569765 research-articleXXXX
FASXXX10.1177/1938640015569765Foot & Ankle SpecialistFoot & Ankle Specialist
vol. XX / no. X
Foot & Ankle Specialist
〈 Case Report 〉 An Isolated Dorsal Dislocation of the Lateral Cuneiform Abstract: We present a case of an isolated dorsal dislocation of the lateral cuneiform bone. This particular injury is extremely rare and quite often escapes the initial assessment of the medical examiner. Timely and accurate diagnosis of the injury is very important as the treatment is usually surgical. Levels of Evidence: Therapeutic Level IV, Case Report Keywords: lateral cuneiform; dorsal dislocation; tarsometatarsal joint injury
I
njuries to the tarsometatarsal joints are infrequent, with a frequency of approximately 1/55 000.1,2 Isolated injuries of the cuneiforms are rare with only a handful of reported cases in the literature. These injuries, very often, escape the initial assessment of the clinical examiner and the diagnosis is made late, in at least 20% of the cases.3 From a literature review in PubMed, we found 23 articles about isolated fracturedislocations of the cuneiforms (medial, middle, lateral).4-26 Nine of these articles refer to isolated injuries of the medial cuneiform,9,10,12-15,19,22,26 10 of them to
Nikolaos V. Sargiotis, MD, MSc, Nektarios Korres, MD, MSc, Konstantinos D. Anagnostakos, Stavros Tsifetakis, and Panagiotis Baltopoulos, MD, PhD
plantar fracture-dislocation of the middle cuneiform,6,11,16-18,20,21,23-25 and the other 4 articles to fracture-dislocations of the lateral cuneiform.4,5,7,8 From these 23 article, we have found only one article7 about isolated dislocation, without a fracture, of the lateral cuneiform. Although these injuries are rare, it is important to identify and treat isolated dorsal dislocations of lateral cuneiforms because delay or undiagnosed injuries could lead to chronic pain and disability.
Case Report
“
radiographs (anteroposterior and oblique, non–weight bearing) of the foot were performed to evaluate the condition of the foot (Figures 1 and 2). The resident in orthopaedics who was on duty in the ED considered the injury as a simple sprain of the tarsus. He immobilized the patient’s foot in a posterior below the knee splint, gave him thromboprophylaxis with a low-molecular-weight heparin (LMWH;
Isolated injuries of the cuneiforms are
rare with only a handful of reported
A patient, male, aged 51, was admitted to the cases in emergency department (ED) of our hospital after falling from a height of about 2.5 meters. He was complaining of pain in his left metatarsal, and he was unable to bear weight on the injured foot. The left foot was painful, swollen, but without any significant deformation. The neurovascular function of the left foot had not been impaired. The patient did not report pain elsewhere. He also was not in a state to describe the exact mechanism of the injury. Two
the literature.”
Bemiparin sodium 3500 IU, 1 × 1), and recommended discharge and review in 2 weeks. After 6 days the patient returned to the hospital with a similar clinical picture (persistent pain and swelling of the left foot). The new radiograph examination revealed the initial injury, namely, the isolated dorsal dislocation of the lateral cuneiform. A computed tomography (CT) with 3D reconstruction was
DOI: 10.1177/1938640015569765. From the First Surgical Department, First Orthopaedical Clinic, General Hospital of Attica KAT, Attica, Greece. Address correspondence to: Nikolaos V. Sargiotis, MD, MSc, GHA KAT, First Orthopaedical Clinic, Nikis 2, Kifisia 14561, Attica, Greece; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
Downloaded from fas.sagepub.com at UNIVERSITE LAVAL on September 27, 2015
1
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Mon XXXX
Foot & Ankle Specialist
Figure 1.
Figure 2.
Figure 4.
Anteroposterior radiograph of the left foot.
Oblique radiograph of the left foot.
3D reconstruction of the left foot.
Figure 5. Postoperative oblique radiograph.
