motion, and independent digital control.
The FDS primarily flexes the PIP joint, whereas the FDP flexes the DIP joint and also contributes to flexion of more proximal joints.
Epidemiology
Approximately 25% of flexor tendon lacerations occur in the workplace.
Males are affected substantially more often than females, with reported male-to-female ratios of approximately 3–6:1.
Risk Factors
The principal risk factor is occupational or recreational exposure to sharp objects or machinery.
Etiology
Most injuries result from a sharp penetrating mechanism such as a knife, broken glass, sheet metal, or other cutting object.
Crush or high-energy injuries may produce more extensive tendon and soft-tissue damage and generally have a worse prognosis.
Associated Injuries
Flexor tendon lacerations may occur with injuries to adjacent structures.
Digital Nerve Injury
Digital nerve laceration accompanies approximately one-quarter of flexor tendon injuries in some series.
Digital Artery Injury
Digital arteries may also be disrupted, potentially compromising perfusion of the involved finger.
Pulley Injury
The annular or cruciate pulley system may be damaged, particularly in deeper lacerations.
Pulley loss can impair tendon gliding and produce bowstringing.
Joint Injury
A laceration may penetrate the flexor tendon sheath or enter the interphalangeal or metacarpophalangeal joint, producing a traumatic arthrotomy.
Fracture
Associated phalangeal or metacarpal fractures may occur, particularly with high-energy mechanisms.
Diagnosis
Signs and Symptoms
The typical injury is a laceration over the palmar aspect of the finger, hand, or wrist.
Loss of tendon continuity alters the resting posture of the finger.
Change in Finger Posture
The injured finger may rest in greater extension than the adjacent digits because normal flexor tendon tension has been lost.
Comparison with the opposite hand and neighboring fingers is useful.
Loss of Active Flexion
The patient may be unable to actively flex the joint controlled by the injured tendon.
The exact deficit depends on whether the FDS, FDP, or both have been divided.
Loss of Tenodesis
Normally, passive wrist extension causes the fingers to flex because of the tenodesis effect.
Loss of this automatic finger flexion may indicate flexor tendon disruption.
Wrist Squeeze Test
In children or uncooperative patients, squeezing the forearm or flexor muscle mass can produce passive finger flexion when the tendons are intact.
Failure of the expected motion raises concern for tendon injury.
Physical Examination
A careful examination should be completed before local anesthesia whenever possible so that motor, sensory, and vascular function can be accurately documented.
Flexor Digitorum Profundus Testing
To test the FDP, the examiner stabilizes the PIP joint and other proximal joints in extension while asking the patient to actively flex the DIP joint.
Ability to flex the DIP indicates an intact FDP tendon.
Failure suggests FDP disruption or dysfunction.
Flexor Digitorum Superficialis Testing
To isolate the FDS, the examiner holds the other fingers in full extension and asks the patient to flex the finger being tested.
With the other digits immobilized, the tested finger should primarily flex at the PIP joint.
Failure to flex the PIP suggests FDS injury, although anatomic variations must be considered.
Strength Testing
Each finger should be assessed individually for flexion strength.
Weakness may indicate a partial tendon injury even when active motion remains present.
Tenodesis Examination
The wrist is passively moved through flexion and extension while the examiner observes the normal cascade of the fingers.
Abnormal movement suggests disruption of the flexor mechanism.
Vascular Examination
Perfusion must be assessed carefully.
Evaluation may include capillary refill, skin color, temperature, pulse oximetry, and Doppler assessment.
A poorly perfused or dysvascular digit is a surgical emergency.
Sensory Examination
Adjacent digital nerves should be tested before anesthetic injection.
Light touch and two-point discrimination are particularly useful for identifying digital nerve injury.
Wound Exploration
The wound should be carefully evaluated for evidence of partial or complete tendon injury, pulley disruption, foreign material, fracture, and joint penetration.
Exploration should be performed in a controlled fashion to avoid additional damage.
Imaging
Plain Radiographs
Radiographs should be obtained when there is concern for fracture, dislocation, bony avulsion, or retained radiopaque foreign body.
Ultrasound
Ultrasound can identify tendon discontinuity and may be useful when the physical examination is uncertain.
MRI
MRI can also demonstrate flexor tendon injury but is rarely necessary when the history and examination clearly establish the diagnosis.
Differential Diagnosis
Phalangeal Fracture-Dislocation
A fracture or dislocation involving the phalanx or interphalangeal joint can produce pain and loss of active flexion that resembles tendon injury.
Tendon Avulsion
A tendon may be avulsed from its insertion without an open laceration.
An important example is FDP avulsion from the distal phalanx.
Tendon Rupture
Closed tendon rupture can also result in loss of flexion.
Pulley Rupture
Pulley disruption may cause pain and abnormal tendon mechanics while preserving some active flexion.
Initial Treatment
Vascular Assessment
The first priority is to determine whether the finger and hand are adequately perfused.
A dysvascular digit or hand requires emergent operative evaluation.
Severe Associated Injury
Open fractures, major tissue loss, vascular injury, or gross contamination also require urgent surgical management.
Tetanus Prophylaxis
Tetanus immunization status should be reviewed and prophylaxis administered when indicated.
Wound Irrigation
The wound should be thoroughly irrigated with normal saline and gross contamination removed.
Antibiotics
Antibiotic administration depends on contamination, mechanism of injury, open fracture, bite exposure, and other risk factors.
A perioperative intravenous dose may be given for selected injuries according to local protocols.
Elevation and Splinting
The hand should be elevated and placed in a protective splint until definitive surgical assessment is completed.
Specialist Consultation
Early consultation with a hand surgeon or orthopaedic surgeon experienced in tendon repair is appropriate.
Factors Affecting Management
Treatment planning should consider hand dominance, occupation, time since injury, injury zone, tendon involvement, associated neurovascular injury, contamination, and patient comorbidities.
Physical Therapy and Hand Therapy
Postoperative hand therapy is an essential part of treatment.
The goal is to protect the repair while restoring tendon glide and preventing stiffness and adhesions.
Timing
Passive motion is commonly initiated within approximately 3–5 days after surgery, depending on the strength of the repair and the rehabilitation protocol.
Early Active Motion
Early active-motion protocols are increasingly used when a sufficiently strong repair has been achieved and the patient can follow restrictions reliably.
Immobilization
Children, cognitively impaired patients, or adults who cannot comply with movement restrictions may require more prolonged immobilization to protect the repair.
Surgery
Timing of Repair
Primary repair generally provides the best functional outcome.
Repair is preferably performed during the acute period, often within approximately 7–10 days of injury.
Delayed primary repair may still be possible, but direct repair becomes more difficult as tendon retraction, scarring, and muscle shortening develop.
Chronic Injuries
Injuries older than approximately 3–4 weeks often cannot be treated with straightforward primary repair and may require tendon grafting, staged reconstruction, or other reconstructive techniques.
Anesthesia
Repair may be performed under general anesthesia, regional anesthesia, or wide-awake local anesthesia without tourniquet (WALANT), depending on injury pattern and surgeon preference.
Flexor Tendon Sheath Injury
When the flexor tendon sheath is also disrupted, timely repair is desirable because excessive scarring can impair tendon gliding and worsen the functional result.
Surgical Exploration
The wound is extended as necessary to identify the full extent of injury.
The surgeon evaluates the tendon, pulley system, nerves, vessels, joints, and bone.
Minimizing Tissue Trauma
Meticulous technique is important because additional surgical trauma promotes scar formation and adhesions.
Sequence of Repair
After all injuries have been identified, flexor tendon repair is generally completed before nerve and vascular repair.
Tendon Repair Technique
A variety of core suture patterns can be used.
The repair must provide enough strength for early motion while remaining sufficiently smooth and compact to glide through the tendon sheath and pulley system.
Core Sutures
Repair strength generally increases with the number of core suture strands crossing the repair site.
Modern repairs commonly use at least four core strands, with some techniques using six or more.
Epitendinous Suture
An additional circumferential epitendinous suture is commonly placed to improve repair strength and smooth the tendon surface.
Zone II Repair
Zone II injuries require particular attention because both the FDS and FDP pass through the pulley system.
FDP
The FDP is repaired to restore DIP flexion and overall digital function.
FDS
Depending on tendon damage, available space within the sheath, and intraoperative tendon gliding, the surgeon may repair both FDS slips, one slip, or neither, balancing strength against the risk of excessive bulk and adhesions.
Postoperative Splinting
A dorsal blocking splint is typically applied after repair.
