Stabilising the syndesmosis in ankle fractures - It's not just about flexible or rigid.

Posterior cruciate ligament tibial avulsion fracture (PCLAF) is relatively rare. This fracture may be accompanied by soft tissue injuries, most commonly involving the medial collateral ligament (MCL). The present study aimed to determine the rate of MCL injury and its association with fracture characteristics in patients with PCLAF. Patients with PCLAF were identified with computed tomography, and associated ligamentous and meniscal injuries were evaluated with magnetic resonance imaging. Fracture morphology was assessed via heat maps and quantitative measurements. Receiver operating characteristic (ROC) curves and logistic regression analyses were utilized to identify predictors of MCL injury. A total of 148 ethnic Chinese patients with PCLAF were included (mean age, 48.1 ± 12.9 years; 33.1% female), and 28.4% had concomitant MCL injuries. MCL injuries were significantly associated with posterior horn tears of the medial meniscus (p < 0.001). Patients with MCL injuries exhibited a larger fracture distribution area on heat maps. Consistent with that finding, quantitative analysis showed that these patients had a significantly smaller fracture medial border (p < 0.001) and a significantly larger fracture anteroposterior diameter percentage (p < 0.001). Multivariable analysis identified a fracture anteroposterior diameter percentage of ≥50.2% as an independent predictor of MCL injury (odds ratio, 13.74; 95% confidence interval, 4.85 to 38.95; p < 0.001). MCL injury is relatively common in patients with PCLAF and tends to occur concomitantly with a larger avulsed fragment. The fracture anteroposterior diameter percentage may serve as a valuable predictor for identifying concomitant MCL injury. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background:Partial articular supraspinatus tendon avulsion (PASTA) lesions are a common cause of shoulder pain and dysfunction. Transtendinous repair is a surgical technique used to restore tendon integrity while preserving intact tendon and minimizing iatrogenic tendon damage.Indications:This technique is indicated in patients with symptomatic, partial-thickness rotator cuff tears who have failed conservative management.Technique Description:The PASTA transtendinous technique repair is performed in the beach-chair position. The articular-sided tear is visualized, debrided, and 2 suture anchors are placed percutaneously through the tendon into the rotator cuff footprint. The sutures are passed in a boxed mattress configuration, and knot-tying is performed arthroscopically on the bursal side of the cuff, securing the tendon back to its footprint and preserving intact tendon fibers.Results:This construct demonstrates stable fixation of the tendon to its native footprint, with preservation of tendon integrity. Postoperatively, patients undergo a structured rehabilitation protocol. Return to full activity/sport is expected at approximately 4 to 6 months.Discussion/Conclusion:Transtendinous repair of PASTA lesions provides a reliable method for restoring native tendon integrity, while preserving intact tendon fibers. This technique minimizes tendon trauma compared with traditional “take-down” rotator cuff repair techniques, maintains native anatomy, and facilitates anatomic healing with good functional recovery.Patient Consent Disclosure Statement:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Avulsion fractures of the pelvis and hip primarily affect active adolescents. Although most cases are successfully treated with nonoperative management, surgical intervention may be indicated as displacement and risk for nonunion increase. The literature remains heterogeneous and limited by small comparative cohorts. This study summarizes available evidence comparing outcomes after nonoperative and operative treatment, with particular attention to displacement. A literature search of Ovid Medline, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov was completed in July 2024. Patient characteristics, type of activity at the time of injury, displacement distance, treatment modality, complications, and patient outcomes were recorded for specific fracture types, as available. Twenty-four eligible studies were identified and contributed a total of 852 fractures in 849 patients (mean age 14.4±1.7y, 79% male) for analysis. The most common fracture sites were the anterior superior iliac spine (ASIS, 33.1%) and anterior inferior iliac spine (AIIS, 30.4%), followed by the ischial tuberosity (ISCH, 15.5%), lesser trochanter (LT, 13.5%), and iliac crest (IC, 7.5%). Overall, 86.6% of fractures were managed nonoperatively, and 13.4% were managed surgically. In displacement-stratified cohorts, ISCH fractures with displacement >15mm achieved high functional scores with both operative and nonoperative treatment, although pseudoarthrosis occurred in some nonoperatively treated cases with minimal functional limitation. ASIS fractures with displacement >15mm showed similar transient complications before resolution to excellent outcomes in both treatment groups, but faster RTS with the operative management alone. Rates of persistent pain were highest in ISCH fractures (27.3% surgically, 10.9% nonoperatively) and AIIS fractures treated nonoperatively (13.8%). Return to sport was achieved in nearly all cases, with surgically treated ISCH fractures requiring the longest recovery periods (6mo). Both nonoperative and operative management result in favorable outcomes for most adolescent pelvic avulsion fractures. Although displacement frequently influences surgical decision-making, current evidence does not establish a validated threshold at which outcomes reliably diverge. Before displacement can be considered a reliable surgical indication, higher-quality evidence demonstrating superior outcomes at clear displacement thresholds is needed. Level III.

