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Stingrays, found predominantly in warm coastal waters, are responsible for at least 1,500 human injuries in this country each year. These occur most often in the lower extremity. The authors discuss the symptoms and treatment of stingray injuries and present two case reports.
Rehabilitation programs designed to restore leg, ankle, and foot function following injury frequently ignore the proximal muscles. During athletics, these knee, hip, and trunk muscles derive much of their functional power from the foot and ankle. They also serve to integrate distal segment motions into a total movement pattern such as jumping, running, or kicking. The linkage system, which is a theoretical concept, describes the normal biomechanical and physiological interactions between proximal and distal musculoskeletal structures. Immobilization or injury of distal segments interrupts the normal generation, summation, and transmission of muscular forces across joints. Adequate measures must be taken to properly assess proximal structures for weakness and tightness and to prescribe specific exercises to prevent the migration of the effects of injury away from the involved segment.
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A series of 27 successful Superficial Inferior Epigastric Artery free flaps were analysed for a number of clinical and surgical variables. The anatomy and surgical technique of the flap are detailed and its advantages and disadvantages relative to other free flaps used for soft tissue contour are considered. Analysis of the variety of recipient sites of this flap is presented, as are details of the vascular pedicle and our experience with its constancy. It has been found to be a safe flap in experienced hands, with an aesthetic donor site scar, no functional loss and it lends itself to subsequent recontouring with suction assisted lipectomy or open techniques.
The most frequently reported diabetic foot complication is plantar ulceration. Neuropathic fractures occur less often than plantar ulcers but usually result in major structural deformities of the feet. The primary risk factors for plantar ulceration are believed to be loss of protective sensation and the presence of high plantar pressures. Principal etiologic factors in the development of neuropathic fractures are hypothesized to be loss of protective sensation and bone demineralization. Major diabetic foot injuries are preventable by the use of comprehensive screening examinations and patient education. Patients at highest risk of injury should be seen more frequently and receive more extensive therapy. Successful management of plantar ulcerations is dependent on reduction of pressures under the foot and control of infection. Neuropathic fractures require long-term immobilization to promote healing followed by careful monitoring after removal of casts to prevent reinjury. Future research needs include prospective studies on risk factors and validation of treatment techniques.
The pathomechanics of dance injury are explained. Specific injuries are included, such as fractures, ankle sprains, anterior impingement syndrome, posterior impingement syndrome, flexor hallicus longus tendinitis, Achilles tendinitis, and stress fractures.
As part of a larger study of the effect of foot shape on functioning, 47 Royal Australian Air Force recruits with flexible flat feet who were embarking on a 10-week basic training course took part in a randomized controlled trial of orthotic therapy. In particular, recruits were assigned at random to an untreated group or a group that received Australian Orthotics Laboratory, three-quarter-length, flexible, shoe inserts. The groups were assessed at baseline and week 8. Outcome measures included pain, injury, foot health, and quality of life. The untreated group (n = 22) had a greater proportion of heavier recruits than did the treated group (n = 25). There were no significant differences in outcome measures at baseline. Only one-half of the group assigned to orthotic therapy wore the orthotics most or all of the time. At the end of the trial, although the results were not statistically significant, those who were provided with orthotics and wore them had the least lower limb pain and the best general foot health and quality of life. Notably, none of the recruits who wore their orthotics most or all of the time sustained a training injury.
To answer the question, "Does long-distance running injure nerves of the feet and legs?" we invited the 25 members of the Rochester Track Club who had run the greatest number of miles in their lifetime to participate in a study that involved neurologic examination, determination of detection thresholds of touch-pressure, vibratory, and cooling sensations of the foot, and evaluation of nerve conduction. None of the runners had clinical symptoms or signs of peripheral neuropathy. Most of them reported having had toe and foot injuries, sometimes associated with short-lived sensory symptoms. A computer-assisted sensory evaluation of the detection threshold for vibratory sensation of the toe revealed slightly, but significantly, higher values in the runners in comparison with age- and sex-matched control subjects. Similarly, small, but statistically significant, differences were also observed for some attributes of nerve conduction in the leg and foot nerves of the runners. These results suggest that long-distance running causes multiple small injuries to the toes and feet, which lead to measurable differences in the detection threshold for vibratory sensation and in nerve conduction but not to overt neuropathy. The trivial subclinical neuropathic deficits we noted are readily offset by the assumed health and recreational benefits of running.
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Few cases of high pressure water injection injuries of the foot have been reported. These cases suggest that only minimal soft tissue destruction results and that, with conservative or limited surgical management, full recovery should be expected. This is a report of two cases of this "benign variant" of high pressure water injection injury that resulted in toe amputations.