The wrist is generally maintained in neutral to slight flexion, the MCP joints are flexed to approximately 70°, and the interphalangeal joints are kept near extension.
Hand Therapy
The splint is removed or adjusted under controlled conditions during supervised hand therapy, which commonly begins within 3–5 days.
The exact rehabilitation protocol depends on the injury zone and strength of repair.
Follow-Up
Prognosis
Outcome depends strongly on the location, mechanism, severity, and associated injuries.
Clean sharp lacerations generally have a better prognosis than crush, avulsion, contaminated, or high-energy injuries.
Zone II Prognosis
Zone II injuries remain particularly prone to postoperative stiffness and adhesion formation because of the complex tendon-pulley anatomy.
Complications
Loss of Motion
Reduced range of motion may result from scar formation, tendon adhesions, joint stiffness, or inadequate rehabilitation.
Adhesions
Adhesions can tether the repaired tendon to surrounding tissue and limit active flexion despite preserved passive motion.
Loss of Strength
Persistent weakness may occur even after successful healing.
Infection
Infection may complicate contaminated wounds, open fractures, joint injuries, or tendon sheath injuries.
Tendon Rerupture
The repair may rupture if excessive force is applied before adequate healing occurs.
Rerupture may require repeat repair or reconstruction.
Delayed Reconstruction
Severe scarring, chronic tendon loss, failed primary repair, or rerupture may necessitate tendon grafting, staged tendon reconstruction, or tendon transfer.
Patient Monitoring
Follow-up should closely assess wound healing, vascular status, tendon integrity, active and passive range of motion, scar formation, adhesion development, strength, and compliance with splinting and therapy.
Early recognition of excessive stiffness or repair failure allows rehabilitation or surgical planning to be modified before permanent functional loss develops.
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Orthopaedic Surgery - Flatfoot
Basics
Flatfoot, or pes planus, is a condition in which the normal medial longitudinal arch of the foot is reduced or absent.
It may be an asymptomatic normal variant or a painful deformity caused by an underlying structural, neurologic, inflammatory, degenerative, or tendon-related disorder.
Normal Development
A flat-appearing foot is common in infants and young children because the medial longitudinal arch is not yet fully developed.
Physiologic flatfoot may therefore be normal up to approximately 5 years of age.
Classification
Flatfoot can be classified according to flexibility and according to whether it develops during childhood or adulthood.
Flexible Flatfoot
A flexible flatfoot demonstrates loss of the medial arch during weight bearing.
The arch reappears when the patient is non-weight bearing or rises onto the toes.
The hindfoot remains mobile and its valgus alignment can generally correct toward neutral or varus.
Rigid Flatfoot
A rigid flatfoot lacks a normal medial arch both during weight bearing and when the foot is unloaded.
Hindfoot motion is restricted, and valgus deformity does not correct with toe standing.
Rigid flatfoot is more likely to reflect an underlying structural abnormality.
Pediatric Versus Adult Flatfoot
The age at onset provides important diagnostic information.
Pediatric flatfoot is commonly developmental or congenital, whereas adult-onset deformity more often results from posterior tibial tendon dysfunction, arthritis, neuropathic disease, or previous trauma.
Epidemiology
Congenital Flexible Flatfoot
Flexible flatfoot commonly runs in families, although the precise inheritance pattern is uncertain.
Persistent flexible flatfoot has been reported in approximately 14% of adults.
Tarsal Coalition
Tarsal coalition is an important cause of congenital or developmental rigid flatfoot.
Some forms demonstrate familial inheritance, classically described as autosomal dominant with variable penetrance.
Reported prevalence varies widely, from less than 1% to more than 10%, partly because many cases remain asymptomatic.
Adult-Acquired Flatfoot
Posterior tibial tendon dysfunction is one of the most common causes of acquired flatfoot in adults.
The exact population incidence is uncertain.
Risk Factors
Flexible Pediatric Flatfoot
A positive family history increases the likelihood of persistent flexible flatfoot.
Tarsal Coalition
Family history is an important risk factor for tarsal coalition.
Some reports have also described a higher frequency in females.
Posterior Tibial Tendon Dysfunction
Risk factors for adult-acquired flatfoot related to posterior tibial tendon degeneration include hypertension, diabetes mellitus, obesity, and previous trauma.
Other Predisposing Conditions
Additional disorders associated with flatfoot include a tight Achilles tendon, neurologic or neuromuscular disease, inflammatory arthritis, osteoarthritis, post-traumatic arthritis, and Charcot neuroarthropathy.
Neurologic causes may include conditions such as spina bifida, myelodysplasia, stroke, or other disorders affecting muscle balance and foot mechanics.
Etiology
Congenital Flexible Flatfoot
Flexible pediatric flatfoot is usually developmental and may have a familial predisposition.
Tarsal Coalition
Tarsal coalition results from abnormal congenital connection between two or more tarsal bones.
The connection may be fibrous, cartilaginous, or osseous.
Posterior Tibial Tendon Dysfunction
Adult-acquired flatfoot commonly results from degeneration, attenuation, elongation, or rupture of the posterior tibial tendon.
As tendon function deteriorates, the medial arch progressively collapses and the hindfoot drifts into valgus.
Charcot Neuroarthropathy
Flatfoot resulting from Charcot neuroarthropathy develops because of bone fragmentation, resorption, fracture, joint instability, and progressive collapse.
Other Causes
Other important causes include congenital vertical talus, peroneal spastic flatfoot, previous trauma, and severe structural deformity.
Diagnosis
Signs and Symptoms
The most obvious feature is a low or absent medial longitudinal arch.
Some patients remain completely asymptomatic.
Others develop pain, fatigue, swelling, or progressive deformity.
Pain
Pain is commonly felt along the medial arch or medial ankle.
Symptoms may worsen with prolonged walking, sports, high levels of activity, or following trauma.
Progressive Deformity
Some forms of flatfoot gradually worsen with time, particularly adult-acquired flatfoot related to posterior tibial tendon dysfunction.
Shoe Wear
Abnormal loading may produce increased wear along the medial aspect of the shoe.
History
The history should establish age at onset, progression, family history, activity level, previous trauma, neurologic or systemic disease, and associated pain or swelling.
Pediatric History
Pediatric flexible flatfoot is often noted from an early age.
Parents may report fatigue, decreased endurance, difficulty participating in sports, or pain after prolonged activity.
Adult-Acquired Flatfoot
Posterior tibial tendon dysfunction commonly presents as gradually progressive aching and swelling along the medial ankle and foot.
With progression, the foot may flatten and abduct, and walking becomes increasingly difficult.
Physical Examination
Determining Flexibility
The most important initial examination step is determining whether the flatfoot is flexible or rigid.
This distinction substantially narrows the differential diagnosis and influences treatment.
Rigid Flatfoot
In rigid flatfoot, the medial longitudinal arch remains absent during both weight bearing and non-weight bearing.
Hindfoot motion is limited, and the valgus deformity does not correct when the patient rises onto the toes.
Flexible Flatfoot
In flexible flatfoot, the arch disappears during standing but reconstitutes when the foot is unloaded or during toe standing.
The hindfoot remains mobile and usually moves from valgus toward neutral or varus with heel rise.
Forefoot Abduction
Increasing deformity may produce lateral deviation of the forefoot relative to the hindfoot.
This creates the characteristic “too many toes” sign when the patient is viewed from behind.
Posterior Tibial Tendon Examination
Resisted Inversion
Strength of inversion should be tested against resistance.
Weakness or inability to invert the foot may indicate posterior tibial tendon dysfunction.
Single-Leg Heel Rise
The patient is asked to rise onto the toes while standing on the affected limb.
Pain, weakness, inability to perform the maneuver, or failure of the hindfoot to move into varus suggests posterior tibial tendon insufficiency.
Inspection and Palpation
The foot should be inspected for arch collapse, hindfoot valgus, forefoot abduction, swelling, callosities, and asymmetry.
Tenderness should be localized carefully, particularly along the posterior tibial tendon, subtalar region, midfoot, and medial arch.
Gait Examination
Gait should be observed for pain, weakness, or abnormal propulsion.
Antalgic Gait
A painful limp may suggest arthritis, tendon inflammation, stress injury, or another painful structural disorder.
Posterior Tibial Tendon Dysfunction
Patients with posterior tibial tendon dysfunction may demonstrate reduced push-off and impaired propulsion.
Neurologic Gait
An awkward or foot-slapping gait raises concern for an underlying neurologic or neuromuscular disorder.
Achilles Tendon
The Achilles tendon should be assessed for tightness.
