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Background: Classification of fifth metatarsal base fractures has been a source of confusion since originally described by Jones in 1902. Zone classifications have been described but never evaluated for reliability. The most recent classification, metaphyseal vs meta-diaphyseal, may be unknown to many surgeons. The purpose of this study was to evaluate reliability of American Orthopaedic Foot & Ankle Society (AOFAS) members classifying fifth metatarsal base fractures and current management of these fractures., Methods: A survey was emailed to AOFAS members including radiographs of 18 fifth metatarsal base fractures. Demographic information was collected in addition to evaluation of the radiographs. Interrater reliability was assessed for each measurement: presence of Jones fracture, zone classification, and metaphyseal vs metaphyseal-diaphyseal, using Fleiss kappa. After 3 weeks, a second email was sent to the members asking to retake the survey to evaluate intrarater reliability. Respondents were asked which region is a Jones fracture, which classification is used, if symptomatic zone 2 and 3 fractures are treated similarly, and what fractures are operative in healthy symptomatic acute fractures., Results: A total of 223 AOFAS members, with a median time in practice of 12 years (range 0-50), completed the initial survey. Eighty members (36%) repeated the survey for intrarater comparison. Interrater reliability was moderate for Jones and zone classification but substantial for the 2-zone metaphyseal/meta-diaphyseal classification. The median intrarater kappa was 0.78, 0.75, and 0.78 for Jones, zone, and metaphyseal/meta-diaphyseal respectively. Seventy percent of respondents treat zones 2 and 3 similarly, and approximately 60% consider an acute symptomatic fracture identified as Jones, zone 2 or zone 3 operative., Conclusion: A 2-zone system may be the best available classification for fifth metatarsal base fractures given high interrater reliability and 70% of AOFAS members treat zones 2 and 3 in similar fashion., Level of Evidence: Level III, diagnostic study.

Background: Assessing and correcting malalignment is important when treating calcaneus fractures. The Harris axial view is commonly utilized to assess varus deformity but may be inherently inaccurate due to its tangential nature. The anterior-posterior (AP) calcaneal profile view is a novel radiographic view that is easily obtained with demonstrated increased accuracy for assessing calcaneal axial alignment., Methods: Five nonpaired ankle cadaveric specimens were used in this investigation. Oblique osteotomies were created in relation to the long axis, and varus deformities were produced by inserting solid radiolucent wedges into the osteotomies to create models of 10, 20, and 30 degrees of angulation of the calcaneal tuberosity. Specimens were imaged using both the Harris axial view and the AP calcaneal profile view., Results: For cadavers with 10 degrees of actual varus angulation, the mean Harris axial view angle and the AP calcaneal profile view angle were 10.9 ± 4.8 (range, 5.5-16.0) degrees and 13.0 ± 5.5 (range, 7.3-20.9) degrees, respectively. For cadavers with 20 degrees of actual varus angulation, the mean Harris view angle and the AP calcaneal profile view angle were 11.5 ± 2 (range, 8.2-13.6) degrees and 18.1 ± 4.8 (range, 11.7-23.5) degrees, respectively ( P = .005). On pairwise comparison with Bonferroni correction, there was a significant difference between the Harris axial view angle and both the AP calcaneal profile view angle ( P = .012) and actual angulation ( P = .011). For cadavers with 30 degrees of actual varus angulation, the mean Harris axial view angle and the AP calcaneal profile view angle were 18.3 ± 4.3 (range, 13.3-23.6) degrees and 28.3 ± 2.9 (range, 24.4-31.1) degrees, respectively ( P < .001). On pairwise comparison with Bonferroni correction, there was a significant difference between the Harris axial view angle and both the AP calcaneal profile view angle ( P = .001) and actual angulation ( P < .001). There was no significant difference between the AP calcaneal profile view angle and actual angulation ( P > .999)., Conclusion: The AP calcaneal profile view is a novel radiographic view that is easily obtained with demonstrated increased accuracy for assessing calcaneal axial alignment. While both views demonstrated similar measurement error for lesser degrees of varus malalignment, the AP calcaneal profile view demonstrated more accurate measurement of increasing heel varus compared with the Harris view., Clinical Relevance: The AP calcaneal profile view could be used in addition to other radiographic views when treating displaced, intra-articular calcaneus fractures to help optimize correction of hindfoot alignment.

