- Email: [email protected]
Nonunion of paediatric talar neck fracture
. 48 .
Chinese Journal of Traumatology 2014;17(1):48-49
Nonunion of paediatric talar neck fracture Nipun Jindal, Parmanand Gupta*, Sandeep Jindal 【Abstract】Fractures of the paediatric talus are infrequent injuries, most complicated by posttraumatic arthrosis and avascular necrosis in the course of treatment. Nonunion in children has not been reported before in literature. We report a case of a 12-year-old boy who had a nonunion of Hawkins type II fracture of talar neck. The nonunion was treated surgically with a good clinical outcome. The goals
of management in nonunion of paediatric talar neck fracture are different from those in fresh fractures. A suboptimal reduction should be acceptable without trying a radical surgery which may cause further impairment. Key words: Talus; Fractures, ununited; Paediatrics
F
and anterolateral exposures centred on the region of talar neck. After curetting out the fibrous tissue from the nonunion site, 2 partially threaded cannulated cancellous screws (4 mm) were inserted from a separate posterolateral incision. Graft was harvested from iliac crest and put into the nonunion site. Subtalar joint could not be reduced by closed means even after reduction and operative fixation of talar neck fracture.
ractures of the talus in paediatric age group are relatively rare, accounting for around 0.08% of injuries.1 Out of these, a vast majority (about 50%-80%) of these fractures involve the talar neck.2-4 Complications like posttraumatic arthrosis and avascular necrosis plague the course of treatment, especially in displaced fractures.2 Nonunion of talus fracture has been described in literature as a complication in adult; however, a thorough search of the literature did not find any case report of nonunion in children. The purpose of our study is to report a nonunion of Hawkins type II fracture of talar neck.
CASE REPORT A 12-year-old boy presented to our hospital with complains of pain in left ankle region on walking. He had sustained a fall 8 months ago for which his foot was immobilized in plaster for 3 months after some manipulation by the primary treating physician. Radiographs at presentation revealed nonunion of proximal part of talar neck with subtalar joint subluxation (Figure 1). There was no avascular necrosis of talar body on magnetic resonance images (Figure 2). A surgical plan of open reduction and internal fixation was made. It was accomplished through medial DOI: 10.3760/cma.j.issn.1008-1275.2014.01.011 Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India (Jindal N, Gupta P) Department of Orthopaedics, Giansagar Medical College and Hosiptal, Banur, Patiala, India (Jindal S) *Corresponding author: Tel: 91-9646121593, Email: [email protected]
Chin J Traumatol 2014;17(1):48-49
The foot was immobilised in below knee cast for 6 weeks and graduated mobilization started thereafter. The follow-up period was 33 months and there was no evidence of osteonecrosis on radiographic and CT evaluation (Figures 3 and 4). Clinically there was a full range of motion at ankle but a mild restriction of eversion at subtalar joint (Figure 5). The boy was pain free and engaged in outdoor activities such as playing amateur football.
DISCUSSION Paediatric foot is less prone to develop fractures after trauma than adult foot mostly due to elastic cartilage. Even within the paediatric population, younger children suffer from less severe types of fractures after sustaining similar energy trauma than older children.5 However, complications are still likely to be encountered in the course of talar fractures’ treatment considering the precarious blood supply to the bone6 as well as complex ankle and subtalar articulations. Avascular necrosis and posttraumatic arthrosis are most commonly reported complications of paediatric talar fractures.2 Predisposing factors identified are associated foot injuries and older age.3,5,7 Nonetheless avas-
. 49 .
Chinese Journal of Traumatology 2014;17(1):48-49
cular necrosis has been reported in even undisplaced talar neck fracture in a 6-year-old child.8 Other complications reported in literature are delayed union and neurapraxia.2 An important point in treating nonunion of talar neck fractures is to avoid overzealous dissection which may increase the chance of avascular necrosis. Surgical approach to talus fractures should be very cautious since the already precarious blood supply may get jeopardised. Eberl et al5 recorded no case of osteonecrosis in their series of fresh paediatric talus fractures treated nonoperatively while as many as 5 out of 16 cases treated surgically were complicated by persistent osteonecrosis. The key to open reduction of subtalar articulation is sinus tarsi approach which may cause
potential damage to the vascularity since the vascular supply of the talar body enters from the region of sinus tarsi and the tarsal canal.6 So in our case, we did not attempt anatomical subtalar reduction, and we fixed the talar neck in an acceptable position via combined medial and anterolateral approaches. Although wide generalization cannot be made by a single case, we recommend that the goals of treatment in nonunion of paediatric talar neck fracture are quite different from the ones in fresh fractures. In old or neglected fractures surgeon needs to balance the surgical approach to give maximum benefit to the patient without causing additional harm. A suboptimal reduction is more desirable than a radical surgery which may cause further impairment.
