Treatment of Navicular Stress Fracture Accompanied by Os Supranaviculare: A Case Report

Navicular stress fractures (NSFs) are relatively uncommon, and predominantly affect athletes. Patients complain of vague pain, bruising, and swelling in the dorsal aspect of the midfoot. Os supranaviculare (OSSN) is an accessory ossicle located above the dorsal aspect of the talonavicular joint. There have been few previous reports of NSFs accompanied by OSSN. Herein we report the case of a patient with OSSN who was successfully treated for an NSF. A 34-year-old Asian man presented with a 6-month history of insidious-onset dorsal foot pain that occasionally radiated medially toward the arch. The pain worsened while sprinting and kicking a soccer ball with the instep, whereas it was temporarily relieved by rest for a week and analgesics. Plain radiographs of the weight-bearing foot and ankle joints revealed a bilateral, well-corticated OSSN. Computed tomography (CT) revealed a sagittally oriented incomplete fracture that extended from the dorsoproximal cortex to the center of the body of the navicular. The OSSN was excised and the joint was immobilized with a non-weight-bearing cast for 6 weeks, followed by gradual weight bearing using a boot. The 5-month follow-up CT scan demonstrated definite fracture healing. At the 1-year follow-up, the patient’s symptoms had resolved, the American Orthopedic Foot and Ankle Society midfoot score had improved from 61 to 95 points, and the visual analog scale pain score had improved from 6 to 0. We describe a rare case of NSF accompanied by OSSN. Because of the fracture gap and biomechanical properties of OSSN, OSSN was excised and the joint was immobilized, leading to a successful outcome. Further research is required to evaluate the relationship between NSFs and OSSN, and determine the optimal management of NSFs in patients with OSSN.

Coalizão da articulação talocalcaneana com Os sustentaculum - Uma coalizão incomum / Coalition of the medial portion of the talocalcaneal with the associated Os sustentaculum – An uncommon coalition

Introdução: O Os sustentaculum é um osso acessório raro localizado na extremidade posterior do sustentaculum tali. A coalizão tarsal pode ser considerada uma anomaliacongênita que pode se tornar sintomática. Frequentemente, é necessária a TC ou a RM para confirmar o diagnóstico de coalizão talo-calcânea quando os achados nas radiografiassão ambíguos. Objetivo: Relatar um caso incomum de Coalizão da articulação talocalcaneana com Os sustentaculum, diagnosticado por exames de imagem. Relatodo Caso: Mulher de 26 anos com “caroço” no tornozelo direito há 10 anos promovendo dor intermitente. Apresenta piora ao usar salto – independentemente do tempo, ao andar ou ao ficar em posição ortostática por mais de 1 hora, referindo dor a palpação e irradiação para o pé. A radiografia do tornozelo direito apresenta ossículo acessório na porção medial da articulação talo-calcânea – Os sustentaculum, confirmada pela tomografia computadorizada. A ressonância magnética diagnostica coalizão talo-calcânea extra-articular com Os ustentaculum. Conclusão: É importante ressaltar que o Os sustentaculum não é apenasum ossículo acessório ou uma fratura antiga, ele é um componente de um tipo de coalizão talo-calcânea extra-articular, o que faz com que essa condição seja geralmente sintomática. Portanto, se um paciente com Os sustentaculum apresentar sintomas na área articular talo-calcânea medial, uma coalizão talo-calcânea extra-articular com Os sustentaculum deve ser considerada. Palavras-chave: Coalizão tarsal, Tomografia computadorizada por raios X, Imagem por ressonância magnética, Radiografia ABSTRACT Introduction: The Os sustentaculum is a rare accessory bone located at the posterior end of the sustentaculum tali. The tarsal coalition can be considered a congenital anomaly that can become symptomatic. Often, CT or MRI is required to confirm the diagnosis of the talo-calcaneus coalition when the findings on radiographs are ambiguous. Objective: To report an unusual case of a coalition of the talocalcaneal joint with Os sustentaculum, diagnosed by imaging exams. Case Report: A 26-year-old woman with a “lump” in her right ankle for 10 years causing intermittent pain. She worsens when wearing heels - regardless of the time when walking or standing in an orthostatic position for more than 1 hour, referring to pain on palpation and irradiation to the foot. The right ankle radiograph shows an accessory ossicle in the medial portion of the talocalcaneal joint – Os Sustentaculum, confirmed by computed tomography. Magnetic resonance imaging diagnoses extra-articular talo-calcaneus coalition with Os sustentaculum. Conclusion: It is important to emphasize that the Os sustentaculum is not just an accessory ossicle or an old fracture, it is a component of a type of extra-articular talo-calcaneus coalition, which makes this condition generally symptomatic. Therefore, if a patient with Os sustentaculum shows symptoms in the medial talo-calcaneus joint area, an extra-articular talo-calcaneus coalition with Os sustentaculum should be considered. Keywords: Tarsal coalition, X-ray computed tomography, Magnetic resonance imaging, Radiography