To investigate specific radiological risk factors in patients with patellar dislocation accompanied by inferomedial patellar margin avulsion fractures and provide evidence for clinical treatment strategy selection, this study conducted comparative analysis of radiographic measurements and clinical function between patients with patellar dislocation with and without such avulsion fractures. A total of 73 patients with patellar dislocation who underwent medial patellofemoral ligament (MPFL) reconstruction at the Affiliated Hospital of Chengde Medical University were included. Basic patient data, affected side, injury mechanism, and type of patellar dislocation were collected. The subjects were subsequently divided into an experimental group and a control group based on the presence or absence of a concomitant inferomedial patellar marginal avulsion fracture. Imaging evaluations, including MRI, CT, and X-ray examinations, were comprehensively performed for comparative analysis. MRI was used to assess the height of the vastus medialis obliquus (VMO); CT was used to measure patellar thickness, patellar width, lateral patellar facet angle, Wiberg angle, Wiberg index, the length ratio of lateral to medial patellar facets, trochlear depth index, sulcus angle, lateral trochlear inclination, tibial tubercle-trochlear groove (TT-TG) distance, the cross-sectional area ratio of VMO to vastus lateralis muscle (VLM), medial-lateral width of the femoral condyle, and the length of different regions of the femoral condyle, as well as to classify the patella and trochlea. The Caton-Deschamps index was measured on X-ray. Additionally, clinical function was evaluated and compared using Lysholm score, IKDC score, Tegner score, and VAS score preoperatively and at 6 months postoperatively. Statistically significant differences were observed between the experimental and control groups regarding injury mechanism, type of patellar dislocation, the ratio of lateral to medial patella facet length, and Wiberg scores (P < 0.05). Injury mechanism, types of patellar dislocation, the Wiberg angle, and the length ratio of the lateral to medial patellar facets have significant predictive value for the occurrence of avulsion fractures of the inferomedial patellar margin following patellar dislocation. Furthermore, patients with patellar dislocation, whether accompanied by avulsion fractures of the inferomedial patellar margin or not, undergoing isolated medial patellofemoral ligament reconstruction show no difference in postoperative clinical function.

In patients with mallet fractures, surgical fixation is traditionally recommended when over one-third of the distal phalanx articular surface is involved. Mallet finger patients with small-sized avulsion fractures, involving around 20% of the distal phalanx articular surface, can have instability at the distal interphalangeal (DIP) joint. This biomechanical study was conducted to determine whether damage to DIP joint collateral ligaments in mallet finger patients with small-sized avulsion fractures contributes to DIP joint instability causing subluxation in these patients. Nineteen cadaveric fingers were given a mallet finger-style avulsion fracture, ranging from 9% to 35% involvement of the distal phalanx articular surface. DIP joint stability was tested with the DIP collateral ligaments intact, with collateral ligaments partially damaged, and finally with full collateral ligament resection. Mixed models were used to study the relationship between stability and collateral damage. A receiver operating curve analysis along with Youden's J statistic was used to determine the avulsion fracture size at which the DIP joint becomes unstable for different degrees of collateral damage. The likelihood of subluxation differs by degree of collateral ligament damage, with subluxation probability increasing as collateral damage moves from intact to 50% cut to 100% cut. In fingers with 50% collateral resection, avulsion fractures involving >28% of the distal phalanx articular surface are more likely to experience subluxation. In fingers with 100% collateral resection, avulsion fractures >15% are more likely to subluxate. Collateral ligament injury contributes to instability at the DIP joint in a mallet fracture, increasing the likelihood of palmar subluxation. Collateral ligament injury contributes to DIP joint instability in mallet fractures involving <40% of the articular surface, supporting the need for assessing finger stability with a physical examination.