Lisfranc injuries require anatomic reduction and stabilization of the tarsometatarsal joints. We describe a novel technique that provides flexible fixation that is simple, cost-effective and that may offer certain advantages over more traditional techniques., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Surgical fixation of Jones fractures is often recommended to facilitate recovery and achieve union. Iatrogenic fracture displacement during intramedullary screw fixation is a commonly encountered technical issue. This may be related to fracture location in relation to the surrounding ligamentous attachments, namely the robust intermetatarsal ligaments found at the proximal articulation of the 4th and 5th metatarsals. This study examines the relationship between fracture line and its location in regards to the surrounding ligamentous structures and its effect on Jones fracture displacement, reduction and fixation in a cadaveric model., Methods: Eighteen fresh-frozen cadaveric feet were dissected with preservation of all ligamentous attachments. Given the similar anatomic distal extent of the dorsal and plantar intermetatarsal ligaments on the 5th metatarsal, measurements were obtained detailing the anatomic position of the dorsal intermetatarsal ligament (DIL) only. The specimens were divided into two groups with modelled fractures created at the 4th & 5th metatarsal articulation proximal to the distal extent of the DIL (Group 1) or just distal to the DIL (Group 2). Fractures were fixed in standard fashion with serial fluoroscopic images obtained to study fracture gapping and rotation., Results: There was approximately 5 mm of fracture gapping created iatrogenically during tapping with no statistically significant differences between Group 1 and Group 2 (4.53 mm versus 5.25 mm, p = 0.5430). The distal aspect of the DIL was anatomically located 2.77 mm (Range 1.58 mm-4.46 mm) distal to the 4th & 5th metatarsal articulation., Conclusions: Considerable iatrogenic fracture gapping occurs during intramedullary screw fixation of Jones fractures in a cadaveric model regardless of fracture location in relation to the intermetatarsal ligamentous attachments. Specific techniques may be required to maintain anatomic alignment during tapping and screw fixation to prevent iatrogenic displacement., Level of Evidence: V, Expert Opinion., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: While trans-syndesmotic fixation with metal screws is considered the gold standard in treating syndesmotic injuries, controversy exists regarding the need and timing of postoperative screw removal. Formal recommendations have not been well established in the literature and clinical practice is highly variable in this regard. The purpose of this systematic review is to critically examine the most recent literature regarding syndesmotic screw removal in order to provide surgeons an evidence-based approach to management of these injuries., Methods: The Cochrane Library and PubMed Medline databases were explored using search terms for syndesmosis and screw removal between October 1, 2010 and June 1, 2016., Results: A total of 9 studies (1 randomized controlled trial and 8 retrospective cohort studies) were found that described the outcomes of either retained or removed syndesmotic screws. Overall, there was no difference in functional, clinical or radiographic outcomes in patients who had their syndesmotic screw removed. There was a higher likelihood of recurrent syndesmotic diastasis when screws were removed between 6 and 8 weeks. There was a higher rate of postoperative infections when syndesmotic screws were removed without administering preoperative antibiotics., Conclusion: Removal of syndesmotic screws is advisable mainly in cases of patient complaints related to the other implanted perimalleolar hardware or malreduction of the syndesmosis after at least 8 weeks postoperatively. Broken or loose screws should not be removed routinely unless causing symptoms. Antibiotic prophylaxis is recommended on removal. Radiographs should be routinely obtained immediately prior to removal and formal discussions should be had with patients prior to surgery to discuss management options if a broken screw is unexpectedly encountered intraoperatively. Radiographs and/or computed tomography imaging should be obtained after syndesmotic screw removal when indicated for known syndesmotic malreduction., Levels of Evidence: Level IV: Systematic review.

Background: Routinely obtaining adjacent joint radiographs when evaluating patients with ankle fractures may be of limited clinical utility and an unnecessary burden, particularly in the absence of clinical suspicion for concomitant injuries., Methods: One thousand, three hundred and seventy patients who sustained ankle fractures over a 5-year period presenting to two level 1 trauma centers were identified. Medical records were retrospectively reviewed for demographics, physical examination findings, and radiographic information. Analyses included descriptive statistics along with sensitivity and predictive value calculations for the presence of adjacent joint fracture., Results: Adjacent joint imaging (n=1045 radiographs) of either the knee or foot was obtained in 873 patients (63.7%). Of those, 75/761 patients (9.9%) demonstrated additional fractures proximal to the ankle joint, most commonly of the proximal fibula. Twenty-two of 284 (7.7%) demonstrated additional fractures distal to the ankle joint, most commonly of the metatarsals. Tenderness to palpation demonstrated sensitivities of 0.92 and 0.77 and positive predictive values of 0.94 and 0.89 for the presence of proximal and distal fractures, respectively. Additionally, 19/22 (86.4%) of patients sustaining foot fractures had their injury detectable on initial ankle X-rays. Overall, only 5.5% (75/1370) of patients sustained fractures proximal to the ankle and only 0.2% (3/1370) of patients had additional foot fractures not evident on initial ankle X-rays., Conclusion: The addition of adjacent joint imaging for the evaluation of patients sustaining ankle fractures is low yield. As such, patient history, physical examination, and clinical suspicion should direct the need for additional X-rays., Level of Evidence: Level IV., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Bohler's angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam's obliquity on the measurement of BA., Methods: A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement., Results: A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = -4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity., Conclusions: Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons' ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph., Levels of Evidence: Level V: Cadaver bench study., (© 2016 The Author(s).)