Limited ankle dorsiflexion caused by gastrocnemius-Achilles contracture can worsen a flatfoot deformity and contribute to symptoms.
Imaging
Weight-Bearing Radiographs
Imaging should be obtained while the patient is standing whenever possible because deformity is best appreciated under physiologic load.
Standard evaluation may include weight-bearing AP, lateral, and oblique views of the foot, with ankle views when ankle or hindfoot pathology is suspected.
Calcaneal Pitch
The calcaneal pitch decreases as the medial longitudinal arch collapses.
In severe flatfoot it may approach 0°.
Talus–First Metatarsal Angle
The relationship between the talus and first metatarsal can be assessed on weight-bearing radiographs.
Normally, these structures are nearly collinear.
Increasing angular divergence reflects progressive arch collapse.
Severity
Historically, an angle of approximately 15° or less has been considered mild, 15–30° moderate, and greater than 30° severe, although interpretation depends on the exact measurement method and clinical context.
Imaging for Tarsal Coalition
Oblique Radiographs
An oblique foot radiograph may demonstrate a calcaneonavicular coalition.
CT
CT is particularly useful for defining a talocalcaneal coalition, determining its extent, and assessing associated degenerative change.
Arthritis
Cross-sectional imaging can also assess the degree of subtalar, hindfoot, or midfoot arthritis.
Imaging for Charcot Arthropathy
Radiographs should be evaluated for fragmentation, collapse, subluxation, sclerosis, and resorption, all of which may indicate Charcot neuroarthropathy.
MRI
MRI is useful for evaluating posterior tibial tendon degeneration, tenosynovitis, partial tearing, or rupture.
It can also assess associated ligament and soft-tissue pathology.
Pathological Findings
Charcot Neuroarthropathy
Pathologic changes include bone fragmentation, fracture, resorption, and progressive joint collapse.
Posterior Tibial Tendon Dysfunction
The tendon may demonstrate degeneration, thickening, attenuation, tenosynovitis, or tearing.
Tarsal Coalition
A coalition may consist of fibrous, fibrocartilaginous, or osseous tissue between adjacent tarsal bones.
Differential Diagnosis
Pediatric Flatfoot
Important pediatric causes include benign flexible flatfoot, tarsal coalition, congenital vertical or oblique talus, and accessory navicular.
Adult-Acquired Flatfoot
In adults, the differential diagnosis includes posterior tibial tendon dysfunction or rupture, midfoot arthritis, Charcot neuroarthropathy, and neuromuscular disease.
Treatment
General Principles
Asymptomatic flatfoot does not require treatment.
Education and reassurance are appropriate, particularly in children with benign flexible flatfoot.
Treatment is directed toward symptoms and the underlying cause rather than the appearance of the foot alone.
Pediatric Flexible Flatfoot
Asymptomatic Children
No treatment is necessary when the child has painless, flexible flatfoot with normal function.
Activity-Related Pain
If symptoms occur with activity, supportive shoes may be helpful.
A prefabricated or custom medial arch support can be considered for comfort.
Orthoses
Orthotic devices may reduce symptoms in some children, but they do not reliably create a permanent arch or alter the natural structural development of the foot.
Evidence supporting routine use in asymptomatic children is limited.
Tarsal Coalition
Initial treatment of a symptomatic coalition may include rest, temporary activity restriction, NSAIDs, and immobilization in a below-knee cast or walking boot.
Immobilization
Short-term immobilization may substantially reduce pain by limiting motion across the symptomatic coalition.
Tight Achilles Tendon
Flatfoot associated with a tight heel cord may improve symptomatically with Achilles and gastrocnemius stretching.
Physical therapy can assist with a structured stretching program.
Adult-Acquired Flatfoot From Posterior Tibial Tendon Dysfunction
Initial treatment may include rest, NSAIDs, temporary immobilization, orthotic support, bracing, and weight reduction when appropriate.
Immobilization
An acute painful episode may be treated with a below-knee cast or walking boot to reduce tendon loading.
Long-Term Support
Custom arch supports or an ankle-foot orthosis may help control hindfoot valgus and support the medial arch.
Corticosteroid Injection
Direct corticosteroid injection into the posterior tibial tendon is generally avoided because of concern for tendon weakening or rupture.
Midfoot Arthritis
Treatment may include orthotic arch support, NSAIDs, footwear modification, rocker-bottom soles, stiff or steel-shank shoes, and selected intra-articular corticosteroid injections.
Charcot Arthropathy
Acute Phase
Acute Charcot neuroarthropathy requires off-loading and immobilization, commonly with a total-contact cast or equivalent protective device.
Weight bearing may need to be restricted depending on severity.
Long-Term Management
After the acute inflammatory phase settles, custom orthoses, bracing, and protective footwear may be required.
Surgery is reserved for severe deformity, instability, recurrent ulceration, or failure of nonoperative treatment.
Physical Therapy
Physical therapy can improve ankle and foot mobility, strength, gait, and Achilles flexibility.
It is particularly useful when heel-cord tightness contributes to symptoms.
Orthotic Services
An orthotist may fabricate custom arch supports or braces when more substantial mechanical control is needed.
Medication
NSAIDs may be useful when pain and swelling are significant.
They are particularly helpful during episodes of posterior tibial tendinitis, arthritis, or other inflammatory symptoms.
Surgery
Surgery is rarely required for uncomplicated flexible flatfoot.
It is considered when there is persistent pain despite appropriate conservative treatment, progressive deformity, instability, or rigid structural abnormality.
Surgical Planning
The choice of procedure depends on patient age, activity level, deformity flexibility, degree of arthritis, underlying cause, and medical comorbidities.
Procedures may include soft-tissue reconstruction, osteotomy, coalition resection, or arthrodesis.
Pediatric Flexible Flatfoot Surgery
When surgery is required for a symptomatic flexible deformity, treatment generally involves osteotomies designed to restore alignment, correct hindfoot valgus, and improve foot mechanics.
Soft-tissue procedures may be added when necessary.
Tarsal Coalition Surgery
Coalition Resection
A symptomatic coalition that fails conservative treatment may be resected.
Interposition of fat, muscle, or another tissue may be used to reduce the risk of reformation.
Subtalar Arthrodesis
If a talocalcaneal coalition involves a large portion of the subtalar joint, historically more than approximately 50%, or if substantial degenerative arthritis is present, subtalar fusion may be preferred over resection.
Achilles Tendon Lengthening
Persistent equinus caused by a tight Achilles tendon may require surgical lengthening.
Techniques include Z-lengthening or controlled partial tendon lengthening, depending on severity and age.
Posterior Tibial Tendon Surgery
Early Disease
In early posterior tibial tendon disease with relatively preserved tendon structure and alignment, synovectomy or debridement may occasionally be sufficient.
Flexible Deformity
Flexible adult-acquired flatfoot may require a combination of tendon transfer, calcaneal osteotomy, midfoot osteotomy, ligament reconstruction, or limited arthrodesis.
Rigid Deformity
When the deformity becomes rigid or significant arthritis is present, fusion procedures are often required.
Follow-Up
Prognosis
Most patients with flexible flatfoot do not develop progressive deformity and never require corrective surgery.
Children with asymptomatic flexible flatfoot generally have an excellent prognosis.
Adult-Acquired Flatfoot
Posterior tibial tendon dysfunction is an important exception because it may progressively worsen from a flexible deformity to a rigid arthritic flatfoot if untreated.
Complications
Most patients managed nonoperatively have little risk of major complications.
Persistent pain, worsening deformity, arthritis, callus formation, and reduced mobility may occur when the underlying disorder progresses.
Posterior Tibial Tendon Dysfunction
Progressive tendon insufficiency may cause increasing hindfoot valgus, forefoot abduction, arch collapse, ligament failure, and eventually rigid deformity with arthritis.
Patient Monitoring
Follow-up frequency depends on the underlying cause and severity.
Symptomatic or progressive patients may be reassessed at approximately 3-month intervals initially.
Monitoring should document pain, function, arch height, hindfoot alignment, flexibility, single-leg heel-rise ability, gait, shoe wear, and progression of deformity.
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Orthopaedic Surgery - Fibula Fracture
Basics
Fibular fractures are classified anatomically as proximal, midshaft, or distal fractures.
Because the fibula participates in both the knee and ankle complexes, an apparently isolated fibular fracture may be associated with injury to the tibia, tibiofibular syndesmosis, ankle joint, or knee.
Associated Structural Injury
A truly isolated fibular fracture is relatively uncommon.
In many cases, the amount or direction of force required to fracture the fibula also injures other structures within the leg.