Is Fixation Strategy Associated With Complication Risk in Ogden Type IV Tibial Tubercle Avulsion Fractures? A Multicenter Study of the Tibial Tubercle Study Database.

Posterior cruciate ligament (PCL) tibial avulsion fractures are relatively infrequent injuries but may result in persistent posterior instability and compromised knee function if not managed appropriately. This prospective case series included 12 patients with isolated PCL tibial avulsion fractures who underwent fixation using a mini-open posterior approach between January 2020 and December 2023. Fractures were classified according to the McKeever classification. Patients were followed clinically and radiologically for a mean duration of 11.25±1.60 months (range, 9-14 months). Functional outcomes were assessed using the International Knee Documentation Committee (IKDC) subjective score, Lysholm knee score, and knee range of motion. At final follow-up, all patients demonstrated satisfactory knee stability and functional recovery. The mean IKDC score was 92.75±1.66, and the mean Lysholm score was 93.4±2.1. The mean knee range of motion was 130.75°±6.30°. Radiographic union was achieved in all cases, and no major procedure-related complications were observed. Mini-open posterior screw fixation is a safe, reproducible, and effective technique for the management of displaced, isolated PCL tibial avulsion fractures, particularly in settings where arthroscopic resources may be limited. IV (Prospective case series).

Reply to the Letter to the Editor: Does Insertional Reattachment for Acute Sleeve Avulsion Fracture of Achilles Tendon Provide Sustained Function and Sports Participation?

To investigate the effectiveness and technical points of posterior open approach combined with suture bridge technique for the treatment of tibial insertion avulsion fractures of posterior cruciate ligament (PCL). A retrospective analysis was conducted on 21 patients with PCL tibial insertion avulsion fractures who underwent posterior open approach combined with suture bridge technique between July 2023 and July 2025. There were 14 males and 7 females, aged 11-68 years (mean, 48.3 years). Fracture displacement ranged from 3.9 to 13.7 mm, with an average of 7.9 mm. Preoperative Lysholm score was 46.1±3.9, International Knee Documentation Committee (IKDC) subjective score was 44.8±4.1, and posterior knee laxity was (4.1±0.5) mm. The time from injury to surgery ranged from 1 to 30 days, with an average of 9.4 days. The operation time and intraoperative blood loss were recorded. Knee function was assessed using Lysholm score and IKDC subjective score. Posterior knee laxity was measured bilaterally using a KT-2000 arthrometer, and the results were expressed as the side-to-side difference. All surgeries were successfully completed. The operation time ranged from 40 to 130 minutes (mean, 80.2 minutes), and intraoperative blood loss ranged from 7 to 20 mL (mean, 10.4 mL). All incisions healed by first intention without early complication such as surgery-related infection or neurovascular injury. All 21 patients were followed up 12-20 months, with a mean of 18.3 months. Radiographic examination showed anatomical reduction and bony union in all fractures, with healing time ranging from 8 to 14 weeks (mean, 11.5 weeks). During follow-up, no reduction loss, implant loosening or breakage was observed. At last follow-up, the Lysholm score was 90.3±3.1, IKDC subjective score was 91.0±3.1, and posterior knee laxity was (1.6±0.4) mm, all showing significant differences compared with preoperative values ( P<0.05). The posterior open approach combined with suture bridge technique for PCL tibial insertion avulsion fractures offers the dual advantages of reliable reduction under direct vision and robust fixation with suture bridge, demonstrating safety and efficacy. It is particularly suitable for complex cases such as comminuted fractures, old fractures, or those complicated by posterior neurovascular injury.