Accessory medial cuneiform bone in a child: unreported site and review of literature

<p>Accessory ossicles of the foot are not uncommon finding in foot radiographs which has confused radiologists and orthopedic surgeons from time immemorial. Occasionally these bones are symptomatic, hindering daily activities of patients. We present a case report of an eleven years old girl with a symptomatic accessory medial cuneiform on the dorsal aspect of left foot. The child was evaluated radiologically and after a trial of failed conservative treatment, she was operated upon. Intraoperatively a superficial nerve on dorsum of this accessory ossicle was found, and the extra bone was excised. This accessory bone was found to be related to medial cuneiform bone at its dorsal and distal surface making to suggest its name as "Os cuneo-I metatarsale-I dorsale". Detailed radiological evaluation is mandatory for identification and exact anatomical localization of the extra bone before proceeding to excision, when non operative treatment fails to relieve the symptoms.</p><p><strong> </strong></p>

The Incidence of Accessory Ossicles of the Wrist: A Radiographic Study

Objective Accessory ossicles of the wrist are generally asymptomatic and detected incidentally as radiological findings. These bones are rarely symptomatic but can produce pain in cases of impingement or direct trauma. More frequently, these bones are misinterpreted as avulsion fractures in trauma patients, which may lead to unnecessary immobilization and overtreatment. The aim of this study is to determine the incidence of accessory ossicles of the wrist and also determine if the incidence is related to age, gender, or ongoing wrist pain. Materials and Methods A total of 1146 wrist radiographs were included in the study. All radiographs were analyzed for the presence of 20 different accessory ossicles of the wrist. Patients were also divided into two groups, as with and without accessory ossicle. Two groups were compared in terms of age, gender, and side. Results About 113 accessory ossicles were detected in 111 (9.7%) radiographs. The most common accessory ossicles were os triangulare and os ulnostyloideum, and the least common accessory ossicles were os gruberi and os praetrapezium. Patients who had accessory ossicle had a significantly higher age than those who did not have accessory ossicle. There was no significant difference between the patients with and without accessory ossicle in terms of gender and side. Conclusions The results of this study showed that the most common accessory ossicles in the wrist were os triangulare and os ulnostyloideum, and the incidence of accessory bones increased with age. Clinical Relevance Since accessory ossicles of the wrist can be confused with fractures in trauma patients and are frequently ignored in patients presenting with pain, it is very important to know the incidence and distribution of these ossicles. Therefore, this study is important, in that it provides potentially guiding anatomical data for clinicians in terms of diagnosis and management.

Chronic Fracture of the Posteromedial Tubercle of the Talus Masquerading as Os Trigonum Syndrome

Posterior ankle impingement syndrome (PAIS) can be caused by osseous pathology from the posterior aspect of the talus. The commonest cause is an os trigonum, an accessory ossicle arising from the lateral tubercle of the posterior talus. We have observed cases where the osseous impingement is due to a chronic fracture nonunion of the medial tubercle of the posterior talus with unique symptoms, differentiating this clinical syndrome from the more common os trigonum syndrome. These can be readily overlooked on imaging and confused with an often coexisting os trigonum. Awareness of these lesions is paramount to ensure appropriate management and safe surgery. We describe a series of patients presenting to the senior author with this clinical syndrome, discuss its unique clinical and radiological features, and describe our surgical technique.

A New Classification of Talocalcaneal Coalitions Based On Computed Tomography For Operative Planning

Background Current classifications emphasize the morphology of the coalition, however, subtalar joint facets involved should also be emphasized.Objective The objective of this study was to develop a new classification system based on the articular facets involved to cover all coalitions and guide operative planning.Methods Patients were diagnosed with talocalcaneal coalition using a CT scan, between January 2009 and February 2021. We classified the coalition into four main types according to the shape and nature of the coalition: I, inferiorly overgrown talus or superiorly overgrown calcaneus; II, both talus and calcaneus overgrew; III, coalition with an accessory ossicle; (I-III types are non-osseous coalition) IV, complete osseous coalition. Then each type was further divided into three subtypes according to the articular facets involved. A, the coalition involving the anterior facets; M, the coalition involving the middle facets, and P, the coalition involving the posterior facets.Results There were 106 patients (108 feet) included in this study. Overall, 8 feet (7.5%) were classified as type I, 75 feet (69.4%) as type II, 7 feet (6.5%) as type III, and 18 feet (16.7%) as type IV. Twenty-nine coalitions (26.9%) involved the posterior facets only (subtype-P), 74 coalitions (68.5%) involved both the middle and posterior facets (subtype-MP), and five coalitions (4.6%) simultaneously involved the anterior, middle, and posterior facets (subtype-AMP). Type II-MP coalition was the most common.Conclusion A new classification system of the talocalcaneal coalition to facilitate operative planning was developed.