Unlabelled: Calcaneus fractures are the most commonly fractured tarsal bone with approximately 75% being intra-articular in nature. Böhler's angle has been found to be reliable and prognostic, and it has been used as a proxy for joint depression and articular involvement. It often guides the need for advanced imaging and/or operative intervention. We describe a rare variant of intra-articular calcaneus fracture-dislocation that results in elevation of a portion of the posterior facet above the posterior talus and a seemingly normal or increased Böhler's angle, which we call the "joint-elevation" calcaneus fracture. Orthopaedic surgeons should be aware of this previously undescribed variant in order to avoid inappropriate treatment or misdiagnosis., Level of Evidence: Therapeutic Level IV: Case Series., (© 2014 The Author(s).)

Background: The purpose of this study was to evaluate prognostic predictors of complications and need for secondary surgery in a series of calcaneal avulsion fractures., Methods: Thirty-three patients who sustained extra-articular calcaneal avulsion fractures from 2002 to 2011 were retrospectively identified. Main outcome measurement was need for secondary surgical procedures. Secondary complications such as soft tissue complications and loss of fixation were noted. Prognostic factors for outcome measures were identified., Results: There was a need for secondary operations in 12 cases. Of those, 10 (83%) had wound complications and 5 (41.7%) had failure of fixation. Two subjects required below knee amputation. Of the entire cohort of 33 patients, 13 (39.4%) had soft tissue complications. Of the 22 that underwent surgery, 6 (27%) had failure of fixation. Increased age was significantly associated with wound complications (P = .029). Hypothyroidism (P = .003), peripheral vascular disease (P = .022), and presence of more than one comorbidity (P = .005) were significantly associated with need for secondary surgical intervention. Skin compromise at presentation was significantly associated with soft tissue complication (P = .036) and failure of fixation (P = .046)., Conclusions: Calcaneal avulsion fractures have a high incidence of soft tissue problems, failure of fixation, and need for additional surgeries. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries., Levels of Evidence: Prognostic, Level II: Retrospective Analysis., (© 2014 The Author(s).)

Unlabelled: The distal tibial blind spot represents an area where improperly measured long screws may pose a risk to surrounding anatomic structures and is not well visualized on AP, mortise, and lateral radiographs. Awareness of this area as well as the use of a 45° external rotation oblique view when placing fixation in this area may prevent iatrogenic injury., Levels of Evidence: Level V, Expert Opinion., (© 2014 The Author(s).)

Background: The purpose of this study was to determine whether obtaining a radiograph of the uninjured contralateral calcaneus (template) before surgery allowed for more precise restoration of Bohler's angle and calcaneal length when performing open reduction internal fixation (ORIF) of intra-articular calcaneus fractures., Methods: Patients who sustained an intra-articular calcaneus fracture requiring surgery who met inclusion criteria were prospectively randomized into those who had a preoperative template obtained for review at the time of ORIF (group 1) versus those who had the contralateral radiograph obtained after surgery (group 2)., Results: There was no benefit of the preoperative template in allowing for more anatomic restoration of Bohler's angle or calcaneal length. Operative time was decreased with the use of a preoperative template when using the extensile lateral or percutaneous approaches., Conclusion: Preoperative templating of the uninjured contralateral calcaneus did not allow for more anatomic reduction or restoration of pre-injury morphology of the calcaneus undergoing operative fixation as based on Bohler's angle and calcaneal length. Templating may be of benefit by reducing operative time., Level of Evidence: Level II, prospective comparative series., (© The Author(s) 2014.)