For this reason, examination should never be limited to the site of maximal fibular tenderness.
Distal Fibula Fractures
Fractures of the distal fibula involving the ankle are by far the most common type.
These injuries are generally considered within the broader category of ankle fractures.
Fibular Shaft Fractures
A fibular shaft fracture without an associated ankle injury is frequently accompanied by a tibial shaft fracture.
The tibia therefore must be evaluated carefully when a shaft fracture of the fibula is identified.
Proximal Fibula Fractures
Fractures involving the fibular head or neck may be associated with substantial injury around the knee.
They can occur after a direct blow or as an avulsion injury involving the insertion of the biceps femoris tendon or lateral collateral ligament (LCL).
Because the common peroneal nerve courses around the fibular neck, it is vulnerable in this region.
Maisonneuve Fracture
A Maisonneuve fracture is a proximal fibular fracture associated with disruption of the distal tibiofibular syndesmosis and medial-sided ankle injury.
It results from a rotational mechanism transmitted upward through the ankle and interosseous membrane.
Mechanism
External rotation at the ankle can injure the deltoid ligament or medial malleolus and disrupt the distal tibiofibular ligaments.
The tear may then propagate proximally through the interosseous membrane.
As the rotational force continues upward, stress becomes concentrated in the proximal fibula, producing a fracture.
Clinical Importance
A Maisonneuve fracture may be overlooked if attention is directed only to the ankle.
Conversely, a patient presenting with a proximal fibular fracture must always undergo careful examination of the medial ankle and syndesmosis.
Epidemiology
Fibular fractures, particularly those involving the distal fibula and ankle, are among the most commonly encountered fractures in orthopaedic practice.
Etiology
Common mechanisms include direct trauma, falls, missteps, sports injuries, and penetrating trauma such as gunshot wounds.
The pattern of associated injury depends on the direction and magnitude of force.
Associated Conditions
Fibular fractures may occur together with:
Tibial shaft fractures, tibial plateau fractures, leg compartment syndrome, medial or lateral collateral ligament injuries of the knee, biceps femoris tendon injury, common peroneal nerve palsy, interosseous membrane rupture, deltoid ligament injury, syndesmotic disruption, and medial malleolar fracture.
Classification
Fibular fractures may be broadly divided into:
Proximal fibula fractures, midshaft fibula fractures, and distal fibula or ankle fractures.
Management depends less on the fibular fracture alone and more on the stability of the associated knee, ankle, tibia, and syndesmosis.
Diagnosis
Signs and Symptoms
Patients with fibular head or shaft fractures commonly present with localized tenderness, swelling, and pain over the injured region.
Neurologic Symptoms
Numbness, tingling, or weakness may indicate injury to the common peroneal nerve, particularly with proximal fibular fractures.
Associated Knee Injury
If the knee has also been injured, patients may have knee swelling, instability, and pain with weight bearing or ligament testing.
Maisonneuve Injury
Patients with a Maisonneuve fracture may have tenderness and swelling over the proximal fibula together with medial ankle pain or swelling.
Ankle symptoms may be more prominent than pain at the actual fibular fracture site.
Physical Examination
Fibula
The entire fibula should be palpated for focal tenderness and swelling.
This is particularly important in patients who initially present with an ankle injury.
Ankle Examination
The ankle must always be examined for medial tenderness, instability, syndesmotic pain, and swelling.
A proximal fibular fracture combined with medial ankle tenderness should raise immediate concern for a Maisonneuve injury.
Knee Examination
The knee should be evaluated carefully in proximal fibular fractures.
Assessment should include the medial collateral ligament, lateral collateral ligament, cruciate ligaments, biceps femoris insertion, and proximal tibiofibular region.
Neurovascular Examination
Motor and sensory function of the common peroneal nerve should be documented.
Particular attention should be given to ankle dorsiflexion, toe extension, eversion, and sensation over the dorsum of the foot.
Distal vascular status should also be recorded.
Laboratory Tests
Routine serum laboratory testing is not required for an uncomplicated isolated fibular fracture.
Laboratory studies are obtained when dictated by associated trauma, planned surgery, or medical comorbidities.
Imaging
Tibia and Fibula Radiographs
AP and lateral radiographs of the entire tibia and fibula should be obtained when a shaft fracture is suspected.
This helps identify associated tibial injury and defines the complete fracture pattern.
Knee Radiographs
AP and lateral knee radiographs are useful when a proximal fibular fracture is present or when associated knee injury is suspected.
Ankle Radiographs
A standard ankle series should include AP, lateral, and mortise views.
These images help identify distal fibular fractures, medial malleolar injury, widening of the ankle mortise, and syndesmotic disruption.
Pathological Findings
Fibular fractures may be spiral, transverse, oblique, or comminuted.
The fracture configuration reflects the underlying mechanism and energy of injury.
Pathologic fractures caused by tumor are uncommon.
Differential Diagnosis
Muscle Injury
A gastrocnemius or soleus tear may produce calf pain and swelling without a fracture.
Tendon Rupture
Tendon injury, including injury around the knee or ankle, may mimic symptoms of a fibular fracture.
Syndesmotic Injury
An isolated syndesmotic sprain may cause ankle pain and instability without an obvious fracture.
Knee or Ankle Injury
Ligamentous injuries, sprains, and articular fractures around the knee or ankle should be considered depending on the location of pain and mechanism.
Treatment
General Principles
Management depends primarily on whether the fracture is isolated or accompanied by ankle instability, syndesmotic disruption, tibial fracture, knee injury, or neurovascular compromise.
Isolated Fibular Shaft Fracture
An isolated fibular shaft fracture without involvement of the ankle or knee is generally a relatively stable injury.
The fibula transmits only a minority of axial load through the leg and is surrounded by well-vascularized muscle, allowing reliable healing.
Immobilization
A splint, walking boot, or short period of casting may be used for comfort, but rigid immobilization is often unnecessary.
Symptomatic Treatment
For uncomplicated injuries, treatment may consist of rest, ice, compression, elevation, and appropriate analgesia.
Recovery
Pain and swelling commonly improve significantly within 1–2 weeks.
Activity can then be advanced according to symptoms.
Most isolated shaft fractures heal by approximately 6–8 weeks.
Weight Bearing
For an isolated stable fibular shaft fracture, weight bearing as tolerated is generally permitted.
The patient may initially use crutches and progress according to pain.
Physical Therapy
Patients with isolated shaft fractures can usually begin progressive weight bearing and motion as symptoms improve.
Physical therapy may be useful for persistent weakness, stiffness, gait disturbance, or associated injury.
Unstable Ankle Injuries
Patients with distal fibular fractures associated with ankle instability generally require restricted or non-weight bearing until sufficient healing or surgical stabilization has occurred.
Medication
Analgesic medication should be provided according to the degree of pain.
NSAIDs, acetaminophen, or short-term stronger analgesics may be used when appropriate.
Surgery
Fibula With Tibial Shaft Fracture
When a fibular fracture accompanies a tibial shaft fracture, treatment is usually directed primarily toward stabilization of the tibia.
The fibula frequently heals without separate fixation.
Tibial Plateau Fracture
Similarly, when the fibular injury accompanies a tibial plateau fracture, the principal reconstructive procedure is directed at the tibial injury unless fibular fixation is specifically needed for stability or soft-tissue reconstruction.
Distal Tibial Fractures
In selected distal tibial fractures, fixation of the fibula can assist with restoration of length, rotational alignment, and overall stability of the tibial reconstruction.
Fibular Plate Fixation
The fibula may be stabilized with a small-fragment plate, traditionally a 3.5-mm compression plate, depending on fracture pattern and surgical strategy.
Maisonneuve Fracture Treatment
Maisonneuve fractures represent an unstable rotational ankle injury and usually require operative treatment when the syndesmosis is unstable.
The key objective is restoration of the ankle mortise and anatomic reduction of the syndesmosis.
Proximal Fibula
The proximal fibular fracture itself usually does not require direct plating in a classic Maisonneuve injury.
Treatment is generally directed at the distal syndesmotic and medial ankle instability.
Medial Malleolus
If a medial malleolar fracture is present and displaced or unstable, it may require open reduction and internal fixation.
Deltoid Ligament
Direct repair of the deltoid ligament is not routinely necessary if anatomic reduction of the ankle mortise and syndesmosis restores stability.
Syndesmotic Fixation
The need for syndesmotic fixation is determined by assessment of instability, frequently using an intraoperative external rotation stress test or other fluoroscopic stress maneuver.
Screw Fixation
Syndesmotic screws have traditionally been used to stabilize the distal tibiofibular joint.