Figure 3.
performed to evaluate the exact extent of the injury (Figures 3 and 4). On the same day an attempt was made for closed reduction in the operating theatre under general anesthesia. It was unsuccessful and the patient was scheduled for the next morning for open reduction and internal fixation of the dislocated lateral cuneiform. After reduction, the cuneiform was held in an anatomical position with 3 K-wires and the foot was immobilized in a posterior below the knee splint (Figure 5 and 6). The next day the patient was discharged from the hospital. We prescribed him thromboprophylaxis with LMWH (Bemiparin sodium 3500 IU 1 × 1) for a further 30 days. Due to socioeconomic reasons the patient could not follow any organized physiotherapy program. The patient was encouraged to begin immediately after the procedure full range of motion of the hip and knee
3D reconstruction of the left foot.
joints of the involved limb. Strengthening of the quadriceps through straight leg raises without extensor lag and of the
Downloaded from fas.sagepub.com at UNIVERSITE LAVAL on September 27, 2015
hamstrings through hamstring curls in a prone position were also prescribed. No weight bearing was permitted until the removal of the K-wires. Two weeks after the surgery stitches were removed, and at 6 weeks from the surgery the K-wires and the splint were removed. By that time the patient was told to start walking with full weight bearing as tolerated with the assistance of crutches. He was also encouraged to begin full range of motion in the ankle joint. A new evaluation was arranged after 2 weeks. Two months
vol. XX / no. X
Foot & Ankle Specialist
Figure 6.
Figure 7.
Postoperative anteroposterior radiograph.
Two-month postoperative face and oblique radiograph.
after the initial injury, the patient had another x-ray control (Figure 7). By that time he walked without any pain with full weight bearing. Twelve months postoperatively the patient underwent new radiological (Figures 8-10) and clinical examination to evaluate the current state of the foot. During the last 12 months he did not follow any physiotherapy program due to socioeconomic reasons. The patient was walking free without any pain. A slight swelling was present over the fourth and fifth metatarsals. The patient himself reported slight pain only after sufficient fatigue. On the x-rays 12 months after the initial injury there were no signs of posttraumatic arthritis of the involved joints.
Discussion The exact mechanism of this injury is not entirely known, possibly because of its rarity. It is probably similar to the mechanism of Lisfranc injuries, namely, rotation combined with axial compression of the foot in a high-energy injury.3 The injury mechanism of this patient could not be verified. We speculate that isolated dorsal
dislocations of lateral cuneiforms are due to a combination of rotation and axial compression while the foot was in plantar flexion and internal rotation. The frequency of these isolated injuries of the lateral cuneiform is very small.4,5,7,8 Our literature review revealed only one published article about isolated dorsal dislocation of the lateral cuneiform.7 Quite often they escape the examiner’s attention in the initial assessment. The very complex anatomy of the tarsus may be responsible for the difficulty in the initial and correct assessment of such injuries through simple radiographs. Computerized tomography imaging, particular 3D reconstitution, may assist
with diagnosis. The most valuable assets a clinician can have is a thorough examination of the patient, a high degree of suspicion, and knowledge of the mechanism of injury. It is important to have an early diagnosis and early treatment of these injuries. Delayed diagnosis and treatment will lead to a disturbance of the architecture of the foot. This disturbance induces alteration of the gait pattern, posttraumatic arthritis of the foot, and limping.5 The effects of such an injury are also identified in other joints such as knees and hips and lumbar spine, probably because of the altered gait pattern. Finally, in many cases, the socioeconomic implications of these
Downloaded from fas.sagepub.com at UNIVERSITE LAVAL on September 27, 2015
3
4
Mon XXXX
Foot & Ankle Specialist
Figure 8.
injuries are very important, for both the patient and the society.
Twelve-month postoperative face radiograph.
References 1. Lattermann C, Goldstein JL, Wukich DK, Lee S, Bach BR Jr. Practical management of Lisfranc injuries in athletes. Clin J Sport Med. 2007;17:311-315. 2. Hardcastle PH, Reschauer R, KutschaLissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br. 1982;64:349-356. 3. Sharma D, Khan F. Lisfranc fracture dislocations—an important and easily missed fracture in the emergency department. J R Army Med Corps. 2002;148:44-47. 4. Vukic T, Ivkovic A, Jankovic S. Stress fracture of the lateral cuneiform bone: a case report. J Am Podiatr Med Assoc. 2013;103:337-339. 5. Shah K, Odgaard A. Fracture of the lateral cuneiform only: a rare foot injury. J Am Podiatr Med Assoc. 2007;97:483-485.