Unlabelled: We describe a simple technique using dual C-arms (large and mini C-arm together) for open reduction internal fixation of calcaneal fractures in the lateral decubitus position that (1) decreases the difficulty of obtaining proper intraoperative imaging; (2) limits C-arm movement, which decreases risk of contamination and operative time; and (3) minimizes the drawbacks of each imaging fluoroscopic modality., Levels of Evidence: Level V, Technical tip, Expert opinion.

Background: Our aim was to assess whether the Lauge-Hansen (LH) and the Muller AO classification systems for ankle fractures radiographically correlate with in vivo injuries based on observed mechanism of injury., Methods: Videos of potential study candidates were reviewed on YouTube.com. Individuals were recruited for participation if the video could be classified by injury mechanism with a high likelihood of sustaining an ankle fracture. Corresponding injury radiographs were obtained. Injury mechanism was classified using the LH system as supination/external rotation (SER), supination/adduction (SAD), pronation/external rotation (PER), or pronation/abduction (PAB). Corresponding radiographs were classified by the LH system and the AO system., Results: Thirty injury videos with their corresponding radiographs were collected. Of the video clips reviewed, 16 had SAD mechanisms and 14 had PER mechanisms. There were 26 ankle fractures, 3 nonfractures, and 1 subtalar dislocation. Twelve fractures with SAD mechanisms had corresponding SAD fracture patterns. Five PER mechanisms had PER fracture patterns. Eight PER mechanisms had SER fracture patterns and 1 had SAD fracture pattern. When the AO classification was used, all 12 SAD type injuries had a 44A type fracture, whereas the 14 PER injuries resulted in nine 44B fractures, two 44C fractures, and three 43A fractures., Conclusion: When injury video clips of ankle fractures were matched to their corresponding radiographs, the LH system was 65% (17/26) consistent in predicting fracture patterns from the deforming injury mechanism. When the AO classification system was used, consistency was 81% (21/26). The AO classification, despite its development as a purely radiographic system, correlated with in vivo injuries, as based on observed mechanism of injury, more closely than did the LH system., Level of Evidence: Level IV, case series.

Background: Recent investigations of displaced clavicle fractures in adults have demonstrated a higher prevalence of nonunion, symptomatic malunion, diminished functional outcome, and decreased strength with nonoperative treatment. Although these data have led to increased surgical management of displaced fractures, little published information is available regarding the consequences of malunion in the pediatric population. The purpose of this investigation was to assess pain, functional outcome, range of motion, and strength in children with displaced clavicle fractures treated nonoperatively., Methods: Clinical evaluation of 16 patients with mid-diaphyseal clavicle fractures and >2 cm of initial displacement was performed; all had undergone nonoperative treatment and went on to radiographic malunion. The mean age at the time of injury was 12.2±3.3 years. Pain, aesthetic appearance, and satisfaction with treatment were rated by patients on a visual analog scale (VAS) (range 0 to 10 with 10 indicating the worst score). Patient-based outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Pediatric Outcomes Data Collection Instrument (PODCI). Bilateral shoulder motion was measured by a physical therapist. Isokinetic strength testing of the bilateral shoulders was performed with a Biodex dynometer. Range of motion and strength were analyzed with a multivariable regression, controlling for hand dominance. The mean follow-up was 27.2 months after injury., Results: All displaced fractures treated nonoperatively achieved union. Overall, there was reduced forward flexion and abduction on the injured side compared with the contralateral sides of 7.3 and 6.5 degrees, respectively, adjusted for hand dominance (P<0.05). Biodex testing did not detect any significant difference in abduction or adduction torque or power between affected and unaffected shoulders. The mean VAS score for pain was 1.6, with 4 patients reporting pain ≥to 3. The mean VAS scores for satisfaction with aesthetic appearance was 2.7, with 4 patients reporting scores >5. The mean VAS scores for satisfaction with treatment was 2.0, with only 1 patient scoring >5. The mean DASH score was 4.9±7.5, with 3 patients scoring ≥10. The mean scores on the DASH sports and performing arts module was 1.9±4.2, with only 1 patient scoring ≥10. The mean global PODCI score was 94.5±6.0. The mean PODCI scores for upper extremity function, sports, and pain were 97.9±5.5, 95.4±5.3, and 84.6±20.5, respectively. Only 1 patient was symptomatic enough to require corrective osteotomy., Conclusions: Skeletally immature patients with established clavicle fracture malunions do not develop clinically meaningful loss of shoulder motion or abduction/adduction strength. Routine surgical fixation for displaced, nonsegmental clavicle fractures may not be justified based upon concerns regarding shoulder motion and strength alone. Further investigation is required to determine the risk factors and causes of pain and functional compromise in the minority of pediatric patients with symptomatic malunions., Level of Evidence: Level IV.