Both tricortical and quadricortical fixation techniques have been used, without clear universal superiority of one configuration.
Screw Removal
Whether syndesmotic screws should be removed routinely remains debated.
Management depends on symptoms, implant type, surgeon preference, and whether the screw breaks or limits function.
Reduction
The most important technical principle is anatomic reduction of the syndesmosis.
The exact position of the ankle during screw insertion is less important than accurate restoration of the tibiofibular relationship.
Alternative Fixation
Bioabsorbable screws and modern flexible fixation devices may be used in selected cases to avoid some of the disadvantages associated with rigid metallic screws.
Follow-Up
Referral
Patients with associated tibial fractures, unstable ankle fractures, syndesmotic injuries, significant knee injuries, or neurovascular abnormalities should be referred to an orthopaedic surgeon.
Prognosis
The prognosis is generally excellent.
Most fibular fractures heal reliably, and the majority of patients recover normal long-term function.
Outcome depends largely on the severity of associated ankle, knee, tibial, or neurovascular injury.
Complications
Nonunion
Nonunion is uncommon but may occur, especially with severe trauma, poor vascularity, or persistent instability.
Malunion
Healing in abnormal alignment may lead to persistent symptoms, particularly when the distal fibula and ankle mortise are involved.
Chronic Pain
Persistent pain may result from malunion, nonunion, syndesmotic instability, nerve injury, or associated ankle or knee pathology.
Hardware Problems
Internal fixation can lead to hardware prominence, irritation, or breakage, sometimes requiring later implant removal.
Compartment Syndrome
Leg compartment syndrome may occur, particularly when the fibular fracture accompanies substantial tibial or soft-tissue trauma.
Increasing pain, tense swelling, sensory changes, or pain with passive stretch should prompt urgent evaluation.
Patient Monitoring
Patients are generally followed clinically and radiographically until fracture union and restoration of function.
For fractures requiring surveillance, plain radiographs may be obtained approximately monthly or at similar intervals, depending on fracture type and treatment.
Follow-up should assess pain, fracture healing, ankle and knee stability, syndesmotic alignment, neurovascular status, gait, and return to activity.
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Orthopaedic Surgery - Fibrous Dysplasia
Basics
Fibrous dysplasia is a benign fibro-osseous disorder in which normal mature lamellar bone is replaced by immature woven bone and fibrous tissue.
The abnormal bone has reduced mechanical strength and may progressively deform under normal loading.
Clinical Characteristics
The condition can produce focal or multifocal defects in bone quality, progressive skeletal deformity, pain, and pathologic fracture.
Patients with polyostotic disease may also have associated endocrine abnormalities.
Café-au-Lait Pigmentation
Café-au-lait skin lesions are particularly associated with multifocal disease and McCune–Albright syndrome.
The lesions classically have irregular borders that have been compared with the “coast of Maine.”
Endocrine Manifestations
Endocrine abnormalities may appear early in childhood.
Precocious puberty may develop during the first years of life and can occasionally be evident as early as infancy.
Classification
Fibrous dysplasia is classified according to the extent of skeletal involvement.
Monostotic fibrous dysplasia involves a single bone.
Polyostotic fibrous dysplasia affects multiple bones and may show asymmetric involvement, often with greater disease burden on one side of the body.
Terminology
Fibrous dysplasia should not be confused with osteitis fibrosa cystica, which is a different skeletal disorder associated with hyperparathyroidism.
Epidemiology
Fibrous dysplasia is uncommon.
Males and females are affected approximately equally.
Risk Factors and Syndromic Association
McCune–Albright Syndrome
The classic McCune–Albright syndrome consists of the triad of:
Polyostotic fibrous dysplasia, café-au-lait skin pigmentation, and precocious puberty.
Other endocrine abnormalities may also occur.
Genetics and Etiology
Fibrous dysplasia results from a postzygotic activating mutation involving the GNAS gene, which encodes the alpha subunit of a stimulatory G protein.
This abnormality leads to excessive intracellular cyclic adenosine monophosphate (cAMP) signaling.
Mosaic Distribution
Because the mutation occurs after fertilization, affected patients have a mosaic distribution of abnormal cells.
The earlier in embryonic development the mutation occurs, the more extensive the disease is likely to be.
This explains why some patients have a single skeletal lesion while others have widespread skeletal and endocrine involvement.
Associated Conditions
Fibrous dysplasia may be associated with various endocrinopathies, particularly in polyostotic disease and McCune–Albright syndrome.
Rarely, malignant transformation may occur, most commonly to osteosarcoma and less often to fibrosarcoma or other sarcomas.
Diagnosis
Diagnosis is often suggested strongly by the characteristic radiographic appearance.
In typical lesions, plain radiographs may be sufficiently characteristic that biopsy is unnecessary.
Signs and Symptoms
Skeletal Deformity
Progressive deformity may develop in involved bones, particularly the proximal femur, pelvis, and craniofacial skeleton.
Because the abnormal bone is mechanically weak, repeated loading can gradually produce bowing.
Neurologic Compromise
Cranial or spinal lesions may occasionally cause neurologic symptoms through deformity or compression of neural structures.
Pain
Patients may experience a chronic dull ache in affected bones, particularly during weight bearing.
Approximately one-third of patients develop chronic pain.
Gait Abnormality
Lower-extremity deformity can produce a limp or waddling gait.
This may be especially apparent with bilateral proximal femoral or pelvic involvement.
Scoliosis
Spinal involvement or asymmetric lower-extremity deformity may contribute to scoliosis.
Physical Examination
Height
The patient’s height should be measured and followed over time, particularly when endocrine disease or extensive skeletal involvement is present.
Spinal Examination
The spine should be examined for scoliosis, kyphosis, or other progressive deformity.
Limb Length and Alignment
Limb lengths and angular deformities should be measured.
All four extremities should be inspected for bowing or asymmetry.
Hip Examination
Hip range of motion should be carefully documented, particularly in patients with proximal femoral involvement.
Loss of motion may reflect progressive deformity or associated pain.
Palpation
Areas of known disease should be palpated for tenderness, swelling, or increased warmth.
New or increasing tenderness warrants reassessment.
Gait
The patient’s gait should be observed for limping, waddling, limb-length inequality, or mechanical abnormalities caused by deformity.
Laboratory Tests
There is no single laboratory test that confirms isolated fibrous dysplasia.
Laboratory investigation is directed toward associated endocrine abnormalities when clinically suspected.
Endocrine Evaluation
Depending on the presentation, testing may include growth hormone, thyroid function, adrenal function, phosphate metabolism, and sex-hormone evaluation.
Further endocrine testing should be individualized.
Imaging
Plain Radiographs
The classic radiographic appearance is a relatively homogeneous “ground-glass” matrix.
This reflects the replacement of normal trabecular bone by immature woven bone and fibrous tissue.
Distribution in Long Bones
Fibrous dysplasia often extends over a long segment of the diaphysis and may involve nearly the entire shaft.
A traditional description is that fibrous dysplasia is a “long lesion in a long bone.”
Cortical Changes
The involved bone may demonstrate cortical thinning and expansion while maintaining a relatively smooth outer contour.
The lesion often blends gradually with surrounding normal bone rather than having a sharply defined border.
Shepherd’s Crook Deformity
A classic complication involving the proximal femur is the shepherd’s crook deformity.
This consists of progressive varus and bowing of the proximal femur caused by repeated loading of weakened dysplastic bone.
Consequences
The deformity increases bending stress across the proximal femur and may lead to worsening angulation, pain, shortening, gait disturbance, and fracture.
Bone Scintigraphy
Technetium bone scintigraphy may be used to identify additional skeletal lesions in patients with suspected polyostotic disease.
Fibrous dysplasia lesions are usually metabolically active and therefore often appear “hot”, although uptake can vary.
CT
CT is particularly useful for evaluating craniofacial lesions, spinal involvement, complex deformity, and surgical anatomy.
It provides excellent detail of cortical structure and osseous expansion.
Pathological Findings
Histologically, affected bone contains multiple small, irregular, disorganized trabeculae of immature woven bone within a fibrous stroma.
Alphabet-Soup Appearance
The irregular trabeculae are often described as resembling “alphabet soup” because of their curved and randomly arranged configuration.
Fibrous Marrow
Normal marrow is replaced by fibrous connective tissue.
The abnormal trabeculae fail to form the organized architecture required for normal mechanical strength.
Osteoblastic Rimming
Typical lesions lack prominent osteoblastic rimming around the abnormal trabeculae.