Figure 9. Twelve-month postoperative face radiograph.
6. Saxby TS, Sharp RJ, Rosenfeld PF. Plantar fracture-dislocation of the intermediate cuneiform: case report. Foot Ankle Int. 2006;27:742-745. 7. Papanikolaou A, Maris J, Arealis G, Papadimitriou G, Charalambidis C. Dislocation of the lateral cuneiform. Report of two cases: one with dorsal and one with plantar displacement. Foot Ankle Surg. 2010;16:e91-e95. 8. Mandracchia VJ, Mandracchia DM, Pelsang DJ. Isolated fracture of the lateral cuneiform. A rare tarsal injury. J Am Podiatr Med Assoc. 1994;84:189-191.
Figure 10. Twelve-month postoperative oblique radiograph.
9. Lynch JR Sr, Cooperstein LA, DiGioia AM. Plantar medial subluxation of the medial cuneiform: case report of an uncommon variant of the Lisfranc injury. Foot Ankle Int. 1995;16:299-301. 10. Levine BP, Stoppacher R, Kristiansen TK. Plantar lateral dislocation of the medial cuneiform: a case report. Foot Ankle Int. 1998;19:118-119. 11. Hubbell JD, Goldhagen P, O’Connor D, Denton J. Isolated plantar fracturedislocation of the middle cuneiform. Am J Orthop (Belle Mead NJ). 1998;27:234-236. 12. Compson JP. An irreducible medial cuneiform fracture-dislocation. Injury. 1992;23:501-502.
Downloaded from fas.sagepub.com at UNIVERSITE LAVAL on September 27, 2015
13. Eraslan A, Ozyurek S, Erol B, Ercan E. Isolated medial cuneiform fracture: a commonly missed fracture. BMJ Case Rep. 2013;2013. doi:10.1136/bcr-2013-010093. 14. Guler F, Baz AB, Turan A, Kose O, Akalin S. Isolated medial cuneiform fractures: report of two cases and review of the literature. Foot Ankle Spec. 2011;4:306-309. 15. Taylor SF, Heidenreich D. Isolated medial cuneiform fracture: a special forces soldier with a rare injury. South Med J. 2008;101:848-849. 16. Verma A, Sharma VK, Batra S, Rohria MS. Neglected isolated plantar dislocation of middle cuneiform: a case report. BMC Musculoskelet Disord. 2007;8:5. 17. Nishi H, Takao M, Uchio Y, Yamagami N. Isolated plantar dislocation of the intermediate cuneiform bone. A case report. J Bone Joint Surg Am. 2004;86: 1772-1777. 18. Fujita M, Yamamoto H, Kariyama K, Yamakawa H. Isolated plantar dislocation of the middle cuneiform: a case report. J Orthop Sci. 2003;8:875-877. 19. Olson RC, Mendicino SS, Rockett MS. Isolated medial cuneiform fracture: review of the literature and report of two cases. Foot Ankle Int. 2000;21: 150-153. 20. Nashi M, Banerjee B. Isolated plantar dislocation of the middle cuneiform—a case report. Injury. 1997;28:704-706. 21. Maitra R, DeGnore LT. Isolated dislocation of the middle cuneiform in a farmer: a case report and review of the literature. Foot Ankle Int. 1997;18:735-738. 22. Patterson RH, Petersen D, Cunningham R. Isolated fracture of the medial cuneiform. J Orthop Trauma. 1993;7:94-95. 23. Bertoldi L, Molinari M, Soldini A, Mora R. Isolated fracture-dislocation of the second cuneiform bone. Case report. Acta Orthop Scand. 1991;62:604-605. 24. Sanders JO, McGanity PL. Intermediate cuneiform fracture-dislocation. J Orthop Trauma. 1990;4:102-104. 25. Smith JS Jr, Kanat IO, Pupp G, Pupp J. Fracture and dislocation of the middle cuneiform. A case report. J Am Podiatry Assoc. 1984;74:406-410. 26. Schiller MG, Ray RD. Isolated dislocation of the medial cuneiform bone—a rare injury of the tarsus. A case report. J Bone Joint Surg Am. 1970;52:1632-1636.
