Comparison of Contact and Damage to Anatomic Structures in the Fixation of Zone II Fifth Metatarsal Fractures with an Intramedullary Screw or an Intramedullary Nail

Category: Sports, Trauma Introduction/Purpose: Percutaneous intramedullary screw fixation of Zone II fifth metatarsal fractures has become commonplace. The potential for injury to the important surrounding anatomy has not been well documented, though some authors have reported unexplained postoperative pain and paresthesia over the lateral aspect of the foot despite hardware removal. The purpose of this study was to determine the contact and injury rate of surrounding anatomic structures with either the use of the traditional intramedullary screw (IMS) inserted “high and inside” or a novel intramedullary nail (IMN) inserted “low and outside” through a relative “safe-zone.” Methods: Zone II fifth metatarsal fractures were created in ten cadaver matched-pairs using a 1 mm thick saw through a small incision. Fractures were randomized to receive either an IMS or an IMN. The surgical technique was performed in accordance with the manufacturer’s instructions. For the IMS group, the guide pin was inserted percutaneously according to the “high and inside” starting point on the base of the fifth metatarsal using fluoroscopy; followed by insertion of the 3.5 mm drill, tissue protector, tap, and screw. For the IMN group, the guide pin was inserted percutaneously “low and outside,” positioned slightly medial and dorsal to the tip of the tuberosity of the fifth metatarsal; followed by the 5.2 mm reamer, tissue protector, and IMN. Dissection was performed to identify damage or contact to the peroneus brevis tendon (PB), peroneus longus tendon (PL), sural nerve (SN), lateral insertion of the plantar fascia (PF) and cuboid-fifth metatarsal jointspace. Results: There were significantly more episodes of PB injury, PL contact, SN contact, and presence in the cuboid-fifth metatarsal jointspace for the IMS group. There were significantly more episodes of contact of the PF with the IMN group but no episodes of damage. The results are summarized in Table 1. Images of contact and damage are shown in Figure 1. Fluoroscopic images of the IMN inserted through the “low and outside” position are shown in Figure 2. Conclusion: We have demonstrated significant contact and injury to surrounding structures with the placement of a “high and inside” IMS for the fixation of Zone II fifth metatarsal fractures. We believe there is a relative safe zone at the “low and outside” position that affords less potential damage to the important surrounding structures. Consideration should be given to the development of implants inserted through the relative safe zone.

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Predictors of Malreduction in Zone II and III 5th Metatarsal Fractures Fixed with an Intramedullary Screw: A Retrospective Analysis

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00284 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0028

Author(s):

Ankit Khurana ◽

Charles C. Pitts ◽

Bradley Alexander ◽

Akshar Patel ◽

Charles R. Sutherland ◽

...

Keyword(s):

Delayed Union ◽

Fracture Site ◽

Entry Point ◽

Entry Length ◽

Increased Risk ◽

Screw Length ◽

Metatarsal Fractures ◽

Screw Diameter ◽

Zone Ii ◽

Intramedullary Screw

Category: Midfoot/Forefoot; Sports Introduction/Purpose: Percutaneous fixation of 5th metatarsal fractures may lead to malreduction due to improper implant selection and placement. Our aim was to test the effects of screw entry, length, and diameter on malreduction, delayed union, non-union, or refracture. Methods: We retrospectively reviewed zone II and proximal zone III 5th metatarsal fractures managed with intramedullary screw fixation. Comparisons were made between plantar cortex distraction/lateral cortex distraction and ratios of screw length, diameter, and entry point using multiple regression analysis. A further analysis was carried out between time to union and distraction in the lateral and plantar cortices. Results: Plantar and lateral gap were both correlated with entry point ratio on lateral and AP view respectively (p<0.001 for both views). We did not see an association between plantar and lateral gap with screw diameter ratio (p=0.393 for AP and p=0.981 for lateral) or screw length ratio (p=0.966 for AP and p=0.740 for Lateral). Ratio of postop/preop apex height on AP and lateral showed correlation to presence of lateral and plantar fracture gap respectively (p<0.0001). Presence of a plantar gap did have a slight influence on time to union (p=0.044). Most fractures showed radiographic union at 12 weeks (38/44 that were followed until union). There were no refractures or nonunions as per available records. Conclusion: Our study shows that screw length and diameter did not lead to significant plantar or lateral fracture site distraction. However, entry point had a significant effect on plantar and lateral gap on post-operative x-ray. Patients with a plantar gap did have an increased risk of delayed union. Entry point should be given more significance rather than screw diameter and length in managing zone 2/3 fifth metatarsal base fractures. This is contradictory to existing radiologic studies. [Table: see text]

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Predictors of Malreduction in Zone II and III Fifth Metatarsal Fractures Fixed With an Intramedullary Screw

Foot & Ankle International ◽

10.1177/1071100720947411 ◽

2020 ◽

Vol 41 (12) ◽

pp. 1537-1545

Author(s):

Ankit Khurana ◽

Bradley Alexander ◽

Charles Pitts ◽

Ashish Brahmbhatt ◽

Benjamin Cage ◽

...