The bone forms through fibro-osseous metaplasia rather than normal lamellar remodeling.
Differential Diagnosis
Unicameral Bone Cyst
A unicameral bone cyst may produce a lucent lesion and pathologic fracture, particularly in younger patients.
Its central location and lack of a ground-glass matrix usually help distinguish it.
Fibrous Cortical Defect
Fibrous cortical defects are typically small, eccentric, cortical-based metaphyseal lesions rather than long intramedullary abnormalities.
Ollier Disease
Ollier disease produces multiple enchondromas with a characteristic cartilaginous appearance rather than the ground-glass matrix of fibrous dysplasia.
Treatment
General Principles
Treatment is determined by symptoms, deformity, fracture risk, location of disease, and associated endocrine abnormalities.
Many asymptomatic lesions can be observed.
Skeletal Deformity
Progressive deformity should be corrected when it causes pain, functional impairment, or increasing mechanical disadvantage.
Endocrinopathy
Associated endocrine disorders should be treated appropriately because hormonal abnormalities can worsen skeletal disease and contribute to deformity or fracture risk.
Craniofacial Reconstruction
Severe craniofacial deformity may require reconstructive surgery when there is substantial cosmetic deformity, functional impairment, or compression of adjacent structures.
Pain Management
Pain can be treated with appropriate analgesics.
Patients with persistent or complex pain may benefit from consultation with a pain-management specialist.
Bisphosphonates
Bisphosphonates have historically been used in selected patients with significant bone pain, although their effect on lesion progression or deformity is limited.
They should not be expected to restore normal bone architecture.
Activity
Increasing activity alone does not strengthen dysplastic bone.
Patients should generally use pain and mechanical symptoms as guides to activity.
High-Impact Activity
High-impact and prolonged endurance activities may increase the risk of fracture in significantly involved weight-bearing bones.
Activity recommendations should therefore reflect lesion severity and mechanical stability.
Physical Therapy
Physical therapy is most useful for postoperative rehabilitation, gait training, maintenance of mobility, and muscle strengthening.
Patients with involvement of several limbs may require individualized therapy because deformities can affect multiple segments simultaneously.
Surgery
General Orthopaedic Principles
The goals of surgery are to correct deformity, restore mechanical alignment, support weakened bone, and reduce the risk of fracture.
Correction of Bowing
Marked bowing should be corrected because deformity increases bending forces and promotes further progression.
Proximal Femoral Deformity
In the proximal femur, corrective procedures may include valgus-producing osteotomy or medial displacement osteotomy, depending on the pattern of deformity.
Mechanical Support
Dysplastic bone should be supported with durable fixation.
Metal implants or structural cortical grafts are generally more reliable than cancellous graft alone.
Intramedullary Fixation
An intramedullary device is usually preferred to a plate when feasible.
Because the implant lies near the mechanical axis and spans a long segment of bone, it provides more effective protection against bending forces and fatigue failure.
Plate Fixation
Plate constructs may be less advantageous in extensive disease because they protect only a localized segment and are exposed to greater bending stress.
Bone Grafting
Simple bone grafting alone often fails because the underlying dysplastic process can recur or replace the graft.
Complete removal of all abnormal tissue is generally unnecessary.
Cortical Allograft
Structural cortical allograft may be preferred when grafting is required because it provides mechanical support and remodels more slowly.
Cancellous Autograft
Autogenous cancellous graft is less useful because it may be rapidly resorbed and replaced by fibrous dysplastic tissue.
Operative Bleeding
Fibrous dysplasia lesions can bleed substantially during surgery.
Preoperative planning should therefore account for possible significant blood loss.
Follow-Up
Prognosis
Disease behavior varies considerably.
Some lesions remain stable after skeletal maturity, whereas others may continue to deform or become symptomatic in adulthood.
New lesions or progression can occasionally occur after skeletal maturity.
Chronic Pain
Approximately one-third of patients may experience chronic skeletal pain.
Polyostotic Disease
Patients with extensive polyostotic disease may have greater morbidity because of skeletal deformity, fractures, endocrinopathy, immobility, and associated systemic complications.
Complications
Fracture
Pathologic fracture is a common mechanical complication because dysplastic bone has reduced structural strength.
Chronic Pain
Persistent pain can substantially affect mobility, function, mood, and quality of life.
Depression
Chronic deformity and pain may contribute to depression and other psychological consequences.
Malignant Transformation
Malignant transformation is rare, occurring in roughly 1% or less of cases in most series.
The most common secondary malignancy is osteosarcoma, although fibrosarcoma and other sarcomas can occur.
Warning Signs of Malignancy
Concerning features include a sudden increase in pain, rapid enlargement of a previously stable lesion, new swelling, increased warmth, cortical destruction, or a new soft-tissue mass.
These findings warrant urgent reassessment.
Patient Monitoring
Patients should be followed periodically by clinicians familiar with the disorder so that progressive deformity and complications can be identified early.
Orthopaedic Surveillance
Patients with significant lower-extremity or spinal involvement may benefit from annual orthopedic review, particularly to monitor proximal femoral bowing and scoliosis.
Long-Term Monitoring
Follow-up should include assessment of pain, gait, limb alignment, limb length, scoliosis, fracture history, endocrine abnormalities, and functional status.
Patients should also be educated regarding the warning signs of malignant transformation and instructed to seek evaluation for any sudden change in a previously stable lesion.
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Orthopaedic Surgery - Fibrous Cortical Defect / Nonossifying Fibroma
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Basics
A nonossifying fibroma (NOF) is a common benign developmental bone lesion seen primarily in children and adolescents with open physes.
Despite its name, the lesion typically undergoes progressive mineralization and involution as skeletal maturity is reached.
When the lesion is very small and confined mainly to the cortex, it is commonly termed a fibrous cortical defect.
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Typical Location
NOFs arise eccentrically within the metaphysis of long bones.
The most common locations are the distal femur, proximal tibia, and distal tibia.
The lesion is characteristically associated with the growing skeleton and usually regresses or becomes incorporated into normal bone by adulthood.
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Staging
Like other benign bone lesions, NOFs can be described according to biologic activity.
Stage 1, or latent lesions, account for the great majority, approximately 96%.
Stage 2, or active lesions, represent roughly 2–3%.
Stage 3, or aggressive lesions, are very uncommon, accounting for less than 1%.
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Natural History
During childhood, some lesions may behave as active stage 2 abnormalities.
With skeletal maturation, they generally become latent and progressively ossify.
Ultimately, most disappear radiographically or leave only a residual area of sclerosis.
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Synonyms
Other names that have been used include benign metaphyseal cortical defect, metaphyseal fibrous defect, benign fibrous histiocytoma, and fibrous xanthoma.
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Epidemiology
NOF is one of the most common benign skeletal lesions of childhood.
It has been estimated to occur in approximately 35% of otherwise healthy children with open growth plates.
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Proposed Mechanism
The exact cause is uncertain.
One proposed explanation is a localized disturbance of cortical remodeling with increased periosteal resorption during growth.
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Associated Conditions
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Neurofibromatosis
Lesions resembling NOFs may occasionally occur in patients with neurofibromatosis, with reported frequencies of approximately 5%.
Their clinical context should therefore be considered when multiple or atypical lesions are present.
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Jaffe–Campanacci Syndrome
Jaffe–Campanacci syndrome is a rare congenital disorder characterized by multiple, often widespread and relatively symmetric NOF-like lesions.
Associated findings may include café-au-lait pigmentation, other nonskeletal abnormalities, and developmental or intellectual impairment.
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Diagnosis
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Signs and Symptoms
Most fibrous cortical defects and NOFs are completely asymptomatic.
They are typically discovered incidentally when radiographs are obtained for trauma or another unrelated complaint.
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Pain
Pain is unusual unless the lesion has weakened the bone sufficiently to cause an impending or completed pathologic fracture.
New weight-bearing pain therefore warrants further evaluation.
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Physical Examination
Most lesions are nontender and produce no visible abnormality.
There should generally be no swelling or pain with weight bearing unless the bone has become structurally compromised.
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Examination for Associated Syndromes
When multiple lesions are present, the patient should be examined for features of neurofibromatosis or Jaffe–Campanacci syndrome, including café-au-lait pigmentation and other systemic abnormalities.
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Imaging
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Plain Radiographs
Plain radiographs usually establish the diagnosis.
The classic appearance is an eccentric radiolucent lesion arising from the cortex of the metaphysis of a long bone.
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Common Sites
The distal femur, proximal tibia, and distal tibia are particularly common locations.
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Cortical Appearance
The lesion is cortical based.