FASXXX10.1177/1938640015569765Foot & Ankle SpecialistFoot & Ankle Specialist
vol. XX / no. X
Foot & Ankle Specialist
〈 Case Report 〉 An Isolated Dorsal Dislocation of the Lateral Cuneiform Abstract: We present a case of an isolated dorsal dislocation of the lateral cuneiform bone. This particular injury is extremely rare and quite often escapes the initial assessment of the medical examiner. Timely and accurate diagnosis of the injury is very important as the treatment is usually surgical. Levels of Evidence: Therapeutic Level IV, Case Report Keywords: lateral cuneiform; dorsal dislocation; tarsometatarsal joint injury
I
njuries to the tarsometatarsal joints are infrequent, with a frequency of approximately 1/55 000.1,2 Isolated injuries of the cuneiforms are rare with only a handful of reported cases in the literature. These injuries, very often, escape the initial assessment of the clinical examiner and the diagnosis is made late, in at least 20% of the cases.3 From a literature review in PubMed, we found 23 articles about isolated fracturedislocations of the cuneiforms (medial, middle, lateral).4-26 Nine of these articles refer to isolated injuries of the medial cuneiform,9,10,12-15,19,22,26 10 of them to
Nikolaos V. Sargiotis, MD, MSc, Nektarios Korres, MD, MSc, Konstantinos D. Anagnostakos, Stavros Tsifetakis, and Panagiotis Baltopoulos, MD, PhD
plantar fracture-dislocation of the middle cuneiform,6,11,16-18,20,21,23-25 and the other 4 articles to fracture-dislocations of the lateral cuneiform.4,5,7,8 From these 23 article, we have found only one article7 about isolated dislocation, without a fracture, of the lateral cuneiform. Although these injuries are rare, it is important to identify and treat isolated dorsal dislocations of lateral cuneiforms because delay or undiagnosed injuries could lead to chronic pain and disability.
Case Report
“
radiographs (anteroposterior and oblique, non–weight bearing) of the foot were performed to evaluate the condition of the foot (Figures 1 and 2). The resident in orthopaedics who was on duty in the ED considered the injury as a simple sprain of the tarsus. He immobilized the patient’s foot in a posterior below the knee splint, gave him thromboprophylaxis with a low-molecular-weight heparin (LMWH;
Isolated injuries of the cuneiforms are
rare with only a handful of reported
A patient, male, aged 51, was admitted to the cases in emergency department (ED) of our hospital after falling from a height of about 2.5 meters. He was complaining of pain in his left metatarsal, and he was unable to bear weight on the injured foot. The left foot was painful, swollen, but without any significant deformation. The neurovascular function of the left foot had not been impaired. The patient did not report pain elsewhere. He also was not in a state to describe the exact mechanism of the injury. Two
the literature.”
Bemiparin sodium 3500 IU, 1 × 1), and recommended discharge and review in 2 weeks. After 6 days the patient returned to the hospital with a similar clinical picture (persistent pain and swelling of the left foot). The new radiograph examination revealed the initial injury, namely, the isolated dorsal dislocation of the lateral cuneiform. A computed tomography (CT) with 3D reconstruction was
DOI: 10.1177/1938640015569765. From the First Surgical Department, First Orthopaedical Clinic, General Hospital of Attica KAT, Attica, Greece. Address correspondence to: Nikolaos V. Sargiotis, MD, MSc, GHA KAT, First Orthopaedical Clinic, Nikis 2, Kifisia 14561, Attica, Greece; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
Downloaded from fas.sagepub.com at UNIVERSITE LAVAL on September 27, 2015
1
2
Mon XXXX
Foot & Ankle Specialist
Figure 1.
Figure 2.
Figure 4.
Anteroposterior radiograph of the left foot.
Oblique radiograph of the left foot.
3D reconstruction of the left foot.
Figure 5. Postoperative oblique radiograph.
