- Email: [email protected]
Fracture dislocation of the calcaneum
Injury Extra (2006) 37, 294—296
www.elsevier.com/locate/inext
CASE REPORT
Fracture dislocation of the calcaneum Julian R. Northover *, Stephen A. Milner 1 Department of Trauma & Orthopaedics, Derbyshire Royal Infirmary, London Road, Derby, Derbyshire, DE1 2QY, UK Accepted 12 January 2006
Introduction Subtalar dislocation (dislocation of the talo-calcaneal and the talo-navicular joints) accounts account for approximately 1% of all joint dislocations.1 However, dislocation of the calcaneum (dislocation of the talo-calcaneal and the calcaeo-cuboid joints) is extremely rare. Only a small number of these have ever been reported in the literature,2—4 with only a fraction of these having an associated fracture.5—7
Case history We report the case of a 33-year-old man who was the passenger of a van involved in a head-on collision. His only injury was that to his left foot, which was on the dashboard at the time of impact. He reported it to have been forcefully inverted at the time of impact. On admission to the A & E department it was noted that his foot was deformed consistent with a lateral subtalar dislocation. His toes were cold and blue and his skin was very tight over his medial maleolus. Because of the concerns for the vascular supply to the foot and the integrity of the skin a * Corresponding author. Tel.: +01332 347141. E-mail addresses: [email protected] (J.R. Northover), [email protected] (S.A. Milner). 1 Tel.:+01332 347141.
manipulation under sedation was performed immediately without pre-reduction X-rays. A plaster of Paris back-slab was applied and then X-rays obtained. These showed some incongruity of both the talo-calcaneal and calcaneo-cuboid joints (Fig. 1(a and b)). A CT scan was then performed which confirmed the incongruity of the talo-calcaneal and calcaneocuboid joints as well as fractures of the sustentaculum tali and the anterior process (Fig. 2(a and b)). There were no other abnormalities of the other tarsal or metatarsal bones. This suggests an injury pattern more consistent with a fracture dislocation of the calcaneum rather than a subtalar dislocation. The patient was taken to theatre for reduction and stabilisation of the subluxed joints. At operation it was found that closed reduction of both the talocalcaneo and calcaneo-cuboid joints was possible but they were very unstable. A 2 mm K-wire was therefore passed across each joint to hold them reduced. Screening of the talo-navicular joint confirmed that it was completely stable. He was then placed in a below knee plaster and mobilised nonweight bearing. A post-operative CT scan was performed to confirm accurate reduction (Fig. 3(a and b)). The K-wires were removed at 6 weeks and the plaster at 8 weeks post-operatively and he was allowed to weight bear. Follow-up at 6 months found him to be symptom free and back at work. Examination of the foot
1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.01.025
Fracture dislocation of the calcaneum
Figure 1
295
(a) Lateral foot radiograph following closed reduction. (b) AP foot radiograph following closed reduction.
Figure 2 (a) CT scan showing fracture of sustentaculum tali. (b) CT scan showing anterior process fracture and subluxation of calcaneo-cuboid joint.
showed good range of movements of the ankle, subtalar and mid-foot joints and X-rays showed the talo-calcaneal and calcaneo-cuboid joints to be reduced with no evidence of joint arthrosis.
Discussion Dislocation of the calcaneum is very rare; having approximately a dozen reported cases.2—4 Fracture
dislocation of the calcaneum is rarer still with only seven references to it in recent literature.5—7 It was first described by d’Aubigue in 1936,5 with the first report in the English literature as recently as 1986 by Court-Brown et al.7 Court-Brown postulated that fracture dislocation of the calcaneum occurs with axial loading of an inverted hind-foot. A primary sheer type fracture occurs of the antero-medial part of the calcaneum which may or may not be associated with a second-
296
J.R. Northover, S.A. Milner
Figure 3 (a) Post op. CT scan showing reduction of sustentaculum tali. (b) Post op. CT scan showing reduction of calcaneo-cuboid joint.
ary compression fracture of the postero-lateral fragment. Further loading causes displacement of the postero-lateral fragment until rupture of the lateral collateral ligament allows it to dislocate. This case seems to uphold Court-Brown’s hypothesis. The injury was described as that of axial loading on an inverted hind-foot. The CT scan confirms the fracture pattern predicted of a small anteromedial fragment and a large postero-lateral fragment with the fracture line running antero-laterally, starting from behind the sustentaculum tali. In this case there was no secondary compression fracture of the poster-lateral fragment. In previous cases of fracture dislocation of the calcaneum, treatment has always been by open reduction and the reduction held by instrumentation or percutaneous K-wire fixation. This case was unusual in that we were able to perform the reduction closed. This closed reduction was again maintained by percutaneous K-wires fixation. This method also
gave a good clinical result, showing that open reduction of these fractures is not mandatory, provided that accurate closed reduction is achieved.
References 1. Leitner B. Obstacles to reduction in subtalar dislocation. J Bone Joint Surg 1954;36A:299—306. 2. Parcellier A, Chenut A. Un case de luxation du calcaneum. Rev Orthop 1928;15:418. 3. Viswanath SS, Shepard E. Dislocation of the calcanium. Injury 1977;9:50. 4. Rao H. A complete dislocation of the calcaneus: a case report. J Foot Ankle Surg 2005;44(5):401—5. 5. d’Aubigue MR. Fracture isolee de la petite apophyse du calcaneum traitee par osteosynthese (Raport de M. Wilmoth). Mem Acad Chir 1936;62:1155. 6. Biga N, Thomine JM. La fracture-luxation du calcanium. A propos de 4 observations. Rev Chir Orthop 1977;63:191. 7. Court-Brown CM, Boot DA, Kellam JF. Fracture dislocation of the calcanius. Clin Orthop 1986;213:201—6.