A case of an injured calcaneus secundarius in a professional soccer player

Background The calcaneus secundarius (CS) is an accessory ossicle of the anterior facet of the calcaneus and is usually asymptomatic. This accessory bone can be frequently mistaken for a fracture of the anterior process of the calcaneus. Few reports of symptomatic CS have been published, and physicians need to be familiar with imaging strategies when encountering chronic ankle pain or in case of suspicion of fracture of the anterior process of the calcaneus. Case presentation We describe the case of symptomatic CS in a professional soccer player injured during a match. First, computed tomography showed a large CS. Second, magnetic resonance imaging (MRI) demonstrated synchondrosis between the CS and the calcaneus, as well as edema (high MR T2 signal) within it, corresponding to posttraumatic edema. The patient was successfully treated with nonsteroidal anti-inflammatory drugs and physiotherapy; no surgical management was necessary. At the 4-week follow-up, he was pain-free and returned to activity. Conclusion This case illustrates the role of imaging for the diagnosis of CS in cases of acute pain of the foot. CT, as well as MRI, helped to confirm the diagnosis of CS traumatized synchondrosis, which can be mistaken for a fracture.

A comprehensive study of the anatomical variations of the posterolateral tubercle of talus

The aim of our study was to establish the prevalence of the different anatomical variants of the posterolateral tubercle of talus on CT imaging. 1478 ankle CT scans were retrospectively reviewed for the different anatomical variants of the posterolateral tubercle of talus, the type and size of os trigonum. Normal sized lateral tubercle was found in 46.1%, an enlarged posterolateral tubercle (Stieda’s process) in 26.1%, os trigonum in 20.5% and almost absent tubercle in 7.3%. A statistically higher prevalence of Stieda’s process was found in males while os trigonum was higher in females (p<0.05). Among feet with os trigonum, 25.7% were non-articulating and identified as a separate bone located posterior to the posterolateral tubercle of talus and 74.3% of os trigonum were identified as fused to the posterolateral tubercle by synchondrosis or syndesmosis. Additionally, 17.5% of os trigonum were associated with intact lateral tubercle, 53.5% were considered as part of the lateral tubercle and 29.0% were without a lateral tubercle. According to its size, 22.8 % of os trigonum were smaller than 0.5 cm, 55.4% were between 0.5 and 1cm, and 21.8% were larger than 1 cm. No significant differences were found between the different types/sizes of os trigonum according to gender (p>0.05). The posterolateral tubercle of talus and its accessory ossicle, the os trigonum, could vary morphologically. The data of this study could be helpful in understanding the clinical problems that could be associated with some of these variants.

Lateral Heel Pain Caused by Impingement of Hypertrophic Peroneal Tubercle and Os Peroneum

Hypertrophic peroneal tubercle (HPT) is an overgrowth of the peroneal tubercle located on the lateral aspect of the hindfoot, which could cause tenosynovitis of the peroneus longus tendon. Os peroneum (OP) is an accessory ossicle that exists in the peroneus longus tendon at the lateral aspect of the calcaneocuboid joint. Both HPT and OP can cause lateral foot pain and occasionally require surgical treatment. We encountered a case of lateral foot pain of HPT coexisting with OP. Careful preoperative magnetic resonance imaging, dynamic ultrasonographic image, and block injection suggested an impingement of HPT and OP as a cause of lateral foot pain. Surgical resection of HPT, while retaining OP, successfully achieved pain relief in the patient. To the best of our knowledge, this is the first report presenting a case of HPT coexisting with OP successfully treated without OP resection.

An unfamiliar physeteroid periotic (Cetacea: Odontoceti) from the German middle–late Miocene North Sea basin at Groß Pampau

The Miocene mica clay locality of Groß Pampau, known for numerous and partly spectacular finds of marine mammals is becoming more and more a prominent site that bears the potential to resolve questions regarding taphonomic relationships and to interpret life communities of the ancient North Sea because of its rich faunal assemblage including invertebrates and other remains of various vertebrate organisms. In the present work we describe a right periotic of Physeteroidea with morphological characters so far unknown from other sperm whales. The periotics of the middle Miocene Aulophyseter morricei demonstrate the closest resemblance to the Groß Pampau specimen in their overall appearance and in the general arrangement and proportions of single structures, particularly of the anterior process and pars cochlearis. A great similarity is also documented with periotics of the living sperm whale, Physeter macrocephalus, especially regarding the shape and disposition of the anterior process and the bony element located dorsally to the accessory ossicle. Kogiid periotics differ strongly from that of the Groß Pampau specimen by having an inflated and short anterior process and, typically, three well-defined spines on it. A new taxonomic naming of the Groß Pampau periotic is not appropriate at this stage, although it might demonstrate the existence of a so-far undescribed physeteroid species. Additionally, its systematic position remains yet unclear and it is unknown at this point if it could belong to Hoplocetus ritzi, another physeterid, whose fragments were discovered in the same locality, or to another, already-described taxon, of which the periotic is still unknown.