Figure 1. Lateral radiograph at presentation showing the nonunion site at the proximal talar neck, subtalar subluxation and no sign of osteonecrosis. Figure 2. T 1- and T 2-weighted sagittal images showing normal vascularity. Figure 3. Lateral and anteroposterior radiograph at final follow-up showing good union and no signs of osteonecrosis. Note the unreduced subluxation at subtalar joint. Figure 4. Sagittal and coronal reconstructed CT images showing no talar collapse and normal bone architecture. Figure 5. Clinical photograph showing normal plantarflexion, dorsiflexion and inversion as well as a mild restriction of eversion.
REFERENCES
5. Eberl R, Singer G, Schalamon J, et al. Fractures of the talus—differences between children and adolescents [J]. J Trauma
1. Linhart WE, Hollwarth ME. Fractures of the child’s foot [J]. Orthopade 1986;15(3):242-50. 2. Smith JT, Curtis TA, Spencer S, et al. Complications of talus fractures in children [J]. J Pediatr Orthop 2010;30(8):779-
2010;68(1):126-30. 6. Gelberman RH, Mortensen WW. The arterial anatomy of the talus [J]. Foot Ankle 1983;4(2):64-72. 7. Hawkins LG. Fractures of the neck of the talus [J]. J Bone Joint Surg Am 1970;52(5):991-1002.
84. 3. Jensen I, Wester JU, Rasmussen F, et al. Prognosis of frac-
8. Talkhani IS, Reidy D, Fogarty EE, et al. Avascular necrosis
ture of the talus in children: 21 (7-34)-year follow-up of 14 cases
of the talus after a minimally displaced neck of talus fracture in a
[J]. Acta Orthop Scand 1994;65(4):398-400.
6 year old child [J]. Injury 2000;31(1):63-5.
4. Meier R, Krettek C, Griensven M, et al. Fractures of the talus in the pediatric patient [J]. Foot Ankle Surg 2005;11(1):510.
(Received June 10, 2013) Edited by Dong Min
Chinese Journal of Traumatology 2014;17(1):48-49
Nonunion of paediatric talar neck fracture Nipun Jindal, Parmanand Gupta*, Sandeep Jindal 【Abstract】Fractures of the paediatric talus are infrequent injuries, most complicated by posttraumatic arthrosis and avascular necrosis in the course of treatment. Nonunion in children has not been reported before in literature. We report a case of a 12-year-old boy who had a nonunion of Hawkins type II fracture of talar neck. The nonunion was treated surgically with a good clinical outcome. The goals
of management in nonunion of paediatric talar neck fracture are different from those in fresh fractures. A suboptimal reduction should be acceptable without trying a radical surgery which may cause further impairment. Key words: Talus; Fractures, ununited; Paediatrics
F
and anterolateral exposures centred on the region of talar neck. After curetting out the fibrous tissue from the nonunion site, 2 partially threaded cannulated cancellous screws (4 mm) were inserted from a separate posterolateral incision. Graft was harvested from iliac crest and put into the nonunion site. Subtalar joint could not be reduced by closed means even after reduction and operative fixation of talar neck fracture.
ractures of the talus in paediatric age group are relatively rare, accounting for around 0.08% of injuries.1 Out of these, a vast majority (about 50%-80%) of these fractures involve the talar neck.2-4 Complications like posttraumatic arthrosis and avascular necrosis plague the course of treatment, especially in displaced fractures.2 Nonunion of talus fracture has been described in literature as a complication in adult; however, a thorough search of the literature did not find any case report of nonunion in children. The purpose of our study is to report a nonunion of Hawkins type II fracture of talar neck.
