Hip-hop Dance and Fracture in the foot

An 11 yrs old girl came yesterday complaining of a swollen and painful left foot after hearing something snap in her foot while doing hip-hop barefoot. She had been training barefoot for 1 year but it did not cause any pain. Now, she could not walk or put pressure on the side of her foot or even tip-toe.

I examined her left foot and found that she had some bruising and swelling around outer part of her midfoot (lateral aspect adjacent to the base of 5th metatarsal). There was severe tenderness at the base of the the 5th metatarsal.

Her X-rays shown that her left foot had a non-displaced transverse fracture of the base of 5th metatarsal (Jones Fracture). She was treated non-surgically with non-weight bearing posterior slab crutches to allow the swelling to subsides. She would benefit from a daily dose of low frequency ultrasound (Exogen) to promote healing. Once the swelling subsides we may consider placing her foot in a functional walking brace but she would not be allowed to walk until after 6 weeks later.

Interesting links:
Diagram of metatarsal fractures

Non-dsplaced fracture neck of radius and avulsion fracture of olecranon

John (not his real name) is a 28 yrs old recreational basketball player who slipped while playing and landed on his outstretched arm (on his left palm). He got up and felt a sharp pain in his left forearm and could not straighten or bend his elbows fully. He also could not twist his wrists (supinate and pronate).

He immediately came over to see me yesterday evening and I examined him and found that he had a very tender common extensor tendon suggesting that he might have partially torn his tendon. He could not do the extensor muscle testing (resisted extension) due to the pain. There was no crepitus but I suspected a possible greenstick fracture of his left radius bone. His pain was still quite unbearable despite getting an injection for pain.

I sent him off for an X-ray of his ulna and radius along with an Orthopaedic consultation as he may need further intervention if there was a fracture. His report from the surgeon shown a non-displaced fracture of the neck of radius with minimal avulsion of his triceps insertion into the >olecranon. He was treated conservatively with Plaster of Paris cast and was due for a review in 3 weeks. This may be followed by support with a functional brace to expedite his rehabilitation process.

Links to articles of interest:-
Radial Head Fractures
The Use of Ultrasonography in the Diagnosis of Occult Fracture of the Radial Neck
Olecranon Fracture

Navicular Stress Fracture

Crystal is an elite basketball player who landed on her right foot after doing a jump shoot and suffered from severe foot pain a week ago. She was taken off the court as she could not continue weight-bearing. Subsequently, she was seen by another colleague and found to be having tenderness and fullness (oedema) over the inner portion of the dorsum of her right foot. Her X-rays showed a Type III Navicular Fracture.

Anatomy:

The navicular bone, located in the midfoot, articulates with the head of the talus, cuboid, and the three cuneiform bones that are involved in the acetabulum pedis. It gives attachment to the spring ligament (superomedial and inferior calcaneonavicular ligament)that can be injured in a failure of the posterior tibialis tendon and cause an adult acquired flatfoot deformity. The navicular bone provides insertion for the posterior tibialis tendon. Some pathologies can be related to the presence of an accessory navicular bone.Osteonecrosis or stress fractures can affect the navicular bone because of its poor vascularization, especially in its central portion.

Radiological classification of Navicular Fracture: dorsal cortical break (type I), fracture propagation into the navicular body (type II), and fracture propagation into another cortex (type III). It includes modifiers "A" (avascular necrosis of a portion of the navicular); "C" (cystic changes of the fracture), and "S" (sclerosis of the margins of the fracture).


She was placed in a non-weight bearing cast for 4 weeks (as she wanted play if there was no pain!). I saw her at 4 weeks post-injury and her repeat X-ray did not show much callous formation. She was placed in a functional walking brace (Donjoy) and advised minimal weight bearing for another 2-4 weeks. She was told that such fractures may take a longer period to heal and some studies suggest that surgery (ORIF) may be an option. I prescribed her low frequency ultrasound treatment (Exogen) to encourage bone healing. Most studies suggest that conservative (non-surgical) management provide good results for non-displaced navicular fracture but a few small studies suggest that elite athletes may benefit from surgery in type II or III fractures. Return to sporting activity varies from 3.0 months (Type I), 3.6 months (Type II) and 6.8 months (Type III) according to Saxena et al*.

*J Foot Ankle Surg. 2000;39(2):96-103

Fractured Clavicle

Mohamed came in last Saturday holding onto his right elbow with a deformed 'collar-bone' (see photo) after a fall from his motorbike. He was in severe pain and requested for immediate 'painkiller' injection. I examined him and found that he had a fracture of the midshaft of his clavicle (commonest site) with the proximal part displaced upward. We splinted the left upper limb with a triangular bandage. His peripheral pulses were normal and his ribs and lungs were not injured. I referred him to my Orthopaedic colleague to reassess the need for surgery due to the displacement and overlap. Usually, non-displaced fractures of the midshaft are treated non-surgically with a triangular or figure of eight bandage (see how to apply) and NSAIDS.

In a retrospective study, 132 patients with united fractures of the middle third of the clavicle and a follow-up of up to 30 months after conservative management were reviewed. Of the patients, 34 (25.8%) were dissatisfied with the result of their management possibly due to shortening of the clavicle.J Shoulder Elbow Surg. 2006; 15(2):191-4



A small study in Belgium suggests that semi-professional athletes may benefit from surgical plate fixation of the fractured clavicle with a possible early return to sports (45 days)at the expense of a significant risk for complications (e.g. infection, non-union, refracture) which would not be considered acceptable in patients with lower functional demands. Acta Orthop Belg. 2005; 71(1):17-21

The patient actually had surgery done and was having full function of his right shoulder within 2 weeks. He was advised to return to his surgeon for removal of the plate after 1 year.

Forefoot contusion after supper!

The local council is going to get a complaint from this patient. He was walking back from 'Mamak' (a spicy, not so fancy, local fast-food) when he accidentally stepped into a pothole in Subang Jaya last Saturday.

He had a painful swelling on the dorsum of his right foot (see photo) and could only walk on his inner side of his foot. He had a painful gait when he walked into my clinic yesterday. I was getting a bit worried as he could not put weight on the side of the foot. After examination, I felt that he could be spared from an X-ray as most of the pain came from the superficial swelling and not the 5th metatarsal (common site of injury for such falls). I once had a 50 year old colleague who fractured her 5th metatarsal in the same manner walking along the pavement! Her risk was higher as she was having Osteoporosis.

Told him to do the RICE treatment (see first-aid) and gave him some Arnica gel and oral NSAIDS. He was advised to avoid excessive walking for another 5 days and return for a review if pain and swelling persisted.