Figure 3.
performed to evaluate the exact extent of the injury (Figures 3 and 4). On the same day an attempt was made for closed reduction in the operating theatre under general anesthesia. It was unsuccessful and the patient was scheduled for the next morning for open reduction and internal fixation of the dislocated lateral cuneiform. After reduction, the cuneiform was held in an anatomical position with 3 K-wires and the foot was immobilized in a posterior below the knee splint (Figure 5 and 6). The next day the patient was discharged from the hospital. We prescribed him thromboprophylaxis with LMWH (Bemiparin sodium 3500 IU 1 × 1) for a further 30 days. Due to socioeconomic reasons the patient could not follow any organized physiotherapy program. The patient was encouraged to begin immediately after the procedure full range of motion of the hip and knee
3D reconstruction of the left foot.
joints of the involved limb. Strengthening of the quadriceps through straight leg raises without extensor lag and of the
Downloaded from fas.sagepub.com at UNIVERSITE LAVAL on September 27, 2015
hamstrings through hamstring curls in a prone position were also prescribed. No weight bearing was permitted until the removal of the K-wires. Two weeks after the surgery stitches were removed, and at 6 weeks from the surgery the K-wires and the splint were removed. By that time the patient was told to start walking with full weight bearing as tolerated with the assistance of crutches. He was also encouraged to begin full range of motion in the ankle joint. A new evaluation was arranged after 2 weeks. Two months
vol. XX / no. X
Foot & Ankle Specialist
Figure 6.
Figure 7.
Postoperative anteroposterior radiograph.
Two-month postoperative face and oblique radiograph.
after the initial injury, the patient had another x-ray control (Figure 7). By that time he walked without any pain with full weight bearing. Twelve months postoperatively the patient underwent new radiological (Figures 8-10) and clinical examination to evaluate the current state of the foot. During the last 12 months he did not follow any physiotherapy program due to socioeconomic reasons. The patient was walking free without any pain. A slight swelling was present over the fourth and fifth metatarsals. The patient himself reported slight pain only after sufficient fatigue. On the x-rays 12 months after the initial injury there were no signs of posttraumatic arthritis of the involved joints.
Discussion The exact mechanism of this injury is not entirely known, possibly because of its rarity. It is probably similar to the mechanism of Lisfranc injuries, namely, rotation combined with axial compression of the foot in a high-energy injury.3 The injury mechanism of this patient could not be verified. We speculate that isolated dorsal
dislocations of lateral cuneiforms are due to a combination of rotation and axial compression while the foot was in plantar flexion and internal rotation. The frequency of these isolated injuries of the lateral cuneiform is very small.4,5,7,8 Our literature review revealed only one published article about isolated dorsal dislocation of the lateral cuneiform.7 Quite often they escape the examiner’s attention in the initial assessment. The very complex anatomy of the tarsus may be responsible for the difficulty in the initial and correct assessment of such injuries through simple radiographs. Computerized tomography imaging, particular 3D reconstitution, may assist
with diagnosis. The most valuable assets a clinician can have is a thorough examination of the patient, a high degree of suspicion, and knowledge of the mechanism of injury. It is important to have an early diagnosis and early treatment of these injuries. Delayed diagnosis and treatment will lead to a disturbance of the architecture of the foot. This disturbance induces alteration of the gait pattern, posttraumatic arthritis of the foot, and limping.5 The effects of such an injury are also identified in other joints such as knees and hips and lumbar spine, probably because of the altered gait pattern. Finally, in many cases, the socioeconomic implications of these
Downloaded from fas.sagepub.com at UNIVERSITE LAVAL on September 27, 2015
3
4
Mon XXXX
Foot & Ankle Specialist
Figure 8.
injuries are very important, for both the patient and the society.
Twelve-month postoperative face radiograph.
References 1. Lattermann C, Goldstein JL, Wukich DK, Lee S, Bach BR Jr. Practical management of Lisfranc injuries in athletes. Clin J Sport Med. 2007;17:311-315. 2. Hardcastle PH, Reschauer R, KutschaLissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br. 1982;64:349-356. 3. Sharma D, Khan F. Lisfranc fracture dislocations—an important and easily missed fracture in the emergency department. J R Army Med Corps. 2002;148:44-47. 4. Vukic T, Ivkovic A, Jankovic S. Stress fracture of the lateral cuneiform bone: a case report. J Am Podiatr Med Assoc. 2013;103:337-339. 5. Shah K, Odgaard A. Fracture of the lateral cuneiform only: a rare foot injury. J Am Podiatr Med Assoc. 2007;97:483-485.