CASE REPORT A 12-year-old boy presented to our hospital with complains of pain in left ankle region on walking. He had sustained a fall 8 months ago for which his foot was immobilized in plaster for 3 months after some manipulation by the primary treating physician. Radiographs at presentation revealed nonunion of proximal part of talar neck with subtalar joint subluxation (Figure 1). There was no avascular necrosis of talar body on magnetic resonance images (Figure 2). A surgical plan of open reduction and internal fixation was made. It was accomplished through medial DOI: 10.3760/cma.j.issn.1008-1275.2014.01.011 Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India (Jindal N, Gupta P) Department of Orthopaedics, Giansagar Medical College and Hosiptal, Banur, Patiala, India (Jindal S) *Corresponding author: Tel: 91-9646121593, Email: [email protected]
Chin J Traumatol 2014;17(1):48-49
The foot was immobilised in below knee cast for 6 weeks and graduated mobilization started thereafter. The follow-up period was 33 months and there was no evidence of osteonecrosis on radiographic and CT evaluation (Figures 3 and 4). Clinically there was a full range of motion at ankle but a mild restriction of eversion at subtalar joint (Figure 5). The boy was pain free and engaged in outdoor activities such as playing amateur football.
DISCUSSION Paediatric foot is less prone to develop fractures after trauma than adult foot mostly due to elastic cartilage. Even within the paediatric population, younger children suffer from less severe types of fractures after sustaining similar energy trauma than older children.5 However, complications are still likely to be encountered in the course of talar fractures’ treatment considering the precarious blood supply to the bone6 as well as complex ankle and subtalar articulations. Avascular necrosis and posttraumatic arthrosis are most commonly reported complications of paediatric talar fractures.2 Predisposing factors identified are associated foot injuries and older age.3,5,7 Nonetheless avas-
. 49 .
Chinese Journal of Traumatology 2014;17(1):48-49
cular necrosis has been reported in even undisplaced talar neck fracture in a 6-year-old child.8 Other complications reported in literature are delayed union and neurapraxia.2 An important point in treating nonunion of talar neck fractures is to avoid overzealous dissection which may increase the chance of avascular necrosis. Surgical approach to talus fractures should be very cautious since the already precarious blood supply may get jeopardised. Eberl et al5 recorded no case of osteonecrosis in their series of fresh paediatric talus fractures treated nonoperatively while as many as 5 out of 16 cases treated surgically were complicated by persistent osteonecrosis. The key to open reduction of subtalar articulation is sinus tarsi approach which may cause
potential damage to the vascularity since the vascular supply of the talar body enters from the region of sinus tarsi and the tarsal canal.6 So in our case, we did not attempt anatomical subtalar reduction, and we fixed the talar neck in an acceptable position via combined medial and anterolateral approaches. Although wide generalization cannot be made by a single case, we recommend that the goals of treatment in nonunion of paediatric talar neck fracture are quite different from the ones in fresh fractures. In old or neglected fractures surgeon needs to balance the surgical approach to give maximum benefit to the patient without causing additional harm. A suboptimal reduction is more desirable than a radical surgery which may cause further impairment.
Figure 1. Lateral radiograph at presentation showing the nonunion site at the proximal talar neck, subtalar subluxation and no sign of osteonecrosis. Figure 2. T 1- and T 2-weighted sagittal images showing normal vascularity. Figure 3. Lateral and anteroposterior radiograph at final follow-up showing good union and no signs of osteonecrosis. Note the unreduced subluxation at subtalar joint. Figure 4. Sagittal and coronal reconstructed CT images showing no talar collapse and normal bone architecture. Figure 5. Clinical photograph showing normal plantarflexion, dorsiflexion and inversion as well as a mild restriction of eversion.
REFERENCES
5. Eberl R, Singer G, Schalamon J, et al. Fractures of the talus—differences between children and adolescents [J]. J Trauma
1. Linhart WE, Hollwarth ME. Fractures of the child’s foot [J]. Orthopade 1986;15(3):242-50. 2. Smith JT, Curtis TA, Spencer S, et al. Complications of talus fractures in children [J]. J Pediatr Orthop 2010;30(8):779-
2010;68(1):126-30. 6. Gelberman RH, Mortensen WW. The arterial anatomy of the talus [J]. Foot Ankle 1983;4(2):64-72. 7. Hawkins LG. Fractures of the neck of the talus [J]. J Bone Joint Surg Am 1970;52(5):991-1002.
84. 3. Jensen I, Wester JU, Rasmussen F, et al. Prognosis of frac-
8. Talkhani IS, Reidy D, Fogarty EE, et al. Avascular necrosis
ture of the talus in children: 21 (7-34)-year follow-up of 14 cases
of the talus after a minimally displaced neck of talus fracture in a
[J]. Acta Orthop Scand 1994;65(4):398-400.
6 year old child [J]. Injury 2000;31(1):63-5.
4. Meier R, Krettek C, Griensven M, et al. Fractures of the talus in the pediatric patient [J]. Foot Ankle Surg 2005;11(1):510.
(Received June 10, 2013) Edited by Dong Min