Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1431–1442.

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:874–83.

The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of ‘missed injury’.

We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk.

Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.

Introduction: Up to 20% of Lisfranc injuries can go unrecognised with resultant long-term morbidity. Spontaneous relocation may mask the injury. Standard AP, lateral and oblique views of the foot are the primary radiological views. Weight bearing views may not be possible acutely and stress views may require anaesthesia. The standard AP view does not show the tarso-metatarsal joint clearly with alignment of the medial border of the second metatarsal to the medial border of the intermediate cuneiform all important.

Materials and methods: We used a tangential AP view of the tarso-metatarsal joint taken by tilting the x-ray beam cephalad. The degree of tilt was dictated by the declination angle of the first metatarsal seen on the lateral view of the foot (20–25 degrees for most people). Sixteen patients had standard AP, lateral and oblique views of their foot at the time of injury and were not diagnosed to have a Lisfranc injury. They remained symptomatic for an average period of 5 weeks (range, 2 to 15 weeks) before they had the tangential view of the Lisfranc joint.

Results: In all 16 patients the first and second tarso-metatarsal joint and the first inter-metatarsal space were more clearly visible. Thirteen patients had abnormal findings to confirm the diagnosis of Lisfranc injury and for 2 surgical treatment would have been appropriate if identified earlier than 14 and 15 weeks respectively.

Discussion and conclusion: This view confirmed the diagnosis in 13 patients who would have otherwise been discharged as a minor soft tissue injury.

We have also used this view successfully for injecting local anaesthetic in the tarso-metatarsal joints to elucidate the exact source of pain.

We recommend this simple view should be routinely used in addition to the standard AP, lateral and oblique views of the foot for mid foot injuries.

Confirmation of cervical stability in multiple trauma patients is often difficult. Prolonged collar immobilization of these patients is often required. Missed injuries can be catastrophic. Since January 2000, the senior author has regularly applied a modification of the classical White & Panjabi stretch test in the operating room as a method of assessing cervical stability in qualifying trauma patients. Review of the first thirty cases finds two cases of stable ligamentous injury identified which would have otherwise been missed, a mean of almost two weeks’ collar immobilization eliminated and no missed instabilities, with no complications or assessment failures to date. The purpose of this study was to present the protocol and preliminary results of a modified White & Panjabi cervical stretch test in the assessment of cervical instability in multiple trauma patients. Multiple trauma patients having no radiographic evidence of cervical instability on static imaging are routinely protected in hard collars until able to cooperate with clinical assessment and/or undergo flexion/extension radiographs for concern to possible discoligame-nous instability in the neck. Beginning in January 2000, such patients who were going to the operating room were routinely assessed with a stress test incorporating fluoroscopically-controlled axial distraction to tensile limit of the neck followed by maximum passive flexion and extension stressing. In the absence of intersegmental hypermobility, cervical precautions and immobilization were considered unnecessary and discarded. Chart documentation was reviewed for outcome and complications after discharge from the hospital. To date thirty-two tests have been performed and twenty-six cases had complete chart documentation available for review. No complications of the procedure and no missed instabilities have been identified. An average of thirteen days’ collar immobilization were eliminated by this protocol. Two cases of ligamentous hypermobility without instability were identified, one at O/C1 and the other at C5/6; both patients were treated observationally and have done well. One case of an undisplaced C2 pedicle fracture in a massively traumatized geriatric case was confirmed as stable on the day of injury, eliminating the need for collar support until the patient died of multiple organ failure twenty-one days later. Two patients went on to have neck pain complaints on regaining consciousness, but could be reassured that there was no instability. The operating-room cervical stress test is a practical and safe maneuver that can eliminate the requirement for collar immobilization in obtunded trauma patients, safely identify subtle ligamentous injuries without frank instability, and confirm stability in cases of undisplaced fracture. The operating-room cervical stress test is an effective tool in screening trauma patients for such injuries. It does not require access to MRI technology and can be used in any hospital with an operating room. Prolonged cervical collar immobilization and missed discoligamentous injuries of the neck in multiple trauma patients can be eliminated with the application of this test