More than 500,000 visits to the emergency room occur annually in the United States, for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiographs are not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographs ordered without missing a clinically significant fracture. Although a fracture is seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with a fall or twisting injury who have focal tenderness, effusion, or inability to bear weight, radiographs should be the first imaging study obtained. If the radiograph shows no fracture, MRI is best for evaluating for a suspected meniscus or ligament tear, or the injuries from a reduced patellar dislocation. Patients with a knee dislocation should undergo radiographs and an MRI, as well as an angiographic study such as a fluoroscopic, CT, or MR angiogram. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures, by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® Acute Trauma to the Knee

This article reviews the imaging aspects relevant to ligamentous instabilities of the foot and ankle with a focus on MRI and ultrasound imaging. A pictorial review of the anatomy of the medial and lateral ankle ligaments, syndesmosis, spring ligament, Lisfranc complex, hallux sesamoid complex, and lesser toe plantar plate as seen on MRI is presented. Selected cases of ligamentous pathology relevant to foot and ankle instability are presented. The value of imaging in the assessment of foot and ankle instability is reviewed.

Imaging in Foot and Ankle Instability.

OBJECTIVE The objective of our study was to assess the diagnostic performance and associations of the direct and indirect MRI features of the metatarsophalangeal (MTP) joint that are thought to be related to tears of the plantar plate (PP) using surgical findings as the reference standard MATERIALS AND METHODS We retrospectively included 23 patients with symptomatic instability of lesser MTP joints who had undergone preoperative 15-T MRI and surgical assessment The MRI examinations were independently assessed by two musculoskeletal radiologists Using the surgical data as the reference standard, we calculated the sensitivity, specificity, and accuracy of each MRI feature in the detection of PP tears Multivariate logistic regression analysis was performed to identify which MRI features were independently associated with PP tears Interobserver reliability was assessed using kappa statistics RESULTS Forty-five lesser MTP joints were included The presence of pericapsular fibrosis was highly sensitiv

Second and Third Metatarsophalangeal Plantar Plate Tears: Diagnostic Performance of Direct and Indirect MRI Features Using Surgical Findings as the Reference Standard.

The first metatarsophalangeal joint (MTPJ) is a complex of supporting structures that is vital to the biomechanics of the foot, and forced hyperextension of the first MTPJ, known as turf toe, may l...

High-Resolution MRI of the First Metatarsophalangeal Joint: Gross Anatomy and Injury Characterization.

Knowledge and command of anatomy is paramount to effectively treating disorders of the lesser metatarsophalangeal (MTP) joints. The osseous structures consist of the proximal phalanx of the toe and the metatarsal head. The soft tissues on the dorsum of the MTP joint include the joint capsule and the tendons of extensor digitorum longus and extensor digitorum brevis. The proper and accessory collateral ligaments form the medial and lateral walls and contribute to stability in the coronal and sagittal planes. The plantar plate forms the plantar border of the MTP joint and stabilizes the MTP joint against hyperextension and dorsal translation.

Anatomy and Physiology of the Lesser Metatarsophalangeal Joints.

MR Imaging of the Plantar Plate: Normal Anatomy, Turf Toe, and Other Injuries.

The plantar plate has recently gained more attention as an important structure contributing to lesser metatarsophalangeal joint stability. This has prompted a significant growth of interest in the anatomy and biomechanics of the plantar plate and in the diagnosis and treatment of its injuries. Improved understanding of plantar plate function and predictable patterns of degeneration and failure has led to the development of a clinical staging and surgical grading system of plantar plate lesions. Relatively recent innovations allow the surgeon to access and repair plantar plate tears directly with reinsertion onto the base of the proximal phalanx. The addition of direct plantar plate repair represents a significant advance in the surgical restoration of alignment and functional stability of the lesser metatarsophalangeal joint.

Etiology, Clinical Assessment, and Surgical Repair of Plantar Plate Tears.

Plantar Plate Repair for Subluxed Metatarsophalangeal Joint

Objective: The hind foot pain caused by plantar fasciitis is becoming more common. Due to the excellent results after conservative treatment, a small percentage of patients need surgical intervention. The objective of this study is to present the clinical results obtained in patients with plantar fasciitis submitted to endoscopic release. Methods: From 1991 to 2010, 22 patients (26 feet) were submitted to the treatment proposed for plantar fasciitis. All were treated conservatively without success for 14,8 months on average. Through two portals (one medial and one lateral) and fenestrated cannula with a blunt trochar was inserted from medial to lateral, dorsally to the plantar fascia, being exteriorized in the lateral portal. Under direct visualization, the medial two thirds of the fascia was released with a hook knife. Results: After an average follow-up of 9.6 years (2~19 years) we observed an improvement of AOFAS Score from 49 pre-op to 89 post-op. The only two patients (two feet – 8%) who had no improvements after treatment were submitted to a new procedure to treat new pathologies. Discussion: The plantar fasciitis should be treated conservatively and persistent cases need surgical treatment. To decrease the recovery period, minimally invasive methods have been developed to treat several pathologies. The technique proposed follows these new trends, proving to be safe and effective to treat plantar fasciitis. Conclusion: The endoscopic plantar fascia release proved to be a safe and effective procedure.

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Caio Nery

Papers

MR Imaging of the Plantar Plate: Normal Anatomy, Turf Toe, and Other Injuries.

Etiology, Clinical Assessment, and Surgical Repair of Plantar Plate Tears.

Plantar Plate Repair for Subluxed Metatarsophalangeal Joint

Tratamento endoscópico da fascite plantar: estudo retrospectivo de resultados a longo prazo