Keyword(s):

Delayed Union ◽

Fracture Site ◽

Diameter Ratio ◽

Entry Point ◽

Screw Length ◽

Metatarsal Fractures ◽

Screw Diameter ◽

Zone Ii ◽

Intramedullary Screw ◽

Lateral Gaps

Background: Proper implant selection and placement is crucial during fixation of zone II and III fifth metatarsal fractures to avoid postoperative complications. This study examined the effects of screw parameters and placement on malreduction, delayed union, nonunion, and refracture rate. Methods: A retrospective review of zone II and proximal zone III fifth metatarsal fractures managed with intramedullary screw fixation was conducted. Comparisons were made between cortex distraction (gap) and ratios of screw length, diameter, and entry point. Further analysis was carried out between time to union and distraction in the lateral and plantar cortices. Results: The plantar and lateral gaps were both associated with the mean entry point ratio on the lateral and anteroposterior (AP) views ( P < .001 for both views). No association between the plantar and lateral gaps and the screw diameter ratio ( P = .393 for AP and P = .981 for lateral) or the screw length ratio ( P = .966 for AP and P = .740 for lateral) was identified. The ratio of postoperative to preoperative apex height on AP and lateral views was correlated with the presence of lateral and plantar fracture gaps ( P < .001). The presence of a plantar gap was associated with increased time to union ( P = .022). A majority of fractures showed radiographic union at 12 weeks (38/43). Only 5 of 38 patients had delayed union. There were no refractures or nonunions as per available records. Conclusion: Plantar or lateral fracture site distraction (gap) was not influenced by screw diameter ratio or screw length ratio. The entry point ratio had a significant effect on plantar and lateral gaps on postoperative radiographs, with lateral and inferior placement leading to fracture site distraction. Patients with a plantar gap did have an increased risk of delayed union. The results of this study emphasize the significance of the entry point when managing zone II and III fifth metatarsal base fractures. Level of Evidence: Level IV, case series.

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Optimal Starting Point for Fifth Metatarsal Zone II Fractures: A Cadaveric Study

Foot & Ankle International ◽

10.1177/1071100717702688 ◽

2017 ◽

Vol 38 (7) ◽

pp. 802-807 ◽

Cited By ~ 7

Author(s):

Geoffrey I. Watson ◽

Sydney C. Karnovsky ◽

Gabrielle Konin ◽

Mark C. Drakos

Keyword(s):

Average Distance ◽

Entry Point ◽

Intramedullary Fixation ◽

Starting Position ◽

Femur Fractures ◽

Starting Point ◽

Intramedullary Canal ◽

Metatarsal Fractures ◽

Zone Ii ◽

The Ideal

Background: Identifying the optimal starting point for intramedullary fixation of tibia and femur fractures is well described in the literature using a retrograde or anterograde technique. This technique has not been applied to the fifth metatarsal, where screw trajectory can cause iatrogenic malreduction. The generally accepted starting point for the fifth metatarsal is “high and inside” to accommodate the fifth metatarsal’s dorsal apex and medial curvature. We used a retrograde technique to identify the optimal starting position for intramedullary fixation of fifth metatarsal fractures. Methods: Five matched cadaveric lower extremity pairs were dissected to the fifth metatarsal neck. An osteotomy was made to access the intramedullary canal. A retrograde reamer was passed to the base of the fifth metatarsal to ascertain the ideal entry point. Distances from each major structure on the lateral aspect of the foot were measured. Computed tomography scans helped assess base edge measurements. Results: In 6 of 10 specimens, the retrograde reamer hit the cuboid with a cuboid invasion averaging 0.7 mm. The peroneus brevis and longus were closest to the starting position with an average distance of 5.1 mm and 5.7 mm, respectively. Distances from the entry point to the dorsal, plantar, medial, and lateral edges of the metatarsal base were 8.3 mm, 6.9 mm, 9.7 mm, and 9.7 mm, respectively. Conclusion: Optimal starting position was found to be essentially at the center of the base of the fifth metatarsal at the lateral margin of the cartilage. Osteoplasty of the cuboid or forefoot adduction may be required to gain access to this site. Clinical Relevance: This study evaluated the ideal starting position for screw placement of zone II base of the fifth metatarsal fractures, which should be considered when performing internal fixation for these fractures.