Background: The aim of this study was to determine the ability of the Harris heel view to confirm placement of the sustentacular screw during calcaneal fixation., Methods: A 4.0 cancellous screw was placed in a cadaveric specimen, from lateral to medial in 5 configurations: (1) within the sustentaculum, (2) misdirected inferiorly to sustentaculum, (3) misdirected superiorly to sustentaculum, (4) misdirected anteriorly to sustentaculum, and (5) misdirected posteriorly to sustentaculum. Harris heel views were obtained at 5 angulations and were analyzed to determine screw placement., Results: A screw placed anatomically was radiographically confirmed by the Harris heel view to be within the sustentaculum in all views. An inferiorly misdirected screw appeared radiographically within the sustentaculum at 30, 40 and 50 degrees but was confirmed misplaced on the 10- and 20-degree views. A posteriorly misdirected screw was confirmed misplaced on all 5 views. An anteriorly misdirected screw appeared radiographically within the sustentaculum on the 10-degree view but was confirmed misplaced on all other views. A superiorly misdirected screw was confirmed misplaced on all views., Conclusions: Clinicians should be aware that several specific axial heel views are required to verify placement of the sustentacular screw. An inferiorly misdirected screw will appear to be within the sustentaculum with the standard Harris heel view., Clinical Relevance: Heel views should be obtained from a range of 10 to 50 degrees to confirm accurate placement of the sustentacular screw.

This article describes a case of an ankle fracture following hip arthroscopy. A 58-year-old woman underwent hip arthroscopy for a labral tear. She was placed in a lateral decubitus position with her foot in a padded boot. Traction was maintained for approximately 30 minutes. She was instructed to bear weight as tolerated with crutches postoperatively. At 2-week follow-up, she reported ipsilateral ankle pain. Radiographs revealed a minimally displaced medial malleolus fracture. She was treated with a cast followed by a cam walker boot and successfully went on to complete union and resolution of her symptoms. The following risk factors exist for ankle fracture after hip arthroscopy: history of ankle sprains, ligamentous laxity (more common in women), and small feet with large calves (more likely to become plantarflexed during traction). Distraction performed with the ankle rotated is also likely to place added stress on the medial or lateral ligamentous structures. It is important to counsel patients preoperatively about the risk of ankle pain after hip arthroscopy, to be aware of the possibility of ankle pathology postoperatively, and to have a low threshold for ordering radiographs. Radiographs are warranted if patients continue to have ankle pain after 72 hours postoperatively., (Copyright 2012, SLACK Incorporated.)

We describe a previously unreported problem of a patient who underwent errant 4-cortex syndesmotic screw fixation with resultant posterior tibial tendon tear necessitating removal of hardware and repair of a tendon tear.

Background: Crush injuries to the foot are a common workplace injury and a significant source of morbidity, disability and lost wages. Many regulatory bodies including the Occupational Safety and Health Administration (OSHA) recommend the use of safety shoes in certain occupations to help protect against these occupational hazards. However there remains controversy and paucity of published data regarding the protection afforded by a steel toe cap in regards to clinical injury pattern. This study looks to investigates the protective influence of a steel toe cap on crush injuries of the forefoot., Materials and Methods: Five non-osteoporotic paired cadaver lower extremities were appropriately fitted to a standard work boot. One foot of each pair was fitted into a steel toe capped boot (designated ``ST'' group) while the other foot was fitted into an identical version of the work boot but without the protective steel toe cap (designated ``NST'' group). Each foot was crushed using a custom designed rig with a load of 150 lb dropped from a calibrated height of 3 feet to the forefoot. X-rays were obtained to assess fracture location & comminution and stress fluoroscopy was used to assess for any ligamentous Lisfranc injury., Results: The NST group averaged 8.2 fractured bones per foot while the ST group averaged 3.6 fractured bones per foot (p = 0.001). The NST group demonstrated significantly more metatarsal fractures (3.2 fractures/foot) versus the ST group (one fracture/foot) (p = 0.020). The NST group demonstrated significantly more proximal phalanx fractures (4.2 fractures/foot) compared to the ST group (2.6 fractures/foot) (p = 0.035). Middle and distal phalanx fractures were not significantly different between the two groups. A higher percentage of the bones fractured were deemed comminuted in the NST group (53.6%) versus the ST group (38.8%) although this did not reach statistical significance., Conclusion: This study demonstrated that the steel toe affords protective advantages in crush injuries to the foot in limiting the number and severity of metatarsal and proximal phalanx fractures. However the steel toe does not fully protect the forefoot from injury., Clinical Relevance: Crush injuries to the foot are a common workplace injury. Strict adherence to workplace safety standards may limit the severity of crush injuries to the foot and additional safety measures such as metatarsal guards should be considered when appropriate.

