MRI’s have become a common tool in the diagnosis and treatment of bone and joint deformities. Often an MRI report will refer to a bone contusion. What’s a bone contusion and how does it compare to a fracture?
Bone contusions go by a number of names including bone bruise, bone edema and bone swelling. A contusion by definition is ‘A bruise; an injury attended with more or less disorganization of the subcutaneous tissue and effusion of blood beneath the skin, but without apparent wound. ‘ Although this is the definition for a skin contusion, the same definition applies to bone. A bone contusion is an injury that involves injury to the surface bone and subsequent damage to the underlying bone sub-structure.
Bone contusions come in a variety of patterns. Some involve non-articular bone, but most are going to be both a cartilage and bone injury, involving the joint. Bone contusions that involve the cartilage go by another broad group of names; osteochondral lesions, transchondral lesions, transchondral fractures. We’ve got a bit of information on ankle transchondral fractures of the ankle on Myfootshop.com.
I look at bone contusions as a subtle form of fracture. Sure, there’s no defined break, but the bone is going to manage a bone contusion just as if the bone is fractured.
So how long does a bone contusion take to heal? Might take even longer than a fracture in that the bone is effected by a crush (contusion) injury. So plan on months for complete healing. Granted, the rate of healing will vary by the general health of the patient, the nature of the injury and the location of the injury.
Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com
Talar fractures are unfortunately all to common. Talar fractures can be quite debilitating and lead to a loss of career or limitations in activities. Talar fractures are a common sequelae of motor vehicle accidents and falls from a height. We see talar fractures in rock climbers and roofers.
One complication of a talar fracture is avascular necrosis (AVN). AVN occurs when the blood supply to the talus is disrupted. Avascular simply means no blood and necrosis means that the bone dies as a result of this loss of blood.
But AVN can also occur in the talus in the absence of trauma. I saw a case today of non-traumatic AVN in a pleasant 72 y/o housewife. She described a mild sprain several months ago but didn’t seem to relate the sprain to her current pain. Plain films were negative for change. MRI indicated extensive necrosis of the distal tibia and neck of the talus suggesting a dorsiflexion injury of the ankle.
AVN can occur at a number of locations in the body, most commonly the hip. Due to load bearing of the hip, fracture is a common outcome of AVN in the hip.
We know that the talus is particularly susceptible to AVN due to the fact that it is 3/5 covered with cartilage. This cartilage makes up the joint surfaces of the ankle and subtalar joints. And anywhere we find cartilage, we cannot have a blood vessel enter the bone. Therefore, the more cartilage, the less vascular inflow and increased risk for AVN.
But without a history of trauma, how does AVN occur? A direct correlation between steroid use and AVN of the hip is found in the literature. Why steroids? We’re not really sure. Occlusion by embolis is another possibility. But I think we have a lot to learn about the etiology of non-traumatic AVN.
We’ll keep this patient partial weight bearing in a walking cast and keep her on a walker. She knows that it’ll be a number of months before I feel comfortable with her bearing full weight on the foot. She also realizes that as the AVN progresses, the possibility of collapse of the talus ever present.
Jeffrey Oster, DPM
Medical Director
Myfootshop.com
The California Public Retirement System (CalPERS) just won a $895 million (yes, million) dollar settlement against health care giant UHC for their illegal stock option granting program. These options enabled the management of UHC to draw millions of dollars from the company by back dating stock options. Bravo CalPERS and thanks for standing tall.
UHC has lowered projections for share holders. So what else is new? They’ve lowered payment to my practice for years to a degree that UHC represents my lowest paying private insurer. They also anticipate a 4000 job layoff this year.
There’s a bad intersection coming. I don’t know how it’s going to play out, but costs keep rising, reimbursement keeps dropping. Throw an election into the mix and it’s going to be an interesting next couple of years.
Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com
Lisfranc’s fractures and dislocations can be complex and a part of mixed trauma. I saw a case last week in which the patient had sustained a motorcylce injury resulting in a Lisfranc dislocation of the first and second metatarsals, fracture of the third metatarsal and fracture of the medial cuneiform. The third metatarsal was intact at the base without disruption of Lisfranc’s joint but had a mid shaft fracture.
The goal in Lisfranc fractures is to realign the normal joint architecture to avoid future arthritis. The cases are often misdiagnosed and under treated. In this case an MRI confirmed our suspicions of a disruption of Lisfranc’s ligament and a diastasis of the first and second metatarsals. This case was an excellent candidate for use of Arthrex’s new Mini TightRope System. Traditionally the medial cuneiform would be used to fixate the second metatarsal with rigid fixation. In this case where the patient had a fractured medial cuneiform with a weak medial wall, we chose to pass the TightRope from the mid-shaft 1st metatarsal to the base of the second metatarsal. This was accomplished through a 1cm incision and performed under fluoroscopy.
I saw the patient for a 2 week f/u visit yesterday for removal of the single suture. He’s doing quite well with minimal edema. He’ll be in a cast for a total of 6 weeks, non-weight bearing. I’ll transition him to a walking cast for 4 weeks to follow.
Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com
It’s rare anymore to see a polio deformity but I saw one this week. A 52 y/o male presented to the office with a deformity of the right leg. The polio vaccine would have been available for him as a child….but that’s another story. Vaccines work and it’s a mystery why some folks choose not to use them.
This fellow presented with calcaneal varus and ankle arthritis. Calcaneal varus is a deformity of the heel (calcaneus) that when viewed from the back, the heels are positioned as such… \ / . In this case, the right calcaneal varus was rigid (uncompensated). I performed his surgery on Tuesday that involved a Dwyer osteotomy of the heel. A Dwyer is a closing wedge performed on the lateral aspect of the heel that swings the heel back under the leg. I also performed a scope on the right ankle to clean up residual arthritis of the ankle.
What’s rewarding about this case is the impact that it’ll have on this fellow’s life. He’s not going to be perfect and we can’t restore the muscle tone of the leg post-polio, but he’ll be able to walk again.
Jeffrey Oster, DPM
Myfootshop.com