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The DWQ-EMR Embedded Tool to Enhance the Family Physician-Caregiver Connection: A Pilot Case Study

Geriatrics ◽

10.3390/geriatrics6010029 ◽

2021 ◽

Vol 6 (1) ◽

pp. 29

Author(s):

Kristina Marie Kokorelias ◽

Einat Danieli ◽

Sheila Dunn ◽

Sid Feldman ◽

David Patrick Ryan ◽

...

Keyword(s):

Family Caregivers ◽

Best Practice ◽

Data Gathering ◽

Family Physicians ◽

Efficient Manner ◽

Efficient Access ◽

Increased Risk ◽

Starting Point ◽

To Receive

The number of family caregivers to individuals with dementia is increasing. Family physicians are often the first point of access to the health care system for individuals with dementia and their caregivers. Caregivers are at an increased risk of developing negative physical, cognitive and affective health problems themselves. Caregivers also describe having unmet needs to help them sustain care in the community. Family physicians are in a unique position to help support caregivers and individuals with dementia, but often struggle with keeping up with best practice dementia service knowledge. The Dementia Wellness Questionnaire was designed to serve as a starting point for discussions between caregivers and family physicians by empowering caregivers to communicate their needs and concerns and to enhance family physicians’ access to specific dementia support information. The DWQ aims to alert physicians of caregiver and patient needs. This pilot study aimed to explore the experiences of physicians and caregivers of people using the Questionnaire in two family medicine clinics in Ontario, Canada. Interviews with physicians and caregivers collected data on their experiences using the DWQ following a 10-month data gathering period. Data was analyzed using content analysis. Results indicated that family physicians may have an improved efficacy in managing dementia by having dementia care case specific guidelines integrated within electronic medical records. By having time-efficient access to tailored supports, family physicians can better address the needs of the caregiver–patient dyad and help support family caregivers in their caregiving role. Caregivers expressed that the Questionnaire helped them remember concerns to bring up with physicians, in order to receive help in a more efficient manner.

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Fifth Metatarsal Jones Fractures in the Athlete

Foot & Ankle International ◽

10.1177/1071100717741856 ◽

2017 ◽

Vol 39 (2) ◽

pp. 250-258 ◽

Cited By ~ 18

Author(s):

David A. Porter

Keyword(s):

Screw Fixation ◽

Nonoperative Treatment ◽

Fracture Site ◽

Medullary Canal ◽

Return To Sports ◽

Stress Reactions ◽

Current Standard ◽

Level Of Evidence ◽

Metatarsal Fractures ◽

Intramedullary Screw

Fifth metatarsal fractures, otherwise known as “Jones” fractures, occur commonly in athletes and nonathletes alike. While recent occurrence in the popular elite athlete has increased public knowledge and interest in the fracture, this injury is common at all levels of sport. This review will focus on all three types of Jones fractures. The current standard for treatment is operative intervention with intramedullary screw fixation. Athletes typically report an acute episode of lateral foot pain, described as an ache. Radiographic imaging with multiple views of the weightbearing injured foot are needed to confirm diagnosis. If these images are inconclusive, further magnetic resonance imaging (MRI) or computed tomography (CT) is used. Nonoperative treatment is not commonly used as the sole treatment, except when following reinjury of a stable screw fixation. While screw selection is still controversial, operative treatment with intramedullary screw fixation is the standard approach. Technical tips on screw displacement are provided for Torg (types I, II, III) fractures, cavovarus foot fractures, recurrent fractures, revision surgery, occult fractures/high-grade stress reactions, and Jones’ variants. Excellent clinical outcomes can be expected in 80% to 100% of patients when using the intramedullary screw fixation to “fit and fill” the medullary canal with threads across the fracture site. Most studies show the timing for return to sports with optimal healing to be seven to twelve weeks after fixation. Level of Evidence: Level V, expert opinion.

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The Peroneus Brevis and Plantar Fascia Insertions Are Related to Proximal Fifth Metatarsal Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000198 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0001

Author(s):

Ali Hosseini ◽

Pim Van Dijk ◽

Sofie Breuking ◽

Bryan Vopat ◽

Daniel Guss ◽

...