www.elsevier.com/locate/inext
CASE REPORT
Fracture dislocation of the calcaneum Julian R. Northover *, Stephen A. Milner 1 Department of Trauma & Orthopaedics, Derbyshire Royal Infirmary, London Road, Derby, Derbyshire, DE1 2QY, UK Accepted 12 January 2006
Introduction Subtalar dislocation (dislocation of the talo-calcaneal and the talo-navicular joints) accounts account for approximately 1% of all joint dislocations.1 However, dislocation of the calcaneum (dislocation of the talo-calcaneal and the calcaeo-cuboid joints) is extremely rare. Only a small number of these have ever been reported in the literature,2—4 with only a fraction of these having an associated fracture.5—7
Case history We report the case of a 33-year-old man who was the passenger of a van involved in a head-on collision. His only injury was that to his left foot, which was on the dashboard at the time of impact. He reported it to have been forcefully inverted at the time of impact. On admission to the A & E department it was noted that his foot was deformed consistent with a lateral subtalar dislocation. His toes were cold and blue and his skin was very tight over his medial maleolus. Because of the concerns for the vascular supply to the foot and the integrity of the skin a * Corresponding author. Tel.: +01332 347141. E-mail addresses: [email protected] (J.R. Northover), [email protected] (S.A. Milner). 1 Tel.:+01332 347141.
manipulation under sedation was performed immediately without pre-reduction X-rays. A plaster of Paris back-slab was applied and then X-rays obtained. These showed some incongruity of both the talo-calcaneal and calcaneo-cuboid joints (Fig. 1(a and b)). A CT scan was then performed which confirmed the incongruity of the talo-calcaneal and calcaneocuboid joints as well as fractures of the sustentaculum tali and the anterior process (Fig. 2(a and b)). There were no other abnormalities of the other tarsal or metatarsal bones. This suggests an injury pattern more consistent with a fracture dislocation of the calcaneum rather than a subtalar dislocation. The patient was taken to theatre for reduction and stabilisation of the subluxed joints. At operation it was found that closed reduction of both the talocalcaneo and calcaneo-cuboid joints was possible but they were very unstable. A 2 mm K-wire was therefore passed across each joint to hold them reduced. Screening of the talo-navicular joint confirmed that it was completely stable. He was then placed in a below knee plaster and mobilised nonweight bearing. A post-operative CT scan was performed to confirm accurate reduction (Fig. 3(a and b)). The K-wires were removed at 6 weeks and the plaster at 8 weeks post-operatively and he was allowed to weight bear. Follow-up at 6 months found him to be symptom free and back at work. Examination of the foot
1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.01.025
Fracture dislocation of the calcaneum
Figure 1
295
(a) Lateral foot radiograph following closed reduction. (b) AP foot radiograph following closed reduction.
Figure 2 (a) CT scan showing fracture of sustentaculum tali. (b) CT scan showing anterior process fracture and subluxation of calcaneo-cuboid joint.
showed good range of movements of the ankle, subtalar and mid-foot joints and X-rays showed the talo-calcaneal and calcaneo-cuboid joints to be reduced with no evidence of joint arthrosis.
Discussion Dislocation of the calcaneum is very rare; having approximately a dozen reported cases.2—4 Fracture
dislocation of the calcaneum is rarer still with only seven references to it in recent literature.5—7 It was first described by d’Aubigue in 1936,5 with the first report in the English literature as recently as 1986 by Court-Brown et al.7 Court-Brown postulated that fracture dislocation of the calcaneum occurs with axial loading of an inverted hind-foot. A primary sheer type fracture occurs of the antero-medial part of the calcaneum which may or may not be associated with a second-
296
J.R. Northover, S.A. Milner
Figure 3 (a) Post op. CT scan showing reduction of sustentaculum tali. (b) Post op. CT scan showing reduction of calcaneo-cuboid joint.
ary compression fracture of the postero-lateral fragment. Further loading causes displacement of the postero-lateral fragment until rupture of the lateral collateral ligament allows it to dislocate. This case seems to uphold Court-Brown’s hypothesis. The injury was described as that of axial loading on an inverted hind-foot. The CT scan confirms the fracture pattern predicted of a small anteromedial fragment and a large postero-lateral fragment with the fracture line running antero-laterally, starting from behind the sustentaculum tali. In this case there was no secondary compression fracture of the poster-lateral fragment. In previous cases of fracture dislocation of the calcaneum, treatment has always been by open reduction and the reduction held by instrumentation or percutaneous K-wire fixation. This case was unusual in that we were able to perform the reduction closed. This closed reduction was again maintained by percutaneous K-wires fixation. This method also
gave a good clinical result, showing that open reduction of these fractures is not mandatory, provided that accurate closed reduction is achieved.
References 1. Leitner B. Obstacles to reduction in subtalar dislocation. J Bone Joint Surg 1954;36A:299—306. 2. Parcellier A, Chenut A. Un case de luxation du calcaneum. Rev Orthop 1928;15:418. 3. Viswanath SS, Shepard E. Dislocation of the calcanium. Injury 1977;9:50. 4. Rao H. A complete dislocation of the calcaneus: a case report. J Foot Ankle Surg 2005;44(5):401—5. 5. d’Aubigue MR. Fracture isolee de la petite apophyse du calcaneum traitee par osteosynthese (Raport de M. Wilmoth). Mem Acad Chir 1936;62:1155. 6. Biga N, Thomine JM. La fracture-luxation du calcanium. A propos de 4 observations. Rev Chir Orthop 1977;63:191. 7. Court-Brown CM, Boot DA, Kellam JF. Fracture dislocation of the calcanius. Clin Orthop 1986;213:201—6.