The overlying cortex may become thinned, particularly in larger lesions, but it is usually preserved unless fracture occurs.
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Sclerotic Margin
A characteristic scalloped rim of reactive sclerotic bone surrounds the lesion.
This well-defined border is an important feature of its benign appearance.
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Multiloculated Appearance
Many lesions have a multiloculated or lobulated configuration, producing a characteristic “bubbly” appearance on radiographs.
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Size
Lesions may range from only a few millimeters to several centimeters.
A very small lesion is generally termed a fibrous cortical defect, whereas a larger lesion extending into the medullary cavity is more often called an NOF.
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Number of Lesions
Most NOFs are solitary, although more than one lesion may occur in the same patient or in multiple bones.
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Bone Scintigraphy
If bone scintigraphy is performed, an active lesion may demonstrate increased tracer uptake because of the reactive bone along its periphery.
As the lesion heals and becomes inactive, scintigraphic activity generally decreases and may return to normal.
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MRI
MRI is not routinely required when the radiographic appearance is characteristic.
It can, however, be useful when there is concern for a stress fracture, pathologic fracture, or atypical lesion.
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Pathological Findings
Histologically, the lesion consists predominantly of fibrous connective tissue arranged in a whorled or storiform pattern.
This appearance has sometimes been described as having a “starry-night” quality.
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Cellular Components
Additional findings may include multinucleated giant cells, lipid-laden or foamy histiocytes, and hemosiderin deposition.
True cystic spaces are not a typical feature.
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Differential Diagnosis
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Chondromyxoid Fibroma
Chondromyxoid fibroma can also present as a metaphyseal lytic lesion and may need to be distinguished from NOF when the imaging appearance is atypical.
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Giant Cell Tumor
Giant cell tumor generally occurs in skeletally mature patients and has a different distribution, often extending to the epiphysis.
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Fibrous Dysplasia
Fibrous dysplasia may produce an intramedullary lucent or ground-glass lesion and should be considered when the lesion is not classically cortical and eccentric.
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Treatment
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General Principles
Most NOFs require no treatment because they are benign and spontaneously involute with skeletal maturity.
Observation is appropriate for asymptomatic lesions with a typical radiographic appearance.
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Activity
Children with small, asymptomatic lesions may participate in normal activities without restriction.
Routine limitation of sports or weight bearing is unnecessary.
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New Weight-Bearing Pain
If a child develops new pain during weight bearing, AP and lateral radiographs should be obtained to look for an occult or stress fracture.
MRI is useful if radiographs are inconclusive but clinical suspicion remains high.
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Observation
Large asymptomatic lesions may be followed radiographically until sufficient healing or skeletal maturity occurs.
The exact frequency depends on lesion size and fracture risk.
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Follow-Up of Large Lesions
Children with larger lesions may be reviewed approximately every 6 months, particularly when a substantial portion of the cortex is involved.
Monitoring may continue until the lesion becomes sclerotic or growth is complete.
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Small Lesions
A small, asymptomatic lesion involving less than approximately 25% of the cortical width generally does not require routine serial surveillance when the diagnosis is secure.
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Fracture Risk
The principal clinical concern is pathologic fracture.
Risk increases when a lesion occupies a large portion of the bone diameter or substantially weakens the cortex.
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Lesions Involving More Than 50% of the Cortex
If more than approximately 50% of the cortical width is involved and the patient is symptomatic, the risk of pathologic fracture is increased.
Such lesions require closer observation and may warrant operative treatment.
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Protected Weight Bearing
When an impending pathologic fracture is suspected, the child should avoid unrestricted loading.
Non-weight bearing or protected weight bearing may be recommended until definitive management is determined.
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Surgery
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Indications
Surgery is generally reserved for lesions with impending pathologic fracture, substantial structural weakness, persistent symptoms, or selected completed fractures.
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Curettage
The lesion can be treated by curettage, removing the fibrous tissue from the involved bone.
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Bone Grafting
After curettage, the defect is usually filled with bone graft or another suitable bone substitute to restore structural strength.
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Internal Fixation
Internal fixation is usually unnecessary because most lesions heal readily after curettage and grafting.
Fixation may be considered only when fracture stability or lesion size makes additional support necessary.
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Follow-Up
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Prognosis
The prognosis is excellent.
Virtually all typical fibrous cortical defects and NOFs undergo spontaneous healing and sclerosis by skeletal maturity.
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Complications
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Pathologic Fracture
Pathologic fracture is uncommon.
It occurs primarily in large lesions involving more than approximately half of the bone diameter, particularly when the patient has pain or sustains significant trauma.
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Malignant Transformation
Typical NOFs do not undergo malignant transformation.
An aggressive or progressively destructive appearance should prompt reconsideration of the diagnosis rather than being interpreted as expected NOF behavior.
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Patient Monitoring
When follow-up is required, serial AP and lateral radiographs are used to document lesion stability, progressive sclerosis, cortical strengthening, and eventual involution.
Patients should be reassessed sooner if they develop new pain, swelling, difficulty bearing weight, or symptoms suggesting fracture.
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Orthopaedic Surgery - Femoroacetabular Impingement
Basics
Femoroacetabular impingement (FAI) results from abnormal contact between the femoral head-neck junction and the acetabular rim during hip motion.
Repeated impingement can produce hip pain and functional limitation, particularly in young and active patients.
Over time, abnormal contact may damage the acetabular labrum and adjacent articular cartilage and may contribute to the development of hip osteoarthritis.
Classification
FAI is classified according to whether the predominant structural abnormality arises from the femur, acetabulum, or both.
The three principal patterns are cam, pincer, and mixed impingement.
Cam Impingement
Cam impingement results from an abnormal contour of the femoral head-neck junction.
Instead of maintaining a smooth spherical transition between the femoral head and neck, the proximal femur develops a prominence that contacts the acetabular rim during hip flexion and rotation.
Femoral Abnormalities
Associated findings may include a decreased femoral head-neck ratio, reduced head-neck offset, femoral neck retroversion, and an aspherical femoral head.
These abnormalities reduce clearance between the femur and acetabulum.
Mechanism of Damage
During flexion and internal rotation, the abnormal femoral prominence enters the acetabulum and may shear the adjacent labrum and cartilage.
Repeated loading can lead to progressive chondrolabral injury.
Pincer Impingement
Pincer impingement results from excessive acetabular coverage of the femoral head.
The acetabular rim contacts the femoral neck earlier than normal during hip motion.
Acetabular Abnormalities
Potential causes include acetabular retroversion, acetabular protrusio, coxa profunda, and excessive focal or global acetabular rim coverage.
Mechanism of Damage
Repeated contact between the acetabular rim and femoral neck may damage the labrum.
A countercoup cartilage lesion may also develop posteriorly in some patients because the femoral head is levered within the socket.
Mixed Impingement
Many patients demonstrate both femoral and acetabular abnormalities.
This is referred to as mixed cam-pincer impingement.
Epidemiology
Radiographic morphology associated with FAI is common even among people who have no hip symptoms.
Reported prevalence of cam-type morphology in asymptomatic individuals has ranged from approximately 5–57%, while pincer-type features have been reported in approximately 29–67%.
Therefore, imaging abnormalities alone do not establish symptomatic FAI.
Symptomatic Patients
Among patients undergoing surgery for symptomatic FAI, one series found approximately 47% with predominantly cam impingement, 8% with pincer impingement, and 45% with combined cam and pincer abnormalities.
Etiology
Athletic Participation
High-impact athletic activity during skeletal development may contribute to the development of cam morphology.
Sports commonly associated with repetitive hip loading include soccer, basketball, and hockey.
Pediatric Hip Disease
Residual deformity after childhood hip disorders can predispose to FAI.
A particularly important example is slipped capital femoral epiphysis (SCFE).
Other developmental abnormalities can also alter the relationship between the femoral head, neck, and acetabulum.
Trauma
Previous injury to the proximal femur or acetabulum may alter hip anatomy and result in secondary impingement.
Genetics
Genetic and developmental factors may influence proximal femoral and acetabular morphology and contribute to susceptibility.
Diagnosis
Signs and Symptoms
The typical patient reports deep groin pain, although pain may also be felt in the buttock or lateral hip.
Symptoms are often associated with activities requiring hip flexion, rotation, or prolonged sitting.
Groin Pain
Groin pain is the classic presentation.
Patients may describe a deep ache or sharp pain during squatting, running, pivoting, or sitting in a low chair.
Gluteal Pain
Some patients localize discomfort posteriorly around the gluteal region rather than directly in the groin.