We estimated the prevalence of foot symptoms and disease and evaluated foot care practices in a primary care based sample including 2106 people with diabetes in Trinidad. Symptoms of neuropathy were reported by 1030 (49%), previous foot ulceration by 257 (12%), and amputation by 92 (4%). Previous foot ulceration was associated with longer duration of diabetes (odds ratio 1.05, (95% CI 1.04-1.06) per year) and greater severity of neuropathy symptoms (1.17 (1.10-1.24) per unit increase in score). A history of foot ulceration gave relative odds of amputation of 16.3 (8.1-32.9). In those with previous foot ulceration, 120 (47%) went barefoot in the home, and 44 (17%) went barefoot outside the house. Overall, 1491 (71%) subjects reported they cut their toenails themselves, help was provided by a friend or relative to 584 (28%) and by a nurse or chiropodist to 13 ( < 1%). Most patients (1320, 63%) reported that they would treat a cut or blister on the foot themselves, while only 650 (31%) would attend for health care. Diabetic foot disease is common but care practices predispose to foot injury. Implementation of a strategy to improve care of the feet is needed.
Physicians argue that patient preferences influence their test ordering and their potential for compliance with clinical practice guidelines (CPG). This study was conducted to evaluate patient satisfaction with clinical practice in emergency department (ED) settings using a validated and widely publicized set of CPGs. Patients presenting to 4 hospital EDs were eligible if they had sustained acute ankle or foot injuries. All sites were involved with the dissemination of radiography CPG, and use of radiography was determined by treating physicians. Telephone follow-up was attempted for all patients who did not receive ankle or foot radiography (Group 1). A random sample of 25% of patients who had a normal radiograph interpretation (Group 2) was also chosen for follow-up. Structured telephone interviews were administered and included information on post-encounter health care utilization, subsequent radiography, and patient satisfaction. A structured questionnaire was administered to all ED physicians (N = 60) to elicit their perspectives on the clinical practice guidelines. In Group 1, 342 (69%) of 494 non-radiographed patients were successfully contacted. In Group 2, 623 (77%) of 812 patients with normal ED radiographs, were successfully contacted. After ED discharge, 86 (25%) Group 1 and 191 (31%) Group 2 patients had visited another physician within 2 weeks of the initial ED encounter (P =.07). Subsequent ankle radiography was similar between the groups (38 [11%] in Group 1 vs. 59 [10%] in Group 2; P =.38). Patients appeared to be similarly highly satisfied with physician care (P =.58) and with discharge instructions (P =.12) in both groups. Overall, 76% of physicians supported the use of CPGs; however, 78% reported that patient expectations influenced their application of the Ottawa Ankle Rules. This study suggests that patients are equally satisfied with care, access additional health care services similarly and obtain the same percentage of radiographs irrespective of the initial ED ankle/foot radiograph ordering. These results may help physicians in re-evaluating their perceptions that patient expectation influence utilization and have important implications in guideline development.
One of the most important goals of modern microsurgical reconstruction is to decrease donor site morbidity as much as possible. With free flaps for lower limb reconstruction, economy of donor sites was designed and performed in 39 patients. Among these 39 patients, 17 had multiple flaps raised from a single incision for reconstruction of multiple defects in one or both lower extremities. Microvascular reconstruction of multiple defects is a challenging problem, particularly if it is to be performed simultaneously. The patients were followed for more than 3 years. Immediate complications and long-term disabilities were analyzed. From the data we conclude that this method has the following advantages: (1) economy of donor site incisions, (2) less harvest time, and (3) availability of any composite tissue for transfer. Donor site morbidity can be reduced by good planning, careful dissection, meticulous hemostasis, and adequate postoperative management.
The sural artery flap is a distally based fasciocutaneous flap. It is based on a reverse flow through anastomoses between the peroneal artery and the communicating vascular network of the medial sural nerve. In the difficult area of defects in the lower leg and the ankle and heel region, it has a wide variety of indications, even in vascularly compromised patients. It has the largest arc of rotation of all flaps that have been described in this region. The most important advantage is that it does not compromise a major artery. Furthermore, it is simple to dissect and has a low donor morbidity. A series of 15 patients is described in which we covered defects in the lower leg, malleolar, and heel regions. Seven patients were vascularly compromised seriously. Twelve flaps survived completely, two survived partially, and one flap failed.
A 66-year-old woman with idiopathic osteonecrosis of the first metatarsal head was treated by arthrodesis of the first metatarsophalangeal joint with a good result. The patient had no history of foot injury, no record of corticosteroid administration, no excessive alcohol intake, and no other predisposing conditions for osteonecrosis. Surgical intervention, by removal of the necrotic area followed by metatarsophalangeal joint fusion, alleviated her foot pain.
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After the spontaneous epithelialisation of the defects of soft parts so called unstable scars remain which, because of ulceration, are sources of infection, endangering both soft parts and bones. Substitution with soft tissues of adequate blood supply enables the complete sanation of the septic foci and by this the rapid healing of the patient with full function. Beside this a better cosmetic result can be achieved. In septic environment, if possible, local muscle flaps and free flaps are used, depending on the extent and localization of the defect. Experiences, gained in these operations are described.
The practice of the martial arts is associated with a variety of lower-extremity injuries. Previous studies of the martial arts have examined injuries to the entire body, while providing only limited information on trauma to the foot and ankle. After a comprehensive review of the literature on martial arts injuries, the authors report the results of a survey on foot and ankle injuries sustained by martial arts practitioners.