Keyword(s):

Surface Area ◽

Fracture Mechanism ◽

Soft Tissues ◽

Plantar Fascia ◽

Dorsal Side ◽

Fracture Zones ◽

Surface Areas ◽

Metatarsal Bones ◽

Metatarsal Fractures ◽

Peroneus Brevis

Category: Midfoot/Forefoot Introduction/Purpose: Proximal fifth metatarsal fractures (PFMF) are among the most common fractures in the foot and can be categorized into three fracture zones [1]. To investigate the fracture mechanism of PFMF in different zones, a better understanding of the anatomy of the bone and its surrounding soft tissues is required. Both the plantar fascia (PF) and the peroneus brevis (PB) tendon insertions are at the base of the fifth metatarsal, and may contribute to the pathophysiology of PFMF. However, the role of the PB and PF insertions in the pathogenesis of PFMF remains unclear. The purpose of this study was to accurately define the footprint of the PB and PF insertions of the base of the 5th metatarsal in relation to the different zones of PFMF. Methods: 21 cadaveric fifth metatarsal bones were harvested from cadaveric feet. All bones were freed of any remaining soft tissue adherence, except for the PB and the PF insertions. Three reference screws with a diameter of 1 mm were placed and secured on each bone with 2 screws distally and 1 screw proximally for registration. All bones were CT scanned to create a 3D bone reconstruction. Next, the insertions of the PB and PF and the reference screws of each bone were digitized and then mapped to its corresponding 3D bone model. In order to describe the three different fracture zones of the 5th metatarsal, an established coordinate system was made for each bone to simulate separate fracture zones (Figure a) based on Lawrence guideline [1]. The shape, location and surface areas of both insertions and their relation to the different fractures zones were determined (Figure b). Results: The insertion of the PB was oval shaped and located on the dorsal side of the base, with a mean surface area of 88.1 ± 46.4 mm2. The PF was oval shaped and situated around the tip of tuberosity, with a mean surface area of 150.7±53.5 mm2. The PB insertion was present in zone 1 fractures in 100% (21/21) of the 5th metatarsal models and 29% (6/21) of the models for zone 2 fractures. The PF insertion was involved in 100% (21/21) of the 5th metatarsal models for zone 1 fractures and 43% (9/21) of the models for zone 2 fractures. Conclusion: Results of this study demonstrate that the insertion of both the PB and PF are involved in all zone 1 PFMF and a significant percentage of zone 2 PFMF. The location of tendon insertions affect the forces exerted on the bone, which may indicate a relation of the insertions of both the PB and the PF with the fracture mechanism of many zone 1 and 2 PFMF. Moreover, in the treatment of these fractures, care should be taken to maintain or restore the anatomy of these insertions to maximize functional outcomes.

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Impacted teeth: Their place is in the dental arch

Dental Press Journal of Orthodontics ◽

10.1590/2177-6709.24.6.020-026.oin ◽

2019 ◽

Vol 24 (6) ◽

pp. 20-26 ◽

Cited By ~ 1

Author(s):

Alberto Consolaro ◽

Mauricio de Almeida Cardoso

Keyword(s):

Dental Arch ◽

Impacted Teeth ◽

Unerupted Tooth ◽

Starting Point ◽

Unerupted Teeth ◽

To Receive ◽

Over Time

ABSTRACT The starting point for the treatment of unerupted teeth should consider the fact that, biologically, the pericoronal follicle maintains the ability to release EGF and other mediators responsible for eruption over time. The eruptive events may be guided and directed, so that teeth may occupy the space prepared to receive them in the dental arch, as showed in the case presented to evidence the following principle to be considered in these cases: “Regardless of the position of an unerupted tooth, it may be biologically directed to its place in the dental arch. The orthodontist should apply a mechanics to guide it and park it at its site.”

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Cuboid Edema Syndrome Following Fixation of Proximal Fifth Metatarsal Fractures in Professional Athletes

Foot & Ankle Specialist ◽

10.1177/1938640019857798 ◽

2019 ◽

Vol 12 (4) ◽

pp. 373-379 ◽

Cited By ~ 2

Author(s):

Lauren Roberts ◽

Alessio Bernasconi ◽

Cesar de Cesar Netto ◽

Andrew Elliott ◽

William Hamilton ◽

...

Keyword(s):

Case Report ◽

Elite Athletes ◽

Magnetic Resonance Images ◽

Complete Healing ◽

Professional Athletes ◽

Screw Head ◽

Level Of Evidence ◽

Metatarsal Fractures ◽

Literature Highlight ◽

Intramedullary Screw

Stress fractures of the proximal fifth metatarsal are common injuries in elite athletes. Fixation using an intramedullary screw represents the most popular surgery performed for treating these injuries, with excellent results in most cases. However, multiple reports in the literature highlight the possibility of painful hardware, usually related to the presence of the screw head, following intramedullary fixation In this case report, we outline 4 cases of professional athletes who developed lateral-based foot symptoms following complete healing of their surgically treated proximal fifth metatarsal fractures and were found to have significant cuboid edema on magnetic resonance images. We also outline recommendations regarding specific surgical technique considerations aiming to minimize this possible complication. Level of Evidence: Level V: Case report.

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