Lateral Hip Pain
Pain over the greater trochanter may develop secondarily because altered hip mechanics can overload the abductor tendons or trochanteric bursa.
Pain With Hip Flexion
Patients commonly report difficulty with deep hip flexion.
Activities such as moving from standing to sitting, getting into a car, squatting, or bringing the knee toward the chest may aggravate symptoms.
Mechanical Symptoms
Clicking, catching, popping, or locking may occur.
These symptoms often suggest associated labral or chondral pathology.
Physical Examination
Hip Flexion
Hip flexion may be reduced because of pain or mechanical impingement.
Internal Rotation
Loss of internal rotation, particularly with the hip flexed, is common.
The restriction may be caused by bony morphology, pain, or both.
Resting Position
The lower extremity may rest in slight external rotation in some patients.
Provocative Tests
Anterior Impingement Test
The anterior impingement maneuver is performed by placing the hip in flexion, adduction, and internal rotation.
Reproduction of the patient’s groin or hip pain represents a positive test.
This maneuver is commonly referred to as the FADIR test.
Posterior Impingement Test
The posterior impingement test places the hip in extension and external rotation.
Reproduction of hip or groin pain suggests posterior impingement or related intra-articular pathology.
Imaging
Plain Radiographs
Plain radiographs are essential for evaluating hip morphology.
A standard assessment commonly includes an AP pelvis view together with lateral views of the proximal femur.
AP Pelvis
The AP pelvis view is used to assess acetabular coverage, joint-space preservation, femoral head shape, acetabular version, and degenerative changes.
Cross-Table Lateral View
An axial cross-table lateral radiograph can demonstrate abnormalities of the anterior femoral head-neck junction.
Frog-Leg Lateral View
A frog-leg lateral view may help identify loss of the normal femoral head-neck offset or a cam-type prominence.
False-Profile View
For a false-profile view, the patient stands with the pelvis rotated approximately 65° relative to the imaging plate.
This view is useful for assessing anterior acetabular coverage of the femoral head.
MRI
MRI can evaluate both osseous morphology and associated soft-tissue abnormalities.
It is particularly useful for identifying labral tears and articular cartilage damage.
Femoral Head-Neck Anatomy
MRI can also characterize the contour of the femoral head-neck junction and help define cam morphology.
Excluding Other Disease
MRI is useful for excluding alternative causes of hip pain, including avascular necrosis of the femoral head.
Pathological and Radiographic Findings
Cam Morphology
A cam lesion may produce a characteristic pistol-grip deformity, with loss of the normal concavity of the femoral head-neck junction and an aspherical femoral head.
Pincer Morphology
Findings suggesting pincer-type impingement include acetabular protrusio, coxa profunda, and acetabular retroversion.
Crossover Sign
On an appropriately positioned AP pelvis radiograph, acetabular retroversion may produce a crossover sign, in which the projected anterior acetabular wall crosses over the posterior wall.
Alpha Angle
The alpha angle is one method used to quantify asphericity at the femoral head-neck junction.
It is formed by a line through the center of the femoral head and neck and a second line extending from the center of the femoral head to the point where the anterior or anterolateral head-neck contour departs from the expected spherical outline.
Historically, lower thresholds such as approximately 42° have been described, although interpretation should be made in conjunction with symptoms, examination, and the imaging technique used.
Differential Diagnosis
Hip Osteoarthritis
Degenerative arthritis may produce groin pain, restricted internal rotation, and stiffness similar to FAI.
Radiographs help determine the degree of joint-space loss.
Trochanteric Bursitis
Greater trochanteric pain syndrome produces predominantly lateral hip pain and tenderness rather than classic deep groin pain.
Gluteal or Adductor Tendinopathy
Tendon disorders around the hip may reproduce pain during resisted muscle testing and should be distinguished from intra-articular impingement.
Snapping Hip Syndrome
Snapping hip may cause audible or palpable clicking during movement and can mimic the mechanical symptoms of FAI.
Acetabular Labral Tear
Labral tears frequently coexist with FAI but may also occur independently.
They commonly cause groin pain, catching, or clicking.
Juvenile Arthritis
Inflammatory arthritis should be considered in younger patients with persistent pain, stiffness, or systemic features.
Femoral Head Osteonecrosis
Avascular necrosis can cause progressive hip and groin pain and should be excluded, particularly when risk factors are present.
Athletic Pubalgia
Sports hernia or athletic pubalgia may present with groin pain in active patients and can resemble FAI clinically.
Treatment
General Principles
Treatment depends on the severity of symptoms, degree of functional impairment, associated labral or cartilage injury, and presence of established osteoarthritis.
Asymptomatic radiographic morphology alone generally does not require treatment.
Nonoperative Management
Patients with mild or moderate symptoms should usually begin with nonoperative treatment.
Conservative care can improve symptoms but does not change the underlying bony morphology.
Activity Modification
Activities that repeatedly place the hip in deep flexion, adduction, or internal rotation may need to be reduced or modified.
Examples include deep squatting, low sitting positions, or repeated pivoting activities.
Physical Therapy
Physical therapy focuses on improving hip mobility within a nonprovocative range, pelvic control, core stability, and strength of the hip musculature.
Movement patterns that repeatedly reproduce impingement should be minimized.
Anti-Inflammatory Medication
Oral NSAIDs may be used for short-term control of pain and inflammation when appropriate.
Surgery
Surgery may be considered when persistent symptoms and functional limitation continue despite an adequate trial of conservative treatment and imaging demonstrates correctable structural pathology.
Hip Arthroscopy
Hip arthroscopy is widely used to treat symptomatic FAI.
It allows treatment of both the bony abnormality and associated labral or cartilage lesions through minimally invasive portals.
Advantages
Compared with traditional open surgery, arthroscopy may be associated with less soft-tissue morbidity, faster rehabilitation, reduced postoperative pain, and fewer wound-related complications in appropriately selected patients.
Osteochondroplasty
For cam impingement, an osteochondroplasty or femoroplasty is performed.
The prominent portion of the femoral head-neck junction is resected to recreate a more normal head-neck offset.
Acetabular Rim Trimming
For pincer impingement caused by focal excessive acetabular coverage, the acetabular rim may be carefully trimmed.
The amount of resection must be controlled to avoid producing iatrogenic acetabular undercoverage or instability.
Labral Treatment
Associated acetabular labral pathology may be treated with repair or selective debridement.
When technically possible, preservation and repair of viable labral tissue are generally favored because the labrum contributes to hip stability and the fluid seal of the joint.
Open Surgical Hip Dislocation
Open surgical dislocation may be considered when deformity is too extensive or complex for arthroscopic management.
Examples include selected patients with major acetabular deformity, severe protrusio, substantial cartilage defects, or marked acetabular retroversion.
Femoral Osteotomy
A femoral osteotomy may be required when abnormal femoral version or other major structural deformity contributes to impingement and cannot be adequately corrected by simple osteochondroplasty.
Periacetabular Osteotomy
Severe acetabular malorientation may require a periacetabular osteotomy to reorient the acetabulum rather than simply trimming the rim.
This is particularly important when rim removal would worsen underlying instability or dysplasia.
Follow-Up
Prognosis
Both arthroscopic and open surgical treatment can produce substantial improvement in appropriately selected patients.
Many patients report improved function and marked reduction in pain after surgery.
Historical series have reported pain reduction approaching 95% at approximately 1 year in selected populations.
Factors Affecting Outcome
The best results generally occur in patients with limited pre-existing cartilage degeneration and preserved joint space.
Advanced osteoarthritis decreases the likelihood that impingement surgery will provide durable benefit.
Complications
Heterotopic Ossification
Ectopic bone formation may occur around the hip after surgery and can cause pain or restricted motion.
Femoral Neck Fracture
Excessive resection during femoral osteochondroplasty can weaken the femoral neck and create a risk of fracture.
Lateral Femoral Cutaneous Nerve Injury
Temporary or persistent numbness related to lateral femoral cutaneous nerve irritation may occur, particularly after procedures involving anterior hip exposure or traction.
Labral Injury
The acetabular labrum may be injured during the original disease process or during surgery.
Cartilage Injury
Articular cartilage damage may be present before treatment or can occur as a surgical complication.
Progressive chondral loss may eventually contribute to osteoarthritis.
Patient Monitoring
Follow-up should assess pain, hip range of motion, internal rotation, mechanical symptoms, gait, strength, and return to desired activities.
After surgery, monitoring should also evaluate wound healing, rehabilitation progress, heterotopic ossification, residual impingement, recurrent labral symptoms, and progression of degenerative joint disease.
