SLR - December 2017 - Brian Hiapo

Subradiographic Foot and Ankle Fractures and Bone Contusions Detected by MRI in Elite Ice Hockey Players

Reference: Baker JC, Hoover EG, Hillen TJ, Smith MV, Wright RW, Rubin DA Subradiographic Foot and Ankle Fractures and Bone Contusions Detected by MRI in Elite Ice Hockey Players. Am J Sports Med. 2016 May;44(5):1317-23. Epub 2016 Feb 17.

Scientific Literature Review

Reviewed By: Brian Hiapo, DPM
Residency Program: Southern AZ Veterans Health Care Systems, Tucson, AZ

Podiatric Relevance: By far, the most common standard of care in primary evaluation of bone fractures in the foot and ankle is to obtain plain radiographs. Traditionally, this has been a sufficient practice when evaluating bone fractures secondary to trauma. However, in cases of trauma to the foot and ankle, how many fractures are going undetected on plain films? The authors of this article pose the hypothesis that Magnetic Resonance Imaging (MRI) is also needed to evaluate and properly diagnose foot and ankle fractures and bone contusions in elite hockey athletes. If this article can prove that fractures in the foot and ankle need further MRI evaluation to detect radiographically occult imaging, how much more likely are we as a profession to begin ordering concurrent advanced imaging to efficiently evaluate our patients with possible foot and ankle fractures secondary to trauma?

Methods: A level IV Case Series was performed with three independent observers, blinded to the mechanism of injury, retrospectively reviewing foot and ankle MRI examinations from 31 acute injuries that occurred in 27 elite ice hockey players who had no radiographically visible fractures. Bone abnormalities were then classified as fractures or bony contusions.

Results: The observers identified at least one bone injury in 27 of the 31 MRI examinations, including 10 with radiographically occult fractures. Agreement was noted among the three observers. A direct blow caused 17 injuries from the hockey puck, resulting in six fractures and six high-grade bone contusions.

Conclusions: In patients with trauma to the foot and ankle with radiographically occult evidence of fracture, the authors concluded that MRI is a useful tool in efficiently evaluating severe bone injuries. Although advanced imaging is not always needed when evaluating foot and ankle fractures, this article proves useful in providing another piece to the puzzle in establishing an accurate diagnosis. In the unique case presented in the article of elite athletes sustaining foot and ankle trauma from a high-velocity puck, further advanced imaging should be considered as standard treatment, regardless of plain film results, as it could possibly change the treatment protocol. However, in the majority of foot and ankle fracture evaluation, plain films should be standard care before considering the need for advanced imaging.

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