Figure 9. Twelve-month postoperative face radiograph.
6. Saxby TS, Sharp RJ, Rosenfeld PF. Plantar fracture-dislocation of the intermediate cuneiform: case report. Foot Ankle Int. 2006;27:742-745. 7. Papanikolaou A, Maris J, Arealis G, Papadimitriou G, Charalambidis C. Dislocation of the lateral cuneiform. Report of two cases: one with dorsal and one with plantar displacement. Foot Ankle Surg. 2010;16:e91-e95. 8. Mandracchia VJ, Mandracchia DM, Pelsang DJ. Isolated fracture of the lateral cuneiform. A rare tarsal injury. J Am Podiatr Med Assoc. 1994;84:189-191.
Figure 10. Twelve-month postoperative oblique radiograph.
9. Lynch JR Sr, Cooperstein LA, DiGioia AM. Plantar medial subluxation of the medial cuneiform: case report of an uncommon variant of the Lisfranc injury. Foot Ankle Int. 1995;16:299-301. 10. Levine BP, Stoppacher R, Kristiansen TK. Plantar lateral dislocation of the medial cuneiform: a case report. Foot Ankle Int. 1998;19:118-119. 11. Hubbell JD, Goldhagen P, O’Connor D, Denton J. Isolated plantar fracturedislocation of the middle cuneiform. Am J Orthop (Belle Mead NJ). 1998;27:234-236. 12. Compson JP. An irreducible medial cuneiform fracture-dislocation. Injury. 1992;23:501-502.
Downloaded from fas.sagepub.com at UNIVERSITE LAVAL on September 27, 2015
13. Eraslan A, Ozyurek S, Erol B, Ercan E. Isolated medial cuneiform fracture: a commonly missed fracture. BMJ Case Rep. 2013;2013. doi:10.1136/bcr-2013-010093. 14. Guler F, Baz AB, Turan A, Kose O, Akalin S. Isolated medial cuneiform fractures: report of two cases and review of the literature. Foot Ankle Spec. 2011;4:306-309. 15. Taylor SF, Heidenreich D. Isolated medial cuneiform fracture: a special forces soldier with a rare injury. South Med J. 2008;101:848-849. 16. Verma A, Sharma VK, Batra S, Rohria MS. Neglected isolated plantar dislocation of middle cuneiform: a case report. BMC Musculoskelet Disord. 2007;8:5. 17. Nishi H, Takao M, Uchio Y, Yamagami N. Isolated plantar dislocation of the intermediate cuneiform bone. A case report. J Bone Joint Surg Am. 2004;86: 1772-1777. 18. Fujita M, Yamamoto H, Kariyama K, Yamakawa H. Isolated plantar dislocation of the middle cuneiform: a case report. J Orthop Sci. 2003;8:875-877. 19. Olson RC, Mendicino SS, Rockett MS. Isolated medial cuneiform fracture: review of the literature and report of two cases. Foot Ankle Int. 2000;21: 150-153. 20. Nashi M, Banerjee B. Isolated plantar dislocation of the middle cuneiform—a case report. Injury. 1997;28:704-706. 21. Maitra R, DeGnore LT. Isolated dislocation of the middle cuneiform in a farmer: a case report and review of the literature. Foot Ankle Int. 1997;18:735-738. 22. Patterson RH, Petersen D, Cunningham R. Isolated fracture of the medial cuneiform. J Orthop Trauma. 1993;7:94-95. 23. Bertoldi L, Molinari M, Soldini A, Mora R. Isolated fracture-dislocation of the second cuneiform bone. Case report. Acta Orthop Scand. 1991;62:604-605. 24. Sanders JO, McGanity PL. Intermediate cuneiform fracture-dislocation. J Orthop Trauma. 1990;4:102-104. 25. Smith JS Jr, Kanat IO, Pupp G, Pupp J. Fracture and dislocation of the middle cuneiform. A case report. J Am Podiatry Assoc. 1984;74:406-410. 26. Schiller MG, Ray RD. Isolated dislocation of the medial cuneiform bone—a rare injury of the tarsus. A case report. J Bone Joint Surg Am. 1970;52:1632-1636.