Background: There appears to be a general lack of consensus in treating calcaneus fractures. Many different patient-based variables such as smoking, diabetes, or occupation, may influence treatment decisions possibly more so than the nature of the injury itself. Indications for operative versus nonoperative treatment are often unclear. The goals of this study were to determine if lack of consensus exists, determine which factors most influence orthopaedic surgeons in choosing operative versus nonoperative treatment and determine if there are differences in treatment based on fellowship training and exposure to these injuries., Materials and Methods: Practicing orthopaedic surgeons of various backgrounds and training were administered an electronic survey. The survey consisted of clinical vignettes and questions regarding fellowship training, demographics and exposure to calcaneus fractures. Orthopaedic surgeons were asked to weigh the importance of patient-based variables in determining operative versus nonoperative treatment., Results: For patients with an uncomplicated medical history, there was a general consensus on treatment as guided by the Sanders classification. For those with a complex medical history, there was less consensus on management despite fracture pattern. Foot & ankle fellowship-trained surgeons (F&AT) ranked calcaneal deformity as more important than trauma fellowship-trained surgeons (NFT), and ranked peripheral vascular disease (PVD)/diabetes mellitus (DM) more important than did both trauma fellowship-trained surgeons (TFT) and NFT surgeons. There was no significant difference in choosing operative versus nonoperative treatment for surgeons treating more calcaneus fractures (more than four per month) versus those who treated fewer (less than one a month)., Conclusion: There was general agreement among surgeons regarding the most important variables for determining management of calcaneus fractures. How this information is utilized varies according to practitioner and leads to varying consensus. There was generalized consensus regarding management in cases of anatomic deformity at either end of the spectrum of severity and non-complex medical histories. When additional confounders were added, the agreement between surgeons declined.

Purpose: An inherent deficiency in the understanding of the biomechanics of fractures is the reliance on cadaveric or other nonphysiological injury models resulting from the prohibitive ethical and practical considerations of conducting injury studies in live participants. We describe a novel methodology for studying injury mechanisms using in vivo injury videos obtained from Youtube.com demonstrating injuries as they occur in real time and correlating them with the resulting injury radiographs., Methods: Over 1000 video clips of potential ankle fractures were assessed for clear visualization of the mechanism of injury, including the foot position and deforming force. Candidate videos were selected if the mechanism of injury was classifiable by those described by Lauge-Hansen and there appeared to be a significant mechanism to likely cause fracture. X-rays were then requested from the individuals posting the video clips. Videos and x-rays were reviewed and classified using the Lauge-Hansen system in a blinded manner. The deforming mechanism in the video clips was classified as supination external rotation, supination adduction (SAD), pronation external rotation (PER), or pronation abduction. X-ray fracture patterns were similarly classified., Results: Two hundred forty videos were selected and individuals posting the videos were contacted. Of 96 initial positive responses, we collected 15 videos with their corresponding radiographs. Eight had SAD-deforming trauma and seven had PER-deforming trauma as appreciated in the videos. There were 12 true ankle fractures. All five fractures judged by video to be SAD injuries resulted in a corresponding SAD pattern radiographic ankle fractures. Of the seven fractures judged by video to be PER injuries, only two resulted in PER pattern radiographic ankle fractures. Five PER injuries resulted in supination external rotation ankle fracture patterns., Conclusion: Our series shows that when in vivo injury videos are matched to their corresponding x-rays, the Lauge-Hansen system is only 58% overall accurate in predicting fracture patterns from deforming injury mechanism as pertaining to SAD and PER injury mechanisms. All SAD injuries correlated but only 29% of PER injuries resulted in a PER fracture pattern. This study illustrates the ethical and practical difficulties of using public access Internet YouTube videos for the study of injury dynamics. The current case series illustrates the method's potential and may lead to future research analyzing the validity of the Lauge-Hansen classification system as applied to in vivo injuries.