Closed modeling methods for lateral ankle sprain (ALAS) avoid surgical drawbacks but lack standardization due to reliance on the operator's subjective force, leading to variable outcomes. This study aimed to refine a closed ALAS rat model by quantifying manipulation parameters and establishing optimal ranges for different injury grades. Ninety rats were randomly assigned to groups receiving manual ankle inversion under different combinations of force (0-8 N or 8-16 N) and plantar flexion angle (100°-130° or 130°-160°), with control groups. A flexible thin-film pressure sensor and a goniometer were used to standardize the applied force and angle. Multimodal assessments were conducted, including ankle thickness and calcaneofibular ligament (CFL) length measurement, micro-CT, MRI, histopathology (HE and Masson's staining), pain threshold testing, and CatWalk gait analysis at multiple time points up to 28 days postmodeling. The severity of the injury was directly correlated with the applied force and angle. Group D (8-16 N, 130°-160°) exhibited the most severe damage, including avulsion fractures, significant CFL elongation and partial tearing, diffuse MRI signal alterations, and prolonged pain and gait instability (>28 days). Groups A and B (0-8 N, both angles) induced mild injuries (slight edema, minor fiber loosening) with rapid functional recovery by day 7. Group C (8-16 N, 100°-130°) resulted in moderate, partial-thickness ligament injuries with recovery by day 10. Behavioral and imaging findings consistently demonstrated a dose-dependent response to the modeling parameters. This study successfully established a modified and quantifiable closed ALAS rat model. The optimal parameters for a grade I ALAS model are 0-8 N of force with plantar flexion of 100°-130° or 130°-160°. For a grade II ALAS model, the parameters are 8-15 N of force with plantar flexion of 100°-130°. This standardized model enhances reproducibility and provides a reliable foundation for future research into ALAS mechanisms and therapies.

Letter to the Editor: Does Insertional Reattachment for Acute Sleeve Avulsion Fracture of the Achilles Tendon Provide Sustained Function and Sports Participation?

The inclusion of the palmar plate of the distal interphalangeal joint in the repair of flexor digitorum profundus tendon avulsion injuries has been described in acute cases. We present a case series reporting the technique in patients with delayed presentation. Level of evidence: III (Retrospective comparative study).

Elbow injuries resulting from acute trauma or repetitive overuse are a common source of pain and functional limitation in both athletes and the general population. This review presents a radiologic approach to the evaluation and management of these conditions. It describes the roles of key imaging modalities and provides practical guidance for assessing traumatic injuries such as fractures, ligamentous disruptions, and tendon avulsions. Common overuse conditions, such as medial epicondylitis, lateral epicondylitis, and nerve compression syndromes, are reviewed with attention to characteristic imaging features and diagnostic challenges. The article also explores the role of image-guided interventions, particularly ultrasound-guided injections, in both diagnosis and treatment. By consolidating imaging strategies and emphasizing the strengths of each modality, this review will help radiologists and clinicians achieve an accurate diagnosis and manage elbow injuries effectively, ultimately promoting better outcomes and a timely return to activity.

Patellar tendon reinsertion after a multifragmentary avulsion fracture of the distal pole

AimsFlexion varus tibial plateau fracture (FVTPF) is associated with a substantial reoperation rate and poor outcomes. This study aims to clarify its fracture characteristics, investigate concomitant ligament and meniscus injuries, and explore correlations between fracture morphology and soft-tissue involvement.MethodsFVTPF patients with available CT and MRI data were included. Fracture mapping was used to present the fracture line and depression area in a spatial manner. Fracture morphological parameters were measured on CT, and ligament and meniscus injuries were assessed on MRI. Association between fracture morphological parameters and ligament/meniscus injuries was analyzed. Receiver operating characteristic (ROC) analysis was adopted to determine the reliable fracture parameter for diagnosing lateral meniscus (LM) entrapment.ResultsThere were 108 patients who met the inclusion criteria. The medial fragment of FVTPF exhibited various morphological patterns, with the posterolateral depression area representing a mean 16.7% (SD 7.0) of the entire plateau. FVTPF cases with comminuted medial fragments were associated with greater lateral plateau widening, maximal depression depth, and medial plateau displacement (p < 0.001, respectively). The rate of anterior cruciate ligament (ACL) avulsion fractures was 85.2% (92 patients). The rate of overall LM injuries was 54.6% (59 patients), which was significantly higher in FVTPF cases with comminuted medial fragments (80.0% (24 patients), p = 0.001). ROC analysis revealed that maximal depression depth was a favourable predictor for LM entrapment, with a cut-off point of 18.4 mm (sensitivity 88.9%; specificity 94.4%).ConclusionFVTPF showed various morphologies of the main medial fragment, with the depression area located in the posterolateral plateau. The ACL avulsion fractures were predominant in FVTPF, followed by LM injuries. FVTPF cases with comminuted medial fragments were associated with a significantly higher rate of LM injuries. Among the bony fracture parameters, maximal depression depth showed a considerable value in predicting LM entrapment.Cite this article: Bone Joint Res 2026;15(3):288–299.

Overlooked hindfoot fractures.

Avulsion fracture of the ischial tuberosity (AFIT) is a clinically rare injury that primarily occurs in adolescents participating in competitive sports. AFIT can be challenging to diagnose and manage due to its subtle presentation and the potential for misdiagnosis. Selecting an appropriate treatment method remains challenging due to the lack of universally accepted, evidence-based treatment guidelines for optimal management. A review of the relevant literature indicated that AFIT exhibits more complex healing patterns than other pelvic avulsion fractures with conservative management, and also that the outcomes of AFIT following the surgical treatment of chronic cases are often not as favorable as those of acute cases. Therefore, clinicians should increase their awareness of this type of fracture and consider aggressive surgical intervention in patients with displaced AFIT to ensure optimal outcomes and expedite their return to pre-injury athletic performance levels.

Tibial spine avulsion fractures (TSFs) are the pediatric equivalent of anterior cruciate ligament (ACL) injuries. The optimal management of type II fractures remains debated, and both conservative and surgical strategies have been described. This systematic review compares outcomes of nonsurgical and surgical treatments in type II TSFs and evaluates different surgical fixation techniques. A PRISMA-guided search identified studies reporting clinical and radiographic outcomes of pediatric TSFs. Data were pooled for patient demographics, treatment, complications, and functional results. Comparative analyses were performed for conservative versus surgical management in type II fractures and for suture versus screw fixation across all surgical cases. Thirty-eight studies (1,070 patients) were included. In type II fractures (371 knees), surgical treatment achieved lower rates of clinical instability (0.7% vs. 13.2%, p < 0.0001) and residual laxity (10.2% vs. 23.2%, p < 0.01) compared with conservative care, although with a higher incidence of range of motion deficits and arthrofibrosis. Lysholm scores were significantly higher after surgery (95.7 vs. 87.9, p < 0.001). Across surgical techniques (699 patients), suture fixation showed reduced residual laxity (7.1% vs. 15.7%, p < 0.0003), fewer hardware removals (1.1% vs. 17.5%, p < 0.0001), and better motion preservation compared with screw fixation with no clinically relevant differences in functional scores. Surgical treatment should be considered the preferred option for type II TSFs in active children and adolescents as it provides better stability and function. Suture fixation appears advantageous over screws and minimizes laxity, motion loss, and secondary procedures. High-quality randomized studies are needed to refine treatment algorithms.

Background:Tibial spine avulsion fractures are a relatively common pediatric injury that can be managed with a variety of operative techniques. No consensus exists on the optimal method of fixation, especially in patients with rotatory instability who are at a greater risk of rerupture.Indications:Dual suspensory all-suture constructs with physeal sparing modified Lemaire lateral extra-articular tenodesis (LET) is a novel technique that may offer excellent outcomes for the management of types 2 to 4 tibial spine fractures in patients with rotatory instability.Technique Description:A lateral thigh incision is utilized to obtain an 8 × 1–cm iliotibial band autograft that is whipstitched and passed deep to the lateral collateral ligament in a modified Lemaire fashion. Standard arthroscopic portals are used to reduce the anterior cruciate ligament (ACL) stump. Two separate tip-to-tip tibial guides are used to drill through the ACL stump at different angles, allowing nitinol wires to pass. A scorpion suture passer is used to pass 2 sutures through the mid-body of the ACL that is subsequently shuttled through the tibia. Two TightRope II RT implants are then passed through the suture mechanism and tightened to generate compression at the fracture site. Appropriate drill positioning for femoral fixation of the LET along the lateral epicondyle is confirmed with fluoroscopic guidance. The LET is secured via an onlay fashion and tensioned with the knee at 60° of flexion and neutral rotation.Results:Postoperative course was uncomplicated, and the patient reached 90° of flexion by 1 week postoperatively. The patient initiated a jogging program at 6 months and was cleared to return to sports at 12 months postoperatively without complication.Discussion/Conclusion:Dual suspensory all-suture constructs for ACL repair, with the incorporation of LET, are a viable treatment option for the management of pediatric tibial spine avulsion fractures. Our technique offers the advantages of multiple points of fixation, avoidance of tunnel convergence, reduction in risk of physeal injury, and added stability with LET. Given the high failure rates of ACL repair, especially in pediatric populations, this novel technique appears to offer satisfactory outcomes with rapid recovery in appropriately indicated patients.Patient Consent Disclosure Statement:The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.